Pat Mirenda, Language, Speech, and Hearing

Services in Schools, Vol. 34, No. 3, July, 2003

That quote alone should render unnecessary even one article—let alone two—devoted to singing the praises of manual sign use for people with ASD!  Specifically, what more needs to be said to “sell” readers on the benefits of using manual signs beyond the research-based assertion that their use promotes faster and better vocabulary acquisition than speech alone?  As it turns out, a lot more needs to be said on the subject of manual signs, since getting people to actually use them in the education and treatment of those with ASD is a genuine “hard sell”.   Indeed, one might say that sign language suffers from the Rodney Dangerfield syndrome, because in the phrase made so memorable by that comedian, it gets no respect as an intervention tool for those with ASD!  This article explores the “whats,” the “hows,” and the “whys” of this remarkably simple and yet highly effective intervention tool.  Furthermore, it specifically addresses the use of manual signs by adults as a means of enhancing their verbal messages, rather than the practice of actually teaching manual signs to children with ASD.

What is Sign Language?

While there are many different varieties of sign language, they all have one thing in common—they provide a visually-based way of communicating.  Since I am most familiar with American Sign Language (ASL), it will serve as the vehicle for manual sign use set forth in this article; however, the information presented is applicable to the different types of sign language used in other countries / cultures.

The first thing that must be said about sign language is that it is a natural language in the sense that it can be absorbed from birth, and used to express a wide variety of diverse communicative functions and needs.  In fact, ASL has been recognized by linguists as an authentic language, since it contains the essential elements that all natural languages contain.  In recognition of the legitimacy of sign language as a bona fide communication system, more and more schools across the United States of America are adding ASL to their foreign language offerings.  This would seem to be most appropriate, since according to Daniels (2001) “nearly 15 million people in North America [are] able to communicate to some degree in sign language, making it the third most commonly used language in the country”  (p. 16).

How Can Manual Signs Be Used with Individuals with ASD?

Using sign language to highlight certain words and phrases, has been found to be a highly effective way of enhancing communication and language for all students, particularly those with special needs.  The advantage here is that using manual signs in this manner is eminently user-friendly and flexible—easily learned and readily employed in educational / treatment programs, regardless of philosophy.  Indeed, all that the interventionist needs is a sign language dictionary, a little practice, and a commitment to stick with it.

The following example serves to illustrate just how easy it is to incorporate manual signs into educational / treatment programs that serve students with ASD.  The bold-face type indicates the words that could be signed as they are spoken.  While there is some flexibility, the general rule of thumb is to sign those words that you would want to highlight:

Susie, please come here.  Thank you.  It’s time to do some work.

First we will work, and then we will play.  I’m going to show you three things.       Two will be the same, and one will be different.  Good job!

Before moving on to the next section, it is important to note that a key component of using manual signs in educational programming is that of consistency. Having said that, one of the most frequently observed “bad practices” is the haphazard use of manual signs.  To be of benefit to the student they need to be used consistently across people, activities, and environments—and that most definitely includes teaching parents to use manual signs at home.

Why Use Manual Signs if the Child Can Hear?

The simple answer to this question is that there is a great deal of research that clearly demonstrates the benefits of using manual signs to enhance communication and language in hearing students with special needs.  Expanding on Dr. Mirenda’s above-noted statement regarding the positive effects on language of using manual signs, Daniels (2001) states,

Historically, sign language has proved useful for language-delayed,

language-disordered, and learning-disabled populations.  Typically,

specific signs have served as gestural cues for children with

communicative impairments, for children with Down syndrome, for

children with aphasia, and for children with autism.  Using sign

language as a communicative tool with educationally challenged

hearing children improves their communicative competence and

academic ability (p. 93).  

Daniels (2001), speaking specifically about children with autism, goes on to state that manual signs can be used to “make it easier for children to follow directions, as a way to help children make connections between words and concepts, and ultimately as a method for leading them to speak” (p. 97).

Part two of this article will take an in-depth, “goodness of the fit” look at the specific ways in which the use of manual signs serves the multifaceted needs of individuals with ASD.  It will also examine the widely held myths and erroneous judgments that have prevented sign language from garnering the respect it deserves as a highly effective intervention technique for this population.

References

Daniels, M. (2001).  Dancing with words:  Signing for hearing children’s literacy.

