Communication Assessment and Treatment for Students with Minimal Verbal Skills

Communication Assessment and Treatment for Students with Minimal Verbal Skills

Nancy Brady

University of Kansas

Why focus on individuals with minimal verbal skills?

Autism on the rise

Beyond identification

Communication needs for individuals with autism are also on the rise

Between 25-50% referred to as “minimally verbal” because they fail to develop “functional spoken language.” (DiStefanoKasari, 2016)

◦Includes small percentage who are completely nonverbal

◦Some have a very small repertoire of single words or fixed phrases used in limited contexts

What does this mean for the average school?

Hadley elementary school (home of the Archers)

330 children-

5 children with ASD

~2 or 3 minimally verbal

Outline

Overview of prelinguistic communication

Need for more assessment and intervention strategies

Assessment Strategies

Communication Complexity Scale

Reliability, Validity and Change-over-time data

Intervention Strategies

Multimodal intervention

Overview of Prelinguistic Communication

Who are we talking about?

Individuals who communicate with gestures, eye gaze, vocalizations, idiosyncratic speech productions (some echolalia or “scripted” productions)

Some examples……

We need better assessments for these individuals

Problems with existing assessments:

Floor effects

Caregiver report

Frequencies but not Quality reported

Tied to a specific curriculum

Why is it important to assess prelinguistic behaviors?

Early identification of a language problem

Early identification of a developmental disorder

Predictive value for later language

Provides information for identifying intervention goals, monitoring progress

Responsiveness to prelinguistic behaviors provides linguistic input

Assessment methods

Parent/caregiver report

Direct observations

Structured “testing” assessments

What methods do you use?

Communication Complexity Scale

Developed to Measure Communication Forms and Functions in individuals with minimal verbal skills

Communication Forms

◦Vocalizations

◦Gestures

◦Eye gaze/body posture

Communication Functions

◦Behavior Regulation

◦Joint attention

◦Responses to questions or prompts

Foundations of Communication
Vocalizations

Gestures

Coordinated attention

Vocal development

Early Vocalizations

Crying and experimental sounds

Early Vocalizations

Crying and experimental sounds continued – “Raspberries”

Later Vocalizations

Canonical babbling (reduplicated consonant vowel babbling)

Variegated babbling (jargon babble)

Vocalizations in children with disabilities

Do we hear similar vocalizations in older children and adults with disabilities?

Should we continue to encourage vocal development in older children and adults with disabilities?

Vocalizations in autism

(Plumb, Wetherby, Oetting, & Crais, 2013)Compared vocalizations of 2 yr olds with autism, DD or typical

ASD group used a significantly lower proportion of vocalizations with speech sounds and a significantly higher proportion of atypical (distress) vocalizations.

In ASD group, frequency of speech sounds correlated with developmental outcomes

◦More speech sounds ---- better outomes

“When targeting expressive language, greater gains may be made when targeting an increase in syllabic vocalizations in the context of communication.” p. 732

Gestures

What types of gestures are used in communication?

What gestures do you see?

Gestures are great, but…..

Try this:

Work in pairs or groups

What titles seemed easier and why?

Coordinated Attention

Initiating joint attention

Following joint attention

Gaze following

(Brooks & Meltzoff, 2008)

Communication Complexity Scale (CCS)

CCS Module 1: Introduction

Assessment Contexts for the CCS

Protocols developed by Brady and colleagues

Early Social Communication Scale (ESCS; (Mundy, Hogan, & Doehring, 1996)

Would also be appropriate for the Communication and Symbolic Behavior Scales (CSBS; Wetherby & Prizant, 2003)

Assessment contexts are videotaped for later scoring

What is the CCS?

A 12 point scale to measure expressive communication

Range from alerting responses to 2 word/symbol combinations

Used with individuals with intellectual and developmental disabilities, autism, Down syndrome, cerebral palsy, fragile X syndrome, typically developing infants….

Designed to measure current expressive communication level

◦Based on participant’s behaviors toward objects, people, and events of interest (referents)

Based on well developed and researched theories of early communication development

How was the CCS developed?

