Definitions

Communication: the exchange of ideas with another person not necessarily including verbal communication e.g. winking.

Language: communicating ideas using a system or code that is understood by others who also use that system.

Vocalization: Any speech sound produced by the speech organs.

Verbalization: Any words or approximations of words produced by using speech organs.

Expressive Language: The ability to convey thoughts/feelings to another person in a way that they understand (a gestural sign of ‘thumbs up’ is understood as ‘good’).

Receptive Language: The ability to understand what a person is conveying or communicating to you (another person extends their hand palm up is understood as ‘ give me …..’)

Non-Verbal Communication: Communication that can be expressed through written format, gestural and sign language modalities, body language and facial expressions. Non-verbal communication may supplement verbal communication or may convey messages on its own. Such communication can convey emotion, tone of the communicator. For example: a child stomping his/her feet, crossing his/her arms and pouting his/her lip is showing an act of defiance, an unwillingness to carry out an action or displaying a tantrum. This is very strong communication!

Body Language: Using stance, arm movement or placement, one can convey different meanings to communication by how the body is placed and moved (arms crossed vs. arms uncrossed during a conversation- the arms crossed may convey that the individual is skeptical).

LANGUAGE DEVELOPMENT OF TYPICAL HEARING CHILDREN

The acquisition of language is one that occurs in early childhood and begins as early as birth. Adults help to refine language skills through the use of ‘caretaker’ speech. This refining of language happens between the ages of 5 and 10. This is because most children have completed their acquisition process by the age of 5. Rules of phonology (putting sounds together to form words), syntax (how to put words together to form sentences), semantics (how to interpret the meaning of words and sentences), and pragmatics (how to participate in a dialogue with other communicators) are learned at an early age with great speed. The first two years of life involve breaking each of these systems down, finding separate sounds and putting them together to form words. After age two more sounds and words are produced and rules for language are learned by hypothesizing and deducing from language heard in his/her environment. These stages may occur later in some children and some may verbalize more than others may. However, all children over-generalize a single rule before applying the rule more narrowly and all children speak in one-word sentences before using two word sentences. Further, case studies have shown that for a child to develop language, his/her environment must be interactive with him or her for the child to learn to produce language and not only understand what is being communicated.

Stages of Language Acquisition

Phonation Stage

This stage of language acquisition begins at birth and continues to approximately two to three months of age and is distinguished by the infant making ‘comfort’ sounds. These sounds are quasi-vowel sounds meaning that they are not as full or rich as full vowel sounds. These sounds are made up of phones (smallest units of sound that do not affect meaning but can be discriminated) and phonemes (smallest units of speech that can affect meaning) (Dworetzky, 1996). At this stage it has been found that infants 2 to 4 months are able to make ‘prelinguistic phrases. Found at 2 to 4 months of age is the cooing/gooing stage. Quasi-vowels from the phonation stage are combined with harder sounds that are precursors of consonants (Dworetzky, 1996).

Expansion Stage

The expansion stage is evident from approximately 4 months to 7 months of age. Many new sounds are produced during this time. The number of phonemes rapidly expands giving rise to extended babbling where the first fully formed vowels appear in the babbling repertoire.

Canonical Stage

This stage is present during 7 to 10 months of age. The infant is seen to increase their time babbling greatly. As well, the infant begins to produce syllables in duplicated sequences however the syllables produced are yet to be of those found in the language in his/her environment.

Contraction Stage

The contraction stage replaces the canonical stage after 10 months and continues to approximately 14 months. Phoneme production is narrowed to the phonemes common to the language that the infant is exposed. The infant also acquires the pacing and rhythm of his/her language during this time (Dworetzky, 1996). This is often the time when children will string together syllables that are recognizable to adults, e.g. dadada.

Linguistic Period

At 10 to 17 months of age basic nouns and verbs are acquired. The child can pair the noun or verb with a tangible object or obvious action. This stage is also known as the ‘One word stage’. Speech is limited to single words and more often expressed with a personal signed language. Gesturing is a typical phenomenon exhibiting an effort to communicate with others by the child (Acredolo & Goodwyn, 1988).

