Challenges in Early Intervention - Ep. 033
Early Intervention therapy can be challenging without good information on the developmental order of foundational skills, such as gestures. This episode introduces a fantastic resource for clinicians and parents on gesture development and its connection to language. Find and download a free tracking chart for gestures in the Free Resource Library.
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Music: Simple Gifts performed by Ted Yoder, used with permission
Transcript
Denise: Welcome to The Mindful SLP, the show that explores simple but powerful therapy techniques for optimal outcomes. I'm Denise Stratton, a pediatric speech language pathologist of 30 years. I'm closer to the end of my career than the beginning. And along the way, I've worked long and hard to become a better therapist.
Join me and I'll do my best to make your journey smoother. I found the best therapy comes from employing simple techniques with a generous helping of mindfulness. Joining me in the conversation is Dan, my technical wizard and office manager.
Dan: Welcome everyone. We're so glad you joined us today. Denise, what are we talking about today?
Denise: We are talking about one of my favorite tools for early intervention and how it helped me crack the code with an extremely challenging client.
Dan: Tell me about this challenging client.
Denise: She was three years old when she came to me, she was profoundly delayed in speech and language. She had a rare chromosomal disorder, one of those ones that just has letters and numbers for the name, you know, not even a name, really. Um, she was visually impaired, uh, at the time she did babble and she made eye contact. She liked to look at people and smile, laugh, be happy. She had no spoken words. She had one sign for food, but she pretty much used it for everything.
She had an extremely short attention span and no intentional language.
What does no intentional language look like?
She didn't communicate with an intent to make something happen. So she had no pointing or gestures while other than I should say her one universal sign. No sounds that meant anything specific. Um, no imitation.
Dan: So she wasn't really trying to get anything across, she would just...
Denise: I guess it's not right to say she had no intentional communication, but very, very little intentional communication. If her parents were holding her, as they walk past the pantry and she wanted food, she would lean her entire body sort of that direction that she wanted them to go.
Dan: But really no language as far as anything...
Denise: Yeah, and she was not autistic. And she liked looking at people and she liked babbling. She really didn't have enough attention to kind of capture her learning. I guess she was interested in things, but yeah, it was just really short. Honestly, she was one of the lowest functioning clients I've ever had.
Dan: Wow, that would be really a tough one. Where do you even start? How do you even start thinking about where to work with someone like this?
Denise: After the first session with her, I was thinking that, where do I go from here? She wasn't a candidate for PROMPT therapy. I did try that right away and that wasn't going to work. She wasn't ready for that. And I thought, what am I going to do with her? Normally, clients who come without pointing, I can pretty fast figure out how to get them to point, how to get them to choose. And I mean, we've done some episodes on that, but she wasn't even at that point.
I thought I know what comes before all this pointing and choosing that I've worked so hard to develop. So I Googled early intervention goals. Hey SLPs, have you ever done that when you didn't know where to go? Because sometimes you can see your way clearly, if you can find some well-written goals by someone who does know what direction to go.
Dan: Thank heaven for Google. So what did Google, the all-knowing Google, tell you?
Denise: I came across a website called The First Words Project by Florida State University. It has a chart of development called 16 gestures by 16 months. And I'm just going to quote here from it. Research with young children indicates that the development of gestures from nine to 16 months predicts language ability two years later. Let's consider how gestures develop. Well, the order of specific gestures may vary slightly, children should be using at least two new gestures each month between nine and 16 months. And then it goes on to list, in order, the development of these gestures. And I was like, this is a gold mine because I didn't know what, like maybe the first gesture was for a child. I'd never run across research on how gestures develop. I figured once I knew where she was on this development chart, I'd have my starting point.
Dan: Right, right. That makes sense. So what are some of these gestures?
Denise: Yes. I just want to give you a rundown, because this is great. We'll link the website too.
Dan: We'll definitely link to this in the show notes.
Denise: But this is just gold. So we've just got to go through it.
Dan: Those show notes are located, by the way, at SLP proadvisor.com/blog/ 33, episode 33.
Denise: Now just understand this isn't hard and fast. They will develop this by nine months, but this is generally, I mean, it follows pretty generally this order, em, and this age. So nine months give something to someone shake their head. Their earliest gestures begin to develop from their actions. Okay. And the reactions of others. So they learned to take an object and then as they're able to control their hand movements, they learn to drop the object. Remember kids dropping stuff off the high chair constantly.
Dan: Oh yeah, they would just drop everything.
Denise: Okay. And so they gain the experience from the parent, holding out their hand to catch it, and then they learn to give.
