Communication is power. The first time I had a taste of this was in 1996 when my best friend, Trina, and I studied abroad in the Basque Country in Northern Spain. Before this adventure, I had four years of high school Spanish. One would think communication would have been somewhat manageable for me. Right? Well, it was not. Trina knew French, so she wasn’t any help! Our roommate was from Taiwan. She didn’t speak English, but she spoke Spanish. The accent in that region of Spain was so different than anything I had heard before. Even if someone said a word I knew, I missed it most of the time. It was a good thing we had each other and classmates to rely on because not being able to communicate with most people in our surroundings effectively was terrifying. It was a feeling I could not have fully understood until I experienced it myself.
There was one incident in our apartment that I will never forget. Something was going on with our shower leaking into the apartment downstairs. The landlord came over furious. He was yelling at me in Spanish. I understood it was a water leakage issue and that was about it. This could have been in no way our fault. The building was like 200 years old and we were renting from him. I tried to advocate for myself, but it was hard not knowing the language. Nothing really happened except that it was an extremely uncomfortable interaction. I was in no position to argue with him and felt vulnerable.
When I think about that, it makes me think about all of the other people who cannot communicate with the majority of people in their community. At least I knew I was going home at some point to my easy life where everyone understood what I said. What about the children and adults who cannot communicate with the people in their community? That is their home; they are incredibly vulnerable not being able to express themselves. If something happened to them, how would anyone know?
Fast forward to 2003-2004, and I was in Ireland. If you read my previous articles, you heard a bit about my Ireland adventure. I loved it there so much, but it was not without its challenges. I thought because I spoke English, it would be nothing like my Spain experience. However, that was not the case. This was my lesson in pragmatic language. That is the aspect of language that defines what to say and when to say it, a significant consideration for individuals with autism.
The town I lived in, Chapelizod, was just outside Dublin. I remember waking up one morning with the church bells ringing. It felt like I was in a time-warp. The buildings were so old and charming. Once I went to the town store and forgot my money. They told me that’s fine, bring your money next time. Could you imagine?
I took the bus there from Dublin often. You had to tell the bus driver to stop in your town, or he wouldn’t stop there. That was the first bus lesson. The next thing was figuring out the best way to tell him or her. The first few times I spoke in a full sentence, I said, “I need to get off at the Chapelizod stop please,” pronouncing the word “ChapelIZOD” like the shirt, “Izod.” You know, that polo shirt with the alligator on it. That’s a reasonable assessment, right? Wrong. My accent threw them off every time, and it was a big hassle. Eventually, I learned to keep it short, “Chapelizod.” I also made the “i” was like “igloo,” instead of “i” like “eye.” This was weeks of work to get less than 3 miles down the road. This kind of scenario was a regular occurrence; I found myself simplifying my language to get by without incident. That seriously affected my ability to fully communicate and connect with people the way I usually would.
When I think about this experience, I think about children with speech and language disorders who do this as well. Perhaps the child understands full sentences, but most effectively communicates with one word at a time. Therefore, they say less than they want to. It is likely that if people understood what they said in a full sentence, individuals with autism would continue to expand their expressive language. Before you know it, they would be having conversations they never thought they could.
In my experience, most Applied Behavior Analysis (ABA) programs specialize in early intervention. We know early intervention is so important for children to reach their full potential in learning, communication, and activities of daily living (i.e., teeth-brushing, using the toilet, washing hands, etc.). For this reason, the focus of many modern-day programs is to build up early vocabulary skills, imitation, and communication.
With this approach, the therapist follows the child’s lead initially. The child indicates they want something, and the therapist shows them how to ask for it in a mode understood by people in their environment. This could be through signs, words, pictures, or electronic means. For example, a child might pull your hand towards a cabinet in the kitchen with a cookie in it. The therapist would show them how to produce the sign for cookie or select a cookie picture, and the child gets the cookie. Often times children start verbalizing on their own and no longer require or choose the non-verbal form of communication. Most likely this is due to the ease of communication. More people in their environment understand them when they say the word and their needs are met in a more timely and efficient manner; as opposed to screaming or signing or going to the other room to get their communication book or device. For other children, spoken communication is not their path and they continue to use a modified version. In both scenarios, communication is taught in a systematic manner through the use of behavior analytic principles.
One thing I have found in my 20+ years experience working with children ABA programs, is a lack of adequate curriculum and programming for children once they have “mastered” the ability to speak. Teaching a child to communicate and speak can take years and a lot of hard work. Once that has been accomplished, I see behavior analysts struggle with what to do next. This is when a referral to a speech-language pathologist (SLP) is a must. I keep seeing comments on social media from BCBAs asking the “what next” question and it worries me. I might get an, “oh, that’s a good suggestion” comment if I suggest a formal, standardized speech and language assessment. This is not just a “good suggestion.” This is crucial for a child and a family. Professionals cannot just take a guess and look for a pre-packaged curriculum for higher-level speech and language. This is a child’s life we are talking about here. Once the assessment is done, then an SLP needs to be involved in the treatment to make sure language is taught in a systematic way, in line with typical speech and language development. This is a major topic for discussion in the autism treatment provider community that will probably require wine and a yoga retreat in Sedona! For now, though, I have listed below five fun, therapeutic games for professionals working with children moving from single words to phrases and sentences:
Color + Noun Phrases: The word “ball” tends to be one of the most popular words for almost any child. Therefore, every good therapist should have many of these round wonders on hand at all times! I love the Bright Starts balls and toys to start color + noun phrases, particularly the Count & Roll Buggie. I have never met a child who does not love this toy. It is considered a “baby” toy, but it is also useful for evoking spontaneous speech, language, and communication for preschool and early school-age children. You will need to buy extra balls to have at least ten. I like to have things in tens because it helps me keep track of trials. Put them in a plastic bin so they are under control and ready to go at all times! The downside to this toy is that it is very temperamental. Sometimes it doesn’t like to do what you want it to do for no apparent reason. I found that changing the batteries can fix it. That does not always work, though, so buy two in case one fails in the heat of the moment. This toy is so popular that little people are not happy when it is not working. It is better to be safe than sorry!