Two-Word Stage

Utterances of two-word statements also known as ‘duos’ appear at 18 to 20 months. Children begin to understand the value of language for expressing concepts and desires. Approximately 1000 new two-word statements may appear monthly (Dworetzky, 1996).

Telegraphic Speech

This use of language develops during and following the two-word stage. Grammar and word order play a significant role in conveying meaning while the child omits the use of conjunctions, prepositions or other function words (Dworetzky, 1996). This stage continues until approximately age five and during this time speech is refined by the development of syntactic skills, knowledge of irregular verbs and through caretaker speech of adults in the communication environment.

SOME LANGUAGE DISORDERS AFFECTING HEARING CHILDREN

Expressive Language Disorder

This disorder is characterized by a late onset and slow progression of expressive language in children. Speech is limited and marked by short sentences and simple grammatical structure. The disorder is often identified late, approximately around age six or seven but there is often hope that it can be overcome by adolescence (Mash & Wolfe, 1999).

Phonological Disorder

This is a problem of articulation or sound production rather than word expressiveness. The disorder is also often identified late at six or seven years of age. The child may have trouble controlling his/her rate of speech and are often slow to make certain speech sounds. It is possible for a child to also overcome this disorder by adolescence (Mash & Wolfe, 1999).

Aphasic Disorders

These disorders involve a “complete loss of previously acquired language skills caused by a brain disorder or damage to the area of the brain that affects the ability to speak and write and/or the ability to comprehend and read”(Morgan, 1992). These disorders may also BE a dysphasia, which implies damage to skills. These disorders are not a result of physical disability of body parts involved in producing speech or by hearing or sight loss, rather strictly due to brain malfunction.

Broca’s (Expressive) Aphasia

This type is due to damage in the Broca area of the brain. Difficulty in expression is evident by language that is slow, labored, and non-fluent. The normal rhythm of speech is often absent and writing is often affected. However, the individual is able to communicate meaningfully in the words that are expressed (Morgan, 1992).

Wernicke’s (Receptive) Aphasia

Damage to the Wernicke area of the brain causes a problem in comprehending communication by the individual. The individual is able to use language fluently however the content is often not appropriate with the individual committing grammatical errors and in word selection. Writing is impaired and the individual does not understand written or spoken commands (Morgan, 1992).

Global Aphasia

This is a complete inability to speak, write or understand spoken or written word (Morgan, 1992). There is widespread damage to the cerebral hemisphere on the dominant side.

Nominal Aphasia

This type is an inability to name objects or difficulty in finding words though when offered a choice the individual is able to recognize the target word. This may be caused by a “general cerebral dysfunction or damage to specific language areas”(Morgan, 1992).
These types of aphasia are often treated by the use of speech therapy. Unfortunately the more sever the aphasia the fewer chances there are for recovery.

Some disorders (often developmental) include or are characterized by language abnormalities/disorders. Language problems often impede on the overall functioning of the child producing much stress and frustration.

Autism Spectrum Disorder (ASD)

This developmental disorder is very complex and affects not only cognitive functioning but also motor planning, proprioceptive functioning and language development. A delay in using language is very common (Morgan, 1992). Communication problems appear early and persist over time (Mash & Wolfe, 1999), however vocalizations are present but are often quite repetitive in nature. Some children with ASD may lack the ability to understand or copy speech, some may not be able to imitate gestures and others may respond to sounds inappropriately (Morgan, 1992). Protoimperative gestures/vocalizations (used to express needs), protodeclarative gestures/vocalizations (requesting joint attention) and showing gestures (showing others something of interest) may not be apparent or are delayed (Mash & Wolfe, 1999). Up to half of children with ASD do not develop any expressive language. However, those that do acquire expressive language it is often lacking any depth, it is often repetitive and for most lack imagination (Morgan, 1992). Two other deviant forms of language that a child with ASD may develop are echolalia (a tendency to repeat what is said to him/her, an inability to use language independently), pronoun reversal. Some children with Asperger’s Syndrome or Pervasive Developmental Disorder- Not Otherwise Stated (PDD-NOS) also display a delay in the onset of expressive communication.