Dan: Oh, you mean this was normal. I guess every kid did it.
Denise: So this is how they learn to give, oh.
Dan: I thought they were just trying my patience.
Denise: They learned to shake their head by like turning away from food they don't like, and then turn it back to see if, what the parent noticed. So you see, turn away, turn back, turn away, turn back. Isn't that interesting? Okay.
Dan: This had to have been a fun research project.
Denise: 10 months, reach and raise arms to be picked up. 11 months, show something to someone and wave hi and bye. 12 months, the open hand, an open-hand point kind of with their fingers spread and they could tap kind of with their fingers together.
That's that's how they point first before they isolate an index finger. Okay. And then at this point, they start to, um, accompany these gestures with early speech sounds or grunts. 13 months, clap, blow a kiss. So you can see how these gestures are becoming more meaningful.
Dan: Higher level language thoughts, things like that.
Denise: 14 months, index finger point and the shh gesture, maybe. 15 months, a head nod, a thumbs up.
Dan: And we just thought it was cute, and here it was a developmental plan.
Denise: A hand up to maybe indicate weight or stinky. Ooh, like that. Um, and 16 months other symbolic gestures getting really sophisticated now. It says, I don't know, a high five. Stuff like that.
Dan: A shrug for the, I don't know, or, yeah.
Denise: Um, even it suggests here the universal peace sign, which I don't know if I've ever seen a little kid do.
Dan: Oh yeah, in Japan all the little kids do it.
Denise: Oh, okay. So there you go. A whole lot of development happening between those ages of nine and 16 months.
Dan: Wow. That's really fascinating. So how did you take this into therapy and do therapy around these?
Denise: Well, I made myself a chart of these gestures. And I made a list for if it was mastered or it was emerging with assistance, or it was barely emergent, or it wasn't even there. So by the way, I'm going to have that tracking chart in the free resource library, so you can go to SLP proadvisor.com and just get that tracking chart.
Dan: Slpproadvisor.com/free.
Denise: So I assessed her and she didn't have the ability to give an object. So we were at the very beginning. So I thought, okay, this is what it's going to look like. I'm going to teach her how to give something. So first step, well, she loved bubbles. What client does not love bubbles?
Every client loves bubbles. So I tried blowing bubbles and then I would hand her the wand and I'd hold out my hand for her to give it back to me. And I also did the balloon shooter, with the little puff balls, and we have a simple tools video on how to make that balloon shooter actually, because she liked to watch the little balls pop out.
And so I would hand her the ball after she knew what it could do. Well, that first session that I tried this, her giving me stuff was like the honeymoon session because she handed me stuff like four or five times and I was like, oh, we are on the road. And then she stopped doing that for several sessions in a row.
Dan: Uh, crushing. Interesting. What does she do instead of giving the things back to you?
Denise: She would throw it to the side. Just kind of like toss it off. Yeah. And because of her visual impairment, I knew that she could see better peripheral vision. So I thought, oh, it's a peripheral vision thing. So I tried sitting this side of her, uh, no and then she would throw another direction. So it wasn't that, it was just throwing it away.
Dan: I've seen a lot of kids who do that too. So I guess that's a good start. What did, uh, what'd you do then?
Denise: So I had to kind of, um, out-smart her, so I anticipated where she would throw or drop it and have my hand ready to catch. And then make a big deal about how she gave it to me, even though I really just caught it.
Lots of rewards with bright, shiny light-up toys, because that really attracted her because of her visual impairment, um, things with lights and sound . Yeah. Um, were very reinforcing to her and I had this spinning toy, uh, that flashed and the ball on the top spun. So, you know, if she handed that to me, I would activate it for her.
Dan: Okay. So yeah, really it's giving her incentives to give it to you as opposed to just giving it a toss. Okay. What did you work on besides giving?
Denise: That's a very good question because I couldn't do that for a whole 30 minutes. Um, well, the First Words Project also has a chart of 16 actions with objects by 16 months. Um, I'm not going to go through all that, but that's excellent too. Someday that is worth its own podcast. Um, but I went through that too and found out she was at the level of learning to push and turn things. So basic cause and effect toys. She didn't really do that yet, so I incorporated that, toys where she could push something to make it go or turn something.
Dan: Okay. So I'm picturing in my mind some of those really early BusyBox toys that they would get for infants.
Denise: Well I had this plane that you push the button and it plays music and the plane goes around on the floor, and there was a drum that lit up.
Dan: And of course the flashing lights.
