Strategies – Promoting expressive communication
To access the strategy you are interested in, click on its title.
- Introduction
- Providing the young person with the means to communicate
- Selecting alternative means of expressive communication
- Signing as a means of expressive communication
- Objects of reference as a means of expressive communication
- True object-based icons (TOBIs) as a means of expressive communication
- Photographs as a means of expressive communication
- Pictorial / tactile symbols as a means of expressive communication
- Abstract visual / tactile symbols as a means of expressive communication
- Large print / tactile alternative as a means of expressive communication
- Voice output communication aids (VOCAs) as a means of expressive communication
- Providing the young person with opportunities to communicate
- Waiting
- Enticing
- Feigning ignorance
- Using sabotage
- Violating expectations
- Offering choices
- Promoting conversations
- Encouraging the young person to communicate for a variety of reasons
- Enabling the young person to communicate "don't want"
- Promoting the ability to initiate
- Providing a responsive environment
- Using Intensive Interaction
- Responding to the young person's requests in a positive manner
- Using the "now / next" approach
- Responding to the young person's rejections in a positive manner
- Responding to the young person's questions in a positive manner
Introduction
A helpful framework when considering the nature of communication is the Means – Opportunities – Reasons model. According to this model, in order to communicate expressively, everyone needs
Therefore, when planning the promotion of expressive communication, practitioners need to ensure that they
It is often the means of communication that receives the most attention. Yet, unless the young person also has opportunities and reasons to communicate, providing the means is pointless.
For more details concerning means, opportunities and reasons, see Bell (2013b).
Being an effective functional communicator also requires a crucial skill not directly addressed by the Means – Opportunities – Reasons model: the ability to initiate.
The final key element of promoting expressive communication addressed here is the need for practitioners to provide a responsive environment.
Providing the young person with the means to communicate
As noted in the introduction, a helpful framework is the Means – Opportunities – Reasons model. When promoting the expressive communication of young people with visual impairment and autism, practitioners need to ensure that they provide all three. This section focuses on providing the young person with the means to communicate.
Because many young people in this group do not use spoken language effectively, they require support to use one or more alternative means. In effect, practitioners should adopt Total Communication, which is described in the following sub-section.
Total communication
Total Communication is a communication philosophy. It is not a communication method, nor a teaching method. It is an approach to creating successful and equal communication between people with different communication skills. Using Total Communication amounts to the use of all appropriate means of communication in order to understand the young person and to support the young person to understand you.
Practitioners who adopt the Total Communication approach use Alternative and Augmentative Communication (AAC). There are two main aspects to this
It is important to note that any one young person will actually use several means of communication. This includes young people who use spoken language. The vast majority of people use a wide variety of communicative means: we
Most of these communicative means are used naturally alongside spoken language. Very often, they support the words we produce. But, at times, they contradict what we say (e.g. when we say we feel fine, but our facial expression, body language and tone of voice indicates the opposite). Young people with visual impairment and autism also communicate in a variety of ways, whether intentionally, or not.
Practitioners need to become expert at "reading" each individual young person. This theme is developed below in discussing provide a responsive environment and also in monitoring the young person’s behaviour and moods and responding appropriately.
There are several alternatives to spoken language which practitioners can enable a young person to use. They are discussed in turn below, following the next section.
Selecting alternative means of expressive communication
Deciding on the most appropriate alternative means of communication for a young person with visual impairment and autism is often complex. The process must be carried out on an individual basis, taking into account the needs, skills and interests of the young person.
It is essential to recognise that the "choice" of which alternative means of communication to use actually rests with the young person. The practitioners involved with the young person, and, of course, his / her family, will have a view on the most appropriate means, and will tailor their support accordingly. However, it is important to recognise that the young person is in control, no matter what family and practitioners do: the young person will use whatever means works best for him / her. Practitioners and family should, therefore, be guided by the young person.
Nevertheless, practitioners and family will consider the available alternative communicative means. Key issues, of course, are
Consideration should also be given to how practitioners augment their spoken language to support the young person's receptive communication (see further below).
Many sighted autistic young people process visual information more easily than auditory information, and learn most effectively through vision. Therefore, for those young people with visual impairment and autism who do have some useful vision, it may be most appropriate to consider enabling the expressive use of one or more alternative means of communication with a strong visual element.
Attempts have sometimes been made to place alternatives to spoken language in a hierarchy, moving from the simplest (least symbolic) to the most sophisticated (most symbolic). It is tempting to believe that it would be appropriate to start promoting expressive communication with the simplest (least symbolic) means and moving through the hierarchy, with the aim, ultimately, of employing the most sophisticated (most symbolic).
