That Hurts!

It was 1999 and Danielle was a ten year old with cerebral palsy who was non-speaking and non-ambulatory.  Although she would soon have a defined yes/no we weren't there yet.  She lay on a mat in my classroom in the city and cried.  We tried music, favorite toys, hand lotion and massage and even scolding her to stop.  She didn't.  Finally I verbally listed body parts to her from the toes up touching each one and she stopped crying when I said "do your thighs hurt?"  Two days later we have confirmation of a femur fracture from previously undiagnosed brittle bones.  I filed away the memory of connection between the unusual behavior and the student being in pain.

In 2004 in a classroom for high school students in rural New England a young man, Chuck, with multiple disabilities including spastic quadriplegia, communication impairment and hearing impairment refused to transfer from his manual wheelchair into his power chair.  We argued, I insisted and he went off to his job in the community.  The next day the refusal to transfer chairs happened again.  Danielle came to mind and I asked if he was in pain.  He nodded.  It turned out his seat cushion had popped, all the gel had leaked out and he was sitting on a metal plate.  I again filed away the memory of the connection between unusual behavior and pain.

Recently, in a classroom nearly 60 miles from that classroom in rural New England another young woman with profound, multiple disabilities was crying every day, during every transfer and every slight shift in positioning.  She was unable to indicate in any way what the tears were about.  A few days passed and some people questioned if the behavior was manipulation.  Danielle and Chuck entered my mind and I asked the nurse if we could try giving her some Tylenol just to rule out pain.  The next morning we did just that and to our thrill not a tear was shed all day and for the first time in weeks the student was able to participate in active PT exercises! 

I wish there was some way I could thank Danielle and Chuck (and all my other students) for teaching me that all behavior is communication and that sometimes that communication is simply, "that hurts!"

The Communication Matrix and Seven Levels of Communication

The Communication Matrix describes seven levels of communication:

1. Pre-intentional Behavior
1. the behavior is not under the individuals control
2. the behavior is not intentional for communication 
3. the behavior reflects the state of the individual, 
4. the behavior is not yet differentiated
5. interpretation of the behavior is dependant on the communication partner
6. example - crying may mean hungry, uncomfortable or tired
7. in typical development this occurs from 0-3 months
2. Intentional Behavior
1. the behavior is under the individuals control
2. the behavior is intentional for communication
3. caregivers continue to interpret behavior
4. example - differentiated vocalization meaning hunger
5. in typical development this occurs from 3-8 months
3. Unconventional Pre-Symbolic Communication
1. behavior is under the indivduals control
2. the behavior is intentional for communication
3. the behavior is non-symbolic
4. the behavior is not "socially acceptable" as we grow older
5. example - tugging someone to the location of a desired item
6. in typical development this occurs from 6-12 months
4. Conventional Pre-Symbolic Communication
1. behavior is under individuals control
2. behavior is intentional for communication
3. the behavior is non-symbolic
4. the behavior is "socially acceptable" as we grow older and we continue to use them
5. the behavior may be related to culture (shaking head for no)
6. example - pointing to a desired object or waving "bye-bye"
7. in typical development occurs between 12-18 months
5. Concrete Symbols
1. concrete symbols look, feel or sound like the thing they represent (parts of items, miniature items, photos, line drawings)
2. example - patting chair to mean sit down or using a picture of a shoe to mean shoe
3. this stage is con-current with conventional pre-symbolic communication and language based communication in typical development between 12-24 months (not usually a separate step in communication development)
6. Abstract Symbols
1. symbols are not related to the meaning for the symbol (i.e. picture symbol for want, most spoken words, printed words, sign language words that do not resemble the action/item)
2. symbols are used one at a time
3. in typical development this occurs from 12-24 months
7. Language
1. symbols both concrete and abstract are used in combination to express an idea or thought
2. combination of symbols follows grammatical rules
3. individual understands symbol order impacts meaning
4. in typical development this occurs from 24 months and older

Each of these seven levels calls for different teaching interventions and methods to facilitate learning in our students.  We know that all of these levels of communication have two basic meanings - to obtain or to avoid (aka to get or to get away).  Within those two basic meaning we can desire to obtain or avoid attention, tangible items and/or sensory experiences, which brings us to six basic things to communicate.  Our job is to meet our students where they are at in this six basic communicative purposes and to us shaping to bring that current means of communicating to the next level.

This means we might play simple contingency games, i.e. spinning a favorite toy and waiting for an indication of pleasure (smile/laugh) before repeating the action, thus reinforcing that this non-symbolic communication.  It might also mean requiring a different student say or use a method of AAC to say a full sentence, "I want more, please" before we repeat the same action, this time reinforcing language.

If we understand where our students are, where we would like them to go and how to embed appropriate communication instruction strategies into every moment of the day our students will become better communicators.

Upset because... You can help me by....

A few times in the past I have posted about the success of using a "Upset because/You can help me by" set up on a communication device, book or in a separate binder.

(Link to the first post and the second.)

The "Upset because/You can help me by" framework was something the SLP and I created at my old job to assist a student and have since used with many, many students. The general principal is that when a student with communication challenges becomes upset (angry, sad, irritated, frustrated or any other version of upset) a staff member cues the individual to use the framework to identify the feeling, the cause of the feeling ("I don't know why" and "I am a teenager!" are both acceptable) and how a staff member can assist in easing the situation.