Westport, CT:  Bergin & Garvey.

Mirenda, P. (2003).  Toward functional augmentative and alternative communication for students with autism:  Manual signs, graphic symbols, and voice output communication aids.  Language, Speech, and Hearing Services in Schools, 34, 203-216.

© Diane Twachtman-Cullen, Ph.D., CCC-SLP

Myth #3:  Using pictures or other visual symbols with nonverbal children will cause them to become dependent upon these types of supports.

Not all myths are created equal, and this one is among the most damaging, particularly since individuals on the autism spectrum, with rare exception, have greater strengths in the visual, as opposed to the auditory realm.  For one thing, this myth flies in the face of research.  For another, it insulates the child from receiving valuable and much needed visual support.  Simply stated, there is ample research evidence that demonstrates that the use of pictures and manual signs not only support, but actually facilitate the development of verbal language in many children with and without autism. If that isn’t reason enough to use these supports (and it surely should be!), visual supports can also help to facilitate word retrieval, reduce frustration, and most importantly, provide a means of augmentative communication for the child who is either nonverbal or minimally verbal.

Myth #4:  The best way to increase length of utterance is to insist that the child always says the whole sentence.

I call this one, “the full-sentence press,” because I find insistence on saying the full sentence to be overbearing (and often overwhelming!) for those students with autism who are struggling to retrieve words, formulate thoughts, construct messages, and deliver them to intended listeners.  In my opinion, the mantra, “Tell me in a complete sentence,” quite literally glorifies form (manner) over substance (message).  It also adds additional stress to speaking situations—not a good thing for individuals who typically experience high levels of anxiety.   This is not to say that increased length of utterance is not a desirable goal.  Surely it is.  But there are ways to increase phrase and sentence length that are far more natural, less stressful, and more effective.  For example, manual signs could be used to unobtrusively prompt additional language.  This practice can be applied independently, or in concert with the “playing dumb” phenomenon in which the adult pretends that s/he doesn’t understand something so that the child has to use additional words to elaborate the message.

Myth #5:  The most effective way to teach language is to use flash cards.

Second only in the damage department to myth #3, this myth assumes that labeling a picture can somehow convey its meaning and also ensure appropriate use of the word in the real-world environment.  But saying a word; knowing what it means; and using that word in the appropriate context are all different parameters that involve different types of competencies.  For example, being able to say apple in response to a picture does not automatically enable the child to request an apple when s/he is hungry.  The reason for this is that saying a word involves the physical act of moving the articulators (i.e., speech); understanding what the word means involves semantics (i.e., meaning); and being able to use the word appropriately—for example, to request—involves pragmatics—the social use of language in a particular context.  Since pragmatic communication difficulty is the quintessential element of language impairment in autism, and because it is complex and multidimensional, language use should never be assumed based upon the learning of word labels. Moreover, addressing pragmatic communication impairment requires a context for word use—an element conspicuously lacking in therapy-by-flash-cards.   While flash cards may be useful for language games and additional vocabulary practice, to say that they are the most effective means by which to teach language is a myth, and a seriously misleading one at that!

Coming Full Circle

Ironically, it is likely that the deceptive ease with which verbal language develops in neurotypical people serves to blind us to the underlying complexities inherent in the language-learning process—a shortcoming that can easily lead to the promotion of myths that mitigate against best practices in language development.  Hopefully, the myths discussed within this article and the previous one will give much needed pause to those who fail to understand and appreciate the exquisite complexity of the language learning process.

© Diane Twachtman-Cullen, Ph.D., CCC-SLP

Myth #1: Talking must be easy since so many people do it so effortlessly.

Nothing could be further from the truth. In fact, the act of speaking – and all that it involves – is arguably the most complex task that human beings are called upon to learn. For example, to utter a simple one-syllable word such as church is a motor planning extravaganza, requiring well over twenty precise, exquisitely timed movements, all occurring in a particular sequence. Imagine the motor planning that goes into extended discourse!

The act of speaking, of course, involves more than moving one’s articulators (e.g., tongue, lips, jaws, etc.). It also involves the selection of specific vocabulary to accurately convey one’s message. Given that many words have multiple meanings, and that different words can mean the same thing, this process is anything but straightforward. Talking also involves social decision-making (i.e., pragmatics), such as knowing what, how, and when to say something, and who to say it to. In addition, since communication is a two-way street, talking also involves keeping track of what another speaker says, and what he or she knows, so that an appropriate, on-topic response may be formulated. Problems here run high in ASD. While this explanation barely scratches the surface of the complex multifaceted skill of talking, it should at least convince the reader that the act of speaking is anything but simple.