However, such hierarchies are based on the view-point of communicatively skilled, non-disabled adults. It should not be assumed that any such hierarchy would represent the situation for any individual young person with visual impairment and autism. The discussion that follows inevitably places the alternative means of communication in a sequence. It must be stressed that this sequence is not intended to be hierarchical. There is no intention to suggest that the young person should progress through the communicative means listed here.
Because the means of communication (except voice output communication aids) are described fully in the section on Supporting receptive communication, the next few links are to the relevant item in that section.
Initially, if the individual is very young, has significant learning difficulties, or major difficulties with the abstract nature of spoken language, a concrete means of communication such as objects of reference may be most appropriate. For young people who have slightly more advanced symbolic skills, TOBIs or pictorial / tactile symbols may be useful; these could be enlarged, of course. For older or more able young people, it may be most appropriate to use abstract visual / tactile symbols, large print / tactile alternative or a voice output communication aid (VOCA).
Some sighted autistic young people acquire some signing skills and use signing expressively. However, a very significant difficulty for many autistic young people is that of initiating communication. Supporting a young person to initiate through expressive signing is problematic. The Picture Exchange Communication System (PECS) has been shown to be an effective approach to promote the ability to initiate in many sighted autistic young people. This approach can be adapted for young people with visual impairment by using objects or tactile symbols in place of pictures. Using PECS may well be more successful in promoting spontaneous expressive communication than using signing.
It should be noted that PECS, in itself, is not a means of communication. To support expressive communication in sighted young people, PECS is typically used with pictures; however, it can be used with several different means, such as objects of reference, TOBIs and symbols. Some of these will need to be adapted for a young person with visual impairment; this might mean enlarging them or giving them a tactile element, or, perhaps, doing both.
Although many young people with visual impairment and autism need support to use alternative means of communication, it is essential that practitioners continue to use spoken language themselves. However, it is also essential that practitioners adjust the language they use when communicating with the young person. In particular, they should reduce the amount of spoken language and simplify it.
When selecting the most appropriate alternative means of communication to promote a young person's expressive communication, it may also be useful to consider how best to augment spoken language to support that individual's receptive communication. Using the same means for receptive and expressive communication is probably simpler for the young person; it is certainly simpler for practitioners and the family. Nevertheless, as noted above, it is essential to recognise that the "choice" of which alternative means of communication to use actually rests with the young person.
Practitioners face a major difficulty when selecting the most appropriate alternative means of communication to promote a young person's expressive communication: the process tends to rely very much on subjective impressions. The comfor: Forerunners in Communication Test is designed to make the process more objective, but, as yet, is not available in a version for young people with visual impairment.
Signing as a means of expressive communication
A fuller discussion of signing is provided in the section on Supporting receptive communication. In principle, the young person could be supported to use signing expressively. However, this may present significant difficulties for some young people, especially those who do not initiate and communicate spontaneously. This is because it is not easy to demonstrate to the young person in a clear, concrete way what it is he / she should do to initiate communication by signing. Using the Picture Exchange Communication System (PECS) may well be more successful in promoting the ability to initiate.
Practitioners do not support any of the young people featured in the case studies in this guidance material to use signing expressively. However, practitioners use several signs to support Jivan's understanding and he is beginning to spontaneously offer his hands to participate in signing when he understands the meaning of an event or spoken word. This may indicate some readiness on Jivan's part to use signs expressively.
Objects of reference as a means of expressive communication
These are discussed more fully in objects of reference in the section on Supporting receptive communication. As noted there, it is sometimes necessary for practitioners to select an object which they and other adults will easily associate with the item or activity, even though the young person may not do so initially.
An example is the toy bus Jasper uses expressively to request the song "The wheels on the bus". At the outset, this may have had no meaning for Jasper; as he has no observable use of vision, he is not able to make a visual association between the toy bus and the real thing. However, because he spontaneously uses this object and shows gratification when the song is sung, it is assumed he does associate the toy bus with the song "The wheels on the bus". If this assumption is correct, the toy bus is an object of reference for Jasper. See also promoting the ability to initiate.
True object-based icons (TOBIs) as a means of expressive communication
These are discussed more fully in TOBIs in the section on Supporting receptive communication. TOBIs can be based on photographs. Photographs have major drawbacks which are explained in photographs in the section on Supporting receptive communication. Because of these drawbacks, it is probably best to avoid the use of TOBIs based on photographs with young people who have visual impairment and autism.