Courses of Action Most Often Used

Speech/language pathologists (SLP) often use operant speech training. The SLP will successively increase vocalizations, imitations while teaching the meanings of words (Mash & Wolfe, 1999). The SLP will also help the child effectively label and make requests. Often SLP’s will use a Picture Exchange Communication System (PECS) with a child who has a language disorder. This requires the child to learn the meanings of various pictures of both real and abstract ‘things’ and be able to use the picture to make a request. This system may often require the child to carry a small book of PECS pictures with him/her. This system does however limit the depth of conversation the child may reach because of finite quality of the pictures.

Another type of communication training is sign language training. The steps for teaching sign language are often the same as operant speech training. Signs are first learned then the meanings, and then the use of the signs in a functional way (Mash & Wolfe, 1999). However another method is the child is first taught simple and very meaningful signs that can be used in context daily. Slowly the sign vocabulary is built using many more signs representing different things both abstract and real, the therapist may also decide to use his/her voice while signing to give auditory input to the child (this is known as Simultaneous Communication/SimCom). More often than not, for children with language difficulties sign language is easier to learn and use. Further, a community of sign users is readily available for the child to interact. The Deaf community uses sign language to communicate both receptively and expressively. If the child is able to receptively understand signs he/she may have much opportunity to experience real conversations using this mode of communication

COMMUNICATION

Gesturing

Gesturing is a body movement (often hand or arm) that expresses a meaning of a word so that others can understand what is being conveyed (Weitzman & Mayerovitch 1986). We all use gestures for example shaking/nodding of the head, pointing to objects, waving hello/good-bye. Gestures help children understand what adults are saying because they are often large clear visual movements. Gestures are helpful in two ways:
1. they help to understand words
2. They give the child another form to express themselves or something that otherwise he/she may not be able to express (Weitzman & Mayerovitch 1989).

Thus gestures can accompany facial expressions, exaggerated intonation and specific sounds. Therefore when using gestures with children one should use them often, at the same time as spoken words and consistently (Ibid). Furthermore Weitzman and Mayerovitch (1989) suggests that when working with children to remember:
1. Model the gesture.
2. Model at the child’s level
3. Use gestures when the child is attending to you or an event where there is joint attention (making the gesture context specific)
4. Understand that the child will imitate the gesture before using it spontaneously
5. Use large repetitive movements
6. Understand that this provides another way for the child to
Request
label
comment
promote joint attention

Types Of Gestures
Protodeclarative gestures: vocalizations or gestures that direct the visual attention of other people to objects of shared interest so that the primary purpose is engaging another person in interaction (Mash & Wolfe, 1999). This is also known as engaging in joint attention or showing gestures (the child wants to show someone else a novel experience and share it)
Protoimperative gestures: gestures or vocalizations used to express needs that one cannot fulfil him/herself. For example pointing to an object one cannot reach.
Expressive gestures: gestures or vocalizations used to convey feelings.
Instrumental gestures: gestures or vocalizations used to prompt action on the part of another person to whom the gestures are directed.

Gestures and the Child with PDD or ASD
Children with PDD or ASD often lack a desire to share intentions, thoughts and feelings with other people (Mash & Wolfe, 1999). These children are able to show the ability to use protoimperative gestures but often fail to use protodeclarative gestures. These children may use instrumental gestures, so that they may have another person do something for him/her. However, overall children with PDD and ASD have a great difficulty in understanding and reading emotions and understanding other people’s facial expressions or body language. Therefore they do not understand expressive gestures conveyed by other people and also fail to use these gestures themselves (Mash & Wolfe).

JOINT (SOCIAL) ATTENTION
Joint attention is the ability to “coordinate one’s focus of attention on another person and an object of mutual interest”(Mash & Wolfe, 1999). In typically developing children this ability is apparent by 12 to 15 months of age. Joint attention requires that the child be on the same ‘wave length’ with another person as well as have the ability to draw the attention of another person to an object or event of mutual interest (Mash & Wolfe, 1999). Various ways that a child may attempt to accomplish this could be by pointing, showing, and communicating his/her own interest.

Joint attention and a Child with ASD
Children with ASD may often bring someone to an object or point to an object as a request for a desired object or action. However, children with ASD often show very little desire to share interest or attention with another person for pleasure (Mash & Wolfe, 1999).

