2/5/2016 Required Disclosure Building Verbal Imitation Skills in Toddlers Laura Mize, M.S., CCC‐SLP KSHA 2016 teachmetotalk.com • As owner of The Laura Mize Group, teachmetotalk.com and myei2.com, I receive a salary, compensation for speaking, and royalties from all teachmetotalk.com product sales. • I have no other financial or nonfinancial relationships with any of the other authors, publishers, or SLPs whose work I recommend in this course. @Laura Mize teachmetotalk.com Profiles of Late Talkers Late Talkers are NOT a homogeneous group! @Laura Mize teachmetotalk.com Paul, Chawarska, Volkmar (2008) 1. Cognition ‐ Missing cognitive milestones – shows up in play more than anywhere else! Could mean autism… but could also mean general cognitive delay 2. Joint attention ‐ Self‐absorbed kids 3. Receptive Language Deficits NOT just a late talker if there are receptive language issues! Language comprehension scores are a SIGNIFICANT predictor of outcome 4. Gestures – No emerging gestures like pointing, waving, clapping by 12 months 5. Pretend Play Skills – NOT repetitive movements with toys 6. Repetitive movements – Stereotypic movements Key Purpose of Assessment for Any Late Talker Separating children with only expressive delays from those with larger developmental issues @Laura Mize teachmetotalk.com Risk factors that tell us which ‘late talkers’ may not catch up… (hanen.org) What if it does seem to be “just” late talking? Risk factors that tell us which children may not catch up to peers (hanen.org): • quiet as an infant; little babbling • a history of ear infections • limited number of consonant sounds (p, b, m, t, d, n, y, k, g, etc.) • does not link pretend ideas and actions together while playing • does not imitate (copy) words • uses mostly nouns (names of people, places, things), and few verbs (action words) • difficulty playing with peers (social skills) • a family history of communication delay, learning or academic difficulties • a mild comprehension (understanding) delay for his or her age • uses few gestures to communicate 7. Unusual vocalizations – Atypical sound patterns @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com 1 2/5/2016 Biggest Commonality Among Late Talkers Break It Down…MOST RISK Child isn’t talking! Children with the final three factors: FAMILY HISTORY COMPREHENSION PROBLEMS LIMITED GESTURES are at greatest risk for continuing language delay. More importantly… Child isn’t imitating! (hanen.org) @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Lack of Imitation Means There ARE VERY LIKELY Delays In Other Areas Imitation Matters! The ability to “see and do” are HUGE developmental markers! A child who is imitating is: Socially connected Attention is usually developmentally appropriate Cognitive skills moving along Coordinated motor skills Words – Child IS verbal When we don’t see imitation in children, we suspect other delays too: • • • • • Social Sensory Processing Cognition Motor Verbal @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com More Evidence Why Does This Matter? A child’s ability to imitate actions at 18 months old was a better predictor of his language skills at 36 months old than even gestures. (Child Development 2013) @Laura Mize teachmetotalk.com If you’re not working on the right goals, you won’t see progress…. ESPECIALLY when there are multiple underlying reasons that the child is NOT talking! @Laura Mize teachmetotalk.com 2 2/5/2016 Looking at a Child’s Imitation Skills Levels come from… WILL TYPICAL DEVELOPMENTAL SEQUENCES get you on the right track for treatment for expressive communication delays/disorders! Your focus will be on the reason there’s breakdown at a particular level. (social, cognitive, motor, language, speech) Broken down into tiny steps EASY for parents (and for us!) @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Discuss for each level: Why This Method Works Prerequisites Most importantly… Where to begin treatment Often times in our treatment plans with very young children with speech‐language delays, we jump straight to words. MANY children are NOT DEVELOPMENTALLY READY for this and then we don’t see progress for weeks or months because we started at a level that’s too high for them. @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Another benefit… Overview of the Levels of Imitation EARLY SUCCESS! Success is important for EVERYONE! • Child • Parents • You @Laura Mize teachmetotalk.com • Level One: • Level Two: • Level Three: Level Four: • Level Five: • Level Six: • Level Seven: • Level Eight: Actions with Objects Communicative Gestures Nonverbal Actions with Face/Mouth Vocalizations in Play Exclamatory Words Automatic Speech ‐ Verbal Routines Functional Words Short Phrases @Laura Mize teachmetotalk.com 3 2/5/2016 Building Imitation Through Play How To Target Level One… PLAY! Level One: Imitating Actions with Objects • The child learns to repeat an action that he sees another person perform with an object. • Motor imitation with an object comes first since is targeted first since this is one of the first kinds of imitation we observe in typical development. • Imitation with a familiar object will also be the easiest target for toddlers who aren’t already spontaneously or purposefully imitating actions, gestures, or words. Since we’re working with very young children, play‐based activities are the most developmentally appropriate ways to target new skills. @Laura Mize teachmetotalk.com Most children will already be able to physically accomplish those kinds of tasks on their own in daily routines, but the key skill is getting them to copy what you’ve just shown them. @Laura Mize teachmetotalk.com “We cannot do anything with words until they are build on what was there before words existed.” A. Charles Catania @Laura Mize teachmetotalk.com Toys and playing with a fun adult peak a child’s initial interest and keep the toddler