Practitioners do not support any of the young people featured in the case studies in this guidance material to use TOBIs expressively.
Photographs as a means of expressive communication
These are discussed more fully in photographs in the section on Supporting receptive communication. The discussion there includes an explanation of major drawbacks with photographs. Because of these drawbacks, it is probably best to avoid the use of photographs with young people who have visual impairment and autism.
Practitioners do not support any of the young people featured in the case studies in this guidance material to use photographs expressively.
Pictorial / tactile symbols as a means of expressive communication
These are discussed more fully in pictorial / tactile symbols in the section on Supporting receptive communication.
Practitioners do not support any of the young people featured in the case studies in this guidance material to use pictorial / tactile symbols expressively.
Abstract visual / tactile symbols as a means of expressive communication
These are discussed more fully in abstract / tactile symbols in the section on Supporting receptive communication.
Practitioners do not support any of the young people featured in the case studies in this guidance material to use abstract visual / tactile symbols expressively.
Large print / tactile alternative as a means of expressive communication
This is discussed more fully in large print / tactile alternative in the section on Supporting receptive communication.
Practitioners do not support any of the young people featured in the case studies in this guidance material to use large print / tactile alternative expressively.
Voice output communication aids (VOCAs) as a means of expressive communication
Voice output communication aids (VOCAs) may have a role in promoting the expressive communication of some young people with visual impairment and autism.
VOCAs can be seen as a panacea, with practitioners and / or family members becoming very keen to provide one for a particular young person. However, the following caveats should be borne in mind.
A VOCA is likely to be of little value for a young person who has no understanding of spoken language; this may seem obvious, but is sometimes overlooked. Some young people with very limited skills are provided with a simple VOCA such as a BIGmack. In theory, this enables the young person to request a favourite toy or event; the VOCA is likely to provide a message that says, e.g. "Music".
When recording messages for this purpose, many practitioners include the word "please". Thus, the messages are in the "Music please" format. This is not recommended. This is because there is a risk that the word "please" confuses the young person, who may come to believe that the names for all his / her favourite items end with "please". Thus, if all VOCA request messages end with "please", the young person may come to believe that
This is not helpful. It is therefore recommended that practitioners do not include the word "please" in the messages recorded onto to simple VOCAs. Typically developing infants do not add "please" to their one-word requests.
Even if the word "please" is excluded, there is a risk with this strategy that the young person does not actually acquire any functional expressive communication skills. The young people concerned are those who, in addition to visual impairment and autism have severe learning difficulties, with no understanding of spoken language. It is likely that some young people in this group fail to understand that they are communicating with another person when they activate a simple VOCA to request a favourite item or event; it is possible that the VOCA really acts as a switch which simply enables the young person to obtain the toy or event.
However, if, when the young person activates the VOCA, the practitioner responds to him / her using spoken language, and provides the requested item or event at the same time, the young person may eventually come to understand that he / she is actually communicating with another person. In this situation, the practitioner should simply echo the message produced by the VOCA; so, if the message is "music", the practitioner should say "music" and immediately provide some by activating a CD player, for example.
Providing a VOCA may not help to promote the ability to initiate, i.e. to communicate spontaneously. It may be more appropriate to use PECS, as described in promoting the ability to initiate.
If a VOCA is provided, consideration must be given to several factors.
The VOCA must be more or less constantly available to the young person; there may be a few situations in which this is not feasible, such as in the swimming pool. In such situations an alternative means of communication must be made available to the young person; if this requirement is not satisfied, the young person may be left without the means of communicating expressively, and this is not acceptable.
The VOCA must be very resilient to withstand daily use (and possibly abuse) in both the school and home, and to withstand repeated transfer between these two settings.
Currently, and very sadly, some young people who have been provided with a VOCA for use in school are unable to take it home because of difficulties with insurance; this results in the young person being left without the means of communicating expressively, and this is not acceptable. If a VOCA can only be provided in one of the key settings (e.g. either the family home only or the school only), serious thought must be given as to whether it is the most appropriate expressive means of communication for the young person.
Funding a VOCA is often extremely difficult; in some cases, a VOCA is funded only for use in a specified setting (such as the young person’s current school), which means that when the individual moves on to another school, or transitions into adult life, the VOCA is withdrawn. Again, this results in the young person being left without the means of communicating expressively, and this is not acceptable. It is advisable for practitioners to look ahead and establish what will be possible when the young person transitions into adult life.
