Intervention for Caregivers & Young Children Who Have Multiple Disabilities

and Cochlear Implants: Training

Kathleen Stremel ThomasThe Teaching Research Institute

Western Oregon Universitystremelk@wou.edu

Model Components • Parents/Caregivers are the primary change agents in their

child’s communicative competence

• There is a need to integrate communication, auditory perception, language, speech and pragmatic elements into a social context

• Intervention takes place in natural routines and activities

• Interventions for the child and parent are a systematic process (small steps, discrimination/generalization)

• Intervention is individualized but follows normal development for young children with adaptations

• Diagnostic strategies and data collection are used to monitor progress

• Adult learning methods are used

Critical Components to Remember!

• Need to provide child’s brain with auditory information

• Need to create optimal set of interactive conditions for facilitating the child’s communication & language

• Need for appropriate assessments to identify skills…not a deficit model!

• Need for a quite environment (initially)

• Need for the parent to be close to the child

• Need to attempt to elicit a “response” from the child

• Need routine, normal, everyday caregiving and play interactions to provide the context and content of intervention.

Establishing a Listening Environment

• Minimize background noise

• Position oneself close to the child’s microphone

• Position oneself to best interact with the child in the routine

• Speak at a regular volume

• Use speech that is repetitive

• Use speech that is rich in melody, intonation and rhythm

• Use acoustic “highlighting” techniques

Routines and Activities

• Play routines• 1. Play with objects/constructive

• 2. Pretend Play

• 3. Physical play

• 4. Social games

• Caregiver routines• 1. Comfort related

• 2. Dressing related

• 3. Hygiene related

• 4. Food related

Woods & Kashinath, 2007

• Pre-academic routines• 1. Reading books-shared reading

• 2. Songs and rhymes

• 3. Computer, TV, video

• 4. Art play

• 5. Early numeracy

• Community/Family• 1. Community errands

• 2. Family chores

• 3. Socialization activities

• 4. Recreation

Adult Learning Methods (Trivette, Dunst, Hamby & O’Herin, 2009)

• Introduce (Preview strategies, use visuals)

• Demonstrate/Illustrate the strategy for the parent

• Practice (Engage the parent in the use of the materials, strategies with guided practice/coaching)

• Evaluate (Engage the parent in reviewing the outcome of the application of the strategy with use of video files)

• Reflection (Self-Assessment)

• Mastery

Teaching in Social Interactions

• Critical behaviors are learned in familiar Routines and Activities

• Build in beginnings, middles, and ends to each routine/activity.

• Embbed multiple opportunities to learn in each routine.

• Focus on teaching Joint Activity and Joint Attention

• Don’t hurry through functional routines & activities.

• Provide maximum consequences for positive behavior.

• Build more action steps into routine gradually

• Wait for responses!

Developing Routines: Intervention #1: Partial Participation/Responsiveness/Narrative Description

Name: E. Date: July 7, 2010

Routine: Lunch Routine Major Purpose: Increase words that E. hears; reinforce his verbalizations, responding to words.

Major Intervention Strategies: Joint activity, joint Attention, opportunities to hear words in contexts/responsiveness; pairing verbal and sign, reinforcement, waiting time, Auditory-lead..

Vocabulary Used in Routine: Signs being used in conjunction with speech: kitchen, eat, bathroom, wash hands ,get, towel, dry hands, step up, step down, turn on, water, soap, wash, turn off, lunch, plate, spoon, peanut butter, chips, fruit, eggs, banana, yogurt, more, all done, my/your, cut, milk ,water, cup, clean, dirty, wipe-em, open, close, put in, throw away, table, napkin, put away, down, wash dishes, help, yogurt, cheese, veggie, clean, dirty( food items will change across meals and the names will be used), my, your, Mommy, no, want.New signs: want, apple, raisin, pop, work, help, bread, good, thank you, no, want, drink. Context: Parents eat with E. If he throws food, discuss program with parents.

What is Important to the Parents?

KidsDBCIRoutine/Activities Worksheet

What you do!

R E M DL

Cog

Support &

AT

Targeted Outcomes for the

Child

Consequences &

Expansions/Recasts

Communi

E, let’s go eat!

