Friday, 12 January 2018

Working with demand avoidance needs a different approach!

I had a break through today! I won't get complacent as it might not happen again or at least not the next time I try the same things but.........

F is a beautiful, funny, witty, gorgeous little princess who is like a ray of sunshine...... until you ask her to do something, when she can turn into 'a monster from your worse nightmares' (parental quote, not my words but I do know what they mean). 

I have used demand avoidance strategies on her for a while but the session might go something like this:

Me: 'Ok, thank you for choosing the order of the session F, let's see, you chose the memory game first.'
F: 'yes, but I'm not doing your stupid game now........I'm playing with the plastic fruit'
Me: 'No problem, let's use the fruit for the game.'
F: 'Ok, but I'm not playing on the table.'
Me: 'No problem, let's sit on the floor to do it, we'll have more room anyway.'
F: 'NO and you can't make me!'
Me: 'Where shall we do it because look, (pointing at her written list) you said we'd do it and it's on the list?'
F: 'On the floor under the table.'
Me: 'No problem,' but actually wondering if I'll get out from under the small table she's referring to!

This might happen for all 4 planned activities or we may only manage 2!

Today I 'wondered' (alot!) and did not tell her to do anything at all. I acted as an equal, discussing her favourite things, commenting on her new shoes, drawing on a white board next to F drawing on her white board. I asked no questions but made lots of comments:

'I wonder where F would want to work' (she chose somewhere different to usual)
'I was wondering what F had for xmas'
'I wonder what order we should do these'
'I wonder if F could show me..'
'I wonder if F wants to carry on drawing while we do this activity'
'I'm not sure I know what to do here...'
'I think I need help with this...'

We managed all the activities and both of us looked far less stressed at the end. I will try that again but F may have changed the goals by next week!

We need a different approach, we can't be the adult and tell them what to do. We need to pick battles and  make different priorities but above all we need to understand that this child is very anxious and the anxiety means she needs to feel in control. She doesn't need reprimanding, she needs compassion and support. The children who need the greatest help may ask for it in the most unhelpful way (I don't know who said that, but it works for me)!

I love the ideas and activities  in Understanding Pathological Demand Avoidance Syndrome in Children: A Guide for Parents, Teachers and Other Professionals 
by Phil Christie ,‎ Margaret Duncan ,‎ Ruth Fidler ,‎ Zara Healy. If you work with someone similar to F, I'd highly recommend this book.





Thursday, 28 December 2017

What should I expect for my child's language development?


We like these guidelines:

AGE
Comprehension
Expression
Use of Language
18 months
Points to familiar and common objects on re quest
Understands  simple commands (e.g. Pick it up, fetch your shoes)
Uses at least 10 words meaningfully
Attempts imitation of  words and short phrases
Chatters nonsense to self with wide range of different sounds and intonations
Responds to other people e.g. answering questions
2 years
Shows body parts on request
Associates 2 nouns in a simple command (e.g. put the paper in the bin)
Spontaneous use of approx 50 words which can be understood by familiar adults
Starts conversations with others
2 1/5 years
 Understands simple short stories and conversations
Follows simple stories with  pictures
Combines 3 words
Begins to ask questions, use negatives and adjectives
Participates in  rhymes and songs
Carries on conversation for several turns
Responds to other peoples conversation





3 years
Selects objects pictures in relation to verb (which one do we wear?)
Understands common prepositions (in, on, under, behind)
4 to 5 word sentences which are intelligible to most people
Using plurals and past tenses, not always correctly
Asking what, where, who questions

4 years
Gives solutions to situations (what do you do when you are cold),
Identifies some colours, comparatives and superlatives (big, bigger, biggest)
Uses complete sentences
Asks ‘why’, ‘when’ and sometimes ‘how
Relates stories and simple sequences of events’
Enjoys jokes
Talks about own experiences
Assume adult  shares their knowledge 
5 Years
Follows a simple story without pictures
Asks meaning of abstract words
Size, shape, colour, quantity and position words used as aids to reasoning and understanding

Mastering irregular nouns and verbs (mice, men, drank, say)


if you are concerned please get in touch www.private-speech-therapy.co.uk


What is normal speech development?


I'm always being asked what is normal or typical for speech development. This is the best guide I have found:

Normal Speech Development

2 ½ - 3 years
Sounds used
Sounds emerging
M n

P b t d k g


f  s
W y h


3 – 4 years
Sounds used
Sounds emerging
M n

P b t d k g

F s
‘Sh’  v  z l  ‘ch’  j
W y h




 4 - 5 years
Sounds used
Sounds emerging
M n

P b t d k g

F v s z ‘sh’  ‘ch’ j
Th  r
W l y h


Sp, st, sk, bl, pl, gr

These are based on developmental norms for English (Elks & McLachlan)

If you are worried, please get in touch www.private-speech-therapy.co.uk


Sunday, 10 December 2017

As our knowledge of neuro-science develops, it must inform our practice

Natasha Hallam and I were discussing the importance of keeping up-todate with current research and knowledge with George, aka Autism Advocate Dad at the recent SCERTS training in Sheffield, with Emily Reuben. This is true for all aspects of our work but especially true when working with children with social learning challenges. 