When considering introducing a VOCA, thought should be given not only to the young person’s needs and abilities, but also to those of all potential communication partners, including the family, practitioners and peers. The young person will clearly need support to use the VOCA. The young person’s communication partners will also require support in order to respond effectively to the young person when he / she uses it.
Some young people with visual impairment and autism have a special interest in operating switches / buttons and engage in this frequently; such a young person might frequently play with a VOCA, rather than use it to communicate. A young person may become especially interested in operating switches / buttons because of:
Very careful thought is required, therefore, when considering the introduction of a VOCA to promote expressive communication in a young person with visual impairment and autism.
Practitioners do not support any of the young people featured in the case studies in this guidance material to use a VOCA as a means to communicate expressively.
Providing the young person with opportunities to communicate
As noted in the introduction, a helpful framework is the Means – Opportunities – Reasons model. When promoting the expressive communication of young people with visual impairment and autism, practitioners need to ensure that they provide all three. This section focuses on providing the young person with opportunities to communicate.
Becoming a competent expressive communicator is a major challenge for young people who have visual impairment and autism. What is often overlooked is that typically developing babies, infants and young children have numerous opportunities to communicate every single day. This is essential: typically developing children only become competent communicators because they have so many opportunities to practise their skills; they learn how to communicate by communicating. Young people who have visual impairment and autism also need numerous opportunities to communicate. Unfortunately, it is not easy for practitioners to provide these opportunities.
This section outlines some strategies that may be helpful. In fact, when promoting expressive communication, it is not really feasible to focus on opportunities to communicate in isolation. This is because young people do not communicate unless they have a reason for doing so. The strategies described here are therefore also relevant to the next section, encouraging the young person to communicate for a variety of reasons.
It is important to stress that all the strategies described here must be used sensitively. No young person should ever be deprived of food, fluids, or any aspect of personal care. A strategy sometimes used to elicit expressive communication is to tell a young person that he / she must communicate in some way before being given food, fluids, or personal care. Examples are
Making such demands is unacceptable as it places undue stress on the young person. This is because he / she may not understand the demand, or may be too stressed or anxious to communicate at that time. In addition, if the young person does not communicate, the item cannot be withheld. This means the practitioner has to back down. In turn, this could indicate to the young person that the practitioner lacks predictability and is untrustworthy. Yet being predictable and trustworthy are essential attributes for practitioners supporting young people who have visual impairment and autism. And backing down may make the practitioner feel inadequate and foolish.
When providing a young person who has visual impairment and autism with opportunities to communicate, it is important to take account of the nature and degree of that individual's visual impairment and the nature and degree of his / her autism. Not all the strategies described below are appropriate for all young people who have visual impairment and autism.
Of course, none of these strategies can be effective unless
The strategies described here are:
Waiting
Waiting is a crucial strategy but one which many practitioners find difficult. This is because it can feel very abnormal. Some practitioners feel they are doing nothing while they are waiting, and therefore feel uneasy or embarrassed. The fact is that these young people require practitioners who wait; this is not doing nothing, this is providing the individual with an opportunity to communicate. Waitingis also a crucial aspect ofDepending on the abilities and needs of the young person, there may be many situations in the course of the day in which practitioners could wait. For example, it may be appropriate to
In both cases, waiting provides the young person with an opportunity to ask spontaneously. In the second situation (when the young person requires assistance) waiting in this context is, in effect, the same as feigning ignorance .
Waiting in these situations is most effective with a young person who already communicates spontaneously. If the individual lacks this fundamental skill, it is essential to promote the ability to initiate.
It must be stressed again that no young person should ever be deprived of food, fluids, or any aspect of personal care. Therefore, practitioners should be sensitive when waiting. If, following sufficient time, the young person has not made a spontaneous request, the practitioner should do one of the following, as appropriate in the situation
Waiting is unlikely to be effective on its own, so it should be used in conjunction with other strategies described here. In fact, Waiting is often an essential component of all the strategies which are useful in providing the young person with opportunities to communicate.
Waiting is a useful strategy to encourage young people to communicate for a fundamentally important reason: to request. This includes requesting items and requesting assistance. In other words, Waiting encourages young people to express their needs and wants.
Many young people with visual impairment and autism have difficulty waiting; once they have become aware of a need or desire, they expect to have it satisfied immediately. Waiting can result in considerable stress or anxiety. This strategy should therefore be used with care.
Enticing
Enticing is another strategy that can be used to encourage young people to request items. In essence, this involves making the young person aware in some way that something he or she likes is available, despite being inaccessible.