engaged and participatory for longer periods of time. @Laura Mize teachmetotalk.com This Level is CRITICAL for Children with Cognitive Delays Some experts recommend skipping this level if a child is already vocalizing, but if a toddler’s play skills are delayed, learning how to imitate actions with toys IS the first step to target. By teaching motor imitation in this way, you may be helping a child learn to really “play” with toys for the first time. Play is IMPORTANT for all children in order to help them master important cognitive skills to establish a foundation for language. @Laura Mize teachmetotalk.com Step is also CRITICAL for Suspected ASD Imitation of functional actions with objects has been linked to the development of more mature play skills in children with autism. Over time this step decreases the stereotypic use of toys. By targeting imitation you’ll be teaching the child what to do with the toy or essentially how to play. @Laura Mize teachmetotalk.com 4 2/5/2016 Benefits for ASD Brooke Ingersoll studies – improves JOINT ATTENTION MANY adults are fooled by an echolalic child without much evidence of joint attention and true talking for communication. Even with those kids, you’ll start here for treatment! @Laura Mize teachmetotalk.com What if a kid isn’t there yet???? Prerequisites for Imitating Actions in Play Motor and Social Proficiency at 6‐9 month Developmental Level • Purposefully reach for or swat at an object • Hold a bottle or cup by themselves • Explore a toy with their hands • A child must also be aware of another person in their environment and be able to attend to an activity for more than a few seconds. @Laura Mize teachmetotalk.com When kids are ready, begin by Modeling Actions in Play (Remember…. Don’t jump straight to words!) Level One Activities List Address the underlying reason… Begin with EXPECTED actions with objects 1. Motor Skills – OT and/or PT consult 2. Social Skills – Purposefully target interaction and engagement 3. Cognitive Skills – Direct instruction Blocks, vehicles including cars, trucks, or trains, musical instruments like drums, bells, or toy pianos, dolls and accessories such as a bottle, brush and baby wipe, plastic dishes and utensils, pretend food, and other toys with tools such as a ball toy with a hammer TEST @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Reminder for TYPICAL development 1 Eli – Early Imitation Objects • Our perceptions can become skewed • Imitation comes in EARLY for babies and toddlers @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com 5 2/5/2016 1 Avery Meet a Child Where He Is Use toys he LOVES! CAN use atypical interests: • Cabinet doors • Feathers • Sticks • Train tracks or spinning the wheels on a toy train @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Teach Parents to use Everyday Objects to Target Imitation in Daily Routines Guidelines for Level One Play • Brush his own hair while getting ready • Wash his own legs or the toy duck during bath time • Cover his face with a blanket or wipe during diaper changes • Hold a spoon in the air in imitation of an adult during meals • Pat his own shoes • Play with a child using toys he likes. • Narrate your play using very simple language. • Imitate and respond to a child during play to encourage social interaction and joint attention. • Model familiar actions with toys first and move to new actions over time. • Help a child imitate actions if he’s not doing it on his own. @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Tips to Keep a Toddler’s Attention More Advice about Attention… Move on to new toys at least every 20 minutes or so to encourage renewed participation and decrease the risk of boredom for both of you! Research confirms that a toddler’s attention span is variable at 3 to 6 minutes and will require full adult support to sustain longer than this amount of time. (Gaertner 2008). @Laura Mize teachmetotalk.com (Ingersoll) @Laura Mize teachmetotalk.com 6 2/5/2016 My Best Strategies for Stretching a Toddler’s Attention Span The “one more time” rule… This can be… • ONE more piece of the puzzle • ONE more page of the book • ONE more turn in play • ONE more try with ANY goal (You can also use this strategy the OTHER way to help a child transition from something he doesn’t want to leave.) @Laura Mize teachmetotalk.com “Tell him, Show him, Help him.” Perform an action 3 to 5 times and then provide physical assistance to help the child imitate your action if he doesn’t imitate on his own. @Laura Mize teachmetotalk.com Reciprocal Imitation or Imitating a Child’s Actions Solving Problems with TOYS Sometimes two identical sets of toys, one for the adult and one for the child, can be useful to elicit imitation of actions with objects during play. BUT it can backfire if the child then leaves you out of play! FOLLOWING A CHILD’S LEAD • ONLY in small spaces • ONLY WITH a child who is engaged with you @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Troubleshooting with Actions with Objects Once A Child Imitates PRAISE and REINFORCE with child‐specific reinforcement: “Yay” with clapping Quick squeeze if he’s a sensory seeker Natural reinforcement – briefly play on his own Who REALLY gets to choose the reinforcement? @Laura Mize teachmetotalk.com 1. 2. 3. 4. 