X ( might add spoon as object cue)

E. Gets up and takes Mom’s hand

Yes, we’re going to eat lunch!

Repeat “eat” while signing.

X Sign support

First, “wash hands”

X PParticipation; assists washing hands

Reinforce behavior

Say, let’s go wash hands and sign wash

X X Sign support

Describe what you are doing…turn water on, get soap, wash hands, water off, dry hands…say first, wait and then say and sign.

X X Use “Say it first; then Say it –Sign it” total communication strategy

Participates and access to spoken language

Reinforce behavior

Parent/Caregiver Skills- Level I• Opportunities for Partial Participation

(examples for different children C and E)

• Responsiveness:

- Infant-directed talk (specific to development)

- Follow lead of the child

- Use simple phrases

- Imitate the child’s vocalizations/motor movements

- Talk about what the child is interested in

- Later, acknowledgements, expansions, topic extensions

• Narrative Description

- Describe both your motor actions & the child’s

- Use verbal comments

- Name objects & actions in context of activity

- Verbalizing the child’s nonverbal communication

Auditory Lead-Wait-Support-Auditory Follow-up

• 1. Lead with speech! Say it 1-2 Times!• 2. WAIT (1 second for narrative description)• 3. Support with Visual/Tactile prompt while repeating

the word (1 time)• 4. Say it again – end with speech only• Example: (a) Say, “We have milk!”; Sign and say,

“milk”, with emphasis on last word, repeat, “milk.”

Parent responds contingently to any response the child makes

Parent/Caregiver Skills-Level II

• Opportunities & Teaching to Listen: Environmental Sounds

• Opportunities to teach discrimination, identification and comprehension

- Directives

- Joint Activity/games/rituals

- Turn-taking

- Identification of objects (dissimilar to more similar)

Parent/Caregiver Skills: Level III

• Opportunities for Child’s Communication

- Protest

- Turn-taking

- Recurrence

- Response to Questions

- Change directives to opportunities

- Shaping gestures

- Up the ante

- Playing naïve

- Focus on the most informative of the context (interesting, novel, dynamic)

Strategies

• Provide a small portion• Provide opportunities for “recurrence” • Offer a non-preferred item• Provide opportunities for rejection• Provide choices (preferred-in context/non-preferred-out of

context)

• Change directives to a question, “What do you need?”

• Take a turn/Use a sibling to encourage “offering”• Nothing is Free! Play dumb! Break the chain!• Use less to more support strategies

Auditory Lead-Wait-Support-Auditory Follow-up

• 1. Lead with speech – “What do you want? Say it 1 Time! Later, Delay any verbalization

• 2. WAIT (4-5 seconds for motor or communication response)

• 3. Support with Visual/Tactile prompt while saying the word (1 time) – “Cookie!”

• 4. When child uses any communication act, Repeat the verbal word again –

• 5. If parents are using total communication, the signed word is used for support if the child knows it; if not, use the verbal word and sign at the end of the interaction..”You have Cookie!”

Zone of Proximal DevelopmentUse of Scaffolding (Vygotsky, 1978)

• Use less intense prompts whenever possible

• Know exactly the response you expect from the child

• Set the child up to succeed, not to fail

• Reinforce successive approximations

• Use partial participation strategies

• Up the “ante” gradually

• Pair the learned behavior with the new behavior

• Gradually withdraw your support

References• Barnes, J. M., Franz, D., & Bruce, W. (1994). Pediatric

cochlear implants: An overview of alternatives in education and rehabilitation. Washington, D.C.: Alexander Graham Bell.

• Cole, E. B. & Flexer, C. (2007). Children with hearing loss: Developing listening and talking. San Diego, CA: Plural Publishing.

• Estabrooks, W. (2001). 50 frequently asked questions about auditory-verbal therapy. Toronto, Canada: Learning to Listen Foundation.

• Ertmer, D. J. (2005). The source for children with cochlear implants. LinguiSystems.

• Wilkes, E.M. (2001). Cottage Acquisition Scales for Listening, Language & Speech. San Antonio, TX: Sunshine Cottage