Enticing can be a powerful strategy when employed with fully sighted young people. For example, enticing a sighted young person to communicate could involve
It may be possible to use these types of enticing when supporting a young person who has quite a good degree of residual vision. However, enticing may be more difficult to use with an individual who has very little or no sight.
Nevertheless, in the right situation, enticing can be an appropriate strategy for some young people who have very little or no sight. For example, a preferred item which makes a distinct sound can be placed in a container which the young person is unable to open. The practitioner entices the young person by handing him / her the container and waiting. A similar approach could be adopted with an item which has a very distinct aroma.
Enticing can be useful in naming activities to make them more real and functional. Practitioners sometimes want a young person, or group of young people, to name items. A common strategy is to show the items one at a time, and ask "What's this?" This exercise becomes boring, especially if several items are to be named. It can also be rather pointless, as those involved may be aware that the practitioner knows the answer. In fact, repeatedly asking "What's this?" questions is not truly communicative. (For guidance on asking questions, go to asking clear questions and limiting their use.)
Enticing makes it possible to elicit the names of items in a more interesting and meaningful way; this can be done with an individual, or with a group. In fact, enticing makes it is possible to encourage young people to name items spontaneously. For simplicity, the following points assume the practitioner wants a group of young people to name a set of items at the start of an activity; the same general principles can be used with an individual and in other situations.
Before the activity, the practitioner places the items to be named in a container, or a set of containers: shoe boxes, tins, handbags, holdalls, chocolate boxes, carrier bags, etc. The practitioner then holds up one of the containers, perhaps rattling or rustling it to draw attention to it and the fact that there is something inside. The practitioner asks, for example, "What's coming?" or "What's Judith got?" For the benefit of those with some functional vision, the practitioner removes an item slowly, brings it out a little, and then replaces it, letting each young person see just a part of the item. For the benefit of those with very little or no functional vision, the practitioner brings the item briefly into contact with each young person's hand. The practitioner should avoid asking "What's this?", but should wait for a group member to spontaneously name the item.
An aspect of enticing, then, is waiting.
Naming an item spontaneously is, in effect, giving information, so Enticing can be useful to encourage young people to communicate for this reason.
Feigning ignorance
Sometimes it is clear that a young person wants:
In the first situation, it is natural for a practitioner simply to give the young person a beater, or to ask "Do you want a beater?" However, this natural response fails to provide the young person with an opportunity to communicate. Instead, the practitioner should feign ignorance and wait, providing the young person with the time to ask spontaneously. If, after an adequate pause, the young person has not asked, the practitioner should provide the beater, or ask "Want beater?" Note: in line with recommendations discussed in the section on Supporting receptive communication, this utterance is reduced and simplified.
In the second situation, it is natural for a practitioner simply to assist the young person, or to ask "Shall I help?" Again, this natural response fails to provide the young person with an opportunity to communicate. Instead, the practitioner should feign ignorance and wait, providing the young person with the time to ask spontaneously for assistance. If, after an adequate pause, the young person has not asked, the practitioner should provide the assistance, or ask "Want help?" Note: in line with recommendations discussed in the section on Supporting receptive communication, this utterance is reduced and simplified.
Often more than one practitioner is present when is appropriate. It is essential that they all wait and provide an opportunity for the young person to ask spontaneously.
An aspect of feigning ignorance, then, is waiting.
Feigning ignorance is useful for facilitating communication for the purpose of requesting items / expressing needs and wants and for requesting assistance. As can be seen, feigning ignorance and waiting are complementary strategies that are often required at the same time.
As noted above, many autistic young people have difficulty waiting: once they have become aware of a need or desire, they expect to have it satisfied immediately. Waiting can result in considerable stress or anxiety. Feigning ignorance should therefore be used with care.
Using sabotage
Using sabotage involves making an unexpected change in a situation. Coping with unexpected changes can be very difficult for young people with visual impairment and autism. Therefore, before using sabotage it is important for the practitioner to build a close relationship with the young person. This enables the practitioner to build the young person's trust. Once trust has been established, the young person may gradually become less rigid and tolerate the unexpected changes resulting from events being sabotaged in some way.
Sabotaged events provide the young person with opportunities to communicate. For example, if the young person asks for a drink, the practitioner could give him / her an empty cup. The practitioner should then wait, providing the young person with sufficient time to process what has happened and plan and carry out a response. The young person may understand the situation and communicate in some way about it, perhaps by holding the cup out towards the practitioner to ask for it to be filled. As soon as the young person does so, the practitioner should provide the drink. Clearly, if the young person fails to respond after a sufficient pause, the practitioner must still provide the drink.