Years (and years!) of assessments and coding by Brady and colleagues

◦Beginning in 1990’s with Jim and Lee McLean

◦(Brady, Marquis, Fleming, & McLean, 2004; Brady, McLean, McLean, & Johnston, 1995; McLean, McLean, Brady, & Etter, 1991)

Modified for use with deaf blind individuals

◦(Brady & Bashinski, 2008)

◦Collaborations with colleagues led to current version of the CCS:

◦(Brady, Fleming, Thieman Bourque, Olswang, Dowden & Marquis, 2012)

◦Current coding based on developmental theories

◦Bates, et al., 1979; Bruner 1975; Crais et al., 2004; Iverson & Thal, 1997; Werner & Kaplan, 1984;Wetherby et al., 1988;

What contexts are used for the CCS?

KU CCS protocols

Live observations

Interactive assessments

Module 9:
CCS Scripted Interaction Administration

CCS Administration Guidelines

Purpose: provide opportunities for participant initiated communication

◦Set up an activity, provide turns, wait for communication

Initiations vs. repairs

We also provide opportunities for repairing communication acts

◦Participant initiates, examiner says “what?” (or something similar)

◦Repairs may be repetitions of their original communication or something different

Initiations vs. repairs

Sincerity is important

Natural Play Style

Engaging with the participant in a way that seems like play but is really much more than play

◦Examiner takes part in the activity such as playing an instrument, coloring with the markers, and building a tower with the blocks.

◦Examiner takes turns with the participant and interacts with the materials before setting up the communication opportunity.

Natural Play Style

Create an opportunity for communication!

IMPORTANT:

We want to facilitate requests and comments

Ways to create opportunities

◦Take turns with materials then wait

◦After playing with toys that work, provide a broken toy (seemingly by mistake) then wait

◦Comment about the materials, e.g., torn book, then wait

◦Only provide some of the materials, e.g., Magnatiles, then wait

◦Slip in an unusual object, or discretely start a remote control toy, and wait

Waiting Time

Giving the participant plenty of time to make a request or comment on the situation.

◦Examiner waits at least 5 and up to 10 seconds after providing one of the scripted opportunities before re-presenting the activity again or moving on.

◦Examiner remains natural during waiting time

◦E.g., smile and look interested but patient

Waiting Time

Identifying a Communication Act
Whatare we waiting for?

In order for a behavior to be considered an intentional communicative act, the answer to all three of the following questions must be yes.

•Was the act a gesture, vocalization, verbalization, triadic eye gaze, sign, or speech or speech generated from an SGD?

•Was the act directed toward the examiner? (Direction to the examiner may be indicated through a gesture or look toward the adult.)

•Did the act serve a communicative function, such as regulating the adult’s behavior, attracting the examiner’s attention to the child, or directing the examiner’s attention to an object or event?

Participants don’t always respond to opportunities with an intentional communication act….we’ll get to that!

Sincerity

Have fun with the participant during the administered tasks (or at least act like it)

◦Rather than present assessment tasks as “work” or a kind of test, present the tasks as a fun way to interact with the participant.

◦For child participants, this might be introduced as “playing” or a natural interaction where you are sharing your toys and objects with the child.

◦For adult participants, tasks might be presented as “games” or interesting objects you’d like to share with the participant.

Act surprised by the unfortunate or unusual events of the scripted interactions (those designed to get comments)

◦“Hmm, your toy doesn’t seem to be working. It must be broken. Here, you can play with mine.”

Sincerity

Transitioning Between Items

Smoothly orienting participant towards the next task

◦Assessment materials are organized so that there is not excessive lag time between tasks

◦Examiner might prompt for the participant’s help to “clean up” one task before getting the next out

◦Examiner might count down how much time the participant has left with a certain toy or object- if participant is reluctant to give up the toy

◦Examiner might foreshadow the next activity to help transition to the next item

◦E.g., “Wow, we get to play with bubbles next”

Transitioning Between Items

Moving On

Gauging when to move on to the next task even though the participant made no attempt to request or comment on the object

◦Examiner gives an appropriate amount of time for the participant to respond to the situation but doesn’t excessively linger on a single item.

◦If participant does not communicate during the task, the examiner should attempt to elicit a request or comment from the participant a second time, by setting up the opportunity again.