IMITATION
“Imitation is the ability to copy the behavior of another person”(McColgin, 1988) either physically or verbally. McColgin (1998) notes four ways that imitation skills develop in young children: 1. “mutual imitation” the child imitates the adult after the adult has imitated the child. Things that can be imitated this way are smiling, simple sounds, and clapping. 2. Early symbolic imitation, the child learns how to imitate sounds that are different than the ones he/she makes or actions without sounds that are novel. 3. The child is able to imitate the adult more easily and makes the sounds closer to the adult model. 4. “Deferred imitation” the child learns to imitate without an adult model. Using prior information with his/her own body, he/she uses this information to manipulate objects in the environment.

Tips for Increasing Imitation (Verbal and Physical) (Adapted from McColgin, 1988)
1. Determine the level of difficulty or ability and provide activities at the same ability level or slightly higher.
2. Frequently imitate the child using different movements and sounds throughout the day.
3. Continue to imitate but change the imitation slightly and reinforce when the child imitates the adult version.
4. Continue changing the imitations slightly so that they may represent more fluid movements or movements with purpose, as well as changing the sounds so that they may represent simple words.
5. Provide toys that represent real objects in the household, school and any other social environment the child may be in. Allow the child to play with these things and slowly intrude ‘showing’ him/her new things (more functional) to do with the objects.

Tips for Increasing Sounds (adapted from Communication Skill Builders, 1995)
1. Begin with noises or words that the child is already using and continue to use them in many different contexts.
2. Make noises along with exaggerated body movements.
3. Make silly faces in the mirror (exaggerate mouth movements).
4. Use songs to elicit sounds.
5. Play games involving loud and soft cues.
6. Provide situations where the child must make a noise to continue or begin an activity (e.g. withhold a block until a ‘grunt’ is made).

AUGMENTATIVE FORMS OF COMMUNICATION (Non-Verbal Communication)
Sign Language (ASL)
ASL is an autonomous linguistic system independent of English (Valli & Lucas, 1992). It is a visual/spatial/gestural language that is very expressive and dependent on visual cues of the hands, body and face. ASL contains all the features that are part of a unique communication system for example, it is symbolic and systematic, it has its own morphology and syntax, and there is a community of users of ASL (Bochner & Albertini, 1990).
ASL and Children with ASD
ASL (sign language) is often used as a communication method for many reasons: it is easy to obtain the child’s attention because of the visual and spatial component. The communication component is not dependent on tangible objects that can be lost (e.g. pictures) and the child can learn simple signs quickly and use them in context (e.g. more, help). The fine motor components to sign language may also help in oral motor control and as mentioned above there is a population of ASL users readily available for the child to communicate with. Conversely, some negative aspects of using ASL with children who have ASD may be the fine motor component if the child has very poor fine motor skills. Signs are considered abstract and may pose problems in understanding meaning as well, signs are transient and may not provide the child with the lasting information so that he/she may process at his/her rate. This may prove to be problematic in understanding instructions in sign or slow down the process of learning different and difficult signs.

THE PICTURE EXCHANGE COMMUNICATION SYSTEM (PECS) (Taken from Frost & Bondy, 1994, Pyramid Educational Consultants)
What is PECS?
PECS is a picture communication system where a non-verbal individual is able to communicate with another person by a set of chosen pictures with words to communicate. “Children using PECS are taught to approach and give a picture of a desired item to a communicative partner in exchange for that item” (Frost & Bondy, 1994). PECS are reliant on tangible rewards, such that the item requested is the reward for the child. The use of PECS is done through a series of six phases.

Phase I – The Physical Exchange
Communication training begins with functional acts bringing the child into contact with effective reinforcers.
A reinforcer assessment is conducted to determine what objects, food or stimulation is the most rewarding for the child.
Absolutely no verbal prompts are used, only physical prompts that are phased out.
A few pictures are worked on during a session but only one at a time (e.g. 1st blocks, 2nd puzzle etc.). The child is engaged in an activity where a picture is available to request something to continue the activity (e.g. a puzzle, the trainer will give one or two pieces of the puzzle thereby creating a need for the child to use the picture to communicate that he/she would like more pieces of the puzzle).
Prompts: Hand over hand exchange while the trainer also uses attentional cues e.g. an open hand showing the reinforcement or banging the reinforcement on the floor to gain attention to it. The open hand is also to receive the picture from the child.
Prompts are faded by backwards chaining.
The ‘open hand’ cue is also faded by a time delay before putting a hand out for the picture.