If two practitioners are present when a young person fails to communicate in this situation, the following strategy can be used
In the longer term, it may be appropriate to introduce an object of reference or tactile symbol to signify drink for this young person. The young person's expressive use of this item could be promoted using the strategy described above.
In fact, this approach is fundamentally the same as that used in the Picture Exchange Communication System (PECS). This approach is described in promoting the ability to initiate.
Sabotage can be used in many other similar situations. For example,
A meaning that has considerable communicative value is "more". Because it is an abstract concept, it is difficult for many young people with visual impairment and autism to understand and use. To promote the use of "more", it is necessary to provide many opportunities for the young person to ask for "more". This can be achieved by sabotaging events.
Sabotaging drink times, for example, can offer such opportunities, but only for a young person who drinks readily. At drink time, the practitioner should pour – or support the young person to pour – only a small amount of drink. When the young person has consumed that small amount, the practitioner should wait for the individual to communicate "more" in some way. As soon as he / she has done so, the practitioner should provide another small amount. Clearly, if the young person fails to respond after a sufficient pause, the practitioner must still provide more to drink.
Some young people readily grasp what to do in this situation; it is therefore possible to repeatedly provide small amounts to drink, so that the young person makes several requests for "more". This provides many opportunities to communicate in the space of several minutes.
Sabotage can be useful for encouraging young people to communicate to request items and to ask for "more". It may also encourage young people to protest. This can be the case when an event does not happen in the usual way. In effect, sabotaging events is the same as violating expectations.
It is possible that the young person confronted with sabotage will find the change difficult to cope with and will attempt to reject it. However, the young person may not know how to communicate rejection, and may fall back on an immature means of communication such as turning away or shouting. The practitioner should acknowledge and respond to the young person's rejection by reverting immediately to the normal routine. In the longer term, the staff team should, if possible, enable the young person to communicate "don't want ".
If being confronted with sabotage results in the young person becoming very stressed, he / she may reject the change very vigorously, perhaps by behaving in a manner that is challenging, such as hitting or pinching another person. This should be taken as indicating that he / she is unable to cope with the change. In this situation, care is clearly required. The practitioner should acknowledge and respond to the young person's rejection if possible, preferably by reverting immediately to the normal routine. If the young person is too stressed for this to be viable, it may be best employ a calming strategy (see promoting emotional wellbeing) and then present another activity. To promote the young person's emotional wellbeing and positive behaviour, the most empathic approach is to abandon the use of sabotage, at least for the time being.
Sabotage must be used sensitively. In addition to being alert for possible stress, practitioners should always adhere to the principle that no young person should ever be deprived of food, fluids, or any aspect of personal care.
Violating expectations
People rarely comment when everything fits in with their expectations – there is simply no need to do so. However, when an expectation has been violated in some way, most people are motivated to comment. Practitioners supporting young people with visual impairment and autism typically ensure that routines run smoothly and thus that expectations are not violated. Routine is especially important to young people with visual impairment and autism. It is discussed in the section on promoting positive behaviour in which there is material on
Routine can also be used to augment spoken language to support the young person's understanding of events.
Violating expectations should not be employed with a young person who is not familiar with the routine. This is because it will jeopardise the process of the young person becoming familiar with it; and, in any case, if the individual is not familiar with the routine, he / she will not be aware it has been violated and will therefore not be motivated to communicate about this. Because routine is so important to most young people with visual impairment and autism, almost all those in the group are familiar with their routine. It is likely that only the only context in which an individual would not be familiar with his / her routine is when he / she had recently joined a new setting.
Violating an expectation involves making an unexpected change in a routine. Coping with unexpected changes can be very difficult for young people with visual impairment and autism. Therefore, before violating expectations it is important for the practitioner to build a close relationship with the young person. This enables the practitioner to build the young person's trust. Once trust has been established, the young person may gradually become less rigid and tolerate the unexpected changes resulting from routines being violated in some way.
Violating an expectation can be used sensitively in a familiar routine to provide a young person with an opportunity to communicate. He / she may do so to protest or to comment that something is wrong or unexpectedly absent. In effect, violating a familiar routine is the same as sabotaging it.
Violating a familiar routine can involve interrupting it with a pause, missing out a stage, changing the sequence of events or inserting an additional feature.
For example, if brushing teeth always follows a young person's bath, the practitioner could start to brush the individual's teeth before the bath.
Having violated a routine in some way, the practitioner should wait to provide the young person with an opportunity to protest, or comment in some way that this is "wrong".
