FRAMEWORKS

Getting the m
IF YOU WANT TO MAKE THERAPY FUN EXTEND A CLIENTS RANGE ASSESS COMMUNICATION PROGRESS

When working with children who are early communicators, do you feel you are too reliant on set words, a teddy, picture cards and luck? Charlotte Child certainly did, so set out to find a more effective alternative. Here, she follows up her work on Choices, Changes and Challenges (2004a; b) by focusing on the dynamic communication of First Messages.

hat do you do with a child who is an intentional communicator using a few gestures, vocalisations and early words but is not yet at the single word level? Coupe OKane & Goldbart (1998) discuss research evidence that shows the undue emphasis on the teaching of labelling [being] counterproductive to language development and, indeed, such a focus leading to failure to develop functional communication at the single word level. Current good practice includes combining play-based activities and cognitive development - modelling the vocabulary, following the childs lead during play and commenting on what they are doing - with a strong emphasis on adult-child interaction. The structure of Choices, Changes and Challenges (Child, 2004a; 2004b) allowed me to provide a really functional overview of this phase of development. The ideas were incorporated from well documented good practice, but presented in a logical format that other people could relate and buy in to. Most importantly, though, it took the focus off the development of the childs linguistic skills and onto their development as communicators using whatever skills they already had. However, as a speech and language therapist, I also needed a framework within which I could assess the childrens progress. Also, as I continued to expand my work, it was the range of messages that the changes generated - and the pitfalls of successfully planning them that both interested and challenged me the most. I realised that these issues were linking to some work I had already introduced within the nursery class at Bidwell Brook School, where I was trying to address the transition into first words through using the concept of early meanings. Through combining these ideas I now have an additional framework, First Messages, which has been an extremely useful and fun expansion to my work on functional communication over the last eighteen months.

the first things that children start to tell us about are the people, objects, events and situations in their lives ...its a very dynamic message rather than a set word.

Importance and meaning

Leonard (1984, cited by Coupe OKane & Goldbart, 1998) describes early meanings as aspects of cognitive structure that the child may attempt to communicate about. In other words, the first things that children start to tell us about are the people, objects, events and situations in their lives that have importance and meaning to them. Its a very dynamic message rather than a set word. A common example is the situation where every time a parent sees the rather large family cat waddle into the room, they point it out to their child

and say cat, and they do the same when they see a cat in the street, at someone elses house, in books and on television. One day the child sees the cat walk into the room, and points and says dah; the parent is delighted - theyve learnt the word cat (at last) and they are whisked off to Grandmas to show off their first word. However, the child doesnt show any recognition of Grandmas cat, or indeed any other cat they come upon in their travels, and the parent reports that their child used the word cat once - but not any more. One reason for this (and there are many considerations) is that the child wasnt saying Hey, look, theres a cat (a furry feline that likes milk and mice) but Hey, look, I know what that is and it lives in my house. The child was communicating what the situation meant to them rather than labelling the things involved. (A word of warning: the meaning may be rather specific to the child, like an in-joke, as with our daughter who said Gellar Gellar every time that she saw the dogs in the garden - and we still havent got a clue what she was on about.) Using the concept of early meanings to promote a childs communication skills isnt new; programmes commonly include bye bye, all gone and more. However, they are just the tip of the iceberg and, most excitingly, arent merely a stopgap between communicative behaviours and first words, as they structure and drive the development of a childs communicative and linguistic skills from this point through to two and three word phrases. My framework (table 1) is based on the model in the chapter Teaching First Meanings (Coupe OKane & Goldbart, 1998) which cites the influence of the work of Bloom (1973), Bloom & Lahey (1978) and Leonard (1984). In the original list there are twelve early meanings that can be communicated. However, I have removed denial as, the way I interpreted it, it developed at a later stage than the rest. Also, I included the message thats wrong in rejection as this seemed to be of equal importance to simply rejecting an event or object, and was a common message from creating errors. I kept the original titles in brackets for easy reference to the theory, but used a more descriptive title with families and other people. The phrases after each title are what the child might say if they had the words and helps to illustrate the message and make it more real. I have also developed a much fuller version of this for the families to work from that describes each message with real examples from my own children or my friends (Child, in press). (This necessitated