5. Be more fun! Make the target easier. Avoid power struggles. Consider sensory needs. Sing as you model actions. “Rock – rock – rock the baby.” “Rolling. Rolling. Roll that ball!” 6. IF you can’t sing, CHANT. @Laura Mize teachmetotalk.com 7 2/5/2016 Real life… Jude Level One with Balls The more significantly impaired a child is… DIFFICULT…. Real life therapy the longer this goal will take! @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com What happens when kids After a child masters expected actions… VERY LITTLE INTEREST IN TOYS Move on to unexpected actions What do we do??? This ensures that IMITATION is occurring – not just learning what to do with an object. Look at what he likes & expand attention & task participation FIRST @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Twins – Unexpected Actions More Troubleshooting Make sure child is developmentally ready. If he’s mouthing, throwing, exploring toys with no regard for you, target social & cognitive skills first. If a child is too “busy” get him regulated and calmer first, then present toys. @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com 8 2/5/2016 Using Other Kids at Level One Building Imitation with Gestures • IF a child is struggling with YOU, an educated adult, he IS going to struggle with peers. • Children with atypical development especially need adults! They’re NOT socially advanced enough to have moved beyond parallel play. • Use other kids ONLY if it works for the child you’re teaching. If all of your time is spent managing behavior, then you’re not addressing your goals! In Level Two children begin to imitate actions that convey meaning to another person. Professionals refer to these actions as communicative gestures. Gestures precede words in typical development. It’s a HUGE red flag if gestures aren’t developing! We don’t see children with typically developing language skills who aren’t routinely using gestures. @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Gestures precede words in typical development. It’s a HUGE red flag if gestures aren’t developing! Capone says it’s a red flag for autism if no pointing at 18 to 24 months. We don’t see children with typically developing language skills who aren’t routinely using gestures. How early do gestures emerge in typical development? First Gestures In typical development motor imitation with gestures may first be seen with actions in early parent‐child social routines like Peek a Boo, Patty Cake, So Big, etc… @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com 2.0 Avery Social Games Examples of Early Gestures @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com 9 2/5/2016 2.1 Avery In typical development, we see these more communicative gestures emerge pretty easily… Waving & Pointing May be so, so, so hard for little guys because of a variety of factors: Social – Not enough meaning engagement or social referencing yet Cognitive – Child is not symbolic. Motor – Child can’t perform physical movements yet. • Because of these reasons, I don’t work on waving and pointing as first gestures when a child is really struggling. Try these first… @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Early Gestures To Try Word of Caution: Introduce gestures when the child seems interested in performing the simplest of actions in imitation of another person: Clapping is HUGE! Banging on a table or tray Dancing Give Me Five Knocking on a door Marching Kicking your legs while playing ball or bubbles • If a child isn’t performing ANY Level One imitations, it’s highly unlikely he’s ready for Level Two with gestures. • Imitating actions with objects and interest in another person’s gestures are the prerequisites for Level Two • Back Up and work on Level One as well as social, motor, and cognitive goals if a child isn’t there yet. @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Level Two Activities on Chart Books with Actions to Copy 1. Begin with simple body actions or movements in play that aren’t necessarily communicative, but that the child can imitate 2. Move on to easy gestures in context during play and daily routines. 3. Move to more complex gestures/patterns @Laura Mize teachmetotalk.com • Elmo Says… • Barney Play Nose to Toes • From Head To Toe – Eric Carle CAUTION ABOUT BOOKS: If the child doesn’t let you participate, it’s not a great choice for teaching! @Laura Mize teachmetotalk.com 10 2/5/2016 Same RULES as Level One 1. Model gesture 3‐5 times then help child perform the gesture. 2. Use BIG gestures and heightened affect to attract and keep child’s attention. 3. PLAN your gestures and help parents plan too. @Laura Mize teachmetotalk.com Moving on in Level Two… Introducing Signs • ONLY when a child is imitating earlier Level 2 gestures! • Teach with REQUESTS first (not labels!) Other Kids MAY Be Effective Here Gross motor games are the first times we see evidence of social attention with peers and are particularly effective for toddlers and young preschoolers. GREAT therapy ideas for seeing kids at daycare. Gross motor games: • Running from Point A to Point B and back again • Jumping • Swinging arms • Marching • Social games with peers – “Ring Around the Rosies” @Laura Mize teachmetotalk.com WITH HUGE (and I mean HUGE) Motivators –Food –Toys –Movement Activity Remember… who picks the motivators? THE CHILD, not you! @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Signs List The problem with this argument… First Signs: more, eat, milk, all done, please, go, open, help, mine Next Signs: cookie, cracker, fish, chip, candy, juice, water, cup/drink, choo‐choo, bubbles, balloon, car/truck, plane, baby, play Some controversy….. Some kids may overgeneralize and “get stuck.” @Laura Mize teachmetotalk.com Many babies (even typically developing toddlers!) overgeneralize as they’re learning language. It’s our job to help them learn specific words/signs and not get stuck! @Laura Mize teachmetotalk.com 11 2/5/2016 Elijah Signs • Elijah 2.3 – cranky, end of session first day • Elijah 2.4 – mid 2nd day – happier – warmed up ‐ try signs with funny play routine • Elijah 2.7 – mom goes home, frustrated… • Regulated…. Fun … • Why did this work? Troubleshooting for Level Two 1. Make gestures BIGGER and more FUN! 2. Introduce novelty @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Signs are HARD for Some Kids Remember…. 1. Kids on the spectrum have difficulty with social referencing. (EBP ‐ PECS is the way to go for communication! Frontiers in Integrative Neuroscience 2013) 2. For kids with cognitive and receptive language delays, symbolism is HARD and gestures are symbols. 