Although routine is important for young people who have visual impairment and autism, routines do sometimes have to be abandoned or changed due to unforeseen circumstances. It is therefore advisable to promote in young people the ability to cope with changes in routine. A two-stage strategy for this can also be used to provide opportunities for communicating expressively. The first stage of the strategy involves interrupting a familiar routine and then Waitingfor the young person to comment in some way about the change. As soon as the young person does this, the practitioner should acknowledge and respond to the young person's comment, and continue normally with the routine.
Once the young person regularly copes when a routine has been interrupted and comments about it, practitioners can move onto the second stage of the strategy. Rather than simply interrupting the routine, it is now changed in some way. Again, the practitioner should wait for the young person to comment that the usual routine has been altered. Once the young person has done this, the practitioner should return to the routine.
It is possible that the young person confronted with the violation of an expectation will find the change difficult to cope with and will attempt to reject it. However, the young person may not know how to communicate rejection, and may fall back on an immature means of communication such as turning away or shouting. The practitioner should acknowledge and respond to the young person's rejection by reverting immediately to the normal routine. In the longer term, the staff team should, if possible, enable the young person to communicate "don't want".
If being confronted with the violation of an expectation results in the young person becoming very stressed, he / she may reject the change very vigorously, perhaps by behaving in a manner that is challenging, such as hitting or pinching another person. This should be taken as indicating that he / she is unable to cope with the change. In this situation, care is clearly required. The practitioner should acknowledge and respond to the young person's rejection if possible, preferably by reverting immediately to the normal routine. If the young person is too stressed for this to be viable, it may be best employ a calming strategy (see promoting emotional wellbeing) and then present another activity. To promote the young person's emotional wellbeing and positive behaviour, the most empathic approach is to abandon the use of violating expectations, at least for the time being.
Offering choices
Offering choices could be viewed as an aspect of supporting receptive communication. This is because offering a choice to a young person places him / her in a position which (like an instruction or question) requires a response. However, the position adopted in this guidance material is that offering choices should be viewed as an aspect of providing the young person with opportunities to communicate.
Choices need to be offered with care. This is because many young people with visual impairment and autism find making choices difficult, particularly when there are many options. However, some young people even have difficulty when only two options are given. A possible reason is this: when practitioners offer a choice of two items or activities, the options given are frequently both things the young person likes. This can make it very difficult for the individual to choose: selecting one necessarily involves rejecting the other item, which he / she also likes. Therefore, if a young person has difficulty making choices, it may be more supportive for practitioners to make a large contrast between the two options: that is, to offer something the young person really does like versus something he / she really dislikes.
Perhaps the most serious difficulty withOffering choicesis that it deprives the young person of opportunities to initiate and make spontaneous requests. As initiating is so difficult for young people who have visual impairment and autism, many require an approach which promotes the ability to initiate.
Because offering choices deprives young people of opportunities to initiate and make a spontaneous request, it is recommended that practitioners avoid offering a lot of choices. If they are offered, it may be best to limit the number of options to two.
As with the other strategies designed to provide the young person with opportunities to communicate,Offering choicesrequires that practitioners wait: once a choice has been offered, it is necessary to wait, in order to provide sufficient processing time and provide the young person the opportunity to communicate.
Bob is sometimes offered choices; if he were not, he would probably never request a drink. This is not because he is unable to initiate, as he does so in other contexts, for example, to request activities such as using the providing access to the sensory environment. When the practitioner supporting Bob believes it is time for him to have a drink, he / she asks "Bob, do you want a drink?" He sometimes responds "Yes" but does not spontaneously say what he wants to drink. In such a situation, he is then offered a choice. He is given no more than 2 options, such as "Water, or orange juice?"
For another discussion of offering choices, see Bell (2013c).
Promoting conversations
Conversations are a typical part of everyday life for most people. However, they are something that most young people with visual impairment and autism find very difficult. A key reason for this is probably that conversations are essentially a very social phenomenon, and autistic people have difficulties with social understanding. In addition, typical conversations using spoken language require all participants to understand what everyone else taking part is saying. But, as explained elsewhere, autistic people do not readily understand spoken language.
Nevertheless, being able to participate in conversations is a very valuable social skill and is one that is worth promoting. It is important to emphasise that conversations do not necessarily involve the participants in using spoken language. The very early turn-taking routines a baby enjoys with a primary caregiver can be seen as conversations. Thus, for young people with visual impairment and autism, conversations can involve many kinds of behaviour; for example, depending on the individual's skills and interests, a conversation might involve moving around the room, singing, banging a table or talking about a special interest.