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

FRAMEWORKS
Table 1 Framework: First Messages
1. APPEARED (EXISTENCE) I know what that is! look 2. DISAPPEARED (DISAPPEARANCE) all gone, no, bye bye Telling you about something that has disappeared, or is disappearing Or a request for something or someone to disappear 3. STOPPED (RECURRENCE) more, again, all gone,finished Telling you about something that has disappeared, or is disappearing Or a request for it to continue 4. GONE MISSING (NON-EXISTENCE) name of thing?,gone, Wheres... Communicating that someone or something is missing from its normal place 5. WHERE THINGS ARE (LOCATION) there, name of place, look, on, up Telling you where someone or something is Or a request that something is put in that place 6. WHOSE IS WHOSE? (POSSESSION) mine Communicating ownership 7. REJECTION no way, stop, I dont want to do this, thats wrong. Communicating that a person or object or event is not wanted Or a request for the current activity to stop Or telling you when something is wrong 8. TO SHOW THAT THEY WANT TO MAKE SOMETHING HAPPEN (be the agent) me I want to do it Communicating that they (the child) want to do something that is going on to happen to them too 9. TO SHOW THAT THEY WANT SOMETHING TO HAPPEN TO THEM (be the object) and me Communicating that they want something that is going on to happen to them too 10. COMMENTING ON AN ACTIVITY up go uh-oh Commenting on mishaps Telling you what is going on 11. TO COMMENT ON SOMETHING yucky nice

message
endless patience from my family, particularly when my then eighteen month old daughter scrambled up onto the settee with a conscientious uh-oh as my wine glass went flying. Like all great researchers, though, I reached for my ever ready notebook with an oh, so thats a comment on an action as my long-suffering husband reached for a cloth...)

Positive view
Using these examples to talk to the families reinforced that this is a universal framework not reliant on the child developing the conventional forms of communication such as words or signing. Just as you can describe the functions of language (such as gaining attention, requesting, giving information) as forming the fundamental framework onto which communicative behaviours slot, so too can you view the messages. The ability to communicate the meaning comes first and the child simply becomes more sophisticated in the way they get meanings across. This is a really positive view of communication development for the parents. Many may describe their child as a non-communicator but, after looking at the messages structure, they can identify three or four messages that they recognise their child as giving. I then set targets, using the principles of changes to well known routines, to extend the range of messages that the child communicates. As with all frameworks, there are some technical bits. Firstly there are three pre-requisites that relate to the child being an intentional communicator. Where the child has learnt that they can get an adult to do things for them by using a range of different behaviours, I describe this to parents as If I do ...You do.... At an early stage these are still hit and miss but, at the later stage, the child is remarkably persistent until they get their message across; I refer to this established stage as If I do ...you do...and I wont give up! 1. Cognitive: The child is able to demonstrate an understanding of objects through using a range of them appropriately on themselves (understanding through use). This cognitive point of development is particularly relevant when planning changes as the child needs to have a solid understanding of what should be going on to make the change significant to them. If a child has not yet reached this stage, I continue to focus on choice making (table 2). 2. Communicative: The child is able to use some form of gesture / looking / vocalisation to get a message across and to communicate at least a small range of intentions such as to request and inform (that is, the child is an intentional communicator). 3. Social Interactional: The child is able to have their attention directed to give joint attention to events and objects.

Table 2 Choice making

Can the child make a clear and satisfied choice between two offered items?

YES

Move onto ideas from Changes.

NO
Can the child make a clear and satisfied choice between a favourite and disliked item? Start to make the items more similar in preference.

YES

NO
Will the child take a single offered item if they want it? (And ignore it or push it away if they dont.) Start offering a totally irrelevant or strongly disliked item at the same time as you offer the item you know they like.

YES

NO
Rather than simply handing the child their cup, food, toys/ objects, pause and wait for the child to show an interest or reach to what you are holding.

Can they reach and hold objects?

YES

NO
Do they react as things are about to happen?

YES

NO
Do they react after something has happened?

YES

Develop a Communication Passport that clearly outlines the messages that the child communicates and how you know when they are happy/unhappy like /dislike something want / dont want something.

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If a child has a strong own agenda, then they are unlikely to be aware or interested in social messages. However, I still find this structure to be useful for these children in identifying and joint planning around meltdown messages. Secondly, there are two stages of development: a. The child recognises and understands whats going on The biscuit tin isnt in its usual place and the child may look around for it, they may walk away or they may get really cross with the cupboard; they know that it should be there and isnt. After Grandma has left the house and youve shut the door, your child sits and waves to the door; they understand that someone has disappeared. As these examples show, the adult can observe the child using a range of behaviours which show that they understand whats going on but dont try to tell anyone else about it. b. The child communicates about what the situation means to them When they discover that the biscuit tin is missing they pull the adult to the cupboard or shout for attention until you help. As Grandma is leaving the house they begin to wave, communicating a bye message. Such messages can all be communicated through a combination of communicative behaviours that are unmistakably aimed at another person including: gestures nodding / shaking head, waving, holding out their hand (as a request to be given something), holding out an object (to show it or to give it), pointing, and personalised gestures that the child makes up for themselves vocalisations protowords (a consistent pattern of sounds), right through to two or three word phrases. This breakdown, taken from the Early Communication Assessment in Communication Before Speech (Coupe OKane & Goldbart, 1998), has been the most important expansion to the changes work and my working knowledge. So often after carefully planning a relevant and meaningful change in a childs routine with their parent or with school staff, the feedback would be that nothing happened; the child had simply looked at the adult, or looked at the situation, and maybe smiled or got cross, leaving the parents feeling disheartened and convinced that both the ideas and the new speech and language therapist were decidedly dodgy. However, through breaking it down into the cognitive recognition of the message and then communicating about it to another person, it immediately became clear that the shocked look as the parent put the sock onto their childs hand wasnt a failure but the first stage - the fact that their child did not give a message about what was happening was the very reason that we were working on it. Of course, planning the changes continued to be very important, as what worked for one family didnt for another, emphasising the need for me as the clinician to understand fully the underlying principles