Verb + Noun Phrases: Puppets are another great way to facilitate phrase development. You will need at least one puppet with a name that is easy for your client to say. It can be the name of an animal, like cow, gator (for alligator) or bee. No snakes unless your client has s-blends down! You could also make up an easy name or have the child give the puppet a name, such as Bob, Bobo, or Mo. Also, get a plastic bin with at least ten play-foods with labels that are easy to say. Some examples are, banana (or nana), peas (or pea), or apple (apo). Once organized, this activity is a hit almost every time. At first, you will show the child how to feed the puppet and have the puppet do funny things. I like to cough and say “ewwwwww” or “ewwww, yuck!” and then have the puppet spit out the food. Or I will have the puppet accept the food and say, “mmmmmmmm.” The great thing about this activity is that you can adapt it for beginning communicators as well as children at the emerging phrase and sentence level. Once the child is having fun feeding the puppet, you can work on shaping the phrase “eat ____” and then the child gets to feed the puppet after they say the phrase. You would use the same prompting, shaping, fading strategies you would with any of your goals. Eventually, the child will start saying the whole phrase, “eat apple,” “eat banana (or nana).” To move to three-word sentences, you can add the name of the puppet, “Cow eat pea.” It is also fun to switch roles and have the child hold the puppet if they can do this. Another great thing about this is that you make it a closed-ended activity. When the bin is empty, the activity is done. Then the child helps cleaning up the food you have thrown everywhere!
Verb + Noun Phrases and Verb + Color + Noun Phrases: For children who enjoy coloring and drawing, this is a good one. There are so many different ways to do this, but I usually lean toward drawing shapes, vehicles, or people. Children are inundated with demands from parents and teachers all day long. I find they love to tell us what to do! Drawing pictures is a great way to provide this opportunity. If a child can read, I would use written prompts to help them form the phrase or sentence. For instance, I will write out “draw square” or “draw purple shoes” and prompt the child to read these words to get it started. I do what they ask and pause. Then I will have colored markers available. It may take a few rounds before they take over the steering wheel, but once they do watch out! Children love to tell you to draw hearts, circles, squares, mom, dad, sister; you name it. At the end of the activity, you have a picture to give parents, which is always appreciated.
Carrier Phrases: A modified version of the game “I spy” with books can be a way to motivate children to move from single-words to phrases and sentences. You will want to choose books with pictures of lots of everyday objects already in the child’s vocabulary. I ordered a bunch of great books like this from Usborne Books & More. They have ones with little flaps to open to see the picture. Kids love to open the door and see what is behind it! Be aware that the s-blend in “spy” may be too difficult to pronounce. If that is the case, you can play “I see” instead. Sometimes it helps to start with a written prompt. Write out “I see ____” and prompt the child to point to an item on a page and fill in the blank. You can also model the phrase and take turns. The child produces the phrase for one item on a page; then you do the next one. Once you fade out all of the prompts, this is a perfect activity for small groups with peers. Not only would the child be producing sentences, but also engaging in a structured turn-taking social activity. It’s a win-win!
Sentences: A great way to work on speaking in sentences and conversational turn-taking is with the game “Go Fish.” If a child can read or respond well to written cues, I will write out the script for the game before we play clearly denoting who is saying what with color coding and prompt them through it. For example, in the color red I will write out “do you have a ____.” and in the color green I will write out, “yes.” As an alternate response in green I write, “no, go fish.” The great thing about this is that you can systematically fade the written prompts and eventually play this game with your client! You can then work on eye contact, conversational turn-taking, and narration skills (telling others how to play). After all the prompts are faded and the child is fluent in all of the skills required for this game, they can play it confidently with friends and family members.
The “Forced Compliance” Issue: I am adding this section in response to all of the past and current social media activity regarding this issue. Most people would agree that there is nothing “forced” about what I wrote above: using ABA principles while following the child’s lead to communicate in an effective and efficient way to play and interact with family and friends in their community. Yet I have received a lot of feedback lately from people all over the world regarding the use of “forced compliance” as a major criticism of ABA therapy. One person urged me to stop perpetuating ABA because of this particular practice. He also sent me a video of this telling me it is not something of the past. I understand what people are saying with this. I know some programs in the past and currently work on “compliance” before communication and social interaction.
Honestly, ABA friends, the word “compliance” does not sound nice. If I were in a program for my panic disorder, I would probably not like it if I had to go through “compliance” training before I could talk about what I needed. I get that. That said, sometimes “compliance” in the ABA world means “learning readiness,” such as following directions. Most reasonable people agree that all individuals need to know how to follow directions to go to school and live in a civilized community. So, I get that too.
What I’m saying is that there is a happy medium here. Going in one extreme or the other, things could get lopsided and unreasonable. Regardless of your viewpoint, the science of ABA, in itself, has nothing to do with where you fall on the “compliance” spectrum. If someone is doing something inappropriate with another human being that doesn’t feel nice, that is an issue that should be addressed with that particular person or the program in which they work, not the entire science of ABA and those who dedicate their lives to help families.
For most professionals, using ABA strategies is a way to help people reach their full potential so they can participate in their family and community. That is what life is about, right?
Now go order two Count & Roll Buggie toys and the extra balls on Amazon! You won’t regret it.
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