I took my first Hanen eSeminar a couple of months ago, and I’ve been able to apply what I learnt, straight away. I think this is the first eSeminar or online training, that I’ve paid for. It was easy to log in and I could watch the 2 hour video whenever I wanted with 30 days of unlimited access. There was also a handout to download. It was recorded live, so there were some parts when the presenter asked the people watching live to answer questions or vote. It looked like fun! I used this time to make notes and jot down questions.

Definitions of Late Talkers

The eSeminar was titled: Choosing Initial Vocabulary Targets for Children Who Are Late Talkers. I was interested in the topic because I’ve been seeing more and more children under 2 years old, a good proportion of whom are Late Talkers. Some of the information presented was from Hanen’s Target Word program. Cindy Earle who presented the eSeminar began by describing Hanen’s clinical definition of Late Talkers (as opposed to the research definition.) She said that children with less than 24 words at between 18 and 20 months, 40 words at between 21 and 24 months, and 100 words, with no or limited word combinations at between 24 and 30 months, (and no other major concerns in other areas), require therapy.

Communication Goals and Vocabulary Targets

The eSeminar covered risk factors and predictors of change, and then we started thinking about communication goals. I had previously worked on imitation as a goal, but never being noisy! Cindy talked about the importance of learning to vocalise with every communicative turn or “being noisy” and it’s something I’ve incorporated into my work. Cindy moved on to discussing vocabulary targets, providing a useful checklist, including: target words should be motivating for the child to say and starts with a sound in the child’s repertoire. There was also some interesting information about gestures and a discussion about having the word ‘more’ as a target. I hadn’t really considered before that ‘more’ isn’t useful for initiation. I’ve been focussing on verbs and motivating items since watching the eSeminar.

The eSeminar concluded with some video case studies so we could apply what we’d learnt. I really enjoyed the format, the information presented was relevant to my work, and Cindy easily kept my attention for the 2 hours.

Discount on Hanen’s eSeminars about Autism

April is Autism Awareness Month. Or as the folks over at Thinking Person’s Guide to Autism prefer: Autism Acceptance Month. And Hanen are offering 40% off their Autism eSeminars with the code: AAMSEM16. Check out the eSeminars available and remember the offer expires on 30th April.

Win a free eSeminar

The team at Hanen have kindly offered me a free Autism eSeminar to give away! Leave a comment on this post telling me the vocabulary targets you’ve had most success with (“Thomas?” “Up?” “Cake?”) and I’ll randomly select a winner in a weeks time.

I was delighted to hear how well a little client of mine had done with a new activity (a large container of jelly!) at nursery this week, although I was disappointed that his teacher had predicted he wouldn’t be able to access it.

I then read this journal article: The effect of using ‘full’ language when working with a child with autism: Adopting the ‘least dangerous assumption’ by Anne Emerson and Jackie Dearden, Child Language Teaching and Therapy, 29 (2), 2013. This research paper resonated with me because it discussed the implications of underestimating a child’s ability.

The researchers report that the Minimal Speech Approach (MSA) is recommended  in the UK Government guidance on teaching pupils with autism (Department for Education and Skills, 2002: 18) This approach involves using single words or two word phrases alongside gestures and visual supports.

This single case study describes work with Jack, who had been exposed to the MSA approach at his special school. The researchers investigated the effectiveness of a different way of working, they suggest: “it is ‘less dangerous’ to start by assuming understanding and adjusting language when comprehension difficulties become apparent.”

An Alternative to the Minimal Speech Approach

The researchers describe the specific characteristics of the intervention as follows, (I quote from their paper):

• speaking in complete phrases and using a range of vocabulary;
• speaking slowly and quietly, and waiting longer than might typically be expected for the pupil to respond;
• materials and resources to promote interest, interaction and fine motor skills (including pointing);
• initial focus on activities where there was no ‘correct’ answer so that the student could not fail;
an attitude of expectation that the pupil would be able to respond;
• close observation and commenting on pupil responses;
• a willingness to take risks by introducing complex tasks and discovering the extent to which individuals could manage them whilst ensuring success through scaffolding the learning task;
• literacy activities including reading and spelling accuracy tasks such as matching words and pictures and spelling activities;
• reading comprehension tasks.

