Getting Beyond Imitation for Young Children with Severe Expressive Impairments

1. Getting Beyond Imitation for Young Children with Severe Expressive Impairments Cynthia Cress, Ph.D. University of Nebraska-Lincoln 2007 ASHA presentation, Boston MA

2. Abstract • In many intervention techniques, we rely on children’s imitation of our modeled communication behaviors when prompted. For young children with severe expressive impairments who have difficulty producing verbal or nonverbal imitation in response to a direct partner model, we need strategies to indirectly elicit the target behaviors. This session uses videos and demonstrations of alternative strategies to elicit children’s productions using situational and indirect temptations for behaviors that minimize the role of direct imitation.

3. I. Who may have trouble with imitation? • A. Children who don’t imitate our models when prompted (verbal or nonverbal behaviors): • Speech/motor control issues (e.g. apraxia of speech) • Attention issues • Pragmatic issues (e.g. turns, expectations) • Cognitive issues • Autism spectrum (e.g. relating to partner’s actions) • Communication style or perceived difficulty

4. I. Who may have trouble with imitation? • B. Children who imitate too well, or only when prompted: • Autism spectrum issues • Sensory issues • Prompt dependency • Poor generalization of skills • Pragmatic issues • Communication style or perceived difficulty [clips of Anthony: poor initiation of imitated skills]

5. I. What we may not be able to teach: • C. Spontaneous imitation for communication • “Radar” for watching and incorporating useful actions for a purpose • Both children with too little and too much imitation tend to be poor at spontaneously using imitated skills to communicate a message (though they may echo) • Experience at seeing the usefulness of new actions for accomplishing purposes may help to build the child’s sense of “radar”, but this is rarely something we can teach directly • Comfort with “trial and error” learning will also help promote spontaneous imitation

6. D. What makes traditional imitation hard? • Adult initiated action • Expectation of child response • Limited timing and nature of response • Specific motor initiation problems • Knowledge that speech is a hard skill • “You’re not telling ME what to do”

7. II. How else can we elicit target behaviors? A. Make use of the environment and task to tempt target behaviors or approximations B. Emphasize physical or social play activities that elicit target behaviors spontaneously C. Embed our models into following the child’s intent D. Pair vocal and nonvocal behaviors in simple play E. Practice embedded models of behaviors the child is already good at, gradually insert harder actions F. Make sure we’re only working on “one hard thing at a time” G. Target speech behaviors no more than one step harder for a given activity from what children spontaneously produce Remember: It’s more important that the child produces the behavior for a purpose and sees its effect than that they do it because we told them to do it

8. A. Make use of the environment and task to tempt target behaviors • Produce the behavior for an immediate purpose • Make a toy or social interaction work • Embed or create into a social routine • Use activities that naturally encourage target behaviors or behaviors that can be shaped • Reduce emphasis on the behavior and increase focus on accomplishing the goal • Let the routine or activity signal to the child when it’s their turn to act rather than direct prompting [Ben/Tyler clip - Two purposes of imitating]

9. B. Emphasize physical or social play that elicits target behaviors naturally • Bouncing, tickle, swinging, social routines tend to elicit spontaneous sounds • Play with vibrating toys & large motor acts. • Prime the vocal system with tactile or vibrating stimulation to face and throat • Use books with repeated events or rhymes; attach simple sounds to pictures • Parallel talk or contingent vocal imitation (Adult imitates or puts words to child acts) • Minimize expectations for the child to imitate the adult • If children are not yet aware that their behaviors have meaning, we need to reinforce spontaneous behaviors

10. C. Embed our models into following the child’s intent (translation) • When the child makes gestures or sounds respond to these as meaningful. • When the child produces a gesture but not a sound, adult adds the sound on top of their response as it is happening • Give sound cues during interactive stories, or paired with events/gestures. • Pause to give the child a turn (with gestural ways of participating too) • Exaggerate the target or misarticulated sounds. • Provide tactile feedback for child sounds • Pair tactile prompts with sounds to cue the child, once they vocalize. • Model words or sounds at opportunities, but don’t make the child response a second requirement of the task

11. D. Pair vocal & nonvocal actions in simple play • Work on sounds “sideways” without focusing on the sound as the target action • Adult pairs simple play actions with sounds (e.g., saying “ba” while dropping objects into container) • Build sounds into social routines. • Always give the child a nonverbal way to take a turn and gradually add the vocal part • If you’re targeting a word and getting no vocal behaviors, simplify the sound paired with the action (e.g. let’s play “ooh”) • To reinforce more complex sounds, make results of difficult sounds more interesting than easy ones