3. Motor planning may also be difficult for a child to get his body to do what he wants it to do. Reward the effort, not accuracy. @Laura Mize teachmetotalk.com ANYTIME a child is not making progress, it’s because the goal is too difficult. PERIOD! BACK UP, break your goal down, and work on smaller steps. For Level Two… (use chart!) If you can’t get signs, work on more gestures. If there aren’t any gestures, back up to Level One or use SIMPLER gestures with repeated practice. @Laura Mize teachmetotalk.com Building Imitation with Mouth Movements In Level Three a child learns to imitate nonverbal actions with his face and mouth. This can also include learning to blow horns and whistles. Little controversial in our field at the moment! ORAL MOTOR CONUNDRUM! @Laura Mize teachmetotalk.com SLP Experts who support an oral motor approach… (usually also feeding experts) • Diane Bahr • Lori Overland • Sara Rosenfeld‐Johnson • Pamela Marshalla • Debra Beckman Oral Protocol @Laura Mize teachmetotalk.com 12 2/5/2016 TONS OF RESEARCH to negate using any kind of nonspeech oral motor exercise in therapy as a way to improve speech intelligibility. Dr. Gregory Lof is a leading researcher in this area. Dr. Caroline Bowen @Laura Mize teachmetotalk.com When An Oral Motor Approach IS Indicated • Feeding skills are affected • Muscle tone and/or sensory issues are prevalent or obvious (Open mouth posture, excessive drooling after 2, little awareness of their mouths, strong aversions to toothbrushing, or excessive mouthing after 2) • When you’ve seen little to no progress without it @Laura Mize teachmetotalk.com Level Three Activities • Begin with exaggerated facial expressions and mouth movements. Show a child how to perform the action. • Move on to more refined movements of the mouth like smiling, puckering, smacking, etc… • Introduce a variety of mouth toys such as horns, whistles, kazoos, musical instruments, pinwheels, common household objects such as funnels, tubes, or even cotton balls (Goal is IMITATION or turn taking!) @Laura Mize teachmetotalk.com For a small percentage of late talkers… We MUST help them learn that they have a little mouth and it’s under their control! For many of them, everything they’ve done with their mouths up until now has been reflexive…(eating, drinking, breathing, yawning, crying) ANY oral movement on command may be EXTREMELY difficult for them. • Muscle tone differences • Motor planning difficulties @Laura Mize teachmetotalk.com My BEST Use Of Level Three • Use these activities diagnostically to see if there’s an issue • Only a PART of a child’s therapy program IF it seems to help • These things could be the “back up to” point in therapy if a child can’t move forward • Use as a “treat” or diversion in sessions • Use it as a way to satisfy strong oral cravings • Teach activities to parents and turn it over as a part of a home program @Laura Mize teachmetotalk.com Horns and Whistles Sets • Formal programs: talktools.com is one resource for you and for parents. (Get parents to buy them!) Caution… little EBP • Informal methods: Birthday party favors, Oriental Trading, and other toys like wooden train whistles Debra Beckman Oral Motor Protocol seems to be at least a little more supported by research @Laura Mize teachmetotalk.com 13 2/5/2016 Building Imitation with Early and Easy Vocalizations Just for the record… I’ve treated many, many, many children successfully without the use of a single horn or whistle or introducing any real oral motor imitation tasks. This is usually a very, very small part of our treatment plan for a small percentage of kids on my caseload. In reality, I don’t care if a toddler still can’t blow a whistle if he’s already talking! In Level Four and Level Five a child learns to imitate mouth movements with sound during verbal play. In typical development this phase is noted as babbling. Babbling also occurs in late talkers as they become more noisy before true words emerge. Who likes to work on babbling? @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Experts Who Recommend Targeting These Sounds Stanley Greenspan – Model Affect David Hammer – Apraxia Expert Dr. James MacDonald – Play To Talk Pamela Marshalla – TONS of great information • Hanen – People Games • Dr. Lynn Koegel – Pivotal Response Treatment – Overcoming Autism • • • • Prerequisites for Introducing Play Sounds Child is NOISIER during play. Vocalizations seem to be more purposeful. • • • • Whining when upset (rather than a reflexive cry) Scream or Squeal Purposeful Laughter Purposeful Vocalizations with emotion “Da!” or even a grunt @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com What if this is NOT happening yet? Activities to Promote More Sound MODEL more sounds/vocalizations, but not as many real WORDS. Use those same kinds of noises and Play Sounds from Level Four and Exclamatory Words from Level Five during these next activities: @Laura Mize teachmetotalk.com • Vocalizations during gross motor movement activities like swinging, jumping, running • Gym activities like a trampoline or ball pit • Large spaces that echo • Vocal contagion (Pamela Marshalla) – EVERYBODY talks, sings, or vocalizes Group games are very effective at this stage. • Toys that amplify sound – microphone, funnel, paper towel roll, bucket @Laura Mize teachmetotalk.com 14 2/5/2016 Play Sounds Level Four List – Sounds that are difficult to transcribe or “spell” • Squeal or scream • Fake cough or sneeze or cry • Whine • Raspberries • Slurping with a drink • Exhalation like ‘hhhhh’ after a child drinks • ‘mmmm‐wah’ when blowing kisses • Panting like a puppy • Car noises – sirens, brakes squeaking, etc… @Laura Mize teachmetotalk.com Reminder about typical development… • 4 Eli @Laura Mize teachmetotalk.com Probe for Early Level 4 Vocalizations THIS