Myth #2: He only says a few words, but he understands everything.

There are several reasons why individuals with autism may appear to understand “everything.” The most likely cause, however, is probably attributed to their excellent rote memories, and their ability to follow routines with ease once they learn them. For example, of the child’s typical routine upon arriving home from school is to hang up his jacket, wash his hands, get a glass of milk from the refrigerator, and sit down at the table for a snack, his parents might assume that it is their directional cues that prompt the child’s responses. In actuality there are many cases in which individuals with autism are responding to the customary routine, rather than the verbal prompts to hang up jacket, get a glass of milk, and so forth. A simple way to determine the child’s level of understanding of verbal directives is to either vary the routine (i.e., give directions that are out of the customary order), or direct the child to do something novel. If, under such circumstances the child continues to do what he’s always done, it is likely due to his not understanding everything. And, if you find that to be the case, then it’s a good place to begin building in comprehension.

More speech-language pathology myths to come in the next installment of Autism at Home Series, so please “stay tuned”.

Years later, when I was facilitating summer camps and social skill groups for kids on the autism spectrum, one day I pulled the exercise out of a hat to use with some of the kids I was working with. One girl in particular, Krista, who was about 15, had a very difficult time with language. She was pedantic, with words coming out slow, repetitive and monotone. Her responses to general questions and conversations in social situations were strung together with a great deal of effort and challenge. She had a lot of fun with the exercise – as we made it a game – and I felt she connected to the process steps involved, so I asked her parents if they would allow me to work with Krista over the coming months to see if my process steps worked to improve her speech and language abilities.

As a freshman in high school, Krista wanted to make new friends badly, but had no idea how to go about it. She was isolated and in fear of making new friends at her new “big” school. What to say and how to say it made her confused and anxious. But she desperately wanted to be a part of girls’ life on campus. We began our work together. The improvement in speech and her ability to think on her feet was outstanding.

Teachers, family friends and others in the community began to ask Krista’s parents what they did to create such improvement. How had she improved so quickly? “Krista seems to have come out of her shell. She’s so much more animated.” One teacher said.

Benefits of RFI

Turning Rapid Fire Improvisation into a game with your child is an excellent way to make it fun, entertaining, and educational. Benefits include:

-core connections to the brains synopsis

-exercising brain muscles and memory connections

-connection to observing and really “seeing”

-speed and verbal agility.

-comprehension

-language development

-thinking on your feet

In my work with Krista, I worked with her for 4 months 1 x per week, while at the same time I had her mother doing 3 improvisations each night just before Krista went to bed – a more calm and suggestive hour of the day. After a couple of weeks of perfecting her ability to speak about an object with more definition and pace, I introduced a new strategy. We would work at her computer with the camera, pretending the camera was a girl at school she admired and wanted to get to know.  I would put objects behind the camera that were girl friendly (a necklace, scarf, telephone, etc.) so that Krista could focus on things of interest to other girls.

The goal of filming Krista was to allow her to see herself as others see her. We would talk about what she was feeling when she needed to look away. Krista began to develop both speech and eye contact through this method. Eventually we sent Krista out into her school community to “practice” on a real girl.  The result was that Krista attended most football games, proms, dances, and other activities with peers on campus throughout her high school life. Today Krista is in college in Washington State.

I don’t make scientific claims with this process, but am hoping to get others – experts in the field of speech to look at this more critically as a strategy for language development. Here how RFI works:.

Rapid fire works like this:

Select an object – any object in the room.  e.g., a light switch, drapes, bed, flowers, closet, etc.

