For a book with detailed descriptions of specific teaching techniques for children of different ages, skill levels and impairments, see Blackstone, S. W., Cassatt-James, E. L., & Bruskin, D. M. (Eds.). (1988). Augmentative communication: Implementation strategies. Rockville, MD: American Speech-Language-Hearing Association.

Here are a few issues to keep in mind regarding children with motor impairments.

• Early communication by children with motor impairments may be subtle and unconventional, causing adults to overlook or misread these attempts. Adults, especially family members, may need to be taught how to become sensitive to and foster the child’s early communicative attempts. (See Normal speech and language development.)

• Children with motor impairments sometimes also have visual problems, such as certain types of perceptual difficulties, which may be hard to identify and diagnose. Nevertheless, such difficulties impact the choice of symbol system, as well as the size and arrangement of the symbols. Sometimes the only way to determine the best type of symbols is by trial and error.

• Children with motor impairments are at risk for learned helplessness because they are unable to effectively control their environment either directly or indirectly through communication with others. Communication is one way of providing the child with a powerful means of influencing others and the environment. Early intervention is, therefore, extremely important. (See Learned helplessness and Contacting an organization for services and support.)

• It is important to offer many and varied early literacy experiences and to provide adapted writing devices such as computers as early as the first grade.This allows them to keep up academically with their peers. (See Literacy.)

• Encourage the development of some unaided modes of communication, such as speech, vocalization, facial expressions and gestures. These are often the most efficient means of communicating since they do not dependent on an external device. (See Aided vs. unaided AAC systems.)

• Expect the best from the child. Expect the child to learn to read and write. Try an AAC system that is motorically challenging but allows greater flexibility, speed or growth for the future. (Note, however, that it is important that the child be able to communicate with it almost immediately.)

• Positioning is extremely important. Poor positioning results in unwanted reflexes, pain, fatigue, lack of adequate visibility, poorer motor control, and potentially permanent physical damage. Take the time to position the child so that the child can use his or her hands, eyes, ears, etc. to full advantage.

OTHER RESOURCES:

• "Cerebral palsy and visual impairment: An access challenge" by Cynthia Brown and Tracy Shepherd discusses direct selection and scanning at www.closingthegap.com/cgi-bin/lib/libDsply.pl?a=1013&b=8.

  Help me—and everyone who reads this site—by mailing your suggestions, criticisms and personal experiences to Ruth Ballinger at yaack@iname.com

• "Connections for success: Young children, computers and software" by Linda Benton describes the role of computers in developing motor and cognitive skills at www.closingthegap.com/cgi-bin/lib/libDsply.pl?a=1033&b=1.

• "Optimising access to communication boards and devices: The contribution of the Occupational Therapist" by Desleigh de Jonge at curriculum.qed.qld.gov.au/
  lisc/articles/therapy/thart1.htm.

• Cynthia Cress' Sept. 29, 1997 e-mail response under "single switch info request" offers tips on teaching eye blink switches on the ACOLUG listserv archives at listserv.temple.edu/cgi-bin/wa?A2=ind9709&L=acolug&F=&S=&P=26678.

An eye gaze system, in which the partner ascertains what the child is looking at is often an excellent method of communication for a young child with motor impairments. (Note that this differs from an eye blink switch which is a type of switch and does not depend on where the child is looking.) Gazing at an object of interest is a very intuitive manner of communication that often develops very naturally in children. Its main advantage is speed and effortlessness, both of which normalize conversations, accelerate learning and increase motivation.

Eye gaze communication systems may start with the child looking at objects in the environment, and then move onto symbols on a communication board. More advanced systems may include electronic eye gaze devices in which a computerized device identifies what the child is looking at and produces the message, eliminating the need for a partner to do so.

One of the main disadvantages of eye gaze techniques are their dependence on the sensitivity and diligence of the partner to constantly attend to what the child is looking at, as well as the inability of the child to signal someone who is not paying attention.

If symbols are used, their spacing and organization becomes very important in facilitating accurate interpretation by a partner. For example, it is helpful to separate words that are used in similar contexts, such as spoon and fork, so that they are not readily confused with each other.

OTHER RESOURCES:

• Goossens', C., (1989). Aided communication intervention before assessment: A case study of a child with cerebral palsy. Augmentative and Alternative Communication, 5, 14-26.

• Goossens', C. A., & Crain, S. S. (1987). Overview of nonelectronic eye gaze communication techniques. Augmentative and Alternative Communication, 3, 77-89.