What a wonderfully encouraging set of principles.

Results of the Intervention

The intervention was carried out during 32 sessions, that lasted between 20 and 30 minutes, over 20 months. Before the intervention teaching staff were using instructions with one information carrying word, after the intervention they reported that Jack was able to understand instructions with three information carrying words. The researchers reported that Jack became more motivated to initiate communication, finding creative ways of getting his message across. The intervention revealed that Jack enjoyed books, was able to match words and pictures, spell words, and sequence words into sentences.

In the discussion Emerson and Dearden state:

Following increased adult expectations, exposure to full language and literacy tasks, Jack demonstrated his ability to respond to more complex questions. Therefore by increasing his opportunities and reasons to communicate, the under-estimation of his cognitive abilities and literacy skill became evident. We contest that he had the means (ability to point) and cognitive ability to follow instructions prior to our intervention but was not being given the opportunity to demonstrate these as he was dependent on adult choice of activity.

The authors describe the teaching staff at Jack’s school as: “initially very sceptical about the approach.” However, over time teaching staff were able to identify that Jack could read, and observe other benefits to using more complicated language.

Reading this paper reminded me that by oversimplifying our language we are underestimating our clients, and limiting their progress. We must incorporate the principles outlined above and expose our clients to a range of interesting experiences.  This is especially important when the children aren’t able to provide such clear evidence as Jack was, of their abilities.

Photo of jelly by Gordon McLean.

I recently attended a workshop at The Music House for Children on introducing musical learning to children with Autism. I was energised and inspired by the session and left with several practical ideas I’m keen to try out. The workshop was led by Kirsty Keogh, it was refreshing to hear from a professional outside of speech therapy. Kirsty is experienced at working with children and young people with Autism, I could see from the videos examples how well the children responded to her.

She shared lots of practical ideas about how to use music with groups of children and during individual sessions. I’m going to try the “Island approach” – different instruments are laid out on around 6 mats on the floor. The instruments on the mats stay the same each week, except for those on one mat which change to introduce new instruments. The child chooses which instrument to explore, and then the adult joins them. It looked similar to Intensive Interaction, following the child’s lead and gently extending.

Kirsty suggested that when the child chooses an instrument or is given one, we give them time and space to explore it, by initially not doing anything ourselves. This made so much sense to me, but I realised I tend to jump in and start modelling how things work. I’m going to try waiting! I’m also going to try the way Kirsty suggested to get children to stop playing. A big, loud, dramatic buildup encourages stopping more than quietly trailing off. Starting slowly and softly can help some children with Autism access music, and low pitched instruments are easier for some children to tolerate.

Kirsty suggested we think beyond nursery rhymes, to songs with different rhythms, in different keys. She showed us how a song like Ipi N’tombi can be used as a call and response to encourage vocalisation. It’s impossible to sit still during this song!

Kirsty also shared some resources. Some of my clients would love this vibration speaker, which makes the sound vibrate from any hard surface you place it on! And Kirsty said it’s pretty robust. Drums for Schools have good value percussion instruments. And A Little Birdsong, has songs and ideas for pre-school children.

I played a lot of music as a child and teenager, and I’d love to play more now. I’m going to learn some simple tunes on the piano, and perhaps try and take some Ukulele lessons! They’re inexpensive, portable and sturdy – a winner!

Photo by Tam Tam

A friend has published a practical resource for developing play and communication skills in children on the Autism Spectrum. Ruth Harris, along with two colleagues, has written Teach Me with Pictures. It’s a book of picture scripts that are ready to use – you can photocopy them or print them from a CD-ROM. Ruth has been working on the book for a while; she spoke about it at the initial Therapy Ideas Live event back in July 2011. Congratulations Ruth, Simone and Linda, it’s wonderful!

The book begins with an introductory chapter, explaining what picture scripts are, their benefits and how to use them.

So what are picture scripts?

You know the picture instructions that come with flat-pack furniture from places like Ikea? They’re picture scripts. You follow the pictures step-by-step, breaking up a complex task into manageable pieces.