Phase II – Expanding Spontaneity
Verbal prompts continue to be excluded from PECS training
A variety of pictures are used along with the target picture. The trainer should begin with 1 – 2 distracter pictures to alleviate some confusion, then slowly add more pictures to the learning surface or picture book.
Various people should begin to use the pictures with the child so that he/she may generalize and communicate with more than one person using the PECS.
Shaping of the picture to a picture book or communication board (the picture is slowly moved towards the picture book so that the child understands that the picture can be found in/on the picture book).
Increase the distance between the trainer and child so that the child needs to make an effort to give the picture.
Increase the distance between the child and pictures so that the child understands that by using the pictures he/she will get what he/she communicated through the pictures.

Phase III – Picture Discrimination
- The child should be able to request desired items by going to the picture book and picking the right picture to give to the trainer.
- The child should be able to discriminate between relevant and contextually inappropriate pictures.
- Correspondence checks: ensure that the child is taking what he/she is requesting (the child is now allowed to take what they are requesting rather than the object being given by the adult).
- The size of the pictures is reduced.

Phase IV – Sentence Structure
- The child is able to use a multi-word phrase by using “I want” or “I need” picture symbols.
- The use of a sentence strip with Velcro is used.
- The “I want” picture is already placed on the strip for the child.
- The “I want” picture is moved on the book so that the child needs to find it and put it on the strip before the reinforcement is given.
- The referents (target pictures) are placed out of sight (often in the pages of the book) so that the child must look for what he/she wants.

Phase V – Responding
- The child can spontaneously request items and now answer the question “what do you want?” using the appropriate picture symbols and the sentence strip.

Phase VI – Responsive and Spontaneous Commenting
- The child is able to respond to “what do you want?” “What do you see?” “What do you have?” and other questions using the picture symbols and sentence strip.

PECS and Children with ASD
The PEC System for many children with ASD is a more concrete and ‘real’ system for communication. No formal training is required for the child to learn the meanings of pictures or how to use the pictures because learning is inherent in the activities the trainer chooses. The pictures provide a non-transient message; thus the child is able to view the picture as long as needed to process what is being communicated. Studies have also shown that for some children within a few years of learning the PEC System, language development increased (Frost & Bondy, 1997). However when working with children with ASD, gaining the attention of the child and directing it to the pictures may be quite difficult. Further, the pictures may prove to be a hindrance if the child is constantly on the move (the pictures must accompany the child everywhere), pictures may be lost and certain pictures may not be available to the child when they are needed.

TOTAL COMMUNICATION
“Total communication [TC] is the combined use of signs/gestures/pictures with speech to facilitate communication development. It’s purpose is to provide a language system so [the] child may communicate with others and learn that needs can be met through communication”(Kumin, 1994). The premise of TC is to take advantage of all forms of communication to ensure that the message is getting across to the individual. Therefore TC uses the strength of motor development (signs) and visual perception (pictures/signs) (Kumin, 1994). However TC by most professionals is seen as a transition stage before the child learns to speak. Using total communication with a child who has ASD ensures that wether or not the child learns to speak, there are multiple forms of communication which allow the child draw on the modality that most fits his/her needs. As a result of providing a child with more than one way to communicate his/her needs, the frustration level will therefore lower because he/she is getting his/her message across.

INCIDENTAL LEARNING
Incidental learning the philosophy that learning does not need to be ‘force fed’ to the student at one time. Rather it is the idea that an important lesson can be learned without having realized that something was learned. Incidental learning often occurs when the student is having fun and doing something he/she enjoys. The best way to induce incidental learning is by providing structured but enjoyable tasks that involves the student. Further, the result of the task is dependent on what the student does thereby making the student learn how the result happened and possibly how to change the result.