• When teaching a child with a cognitive disability, it is important to know the communicative/cognitive level at what the child is so that an appropriate intervention program can be developed. (See Cognitive abilities, Assessing intentionality, and the understanding of means-end, causality and symbols, and Normal speech and language development.) If the child is at a pre-intentional and/or pre-symbolic communication stage, it is very important to begin with real objects. A common mistake is to assume the child will be able to communicate with pictures or some other symbol-based AAC system. (See The first goal: Intentional communication and Teaching symbols.)

• Children with cognitive disabilities are highly individualistic; no single intervention plan, symbol system, AAC device or teaching program will work for all (Beukelman & Mirenda, 1992). Traditionally, sign language has been the AAC mode of choice with children who have sufficient motor control. However, research has shown that, at least for some children, a voice output communication aid (VOCA) may be better at facilitating language development, especially beyond the single-word stage. Although it is not clear why this appears to be the case, there is speculation that VOCAs, which utilize recognition memory (i.e. the child just has to remember what the available symbols mean), are easier to learn than sign language, which uses recall memory (i.e. the child has to bring the signs to mind independently). (Iacono & Duncum, 1995; Iacono, Mirenda, & Beukelman, 1993; Romski, Sevcik, Robinson, & Bakeman, 1994). (See Aided vs. unaided AAC.)

  Help me—and everyone who reads this site—by mailing your suggestions, criticisms and personal experiences to Ruth Ballinger at yaack@iname.com

• Children with cognitive disabilities benefit from a variety of cognitive- and communication-related activities. These include playing with regular and switch toys to learn causality and other cognitive skills, imitating simple song-based fingerplay and movement activities , and participating in group activities by using simple AAC devices such as loop cassette tapes. (See Using simple AAC devices in routines.)

OTHER RESOURCES:

• "Total Communication Options for Children with Down Syndrome in the Context of Hanen Programs for Parents" by Claire Watson, Senior S-LP, at www.hanen.org/downsynd.htm.

• "Down Syndrome" by Dr. James MacDonald at www.oberlin.edu/~bmislin/cp/down.htm.

• Research has revealed that children with autistic-like behaviors may often be processing information differently than do other children. They tend to learn information as a gestalt or whole, and may not understand language as made up of individual words and meanings. This may explain why some children with autism are able to repeat entire passages from videos or television, and yet still not be able to use speech in a functional manner (Beukelman & Mirenda, 1992).

• Some children with autistic-like behaviors do not enjoy attention from other people and need to be taught how to take pleasure in social engagement. (See Teaching a child to enjoy social encounters.)

• It is often assumed that the child understands language, and is simply having difficulty with speech output. In fact, evidence suggests that the child’s internal understanding and processing of language, along with social awareness, may be impaired. A common mistake is to focus on teaching the child the technical skills necessary to use an AAC system when the child may not understand intentional communication, or basic communicative behaviors such as taking turns, paying attention to the same object or event as one’s partner (called joint attending), or making eye contact with one’s partner. (See The first goal: Intentional communication and Visually Cued Instruction.) On the other hand, it is not fair to focus only on these behavioral accompaniments to communication to the exclusion of practical communication. The trick is to make functional communication the main goal, and work on these accompanying behaviors to the extent that they further this objective (Beukelman & Mirenda, 1992).

• Early intervention is crucial since there is evidence that tremendous progress can be made in communication and social abilities during the early years. It is frequently recommended that the partner initially follow the child’s lead and respond to the child’s own natural gestures and vocalizations. (See Naturalistic teaching methods.)

• Children with autistic-like behaviors sometimes have difficulty processing communication modes that are transient in time. A spoken word, for example, is very transient, lasting only as long as it takes to be said. Sign language is less transient, but disappears as soon as the next sign is produced. Messages on communication boards and voice output communication devices (VOCAs) can be looked at for as long as necessary and, thus, are the most permanent. Because of their need for more concrete symbols, some children may have greater success with sign language than speech, and some may require communication boards or VOCAs (Beukelman & Mirenda, 1992; Mirenda & Mathy-Laikko, 1989).

  This preference for nontransient modes of communication extends to receptive language. Some children may be significantly better at understanding and processing the communication of others with sign, gesture or picture-based communication than when speech is used (Peterson, Bondy, Vincent, & Finnegan, 1995; Reichle, York, & Sigafoos, 1991; Vaughn & Horner, 1995).