Next the book explains why picture scripts work so well for children with Autism. Get the book and read this chapter, it’s insightful, easy to follow and will help you explain the approach to parents and teachers. Many children with Autism are visual learners, who respond well to predictable and achievable activities – picture scripts are perfect. After discussing the skills picture scripts can promote, the book describes in detail how to use the scripts, so you’re ready to get started.

What activities do the scripts target?

The 40 picture scripts are divided into categories:

• Pretend play
• Drawing pictures
• Building and construction games
• Cooking
• Arts and Crafts
• Everyday living

You can see an example of some of the scripts on the publisher’s blog. I can’t wait to try making sandwiches and drawing monsters in therapy, I think the kids will love it!

This book could be used by SLTs, teachers, parents and anyone supporting children with language, learning or social communication difficulties. The activities have been designed to reflect what typically developing children of around 6 years old do, so we can teach our clients the skills they need to take part in the same activities as their peers. That said, a couple of the scripts are a little American, making nachos and ice-cream soda? Still, a good communication opportunity – talk about cultural differences!

This book is an inspiring starting point, use these scripts and then make your own. What does your client or child need to learn how to do? Write your own script and help teach them!

On Wednesday evening I attended the National Autistic Society’s Ageing and Autism launch event. Francesca Happé talked about the huge gaps in the research, and outlined the things we don’t know about what happens when people with autism age. As autism was first used as a diagnostic label in 1943, the children diagnosed then are now approaching their 60s and 70s.

Saskia Baron’s brother Timothy, was one of these children. In 1961 he was diagnosed with “Childhood Psychosis” which later became known as Autism Spectrum Disorder. He is now 57 years old. Saskia talked movingly about growing up with a sibling with autism, and her worries about Timothy’s future. She described how difficult it is for Timothy to let people know when he is unhappy or in pain. More positively, she talked about how she’s observed that Timothy is still able to learn new skills. Saskia agrees that early intervention is important, however, she feels it’s not justified to remove therapeutic resources in late childhood or early adulthood, as the door to learning is still open.

My clients with autism are between 3 and 6 years old, they’ll be approaching old age in 60 years! Saskia’s presentation made me think about two things, how can I support the siblings of my clients? And how can I teach my clients ways to express their pain?

This week I also had a wonderful conversation with Keena Cummins. I’m using her VERVE technique with several families and was thinking about how to manage parents’ expectations. All the children have been making great progress due to the efforts of their skilled and perceptive parents, yet these parents often express frustration that their children aren’t using more words. Keena suggested I’m clear about what I want parents to focus on:

 “During these therapy sessions I want you to focus on his playing, I’ll worry about his talking. I want you to think about how you’re supporting him to play, explore the toys, and try out his ideas. We’ll be thinking about his words later.”

This makes sense to me, I’ll try it out this week.

I finished running the program for the first time in January and last week I visited the families who’d taken part, to review their progress. So what were the outcomes? All the children had moved forward with their communication; one child listened to a question and responded appropriately by nodding her head, another came up to me and initiated a game by tapping me on the shoulder — they were communicating!

The parents had also made huge, significant changes — they were waiting for their children to communicate, rather than anticipating their needs. They were joining in with activities their children had chosen, rather than trying to re-direct them to activities they’d chosen. I watched one mother notice her son was captivated by sticking pieces of damp paper to the table, and use the intrude strategy to encourage him to indicate he wanted more paper – and it worked!

The parents were overwhelmingly positive about having taken part in the program; they talked about how wonderful it was to meet parents of children with similar needs to their child. They were reassured to learn how to move their children’s communication forward. They noticed small changes and celebrated them.

Why does the program work so well?

• It incorporates what we know about adult learning and changing habits. Hanen’s 4P cycle of prepare, present, practice and personalise engages parents and gets them ready to be successful. A mother commented that although her husband had read the More Than Words book – it just wasn’t the same as attending the sessions.
• It uses video examples during the parent sessions, and video coaching at the home visits, to help the parents see what they’re doing that’s beneficial and identify the next step.
• It uses a group format, which is hugely supportive for parents. Our group was made up of parents who spoke five different languages, they really gelled and it was easy to see how reassuring the group problem solving was.
• The program is intense: we met for seven weekly parent sessions lasting three hours, and four home visits. After Lidcombe therapy, it’s the most intensive intervention package the team offers. It felt like an investment: at the end, parents were so much clearer about what they were trying to achieve, more aware of how their behaviour could support their child, and ready to co-create the therapeutic process.