IS THE LEVEL WHERE I BEGIN THERAPY WITH MOST ‘SPEECH ONLY’ KIDS! • 4.0 Elijah – first day – I’m playing while another therapist talks to mom • 4.2 Elijah – second day – warmed up – I‘m saying, try panting… Not with real words!!! @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Exclamatory Words THESE ‘WORDS’ COUNT! Level Five List – Words that are usually spoken with forcefulness and represent an onset of emotion that can be either positive or negative. Exclamatory words are those you seem to yell to exclaim your message. These kinds of words are probably prevalent in your conversations with young children. All adults who are great with kids instinctively say, “Uh oh,” “Yay!” “Whee,” “Wow!” and even phrases like, “Oh boy!” Sometimes adults don’t want to count these as real words, but they are made of the same phonemes (consonants and vowel sounds) and are a step toward talking for many, many late talking toddlers. @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Value for children is that they are fun, novel, easy, and more than anything else meaningful! You can use these words to increase the frequency and variety of vocalizations a child uses. 15 2/5/2016 These ‘Words’ Work! Many times late talkers already use some vocalizations like these in Level Four and Level Five, but their parents don’t credit them as “words.” We MUST meet kids where they are developmentally and this is where I often begin therapy with late talkers who already have a handful of words or sounds. @Laura Mize teachmetotalk.com Raspberries • Bilabial Voiceless & Voiced – /p,b,m/ ‐ Car • Tongue Tip Voiceless & Voiced – /t,d,n/ ‐ Plane • Back of Tongue Voiceless & Voiced ‐ /k,g/ ‐ Crash • Trachea Voiceless & Voiced – (Non‐English) • Glottis Voiceless & Voiced – Growls ‐ Animals • Nasal – Snort ‐ Pig Work on these to teach kids PLACEMENT and provide strong input to oral mechanism. (Marshalla) @Laura Mize teachmetotalk.com Word of Caution… The strategies we just discussed are NOT useful for a child who isn’t connecting with you socially OR who doesn’t understand LOTS of words. @Laura Mize teachmetotalk.com EASIER for NEW Speech Sounds Level Four and Level Five ‘words’ may make it easier for a child to acquire to use a new sound or class of sounds rather than in a real word. @Laura Mize teachmetotalk.com One More EXCELLENT Resource The Big Book of Exclamations thebigbookofexclamations.com Teri Kaminski‐Peterson @Laura Mize teachmetotalk.com Troubleshooting for Play Sounds Be more fun! Many times increasing your own level of animation and playfulness is what helps a child begin to imitate Level Four and Level Five during play. Change yourself before abandoning this goal. Move, move, move! Balloons, bubbles, run, jump, swing, dance! @Laura Mize teachmetotalk.com 16 2/5/2016 More Troubleshooting Change your volume: Whisper Say it LOUDLY! Add gestures or hand movements: Pow! Oh no! Shiver Exaggerate the vowel sound… adds excitement/affect @Laura Mize teachmetotalk.com Experts Who Recommend Verbal Routines 1. Dr. Rossetti 2. TEACCH Method 3. Giggle Time – Susan Aud Sonders (based on Greenspan) 4. Dr. Lynn Koegel – Pivotal Response Treatment (ABA meets Floortime) – Carrier Phrases 5. Hanen Building Imitation with Verbal Routines In Level Six a child begins to use some real words during very familiar routines. Verbal routines can be completely original or well‐ established nursery rhymes, games, or songs. These words seem to become “automatic” meaning that a child says the word when very familiar and specific conditions occur. @Laura Mize teachmetotalk.com Why do verbal routines work? They are so appealing! The repetitiveness and predictability of your verbal routines will be particularly appealing to children who crave order including toddlers who may go on to be diagnosed with autism. Actually ALL young children can benefit from verbal routines. Effective preschool and kindergarten teachers have used these techniques for years as they sing the same songs to accompany routines in their day. Most loved children’s television and books are based on Verbal Routines. Adults crave verbal routines too! @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Echolalic Kids Common Verbal Routines Learning STRENGTH is Verbal Routines Establish verbal routines during play with easy ones listed. Remember that you’ll teach the verbal routine by saying the words over and over during play. Caution – Be sure you’re working on RECEPTIVE LANGUAGE with these kids! Just because they can say it, doesn’t mean they can understand it! @Laura Mize teachmetotalk.com • “Ready – Set – Go” • Counting by rote to begin a game with “1, 2, 3” • Say “Up, up, up” as you lift a child in your arms and then “Down!” as you drop her to the floor. @Laura Mize teachmetotalk.com 17 2/5/2016 Use Previous Preferred Activities Original Verbal Routines Social games including Patty Cake, Peek‐a‐Boo, So Big, Give Me 5, Ride a Little Horsie, Row Your Boat, and Ring Around the Rosies When a child is making a toy climb a ladder or pushing a car up a ramp, I model, “Up up up” and then say, “Wheeeee!” as the object slides down the slide. Easy songs and fingerplays such as If You’re Happy and You Know It, Itsy Bitsy Spider, and Twinkle, Twinkle Little Star If a child is hiding or obstructed from my view, I sing, “Where Oh Where?” or say, “______, where are you?” Zip! Knock Knock Knock…. Open Baby Doll Routines @Laura Mize teachmetotalk.com 6.2 Avery @Laura Mize teachmetotalk.com Key to Setting up Effective Verbal Routines 1. TIME! Child has heard the routine often enough to recognize it, to remember it, and he’s verbal enough to be able to join in. 2. Cloze Method 3. Expectant Waiting… TELL ME FACE @Laura Mize teachmetotalk.com Build Verbal Routine Around a Toy • 38 Garrett Phlat Ball @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Build Verbal Routine Around an Action • 6.3 Noah @Laura Mize