• Currently, simultaneous communication (i.e. the adult speaks and simultaneously uses AAC to produce key words of the message) is a frequently used teaching method. However, there is evidence that, when simultaneous communication is used, some children attend only to the AAC part of the message and disregard the speech. In general, the child still learns the AAC, but is not learning to understand speech (i.e. is not learning receptive language). These children may have to be explicitly taught to understand speech in addition to AAC (Beukelman & Mirenda, 1992).

• Some children with autistic-like behaviors are hyperlexic, that is they display an unusually strong attraction to the written word. If taught, many will learn to read quickly and early. These children may be excellent candidates for a VOCA that uses letters on a keyboard and printed text in addition to voice output (Beukelman & Mirenda, 1992).

• Because children with autistic-like behaviors often have excellent motor skills, they can be very hard on external AAC devices. Their AAC need to be extremely tough and durable.

• Some children easily become dependent on prompts. Even after they have learned a communication skill, they wait until an adult prompts them before initiating communication or responding. In these situations, prompt-free and verbal prompt-free strategies can be used. Also, since many children prefer very regular schedules and activities, interrupted behavior chains and other routine-based teaching methods often work well (Beukelman & Mirenda, 1992; Mirenda & Schuler, 1988).

• Visually cued instruction is a structured program based on a verbal prompt-free system that has had excellent results with children who are lacking in many of the social concomitants of speech, such as eye contact and joint attention. The child does not have to be an intentional communicator or have an understanding of symbols.

OTHER RESOURCES:

• Temple Grandin, a successful academic, designer and author who has autism, describes very lucidly what it is like to have this diagnosis, its impact on communication, what kinds of interventions are most likely to be successful, and the importance of early intervention. Her writings can be found at the Center for the Study of Autism at www.autism.org.

• "My Experiences with Visual Thinking Sensory Problems and Communication Difficulties" by Temple Grandin, Ph.D. at www.autism.org/temple/visual.html.

• "Learning Styles and Autism" by Stephen M. Edelson, Ph.D. at www.autism.org/styles.html.

• "Social Behavior in Autism" by Stephen M. Edelson, Ph.D. at www.autism.org/social.html.

• "Music Therapy and Language for the Autistic Child" by Myra J. Staum, Ph.D., RMT-BC at www.autism.org/music.html.

• "Conclusions from 26 Years Studying Autistic Children" by Dr. James MacDonald at www.oberlin.edu/~bmislin/cp/autism1.htm#AUTISM.

• "The Hanen Program for Families of Children with PDD" by Elaine Weitzman and Fern Sussman, at www.hanen.org/pdd.htm.

  Help me—and everyone who reads this site—by mailing your suggestions, criticisms and personal experiences to Ruth Ballinger at yaack@iname.com

• "1993 International Conference on Autism: Methods to Enhance Learning" Conference Notes by Lisa Ruble at www.autism-society.org/
  packages/edkids_conference.html.

• "Interventions: Approaches and Methodologies" does not focus on communication, but provides excellent descriptions of several different teaching approaches at www.sna.com/msm/cabp/appendixe.htm.

• "Language Acquisition in Autistic Children: What Does it Tell Us?" by James R. Cash at www.lifestories.com/papers/autism.htm.

• "Hyperlexia Resources" at www.esmerel.org/specific/hyperlex.htm.

Children with sensory impairments, especially vision or combined vision and hearing impairments, are at a disadvantage when it comes to manipulating objects and exploring the world. This places them at risk for cognitive delays and learned helplessness, both of which can negatively affect a child’s social, academic and communication development. Early intervention, therefore, is very important in defending against learned helplessness. Not only can it accelerate the child’s development, but it also assists family members in learning ways of interacting effectively with their child. (See Contacting an organization for services and support.)

Assessing a child with a dual sensory impairment is difficult since, determining what the child is capable of depends on the ability of the child to both comprehend and express what is being asked (i.e. his or her receptive and expressive language capabilities); and, yet, the reason for the assessment is the fact that the child's communication is delayed. It may be necessary, therefore, to teach the child some AAC first, and then conduct a more comprehensive assessment later in order to fine tune the communication program. (See General tips in assessing strengths and abilities.)