2. As quickly as you can say everything and anything you can think of about the object. Talk about the object in a firm voice, do so for 30 seconds at first, evolving to 1 minute per object or thing. A “thing” may evolve into concepts, for example, such as making friends, taking turns, playing a game, etc.) But until you learn how to facilitate and your child learns how the game is played, I recommend you start out with objects.

e.g., THE LIGHT SWITCH – “The light switch is attached to the wall next to the door for easy access when I walk in the room, it is close to the door so I can turn it on immediately when the room is dark. Light switches come in many different shapes and sizes, and styles. The light switch plate in my room is brushed silver…”

When you try this yourself, initially you will probably stammer over your own words. You may find it difficult at first to speak about a random item quickly and succinctly without going “blank”. The exercise – if you are having fun, will make you laugh because you might feel a little silly. Good for you! But you’ll probably need to practice yourself in order to perfect your ability to facilitate your child in rapid fire improvisation. This is the perfect opportunity for you to practice getting good at this exercise WITH your child. Enjoy yourselves with the process steps of this activity. Lighten up.

I suggest you do 2 or 3 improvisation exercises with your child to start, increasing the number of items or things as you go along.  Introduce a video or computer camera later in the process after you and your child are relaxed with the exercise. “Catch” your child being brilliant!  Encourage them to have fun.

Although neither one of us knew it at the time, Charles Hart was describing the quintessential deficit in theory of mind—the lack of knowledge / appreciation that different people have different minds and hence different ways of thinking, feeling, and believing; and further, that these internal mental states have a lot to do with the person’s external behavior. The following examples may help to illuminate these important points.

To have a theory of mind is to be able to attribute mental states to others. In other words, we use mental state terms to try and understand what people mean in order to make sense of their behavior—for example, she’s crying (external behavior) because she feels (internal mental state) sad. People who don’t have autism attribute internal mental states to external behavior quite naturally, using their attributions to guide their own behavior. For example, you wouldn’t ask your boss for a raise if he or she were speaking harshly to someone and hence, in an obvious bad mood! The importance of being able to link external behavior with internal mental state cannot be overstated, since assigning an internal reason for the behavior that we see:

• helps us to understand (i.e., make sense of) a person’s behavior (Daddy is yelling at me because he is angry.);

• enables us to use the information that is gleaned to predict what a person might, or might not do (If he’s angry he might not let me have dessert.); and,

• provides the basis by which we may modify and/or adjust our own behavior to meet the needs of the situation (I’d better not ask him for a cookie right now.).

There is a great deal of research today that indicates that individuals with ASD have deficits in theory of mind, and further, that these are linked to language development. Like autism itself, these deficits exist on a continuum from mild (in the case of more able individuals), to severe (in the case of those with significant challenges).

By “reversing” the content of the bulleted points above one can get an idea how deficits in theory of mind impact individuals with ASD:

• If you aren’t able to understand that a person’s overt behavior has a lot to do with his or her internal mental state (e.g., harsh words reflect anger), you will not be able to make sense of the person’s behavior.

• If you can’t make sense of a person’s behavior, you are not likely to be able to predict what he or she will do.

• Without the ability to predict likely future action, one would not know how to adjust his or her own behavior to meet the demands of the situation.

Joint Attention as an Early Indicator of Theory of Mind Knowledge

Normally developing children, from approximately 9 – 12 months of age, will follow an adult’s line of regard—that is, his or her point or eye gaze—for the purpose of sharing attention. This is called joint attention, and while very few people have even heard of it, joint attention is a critical precursor to language development. In fact, it is actually the gateway to intentional symbolic communication, and very much reflective of underlying theory of mind knowledge. Eventually, neurotypical children learn to use a pointing gesture themselves to attempt to get adults to follow their line of regard, as they quite literally point out items and events of interest to them. Pointing to share attention is considered one of the earliest indicators of theory of mind knowledge. Conversely, the lack, or impoverishment of this type of behavior in children with ASD is indicative of theory of mind difficulty. It should be obvious that given its intimate connection to communication and language development, the competencies involved in the social-cognitive construct of theory of mind should be targeted in intervention activities.

Putting the Horse in Its Proper Place

If one doesn’t understand the concept of theory of mind and how it relates to language development, it is easy to put the proverbial cart before the horse. This happens when we ignore the importance of joint attention and comprehension, and start intervention at the level of language expression. It also occurs when we fail to build in intentionality because we are too busy force-feeding vocabulary. That said, I belong to the “it’s never too late to get it right” school of thought. Human beings are amazingly resilient. Under motivating conditions, it is relatively easy to establish joint attention and to build in intentionality. And, since both of these constructs are foundational to communication and language development that is where the focus of language intervention should always begin.

© Diane Twachtman-Cullen, Ph.D., CCC-SLP

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