◦ If the participant does not respond to this second attempt, examiner says “oh look yours is broken—sorry about that. Here you can play with mine again” (or something that fits the situation) and moves on.

Dealing with Problem Behaviors

Sometimes participants will need to be redirected to the activity or engage in challenging behaviors.

◦Examiner can use small amounts of snack or a preferred toy to encourage the participant to sit back down at the table or as a reward for completing activities.

◦Discourage involvement by another individual such as a staff member or parent

◦If the participant communicates with this individual instead of us, we can’t score the communication 

◦Breaks are allowed. Return to the next activity in the assessment after a break.

PECS

If you include a PECS book and symbols with the assessment…..

Make the PECS book and appropriate PECS symbols available to the participant

◦Examiner presents the appropriate PECS symbol before administering each item

◦Example: Saying, “It’s time for bubbles!” while pointing to the PECS symbol for bubbles

◦The PECS book should be within reach of the child throughout CCS administration

◦Change position of the symbols for each set

◦Include one “foil” like a symbol for a box

Asking Questions

Do not ask questions of the participant, especially yes/no questions, during the assessment

◦Scoring responses to questions can be very difficult

◦E.g., if you ask “Do you want more?” and the participants nods their head, how would you score this?

◦If, by mistake, an examiner asks a question, it receives a “response to question” code for its function

◦An exception to the “Don’t ask questions” rule is saying “what” “Huh” etc. in a communication breakdown/repair opportunity

Example of a question that’s difficult to score

Asking Questions

Your turn….

Practice administering wind up activity with a partner

KU CCS Protocol

Child version

Wind up

Blocks

Snack

Music

Hammer

Fan (ja)

Magnatiles (BR)

Dots (JA)

Bubbles (BR)

Books (JA)

Bumble ball (BR)

Ball Toy (JA)

How do we score these interactions?

Identify the response to the opportunity

Score the behavior according to our 12 point scale

Sample scoring

Score 2- Single orientation

A visual or body shift toward an object, person, or activity

Orientation may be eye gaze, body orientation, gesture, proximity, or touch

Must orient for at least 3 seconds

Score 4- Single orientation + more than 1 PCB

The participant orients to either the object or the examiner and uses more than one PCB during that orientation time.

Usually will involve a vocalization plus a gesture

Score 7- Dual orientation + 1 PCB

The participant orients his/her behavior to both the object and the person/examiner within 5 seconds and uses one PCB during that orientation window

Gestures directed toward the examiner must cross the midline

Score 10- Triadic orientation + more than 1 PCB

The participant combinesbehaviors defined as triadic orientation and two or more PCBs within a 5 second window

Participant looks from toy to examiner, and back to toy, vocalize, and points toward toy

Participant looks from examiner to toy then back to examiner, then picks up toy and gives to examiner while vocalizing

Score 11- Single word

The participant uses speech, signs, or AAC symbol selection to communicate; an unfamiliar observer needs to be able to recognize the word or sign

Summarize the Score

Average of best 3 scores

Average across all responses

Typical score

Research Questions

How do CCS scores compare to scores from the Communication Matrix and the Vineland Expressive Subscale?

Does the CCS reflect changes over time (e.g., after intervention)?

How does change measured with the CCS compare to other measures such as rate of communication?

Communication Matrix (Rowland & Fried-Oken, 2010). Communication matrix: A clinical and research assessment tool targeting children with severe communication disorders.

Online parent assessment!

An easy to use assessment instrument designed for individuals of all ages who function at the earliest stages of communication and who use any form of communication.

How do CCS scores compare to scores from the Communication Matrix and the Vineland Expressive Subscale?

N= 225

Age range 3-60 years

Diagnoses include intellectual disability, autism, Down syndrome, Rett syndrome

Results: Significant correlations for CCS scores, Matrix and Vineland

◦Optimal scores more highly correlated than typical or mode

Does the CCS reflect changes over time
(e.g., after intervention)?

N = 60 children with autism participating in interventions in Kasari lab at UCLA

ESCS context used to assess children pre and post intervention

Results: Significant changes detected for CCS optimal, typical and modal scores for longer interventions

How does change measured with the CCS compare to other measures such as rate of communication?