In addition, children with dual sensory impairments often take longer, and may need assistance, in progressing from unintentional to intentional communication. (See Normal speech and language development and The first goal: Intentional communication.) Choices of AAC are dependent on whatever residual vision or hearing is present. On graphic AAC (e.g. communication boards or voice output communication aids) symbols may have to be larger and more prominent. In other cases auditory and/or tactile-based symbols may have work best, such as the use of real, miniature or parts of objects, textures, or touch-based sign language (Beukelman & Mirenda, 1992; Mar & Sall, 1994; Mathy-Laikko, Iacono, Ratcliff, Villarruel, Yoder, & Vanderheiden, 1989; Schweigert & Rowland, 1992).

Help me—and everyone who reads this site—by mailing your suggestions, criticisms and personal experiences to Ruth Ballinger at yaack@iname.com

OTHER RESOURCES:

• "AAC Strategies for Young Children with Vision Impairment and Multiple Disabilities" by Marjorie Goldware. M.A., SLP and Marsha Silver, M.S., SLP at www.dinf.org/csun_98/csun98_135.htm.

• "Teaching Language Concepts to Multihandicapped Deaf Students" by Marilyn Brasch. M.A. SLP/CCC and Pam Boespflug, M.Ed. at www.dinf.org/csun_98/csun98_006.htm.

• The National Information Clearinghouse On Children Who Are Deaf-Blind offers several fact sheets on communication for persons who are deafblind at www.tr.wou.edu/dblink/products.htm.

All children exhibit undesirable behaviors at times. However, when unwanted behaviors become so frequent or intense that they interfere with the child’s safety or ability to learn, or the safety of others, it is essential that they be addressed. Challenging behaviors can include tantrums, throwing objects, or hitting, kicking, scratching, biting self or others. Self-stimulation (e.g. finger waving or eye poking)can also constitute a challenging behavior. In the past, a variety of techniques have been used in trying to deal with inappropriate behaviors. One of the most recent—and successful—is a comprehensive method called "functional behavior analysis" or "positive behavioral supports" (Carr, Levin, McConnachie, Carlson, Kemp, & Smith, 1994; Durand, 1993; Danquah, Mate-Kole, & Zehr, 1996; Reichle, York, & Sigafoos, 1991). The foundation upon which this technique is based is the belief that every behavior is actually communicating something, either intentionally or unintentionally. For example, parents are frequently heard to say "Oh, she is just doing that for attention." In other words, her behavior is communicating to the parents the child’s desire for attention.

Understanding what a child is expressing through his or her inappropriate behavior does not mean that whatever is being asked for must be given to the child. It does mean, however, that, unless we address the underlying demand, the child will continue to act out in some way to try to get it. We may be able to extinguish an unwanted behavior through behavioral or other means; however, the child will likely simply find another means of communicating his or her desire.

In their very lucid and practical book, Communication-based intervention for problem behavior, Carr, Levin, McConnachie, Carlson, Kemp, & Smith (1994) recommend the following procedures when dealing with severe behavioral issues. These briefly outline the steps involved in a functional behavior assessment with their aim being first to determine what the underlying purposes of a set of behaviors are, and then to identify ways in which those behaviors can be changed or replaced.

The first step in a functional behavior assessment is to determine what it is the child wants when he or she is acting out. This is done by interviewing persons who are witnesses to the behavioral displays, and observing the child in settings where the behaviors are likely to occur. In particular, attention must be paid to the people who are present, their actions prior to the acting out, and, very importantly, their reactions to the behaviors themselves. This is because, typically, acting out is aimed at the people who are present, who then react in ways which inadvertantly reinforce the undesirable behaviors. At this stage it is important to focus on exactly what happens during these episodes as opposed to why they happen, and to emphasize fact and not opinion.

The next step is to examine the information gathered, formulate hypotheses regarding why the behavior occurred, and then test the hypotheses to see if they are correct. In a small percentage of cases the behavior may be occurring due to organic reasons (i.e. neurological or other physical problems that suggest the child does not have control over the behavior). If the child exhibits the behaviors outside of the presence of people, they may have an organic source. These behaviors may require other remedies such as medication or environmental changes. In general, few behaviors are due strictly to organic issues.

Challenging behaviors whose purpose is to communicate typically occur for one or more of three basic reasons: the child wants attention, the child wants a tangible item or to participate in an activity, or the child does not want an item or to participate in an activity. Often the reactions of people to the child’s behavior provide clues as to why the behaviors are occurring. Frequently, the child does wind up getting what he or she wants by acting out. For example, a child who throws a tantrum every time he or she is about to be placed in a bathtub may often get out of taking a bath.