Denise: So yeah, we just had to work on basic cause and effect too. And her motor skills were developing in sync with this. So it does make sense that she was so delayed, because as I said, the gestures developed from their first actions and actions, their physical actions require motor skills. And so, um, she had just barely learned to walk, you know, independently and stuff like that.
She had lots of physical therapy.
Dan: There was other things helping to develop these as you were going on with this speech therapy.
Denise: Yeah. Everything kind of develops in sync. Also, it was really important that she would learn imitation.
Dan: Right. That's another way, those real early skills, that kids do.
Denise: Because they imitate us, right? And she really didn't have imitation.
Dan: So what'd you do? I'm curious what'd you have her try to imitate?
Denise: Well, I imitated her first, first speak their language, remember our podcast? So something that she could do instead of trying to teach her a new motor skill, let's take something she could do. She could bang on a table.
So she would bang on the table. I would bang on the table, she would bang on the table, and it would go back and forth. So although I was imitating her, she was also imitating me because we had this circular thing going, right. Okay. Um, and then we shaped that banging into um, go or again, you know, she banged, I made something go, you know, make the plane go or whatever.
Dan: Yeah, making it to a cause effect type thing. I bang. I get what I want, yeah.
Denise: And because she did show a little bit of ability to sign another word, an adapted sign for more. We worked on that a little bit and I wasn't sure if she would get that. But, um, but we did work on signing more along with everything else we were doing.
Uh, also whenever she babbled, um, I started the same back and forth things. If she babbled to me, I babbled back to her. Just kind of what she said. I was speaking her language right, back and forth, back and forth. And I just touched her face a lot. So she could get used to that, thinking that someday she might be ready for PROMPT.
So a lot of touching her face, a lot of babbling back, just along with all the other stuff we were doing, the whole object that she would develop a direct, meaningful sound imitation.
Dan: Sounds like you've finally got a good path started here and things started to make some progress. So big, big improvement over where you started, where you didn't even know where to go.
Denise: Well, I have to tell you, there were days when nothing seemed to be changing and days with just a little bit of change. In fact, her father asked me one day, if I'd ever had a client as impaired as she was, and I could see he was thinking, is this making any difference? Is she ever going to change? And some days felt like that.
But she was with me just for the summer. I was kind of like the fill-in therapist between, um, the school year. Right. Um, between the end of what we call birth to three in the beginning of her, uh, therapy in the school year. So on her last day, her very last day of therapy. She did amazing things. It was like everything coalesced and she demonstrated more skills on that one day than she had ever had before.
Wow. I mean, I just have to read you a little bit from my notes here. She consistently signed more with one hand, it was opening and closing. Um, it was not by her face, so it was definitely a new sign. It wasn't the sign she'd been using for food. I could tell by where her hand was positioned and she was using it to say more.
And she combined eye contact with pushing a toy towards the therapist, asking her to turn it on. And she did this very consistently while playing with a toy airplane. Also she pushed or gave the toys directly to the SLP and not off to the side. And she reciprocated and she reciprocated verbally with the mmm sound sometimes with a clear intent.
Wow. So I was like, whoa, it worked. Yes, all this hard work and days of thinking, are we making a difference? It did make a difference.
Dan: That's terrific. And of course you send all that information on to the next speech therapist. That's great. So what is our takeaway today?
Denise: There's always a way forward, even with clients who have profound disabilities, the challenge is to find the next step so that you're intervening at the right level. And after that, your pathway is clear. So without the 16 by 16 charts, I would have had a hard time assessing and finding the right level for her to start. And it would have felt like we were just trying to push her in a direction she wasn't ready to go. And then you can sometimes make the erroneous assumption that this is as far as this client is going to go.
So therapists, if you want to use these 16 by 16 development sequences in your therapy, and you want to chart it, you want to track it. I love tracking charts. That's why I've created one for you. Please go to SLP proadvisor.com/free. And you can download, um, a tracking chart for the 16 by 16 gestures.
Dan: And the link to the 16 by 16 gestures and all the other things we talked about today is at SLP proadvisor.com/blog/ 33.
And remember always, when you master the simple, the complex takes care of itself. Thanks for listening to The Mindful SLP. We invite you to sign up for our free resource [email protected] slash free. You'll get access to some of Denise's best tracking tools, mindfulness activities, and other great resources to take your therapy to the next level.
All this is for [email protected] slash free. If you enjoyed this podcast, subscribe, and please leave us a review on apple podcasts and other podcast directories. Come back next week. We'll be talking about teaching narrative comprehension to young adults.