12. E. Start with easy or stimulable actions • Inventory spontaneous sounds and then practice those in activities. • Practice embedded models of behaviors the child is already good at, • Gradually insert harder actions within the same routine • Vary expectations of sounds or actions, three easy ones to one hard one • Addition of the “ie” or “y” endings to words may make them easier to say (final consonants tend to be harder) • Make relatively harder sounds or actions receive more interesting responses

13. F. One hard thing at a time • If a task is a new communication skill, make it easy in other ways. • Motorically - Socially - Motivation • Cognitively - Attention - Language (known word) • Expectations - Timing -Teaching strategy • If we’re working on a difficult communication skill (e.g. learning how to comment), we need to use a behavior that is already a strong skill and gradually generalize this to harder behaviors. • If we’re working on speech skills, it’s OK to have simple or repetitive activities, since motor practice is an important factor in learning a physical behavior like speech. • Make sure to position the child appropriately with support for speech and/or gesture activities

14. G. General complexity of speech goals • Reflexive sounds-interpreted by adults. -Cry/burp to coo/goo to vocal play • Reactive sound making in interactions • Goal is making sounds when child wants to • Vowels usually, or simple consonants /fff/ • Activity-triggered sound making & play • Goal is increasing variety of sound repertoire • Includes vowel combos (uh-oh) and consonant/vowel • Communicative sound making - Goal is associating sounds with purposes - Vowel combos and consonant/vowels with meaning - Can be babbling with intonation (e.g. question vs. comment)

15. III. Overview of Embedding Incidental Imitation: Tempt/Trigger Model • Tempt: Adapting the activity, partners, and environment to naturally elicit behavior • Trigger: Individual’s spontaneously initiated behavior (current skill) • Translate: Associating a new form or function of behavior immediately after the individual produces their current behavior • Touch: Tangible and immediate feedback of the successful behavior and its outcome

16. 1. Tempt: • Give the individual (and/or partner) motivation for wanting to communicate • Anything that can occur in small increments can become a temptation • Start with function and use of communication rather than form • If people have low communication output, you may first need to adapt the environment, activities, or partner responses • Most early communicators have very context-dependent communication, and we need to embed our intervention into a realistic communicative context

17. 2. Trigger: • Trigger the communicator’s existing behaviors before prompting what’s next • Communicator-initiated response to temptation, not starting with an adult-initiated model • Follow the individual’s interest to trigger what they can already do • We can cue the individual to focus on a particular behavior without directly prompting • Any outcomes or prompts need to be embedded into the activity and context

18. 3. Translate. • Translate the existing behavior into a more conventional or complex one without any extra work on child’s part • Respond directly to the individual’s existing behavior as meaningful (even if inferred) • Provide functional and social outcomes of the behavior as you help the child produce new action • Prompt with behaviors, touch, and activities more than verbal prompts when possible • Scale back translation to simpler vocalization or gesture if we can’t translate more complex actions

19. 4. Touch • Make our cues and feedback concrete and direct within the individual’s experience • Interpreting verbal cues and feedback can add its own cognitive load and processing • Touch as feedback helps children realize which behavior successfully got the response • Touch as cue helps us focus the person’s attention on relevant behaviors without prompts • For touch-sensitive individuals, other behavioral or attention cues can be equally concrete

20. IV. Coaching Parents • One hard thing at a time for parents too • Suggest one new strategy to try at a time (e.g. make silly sounds with tickle) • Some parents are used to relying on imitation as a primary teaching strategy • Some parents may not rely on “radar” to recognize and respond to child actions • Some parents may see working on “fixing their speech” as our job

21. A. Why may parents rely on imitation? • Modeling is clear evidence of teaching that the adult can control • Imitation is the only reliable way to elicit the correct response the adult intends • We are used to relying on imitation with other children • It’s easy to see quick results if it works • We may not see the difference between the surface behavior and the intent

22. B. Why can embedded strategies be hard? • We may not be aware of meaningful behaviors beyond the “correct” target • It isn’t real unless it’s speech • It involves changing aspects of how we do normal routines and play • It requires thinking about several things at once • Results may be gradual and not perceived as change • We’re making it “too easy for the child” • We don’t feel in control of the situation

23. Contact Information: Cynthia J. Cress, Ph.D. Associate Professor University of Nebraska-Lincoln 202G Barkley Memorial Center Lincoln, NE 68583-0732 (402) 472-4431 ccress1@unl.edu Website: www.unl.edu/barkley/faculty/ccress.shtml