With advances in MRI technology, our knowledge of neuro-science is developing so we can see how our approach to working with children and young people with ASD should progress.

Children with a diagnosis of ASD have delays or difficulties in:


  • the development of communication
  • the development of social relationships
  • play and imagination
Studies of children with  social language difficulties actually show physical neurological differences in the way they process social stimuli. If a neuro-typical baby look at people's faces, an area of the brain called the limbic system “lights up” with a heady cocktail of dopamine, opioids and oxy-tocin being produced. This is addictive, so the more it happens , the more the baby craves it. The parent is rewarded by the baby's reactions so will do it more and more. The parent-baby interaction is set up and the path to social communication is well underway.
Children who are non-nuero-typical/have ASD do not have this response. The area of the brain is not lit up by human contact but other areas may show sparks  for certain objects which appeal to them. 

 We call this the social motivation models of ASD. This believes that early differences in social attention set up developmental processes that ultimately deprive the child with ASD of adequate social learning experiences. This causes an imbalance in attending to social and non-social stimuli which further disrupts social skill and social cognition development. So, if a child is not motivated to seek out the social attachments his skills will diminish due to lack of experience and practice. If they are motivated, the skills are practised and reinforced.
By 6 months of age, a typically developing child, begins to follow eye gaze and can recognise when they have lost a caregiver’s attention.  A neuro-typical infant may show distress when a caregiver’s eyes avert. The 'still face experiment' is a good example of this, where the infant seeks out his mother's eye contact and when she doesn't get it, she works really hard to try to make it happen before becoming distressed when it doesn't.

By 10 months of age, a child begins to shift gaze from a caregiver to objects of reference to predict and anticipate the actions of others.


By 12 months of age, a child will initiate shared attention on desired items or items that are of interest to the child. 

This means that a neuro-typical child:
  • is drawn toward social vs. non-social stimuli,
  • derives pleasure from this engagement,
  • notices attention shifts of others,
  • initiates bids for engagement, actions, and objects of interest
  • Practices ways of getting more social attention and indeed, they become very skilled.
Children with Autism Spectrum Disorder (ASD) show limited neural sensitivity to social stimuli and tend not to look toward people’s faces. They will  miss gaze shifts between people and objects and will have difficulty predicting actions and initiating bids for engagement.
Another difficulty is picking out speech from background noise:  when a neuro-typical child hears speech sounds, the sounds are processed as social or intentional stimuli, while children with ASD may just  hear sounds.
Plus, MRI scans have shown that children with ASD may use a different area of the brain to process  social stimuli (e.g., faces, speech sounds). This area is the same as we all use  to process images and sounds that are non-biologicalThis makes predictions of actions, intentions, and emotions less efficient and more intellectual. 
So what does that mean for therapy?

We need to respect these differences and early intervention is the key. We must work hard to make them see the point in social interaction for themselves. Hanen's More Than Words is a research lead, evidence based approach which shows how we can develop this, by thinking about how we set up and structure interaction. Later we like social thinking approach to take this further


The theory underlying the approach in the More Than Words programme proposes two key factors:

  1. Learning to communicate is a very social process and that children learn to communicate from birth within everyday interactions with their parents.
  2. Parents foster their child's communication development by responding to it promptly and building on what the child is communicating about. This applies to all children, including those with autism. However, it has been shown that children with autism also benefit from some very specific ways of responding to them.


We need to responsive, which means:

  1. Responding promptly (within a few  seconds of a child doing or saying something).
  2. Responding  positively – responding in a way that shows the child the parent is really interested in what she or he is saying.
  3. Sticking with what the child is “talking” about and interested in  this means not trying to direct his attention to something else when he is already focused on something or someone. We can use his interests as the basis for communication.
Being responsive involves Following the Child’s Lead, which takes advantage of what the child is currently interested in and attending to. We can, therefore, capitalise on the child’s current focus of attention. This is thought to increase the child’s ability to learn from the language he hears since his attention is already 'captured'. This is in contrast to us directing the child’s attention away from what he is interested in to something else, which can be challenging for the child.
It's so exciting: the more we know, the more we can understand and then the more effective we can be!




Tuesday, 28 November 2017

Intensive interaction: learning to enjoy each others company


According to the British Institute of Learning Disabilities (BILD):

'Intensive Interaction is a practical approach to interacting with people .... who do not find it easy communicating or being social ... It helps them develop their communication abilities.'
I really like this approach, which was developed by Dave Hewett and Melanie Nind, in the 1980s. I enjoy using it with those trickier-to-engage individuals.
We use Intensive Interaction to help us develop more successful and meaningful communication when working alongside people with severe or profound and multiple learning disabilities and/or autism, whatever their age.