More Than Words in Private Practice?

This week I’m leaving my NHS post (eek!) and heading out into the world of private practice. I’m trying to figure out how to make More Than Words part of what I offer to parents. I’ll be able to run evening sessions, so working parents could attend, although I’m not sure if logistics-wise I’ll have enough appropriate families on my caseload at the same time, to make up a group. Have you run Hanen programs outside the NHS? How did it work?

If you’re an SLT and would like to attend a More Than Words workshop, Ealing are hosting one from 29 – 31 July 2013, you can register your interest today!

Here’s a summary of two of the presentations.

Intensive Interaction

The keynote presentation was given by Dave Hewett, who, along with Melanie Nind, developed the Intensive Interaction approach. He pitched his talk at just the right level — making great use of video clips, the talk was both clear and fun.

Dave talked about the fundamentals of communication, such as enjoying being with another person, taking turns in exchanges of behaviour, and using and understanding eye contact. He questioned why most of the approaches we use to teach communication don’t attempt to teach these fundamentals of communication first. It seems obvious: if a child hasn’t acquired the fundamentals, it’s very difficult to learn anything else. So why do we tend to start by teaching symbolic representation?

Dave & co started working on Intensive Interaction because they felt the existing curriculum was inadequate — this was in the 1980s. He asked us to think about whether this is still the case today. We don’t expect babies to follow a timetable, so why do we expect this from children with Autism, some of whom are at the same developmental level?

Dave’s visualisation of communication learning and performance showed how complicated the process is. He suggested that the conventional linear teaching approach probably won’t work for something this complicated. He uses the idea of a spiral to describe learning through Intensive Interaction and play: learning takes off and spirals upwards; repetition means that each activity builds on what has gone before.

Again, this seems obvious to me. However, I often identify a target, and then consider which therapy activities I will use to work on it. Which takes me back to the linear model! I’m going to need to think about this: Dave suggested using video as a progress outcome, but I can’t write that on my goal sheet…

Attention: the Bucket

I also attended a workshop called: “Attention: getting it, building it and sharing it — the Bucket and Beyond”. Gina Davies started her session with a dancing chicken, giving us what she gives the children: “an irresistible invitation to learn.”

Like Dave, Gina also used video clips: she showed us a group of children with autism, before and after her 6 week program of attention work — it was amazing. The children in the ‘after’ clip were able to maintain such good attention that the Teaching Assistants in my group didn’t believe they were autistic.

As I understand it, Gina’s program works like this:

The children sit on chairs in a semi-circle facing the lead adult. The adult has an opaque bucket, with a lid on, containing highly motivating toys. She must be the most interesting thing in the room, so anything more interesting must be put out of sight. Along the same lines, the supporting adults should be boring! When a child gets up out of his chair, he must be slowly and calmly guided back to his seat — without verbal instructions.

The adult at the front takes out a toy from the bucket and demonstrates it to the children. The children’s reward must be intrinsic to the activity: the joy of watching a dancing pig! Gina suggested using 4 or 5 different toys in each session.

When the program begins, the children are only able to cope with sitting in their chairs for around 5 minutes, but after 2 mornings each week for 6 weeks they are able to maintain focussed attention for between 10 and 20 minutes. Each morning session is made up of around 4 cycles of 5 minutes bucket time and then a period of free play. Gina also said that at The Little Group, where she devised the program, they take the children running before they start the bucket time!

Gina was an outstanding presenter — I came home rambling on and on about buckets, and was so excited I had to text a friend, to share the bucket idea with her! I will definitely be giving this a try. I will also use it to support me in my quest to get the child-height sink removed from our therapy room; it’s competing with me as the most exciting thing in the room, so it has to go!

Gina also had lots of great ideas about motivating activities to do with the children once they had integrated attention. I need to email her and ask if I can add the flour castle, spagetti fireworks and lemonade fountain to this site!