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

Sunday, 5 November 2017

How should we interact with a child with SM in early years and primary?

Look out for one on secondary coming soon based upon our survey of young people which will be in the Royal College of SLTs Bulletin soon.

We have more short videos and how-to's in the parent hub. Let us know what you would like us to cover next.

Tuesday, 31 October 2017

Can Sleep Loss Affect Children's Ability to Process Speech?

Guest blog from Sarah Cummings

The impact of sleep deprivation in the cognitive performance of adults is a well-researched field. And rightly so. Unfortunately, conducting the same research on children is often a little more complicated – with difficulties arising due to ethical worries around depriving our little ones of sleep. Fair enough. We can’t keep the little beggars up all night, can we?!

Still, sleep loss in children is a vitally important field. Especially considering the staggering amount of cognitive development that takes place at a young age.

Thankfully, more research is being done – with parental consent, I should hasten to add – and we’re slowly beginning to understand the impact of poor-quality or insufficient sleep on children, especially in regards to speech development.

Below are a few ways in which sleep loss seems to impact a child’s ability to process speech.

Speech Perception

A number of studies have been conducted into how sleep-deprived children are able to perceive speech.

One study looked at how sleep-deprived children performed against their well-rested compatriots in a test of speech perception. The experiment compared how well participating six-year-olds were able to identify the beginning sounds of syllables; a test that is predictive of language development in later life.  

The sleep-restricted children were shown to respond significantly slower and brain scans showed considerable differences in brain activity across five separate areas.

What was most revealing about this particular study was that the difference in sleep duration between the sleep-deprived group and the control group was just one hour less a night for a week. Yep, one hour was all it took.

While this is, of course, just one study, the implications are nonetheless important. If a noticeable impact can be made after just one week of one hour less sleep a night, what about children who are chronic poor sleepers? Just imagine the effect on their ability to concentrate in class.

Processing Power

A further study compared a group of 7–11-year-old children, who had been diagnosed with sleep apnea, against a control group.

This experiment involved setting the two groups a cognitive task that involved the identification of words.

While on the face of it both groups’ performance was comparable, when the fMRI results were compared the brain activity of the children with sleep apnea was shown to be greater in the areas of cognitive control and attentional allocation. In plain English, their brains were being put under greater stress – effectively working harder – to achieve the same results as their well-rested friends.

Napping Effects

The systems that connect learning and sleep are becoming increasingly well known.

A process known as ‘consolidation’ takes place when we are asleep – this is where the brain reactivates and replays information from our waking hours, strengthening the neural connections triggered during the information acquisition/learning process.

Although this takes place at night, it can have the same effect during an afternoon nap, or as it is aptly called, a ‘power nap’. This is also true for an adult studying Japanese…but it’s more essential for a child learning new verbs.

In fact, when it comes to children, the effect of napping is even more pronounced. One study conducted around word learning and napping showed that children who were encouraged to sleep shortly after hearing new words retained their newly acquired knowledge significantly better than other children who remained awake.

Both sets of kids were tested a couple of hours afterwards, then a day and then a week after, and the power of the nap was shown to remain true on all three occasions.

Rebecca Gomez, Associate Professor at University of Arizona, agrees with the power of both a good night’s sleep and regular napping:

“Preschool-age children should be getting 10 to 12 hours of sleep in a 24-hour period, whether it’s all at night or a combination of nighttime sleep and napping.”

So, maybe it is time to bring back the afternoon nap – for both you and your little one.

Final Thoughts

As we’ve seen even a difference of just one hour can negatively impact a child’s ability to perceive and process words. Conversely, an hour’s afternoon nap can impact positively on their ability to retain new words. So there is little doubt that a link between sleep and a child’s speech development exists.

Fortunately, there are a number of sleep-related activities that encourage speech development, such as reading your children bedtime stories, but still the most helpful thing for speech development is getting a good night’s sleep. Followed, of course, by a few well-placed daytime naps.

Unfortunately, encouraging a child to do anything they don’t want to do is, as we all know, hard – but little things like setting a consistent bedtime routine and creating a relaxing bedroom environment can make a big difference.

For more advice on how to encourage sleep in children and in adults, check out the expert advice from the guys at the sleep advisor blog. When it comes to nodding off, they really know what they’re talking about.

In the meantime, make sure your kids get enough sleep – night and day – and you can rest assured that their development will respond accordingly.

Sarah Cummings