Hewett and Hind talk about how learning to become better communicators ourselves, we can support the children we care for, or work with, to develop their own confidence and competence as communicators. This is enabled by the child's learning of the Fundamentals of Communication:

              Learning how to be with another person

              Learning Joint focus' and how to have activities with another person

              Learning to attend and concentrate

              Use and understanding of non-verbal communication: body language and gesture

              Use and understanding of eye contacts

              Use and understanding of facial expressions

              Turn taking: taking turns in exchanges of behaviour

              Use and understanding of vocalisations

              Sharing personal space and ...

              Use and understanding of touch.


Intensive Interaction is about creating mutual pleasure:

              During Intensive Interaction we (parents, carers and support staff) adjust our behaviours so that we become more interesting and socially engaging for the child.

              Intensive Interaction flows naturally in time, with rhythms and pauses.

              During Intensive Interaction we respond to a child's behaviours as if they are intentional communications (even if they aren't!).

              During Intensive Interaction we use 'contingent responding ' i.e.  we follow a child's lead and share control of an interaction with them.
              we generally use Intensive Interaction when we want to promote sustained and sociable communication with children (or adults) with a learning need and/or autism, whatever their age or level of disability or development.

              Intensive Interaction is also good for parents, carers and support staff -  it provides a practical way of developing good communication practices, and it can also help develop better relationships between us and the children we care for or work with.

How do we do Intensive Interaction?:

·         Sharing Personal Space: this is the process of being physically close to someone, but in a way, that doesn't make them feel uncomfortable or awkward e.g. by sitting, standing, or even lying close to someone.

      Eye Contact: this is an important means of communication for giving and receiving social acknowledgement. We can give and receive eye contact in a number of ways e.g. looking at and away from each other; playing hide-and-appear games; exchanging eye contact in a mirror; etc.

      Exchanging Facial Expressions: this is done by using facial expressions to socially engage with someone e.g. using clear and sustained smiles; pulling playful faces at each other; using dramatised winks; raising our eye brows; etc.

      Physical Contact: using sensitive and non-directive physical contact can help build mutual trust, and this can be achieved by: sensitively rubbing someone's arm; gently patting their back; holding hands; rhythmically squeezing hands; clapping hands or hand-over-hand games; walking arm-in-arm; tickling; touching foreheads; rubbing noses; etc.

      Vocal Echoing: echoing a child's sounds or vocalisations (even if they are not actually words or phrases) can develop into conversation-like sequences e.g. echoing back a child's vocal sounds, echoing back a child's breathing sounds, or their coughs and sneezes; echoing a sound made by a child's activity or a sound made by a child's body; etc.

      Behavioural Mirroring: mirroring some aspects of a child's physical movements or behaviour can develop into turn-taking sequences that are, or can become, communicative e.g. mirroring aspects of a child's movements or activity; mirroring a child's facial expressions; etc.

      Joint-Focus Activity: a joint-focus activity is when parents, carers or support staff, and the child they are supporting, focus their attention on the same activity or object e.g. jointly looking at things in the environment (i.e. following a child's visual focus); giving a running commentary on a child's actions; looking at pictures or photographs together; actively listening to music together; etc. I think my most (embarrasing but) significant moment was lying on the floor in Matalan in Burton, staring at the heating pipes above with a lovely lad called John, while people stepped over us muttering! I was able to share in his interest, add language and gain John's respect in one easy move.

      Joint Action:  this is just doing things together, not to, not for, but with!
e.g. physically exploring objects together; physically playing together with a ball or a balloon, or water and sponges; making sounds together on the same musical instrument; etc. I especially like to make gloop to share with a child to explore how it rolls but then drips through fingers. The surprise is easy to share.

      Burst-Pause Sequences: a burst-pause sequence is when an action is preceded by a pause, leaving a gap to develop anticipation and expectancy, and so making things more fun e.g.  playing ‘peek-a-boo ' from under a parachute or from behind a cushion; playing 'catch’ together with a '1-2-3 go' countdown to each turn; etc. I like using rhymes for this with younger children. I use the they like best

      Turn Taking: this is when two people engage together in an activity with both people taking separate roles or turns, thus sequencing their actions
e.g.  taking turns to make noises both vocally or physically; taking turns to make movements; passing facial signals back and forth; physically passing things back and forth e.g. balls, or rubber rings or beanbags; deliberately taking turns to bang a drum; etc. I really enjoyed stamping in a puddle the other day with a  child who took turns, this was the first time I had known him to take turns

See more in The Intensive Interaction Handbook Book by Dave Hewett, Graham Firth, Mark Barber, and Tandy Harrison, available from Amazon