teachmetotalk.com 18 2/5/2016 Build Verbal Routine from a Game • 44 Julia ‐ Night Night game Make it up as you go! – Replace MINDLESS NARRATION If a child is digging in the sensory box and dumping beans in a bowl, grab your own shovel or spoon to repeat his actions. As you perform each step say, “Dig dig dig. In the bucket. In the bucket. Dump!” Repeat the same sequence of actions and words many times during play on the first day and every subsequent time you play in the box. As you push a child in a swing, say, “Push.” As he swings say, “Whee!” After a set number of turns pushing and swinging, catch him and say, “Stop!” Then begin your routine again saying, “Push. Whee! Push. Whee! Push. Whee! Stop!” @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com 6.9 Clayton Verbal Routines are POWERFUL and you can build an entire session around verbal routines. EXCELLENT initial strategy for verbal kids with autism who aren’t yet spontaneous or who don’t request. You can use this automatic speech to begin to direct what happens next in play. @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Building Imitation with Single Words Reminder of Typical Development FINALLY…. WORDS! • 7 Caroline Move to words when a child has achieved a fairly high level of mastery with the easier, earlier levels. @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com 19 2/5/2016 Prerequisites for Single Words as your MAIN Focus for Therapy 1. Interaction is not a problem! Social Skills are sufficient. Attention is pretty good. Engagement is present. If you’re struggling to keep a child engaged during fun activities and play, he’s usually not ready to talk yet from a social perspective. @Laura Mize teachmetotalk.com 2. Cognition is moving along! Cognition is most easily assessed by looking at a child’s play skills. When a child’s cognition improves, play skills progress. You’ll see this as a child understands how toys work, plays with a variety of toys, and has mastered basic cognitive milestones such as object permanence, cause & effect, and simple problem solving. You know he imitates actions because he can watch you and play appropriate with even a new toy. If this isn’t happening, the child isn’t ready to talk from a cognitive perspective. @Laura Mize teachmetotalk.com 3. Receptive Language is progressing! 4. Imitation is present! Comprehension is improving. Words have become meaningful. The child more consistently follows simple directions related to his familiar routines and during fun activities with you. If he does not yet understand words, he’s not ready to talk from a receptive language perspective. Imitation skills are established with easier skills. The child imitates actions, gestures, and other kinds of vocalizations. He has the ability to “see and do.” If there’s no evidence that a child understands this process, it’s unlikely you’ll be able to teach him to repeat words. @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Guidelines for First Word Selection Guidelines for First Word Selection 2. Choose words that are fairly easy to say. 1. Choose high frequency, familiar words. Pick words a toddler hears often. These are words a child should understand in order to complete his daily routines and those he should learn to say in order to get his needs met. @Laura Mize teachmetotalk.com Don’t begin with multisyllabic words or words with difficult sound combinations. Early targets would not include words like refrigerator, basketball, or helicopter. @Laura Mize teachmetotalk.com 20 2/5/2016 Guidelines for First Word Selection 3. Choose words with sounds and patterns a toddler already uses. • Sounds – both consonants and vowels • Introduce words with same sounds and in same class /p, b, m/ /t, d, n/ /k, g/ • Syllable shapes – such as CV or reduplication This is ONLY a huge consideration if a child has such a limited repertoire of sounds. You’ll do this to get early success, but remember, you’ll have to hear new sounds sometime…. @Laura Mize teachmetotalk.com Words to Avoid for First Targets Academic Words Colors, Shapes, Numbers and Letters Bryn Mawr List In 2011 researchers at the Child Study Institute at Bryn Mawr College identified the following 25 words every toddler should be using by age 2: all gone, baby, ball, banana, bath, bye bye, book, car, cat, cookie, Daddy, dog, eye, hat, hi/hello, hot, juice, milk, Mommy, more, no, nose, shoe, thank you, yes @Laura Mize teachmetotalk.com Teach REQUESTS Even though the majority of early words in a typically developing child’s vocabulary are labels, STILL teach those words as requests so that you establish Why??? NOT FUNCTIONAL for NEW Talkers Save for AFTER a child has established a functional vocabulary (50 words and short phrases) @Laura Mize teachmetotalk.com RED FLAG for High Functioning Autism in Toddlers • Talking but not communicating • Child knows HUNDREDS of labels and that’s the extent of his/her vocabulary • MUST learn to ask for things, respond to questions, etc… • This is why so many higher functioning kids are missed before ages 3 to 4 @Laura Mize teachmetotalk.com Communicative Intent I have to DO Something to GET Something! @Laura Mize teachmetotalk.com MATERIALS for Teaching Single Words Toddlers learn best by doing! TOYS and Daily Routines NOT Flashcards, Apps, or Electronic Toys ESPECIALLY FOR OUR YOUNGEST KIDS ON THE SPECTRUM @Laura Mize teachmetotalk.com 21 2/5/2016 Strategies to Enhance Imitation of Single Words • Use motivating materials a child likes! Play!!! • Find a balance being both fun and demanding! • Do everything you can to achieve early success! As a professional, you must Master WITHHOLDING! Model the word 3‐5 times fully expecting a child’s best efforts, but then give a child the item he wants regardless of his response. Pleasant persistence and direct cues work best for many children as you say things like, “Tell me ____,” and “Say ____.” (Unless child is echolalic and repeats your prompt!) @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Other Strategies • Lean forward and wait expectantly as if to cue… ‘It’s your turn to talk!’ Elsa • 7.0 Elsa – Potato Heads – Vocal Contagion • 7.1 Elsa • Sing Song Vocal Prosody – motherese • Vocal Contagion – EVERYBODY models! @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Mass Practice Repetition at this level is critical! Multiple opportunities for a child to say and hear the same word over and over again! Mass Practice • 10 Elijah Dr. Caroline Bowen’s recommendation: • 12‐18 models of your target word @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com 22 2/5/2016 Elsa – Muffin Pan • 7.2 • 7.3 Making Sets for Muffin Pan Therapy Any Little Objects: Balls, Bugs, Bows, Army Men – Man, Guy, Horses, Cows, Dogs, Socks, Moons, Cars, Cats, Forks, Spoons, Turtles, Boys, Girls, Fish Stickers – Erasers – Pictures (maybe…) – Toddlers like REAL stuff! @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com By Now…. If not… If you’ve done a good job by being fun and with word selection based on what a kid likes and sounds you know he can say…. You should be getting an attempt almost every time you cue a word. The child is not developmentally ready for words OR he would be imitating you! Back up! @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Moving Along… Choices When a child is imitating several different words well in a session, offer CHOICES! Not just one choices, DOZENS of choices in a sessions and HUNDREDS of choices in a day. Choices turn a child into a full‐time imitator of single words. @Laura Mize teachmetotalk.com • Choices can “trick” a toddler who won’t normally imitate on command into imitating. • Keep it fun! • Keep your choices motivating. If a kid doesn’t like what you have, what’s the point??? @Laura Mize teachmetotalk.com 23 2/5/2016 Rory Vocabulary Development Pay CLOSE attention to expanding a child’s vocabulary at the single word level BEFORE moving to phrases. Some experts disagree with this, but I’ve found… when we build a child’s vocabulary at the single word level, everything else falls into place and phrase production is easier! @Laura Mize teachmetotalk.com Don’t Forget to Teach… • • • • • New Nouns Verbs Prepositions Pronouns Descriptive Words • AAC Learning Lab Chart – reference – link in manual @Laura Mize teachmetotalk.com Help a Child Move Toward Spontaneous Single Words Environmental Sabotage –Communication Temptations • Place favorite items out or reach • Use toys that promote requesting – bubbles • Eat a child’s favorite snack in front of him, but don’t give him a piece until he verbally requests the food. • Set out a more difficult toy that a child must get assistance from you. (wind up toys, Hot Wheels Motorcycle set, a balloon pump, rocket launcher) • Give only 1 PIECE of an activity that requires many parts (paper but no markers, race track with no cars…) @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Troubleshooting Building Imitation with Phrases ALWAYS start sessions with what a child can already say. During Level Eight a child begins to imitate short phrases. If all else fails, cue a child’s default words or signs. As noted in the previous phases, imitation precedes spontaneous use, and it’s no different here at Level Eight with phrases. Learning to imitate two and three word phrases is a critical step in helping a child develop spontaneous phrases and become conversational. BACK UP! @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com 24 2/5/2016 Difficulty With Phrases EASY Patterns First Move to phrases too soon Spontaneous single word vocabulary (35‐50 words minimum) Not enough variety with his words Around 18 Month Developmental Level @Laura Mize teachmetotalk.com • • • • • • • My + Favorite object More + Noun child says frequently Noun + Please More Please Bye bye + Name/noun child says Hi + Name/noun child says Night night + Name child says @Laura Mize teachmetotalk.com 8 Kellie Phrases ‐ “My ____” Holistic Phrases No way! Aw man! Oh no! Oh boy! I got it! Right there/Right here See ya’ C’mon (for come on) 147 8.1 Kellie @Laura Mize teachmetotalk.com Selecting Phrase Targets • Don’t start with carrier phrases! (I want ___, I see ____, Give me ____ ) • Holistic Phrases with Heightened Affect Save these patterns for AFTER other phrase patterns are well established at the spontaneous level! 149 @Laura Mize teachmetotalk.com 25 2/5/2016 More Advice for Phrases Treating Sequencing Issues • Pair words from a child’s existing vocabulary, since these are words you know a child can already say. • Try high frequency word combinations a child he hears in every day routines such as, “Bye bye Dada!” • Use combinations from your well‐established Verbal Routines. If you’ve played baby dolls and have sung or said, “Rock baby” or “Night night baby” If a child only says one word of the phrase, he needs more sequencing practice. Work on the same word in a sequence Up up up – down down down Dog Dog Dog Me me me! Sing! Even the same word or syllable “Row Row Row Row Row…” @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Miles Singing Single Word Treating Sequencing Issues • If child repeats same word, use backward chaining. (“more more” for “more milk”) Sometimes this is due to a motor planning problem, but sometimes it’s cognition! • Practice last word first several times then add the first word. @Laura Mize teachmetotalk.com Backward Chaining Helps to get BOTH words if a child is repeating a word for a phrase “More more” for more milk, practice “milk, milk, milk” then “more milk” Also works for multisyllabic words like Elmo, puzzle, cookie, cracker, goldfish, Daddy, bubble @Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com Use One Word as an Anchor for Phrases Apraxia‐kids.org – several articles with great references for this ‐ helps with motor