•Signficant changes in rates of BR detected with ESCS rates

•Significant changes in JA and BR detected with CCS

•Changes in CCS scores reflect changes in complexity as well as quantity

Significant changes detected with both Optimal and Typical scores.

Summary:

CCS scores compare favorably to existing measures of early communication

CCS scores reflected change over time and in some cases appeared more sensitive than changes in rates

Changes in CCS scores reflect meaningful differences in types of prelinguistic communication

New research looking at CCS scores during live classroom interactions

Live observations

Time sampling instead of scripted protocols

Lots of questions in real contexts!

Comparing live observations to scripted interactions provides a nice contrast between typical and scaffolded behavior.

Comparing live observations to scripted interactions provides a nice contrast between typical and scaffolded behavior.

How could you use data from Scripted and Live observations to inform your practice?

What are good observation contexts in your setting?

Multimodal Intervention for students with minimal verbal skills

Multimodal intervention
(Brady et al., 2015)

A comprehensive approach

◦Speech sound practice (more on this coming up)

◦Joint book reading

◦AAC joint activity routine

◦Computer practice

Video From our first pilot participant

Speech sound practice

Speech Sound Practice

Use Prompt method to prompt individual sounds

◦Physical prompts applied to mouth

Some issues….

◦Kids with autism often don’t like to be touched

◦Stimulus control hard to transfer from the prompt to referent picture or object

◦Prefer imitative control

Joint book reading

Each word presented 5 times in story

Routines

Activity with multiple roles,

Joint focus organized around a meaningful outcome

Predictability

Clear roles

Repetition and flexibility

Examples: snack, washing up, lining up for recess, songs

Your turn

1. Identify 5 words comprised of the following sounds: b, y, w, k, g, s, m, d, h, t, l

◦CVC words

2. think of a basic story and a joint activity routine that use these 5 words

3. Write down 2-3 pages of the story and an outline for the activity

4. Share!

Support for the Multimodal Approach

Investigating a multimodal intervention for children with limited expressive vocabularies associated with autism (Brady et al., 2015)

Going forward

Ongoing study to compare response to multimodal intervention to a treatment as usual condition

Our general hypothesis is that children will learn to say significantly more words in the multimodal intervention than in the “treatment as usual” condition (TAU).

◦Produced during treatment sessions

◦Produced during generalization sessions, recorded with LENA devices.

Questions and Comments?

References

Brady, N., & Bashinski, S. (2008). Increasing communication in children with concurrent vision and hearing loss. Research and Practice for Persons with Severe Disabilities, 33(1-2), 59-71.

Brady, N., Marquis, J., Fleming, K., & McLean, L. (2004). Prelinguistic predictors of language growth in children with developmental disabilities. Journal of Speech, Language and Hearing Research, 47(3), 663-667.

Brady, N., McLean, J., McLean, L., & Johnston, S. (1995). Initiation and repair of intentional communication acts by adults with severe to profound cognitive disabilities. Journal of Speech and Hearing Research, 38, 1334-1348.

Brady, N., Storkel, H. L., Bushnell, P., Barker, R. M., Saunders, K., Daniels, D., & Fleming, K. (2015). Investigating a multi-modal intervention for children with limited expressive vocabularies associated with autism. American Journal of Speech-Language Pathology, 24, 438-459. doi:10.1044/2015_AJSLP-14-0093

Brooks, R., & Meltzoff, A. (2008). Infant gaze following and pointing predict accelerated vocabulary growth through two years of age: a longitudinal, growth curve modeling study. Journal of Child Language, 35(01), 207-220. doi:doi:10.1017/S030500090700829X

McLean, J., McLean, L., Brady, N., & Etter, R. (1991). Communication profiles of two types of gesture using nonverbal persons with severe to profound mental retardation. Journal of Speech and Hearing Research, 34, 294-308.

Mundy, P., Hogan, A., & Doehring, P. (1996). A Preliminary Manual for the Abridged Early Social Communication Scale (ESCS).

Plumb, A. M., Wetherby, A. M., Oetting, J., & Crais, E. (2013). Vocalization Development in Toddlers With Autism Spectrum Disorder. Journal of Speech, Language & Hearing Research, 56(2), 721-734. doi:10.1044/1092-4388(2012/11-0104)