and not just produce a few formulated ideas. I learnt that early changes worked best within clearly understood routines and those with anticipation - so boots in the bath was harder than putting one sock on the childs foot and the second on their hand. I also found that having another adult acting as the childs support was particularly important. There always seemed something rather disingenuous about setting up a situation, for example giving the child the wrong shoes, and then prompting them to tell me that I had got it wrong. It was ever so much more natural and effective with another person working with the child as their advocate - picking up on their uncertainty by clarifying the situation (youve got the wrong shoes), directing them (lets tell Charlotte), and modelling the message (not my shoes), then encouraging the child to have a go at telling me in whatever way that they could. It is important not to set any linguistic targets within these activities in order to maintain the focus on the communication of the message rather than on how the message is communicated.

planning the changes continued to be very important, as what worked for one family didnt for another

Useful and relevant

Well, I said that it has been a fun eighteen months, but my greatest satisfaction has always come from the families successes and hearing how useful and relevant the focus on messages has been for them. Two great moments come from Oscar and Jemima. Oscar had a new puppy and, one day when it was being particularly boisterous, he gained his mums attention and then waved bye bye to it - a wonderful request for disappearance. Jemima and her mum made up a great game of getting into the car and being put into the wrong seat. It started off with the usual shocked uh-oh, mums lost it again look to shrieks of laughter all round. Best of all was when the families and staff at school started to recognise and report back on the new messages themselves, and the sizeable shift from measuring a childs progress in terms of the words they were using to the expansion in the range of messages they were communicating. This work has opened up a whole area of further interest and research for me. It is making sense of the theory and enabling me to translate this into practice. I havent abandoned my linguistic framework, nor do I suggest that it is a replacement, but it does provide a very effective tool within which to assess and plan for children in the earliest stages of linguistic development (from intentional communicators to one and two word level expressive skills),

and it makes the most of their learning style through focusing on the quality of the communication environment and their interactions. Where we cannot rely on children developing more sophisticated language based skills, simply increasing the range of messages that they can communicate has a very positive effect on both their behaviour and peoples perceptions of them as communicators. For children with autistic spectrum disorders who have good technical language skills, revisiting this pragmatic level of development has encouraged more purposeful use of the linguistic skills that they already have. Introducing the ideas to the nursery at Bidwell Brook School and John Parkes Unit, the child development centre, has also been a great experience. We immediately enjoyed the freedom of the ideas and the progress that we saw in the way that the children communicated, the very best indicator that youre getting it right. Best of all it is much more fun, much more effective - and I finally feel that I have got something positive to offer children in these stages that doesnt rely on a teddy, picture cards and luck. Charlotte Child (e-mail chaos@hgf.eclipse.co.uk) is a speech and language therapist with South Devon Healthcare NHS Trust.

Acknowledgement
A huge thank you to Sheena Burdett, nursery teacher, and all the learning support assistants at Bidwell Brook Special School, who again allowed and helped me to try out some rather weird and wacky things. Without their trust this project would never have got off the ground. Also to my daughters - who forced me to live my work, and still think that wearing pants on their head is normal.

References
Child, C. (2004a) Choices, Changes and Challenges. South Devon Healthcare NHS Trust. Available on disk for 6.00, e-mail chaos@hgf.eclipse.co.uk for more information. Child, C. (2004b) It aint what you say, its the way that you say it. Speech & Language Therapy in Practice. Summer: 14-16. Child, C. (2006, in press) The Communication Profile. Speechmark. Coupe OKane, J. & Goldbart, J. (1998) Communication Before Speech. David Fulton: London.

DO I NOTE AND LEARN FROM NATURALLY OCCURRING EXAMPLES OF THERAPY GOALS OR STRATEGIES? DO I RECOGNISE THAT INDIVIDUALISATION OF THERAPY IS CRUCIAL TO ITS SUCCESS? DO I MAKE DIRECT COMMUNICATION THERAPY MORE AUTHENTIC BY INCLUDING A THIRD PARTY TO SUPPORT THE CLIENT?

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005