planning If several nouns and the word “go” are well established and the child seems to need the same word to “get started,” try: Go car, go truck, go choo choo, go boat, go plane Or change first word and use a well‐rehearsed second word such as “please” OR a very familiar “almost default” word… No Mommy, up Mommy, help Mommy More bubble, blow bubble, up bubble, down bubble, pop bubble @Laura Mize teachmetotalk.com 26 2/5/2016 Spontaneous Phrases & Conversations • QUESTIONS may shut a child down. • STILL do lots of commenting and modeling. (1 to 4 ratio) • Playing TOGETHER is what makes this more natural and less like a “firing squad” for a kid. @Laura Mize teachmetotalk.com CHART • Use the chart as a CHEAT SHEET during sessions • Move up and down • When a child seems stuck, figure out where he’s successful and EXPAND that level • Remember, if there’s no progress, the goal is TOO HARD. BACK UP! @Laura Mize teachmetotalk.com QUESTIONS? Email me: [email protected] @Laura Mize teachmetotalk.com 27 Building Verbal Imitation in Toddlers Level One Level Two *Level Three Actions with Communicative Nonverbal Objects Gestures Actions with Your Face and Mouth Expected Actions: Shake a rattle Bang two blocks Pat hands on table Remove a blanket Dump out toys Put objects in box Knock over tower Stack blocks Push a car Roll a ball Hit a balloon Pat a drum Push button on toy Knock on a door Stir with a spoon Hold phone to ear Pat, hug & kiss doll Put hat on Brush a doll’s hair Feed a doll Wash a doll Hammer ball/pegs Simple Big Body Actions such as: Pantomime actions Bang hands on lap Stomp Kick March Dance Animal movements Unexpected: Knock under table Hide hands Place toy on head Roll car down leg Sit on a hat Hand Motions for Songs & Fingerplays Easy Communicative Gestures: Reach to be lifted Wave Clap Blow kisses Give Me 5 Shake head yes/no Pointing Open/close mouth Widen eyes Raise eyebrows Puff out cheeks Round your lips Chatter teeth Smile Pout Blow Grimace or snarl Pucker lips to kiss Smack lips Lick lips Close lips tightly Stick out tongue Pull tongue back in Wiggle tongue Click tongue Pretend to lick *Not necessary for most late talkers! Simple Sign Language Horns Whistles Pinwheels Cotton balls Musical toys like a flute or kazoo ©Laura Mize, M. S., CCC-SLP teachmetotalk.com Level Four Vocalizations in Play Level Five Exclamatory Words Say “ah” in bucket Pant like a dog Audible inhalation Squeal or scream Grunt with effort Yawn Fake cough Fake sneeze Car/Truck noises Siren noise Fake laugh Fake cry Whine Snore Snort like a pig Slurp with drinking Exhale after drink Shiver Indian noise Sh! for quiet Growl Mmm, mmm, mmm Yum or yummy Yuck or yucky Ick or icky Yay Ouch, owie Boo Boo boo Uh oh Oops or whoops Oh Ew Eek Whee Wow Whoa Woo hoo Pow Hooray Aw Man Oh no Oh yeah Oh boy No way Blow Raspberries Animal Sounds Vehicle noises like beep, vroom, woowoo, boom, crash Level Six Automatic Speech in Verbal Routines Pause to let child fill in words with: Ready, Set, Go 1, 2, 3 Social Games Peek-a-boo Patty Cake Give Me 5 Ride Little Horsie Row Your Boat Ring Around The Rosies Early Songs Twinkle Twinkle Itsy, Bitsy Spider If You’re Happy… Wheels on the Bus Old MacDonald Develop your own Verbal Routines during play with the same words each time. Games from Teach Me To Play WITH You Level Seven Functional Words All done/all gone Baby Ball Banana Bath Bye-bye Book Car Cat Choo choo Cookie Cracker Dada/Daddy Dog Eye Hi/hello Hot Juice Milk Mama/Mommy More No Nose Shoe Please Thank you Early Verbs Early Prepositions Early Pronouns Early Descriptives Level Eight Short Phrases My __________ More ________ _______ please More please Bye bye ______ Hi __________ Night night ____ Combine words from a child’s established vocabulary Holistic Phrases: I got it I did it I do it See ya’ Come on Right there What’s that? Where it go? Where are you? Carrier Phrases: I want _______ More _____please I see ______ I like ______ Works Cited/ EBP References AAC Language Lab. (2009). AAC language lab stages chart. Retrieved from http://www.aaclanguagelab.com/materials/AACPartsOfSpeech.pdf. Ellis, E. & Thal, D. (2008). Early Language Delay and Risk for Language Impairment. Perspectives on Language Learning and Education, 15: 93-100. Ellis, E. & Weismer S. (2007). Typical talkers, late talkers, and children with specific language impairment: A language endowment spectrum? In: Paul R, editor. The influence of developmental perspectives on research and practice in communication disorders: A Festschrift for Robin S. Chapman. Mahwah, NJ: Erlbaum; pp. 83–102. McCleery, J., Elliott, N., Sampanis, D., & Stefanidou, C. (2013). Motor development and motor resonance difficulties in autism: relevance to early intervention for language and communication skills. Frontiers in Integrative Neuroscience, Retrieved from http://www.frontiersin.org/Integrative_Neuroscience/10.3389/fnint.2013.00030/full Olswang, L.B., Rodriguez, B. & Timler, G. (1998). Recommending Intervention for Toddlers With Specific Language Learning Difficulties: We May Not Have All the Answers, But We Know a Lot. American Journal of Speech Language Pathology, 7, 23 - 32. Rice, M. L., Taylor, C. L., & Zubrick, S.R. (2008). Language outcomes of 7-year-old children with or without a history of late language emergence at 24 months. Journal of Speech, Language, and Hearing Research, 51, 394-407. Telethon Institute for Child Health Research (2008). Mixed Results For Late-talking Toddlers. ScienceDaily. 16 May 2008. Web. 10 Jun. 2011. Thal D, Tobias S, Morrison D. (1991). Language and gesture in late talkers: A one year followup. Journal of Speech and Hearing Disorders. 1991;34:604–612.[PubMed] Tsiouri, Ioanna, Rhea Paul, Elizabeth Schoen. Simmons, and Moira Lewis.Rapid Motor Imitation Antecedent (RMIA) Training Manual: Teaching Preverbal Children with ASD to Talk. Baltimore: Paul H. Brookes Pub., 2012. Print.