Upset Because And Help By Binder

View more documents from teechkidz.

This booklet is also available on Adapted Learning.

Currently this framework is being used in my classroom, yet again, with a student to ease in periodic distress. This morning myself and the other adults in the room were quite convinced of the power of this method when an AAC user, whom was just introduced to a page set using this method, was able to go from vocalizing in distress to communicating "sadness" because of a "schedule change" and requesting "explaination". Once the staff member responsible for the confusion (that would be me, oops) apologized and promised to make sure to communicate better next time the student pressed, "Sweet!"

The power of simple communication never fails to blow my mind.

All behavior is communication.

Avoidance, Anemia and Our Kids

This is one of those rare personal posts, skip it if you are looking for all sped info (although there is some towards the end.)

Some of you have noticed and e-mailed me about my lack of posts lately. I have noticed my lack of posts as well. I have just been so tired. I get home from work and fall asleep. I try not to, I try to force myself to do all the things I normally do, but to no avail. I had my yearly physical about six weeks ago and all the results were as they always are: my diabetes is in perfect control (thanks miracle pump!), my blood pressure was good, etc, etc. I had low iron, but I always have low iron and was told to eat more leafy greens and red meat, except I don't really eat red meat in order to keep my cholesterol down.

I thought maybe my fatigue was starting on my allergy medication since it was spring, or maybe it was just the time of the year, but finally I gave in and went to the doctor again on Friday afternoon. This time my low iron had depleted even more and was officially anemic. I was prescribed iron and B-12 and sent on my way.

Since getting home from the appointment 48 hours I have logged 36 hours of sleep. No, I am not kidding. That is how completely exhausted was. Now that I am up and have done a couple of errands I am ready for bed again. I am thinking about my students, about all of our special needs students with communication difficulties.

How would they communicate to us that they are this exhausted? How would they let us know that they aren't just tired, that they aren't just fatigued, that they are exhausted beyond comprehension? It was hard enough to play detective on myself and I live in this body, how do we do it for our students or for our children? I was scolding myself, saying, "Kate, for crying out loud, you just went to the doctor, there is nothing wrong with you, suck it up and get busy!" I was wondering if I was engaging in avoidance behavior and if so what exactly was I avoiding? Now I have a lab slip that says that it wasn't avoidance, it was anemia. Now I can cut myself some slack, take the iron and the B-12, eat a steak and a bowl of spinach, and take a long nap twice a day until I feel like myself again.

I know to rule out the medical first with my students. I teach positive behavior support classes to teachers and paraprofessionals several times a year and I drill into their heads to rule out the medical first, but are we doing a good enough job with that? Are we looking at all the signs in front of us? Are we ruling out the right things? Are we being proactive and teaching our students how to communicate how they are feeling physically and emotionally and what they need?

Are we really looking at what they are showing us with their behavior and demeanor and not jumping to conclusions? Are we thinking outside the box and using our empathy to figure out what is going on? If one of our students were this exhausted would we have figured it out?

What do you think?

Hello Tewksbury Teachers and Staff

Today was the fourth and final Positive Behavior Supports class for 25 teachers and paraprofessionals in Tewksbury, MA. Here are some links that may be useful to those visiting from the class and the rest of us in special education:

• Association of Positive Behavior Supports
• The Center for Positive Behavior Interventions and Supports
  
• Behavior Doctor

Sources for Forms:

• Polyxo
• Multimodal Functional Behavioral Assessment Forms
• Functional Analysis Interview
• Center for Evidence Based Practice
  

Here are the two Power Point Presentations I used in teaching the class:

| View | Upload your own

| View | Upload your own

Behavior Supports

• ABA Resources
• Adaptive Behavior and Learning Online Book
• An Overview of Positive Behavior Support
• Association for Positive Behavior Support
• Behavior Doctor
• CECP Funcational Behavior Assessment
• Motivation Assessment Scale
• Positive Behavior Interventions and Supports
• School Wide PBS Implementation Survey

I am upset because...

Every once in while we as teachers (and in this case speech therapists, as the below story was a team effort) get a chance to look back over our successes and think about how we can apply the lessons we learned from then to our next class of students.

A couple of years ago I had a student who faced some behavioral challenges. We addressed them in many ways, but the most successful was teaching the student to use a ChatPC communication device to say, "I am upset because..." that message linked to pages of messages about why the student was upset including, "my schedule is off", "you won't let me do what I want", "I don't understand what is going on", "someone who is supposed to be here isn't here", etc. Each of those messages in turn lead to a page that said, "You can help me by...", then choices of thinks like "give me some space and we will all be safe", "I want to listen to music", "I need a break", etc.

Today my class attended an outdoor tree lighting ceremony. It was cold outside (17 degrees) chaotic and emotionally difficult for several students. The aftermath was fun for no one. In the process of debriefing afterwards I realized that the lessons learned from my student who learned to successfully communicate what was wrong and what was needed could and should be taught to all of my students who have trouble letting us know what is wrong.

Imagine the increase in positive behavior in our students if instead of doing some of the other things we do (excessive rewards, punishments, time outs, restraints) we taught all of our students to communicate what is wrong and what they need. After all, all behavior is communication.