To test the hypotheses, situations that mimic the circumstances under which the behavior is likely to occur must be set up. Half of the time the situation is allowed to continue unchanged (i.e. the child goes on to misbehave). At this point, the child should be given whatever it is that he or she is thought to be wanting. If the behavior then terminates, this indicates the hypothesis was correct, that is the child stopped behaving inappropriately because he or she was successful in obtaining what was being demanded.

The other half of the time, the child should be given what it is that he or she seems to be wanting prior to the behavior occurring. If this prevents the onset of the behavior, then, again, this is an indication that the hypothesis was correct. In other words, the child did not need to communicate his or her need because he or she was already given what was wanted. It is often necessary to modify and retest hypotheses until what the child is communicating with the inappropriate behaviors becomes clear. If the child’s behavior presents an ethical issue, that is if it is injurious to the child or to others, then only the behavior prevention part of the hypotheses testing may be able to be used.

Once the reasons for the behaviors has been identified, it is possible to address them as well as the behaviors. Suggestions for dealing with them include the following.

• Teach the child a more appropriate way of communicating what he or she wants. This new method must be as efficient (i.e. as easy to produce) and as effective (i.e. it gives the child as much, or more, of what he or she wants) as the old behavior. For example, it may not reasonable to expect a child to replace quickly picking up and throwing an object with forming a complicated manual sign or locating and pressing a button on a voice output communication aid (VOCA). However, teaching a child a vocalization or shake of the head may be efficient alternatives.

  This also implies that partners must be aware of and sensitive to the child’s new communication so that they can respond immediately and reinforce it. Naturally, the child may begin using this new communication technique all the time to get what he or she wants. (This, in fact, indicates that the child has really grasped the new method of communicating.) Initially, adults should try to honor it in order to solidify its usage by the child, and to prevent the child from slipping back into the old behaviors. After the child has mastered the new communication techniques, he or she can learn to delay gratification. For example, the child may be told that his or her request will be honored only after he or she continues with the present task for a few more seconds or minutes. (This can be stated in terms that the child can understand, for example "You will get [what you want] after doing this", or "after the timer bell rings.") This delay of gratification can be increased slowly, and/or the reward (i.e. receiving what is being requested) can be increased or decreased as necessary.

• On a larger level, it is important to examine the child’s life as a whole. A life that is inherently unpleasant, boring, frustrating or lacking in the opportunity to make choices will often result in challenging behaviors as the child protests an unhappy existance. This part of the functional assessment is sometimes neglected since it requires that adults make substantial changes that usually result in more time and effort being spent on behalf of the child.

  For example, a child who is acting out to get attention may be doing so out of sheer boredom. In this case, in addition to teaching the child a more appropriate communication method, the adults involved should institute widespread changes in the child’s life.

  Help me—and everyone who reads this site—by mailing your suggestions, criticisms and personal experiences to Ruth Ballinger at yaack@iname.com

  Solutions might be to include the child in a regular classroom, go on more outings, provide the child with more opportunities to be with other peers and adults, and allow him or her to make choices about food, clothing and activities. Making extensive changes like these can be very difficult, and care must be taken not to demand too much of family members, teachers and others, while at the same time respecting the child’s needs. Change does not have to occur overnight, and slow but steady changes are often the most effective since they are not too disruptive, and more likely to be permanent. (See Forging an effective AAC team and Using peers in interventions.)

OTHER RESOURCES:

• "What is a Functional Assessment?" at www.pacer.org/ parent/function.htm

It may be difficult to decide whether or not a child diagnosed with apraxia needs AAC. One obstacle in introducing AAC is the fear that it will hinder the development of speech. Yet studies have shown that the introduction of AAC is not linked with a slow-down in speech development, and is sometimes associated with faster progress. (See Does AAC impede natural speech?—and other fears.) AAC is typically viewed as a temporary secondary strategy, with speech continuing to be the main focus.

A good rule of thumb is that if the child is becoming overly frustrated or is having substantial difficulty in academic or social situations, AAC should be considered. (See When does a child need AAC?) Children whose fine motor skills are not compromised are often good candidates for sign language; however, a different type of AAC may work better depending on other characteristics of the child such as learning style or other disabilities that may be present.

Other important issues regarding the choice of AAC are portability and durability since a child with apraxia is typically able to walk and, in general, has good motor skills (Culp, 1989).

OTHER RESOURCES:

Apraxia-Kids: Speech & Language Topics at www.apraxia-kids.org/index.html