It may be possible for facilitators to gradually promote an interest in participating in spoken conversations in a verbal young person with visual impairment and autism. In order to promote conversations, the practitioner needs to
However, it is likely that the young person will continue to have difficulties with many of the skills involved in participating in conversations; these include
Promoting these skills in a young person with visual impairment and autism will not be easy. There is a range of resources on the market which are designed for use with sighted young people with social communication difficulties, including those with autism.
But, because so many sighted autistic young people are regarded as visual learners, most, if not all these published resources will take a highly visual approach; some may be suitable as they are for young people with visual impairment and autism who have some functional vision. They will need to be adapted (if possible) for use with those who are blind.
Most, if not all, resources for Promoting conversations take a visual approach. Many may not be suitable; others may have some value if they can be adapted to address the needs of individual young people. Some materials are suggested in the Resources section.
Some non-verbal visually impaired autistic young people are very hard to reach. Indeed, some of them give the impression that they would prefer to be left alone rather than to take part in any kind of interaction. However, this impression may be false; it is possible that these young people find it so difficult to interact with others that they have had very little success in this – or even none at all. If this is the case, it is not surprising they seem remote or aloof and (apparently) reject the approaches other people make. Therefore, it is probably inappropriate to regard them as preferring to be left alone; it is better to consider them as not knowing how to interact with other people.
It may be possible for practitioners to gradually promote in such young people an interest in interacting with others. The first part of this process is likely to be building a close relationship with the young person, built on trust. Responding to the young person's own basic behaviours, such as hand clapping, or foot tapping, may then facilitate greater interaction. It may be possible to engage the young person in conversations using these behaviours. Users of this guidance material are advised to employ Intensive Interaction with hard to reach young people.
Encouraging the young person to communicate for a variety of reasons
As noted in the introduction, a helpful framework is the Means – Opportunities – Reasons model. When promoting the expressive communication of young people with visual impairment and autism, practitioners need to ensure that they provide all three. This section focuses on encouraging the young person to communicate for a variety of reasons.
Typically developing babies, infants and young children communicate for different reasons and the range of reasons expands as they acquire more skills and experience. Quite quickly, they communicate for a wide variety of reasons which include
In fact, although the above are some of the observable reasons young typically developing children communicate, perhaps the most important one that most people, regardless of age, have is less obvious: most people communicate because doing so is a key element of establishing and maintaining relationships.
But, although that is a fundamental, underlying reason for most people to communicate, it is not a very likely reason for most young people with visual impairment and autism. This is because of the difficulties these individuals have with social understanding. There are other reasons to communicate (some of which have a clear social element) which are unlikely to be important for young people who have visual impairment and autism
Young people with visual impairment and autism may well communicate expressively in a purely functional way. The table below indicates the reasons that are probably the most important for this group. It also indicates some strategies that are potentially useful for encouraging young people with visual impairment and autism to communicate for those reasons.
In a practical sense, it is not possible to consider in isolation encouraging young people with visual impairment and autism to communicate for a variety of reasons. This is because the strategies that can be employed are some of those used in providing the young person with opportunities to communicate.
| Reason for communicating | Relevant strategies |
|---|---|
| To request items | Waiting
Feigning ignorance Sabotage |
| To request assistance | Waiting
Feigning ignorance |
| To seek information | Some verbal young people with visual impairment and autism seek information; they do so by asking questions, in some cases, repetitively. There is no direct strategy for encouraging young people to ask questions, but it is important to respond to the young person's questions in a positive manner |
| To protest | Sabotage Violating expectations |
| To reject | This strategy is considered separately, in the following section: enabling the young person to communicate "don’t want" . |
Of course, none of the strategies shown in the table above can be effective unless:
Enabling the young person to communicate "don't want"
Communicating "don't want" (i.e. rejecting) is given a section to itself because it is such an important reason to communicate: it enables the young person to reject items, events, activities and changes in routine that he / she does not want, does not like or cannot tolerate. Being unable to reject greatly increases the risk of being exploited and abused.
Some young people with visual impairment and autism behave in ways that challenge because they are unable to reject in any conventional way. Rejecting is a meaning that emerges early in the lives of typically developing children, and those who have visual impairment and autism should be supported to reject, i.e. to communicate "don't want".
One approach to this involves providing the young person with a symbol to represent "don't want". For a young person who has sufficient functional vision, this could be a pictorial / tactile symbol showing the item / event / activity in a black circle with a red diagonal line through it. There are disadvantages with such a symbol
To overcome this difficulty, a generic abstract / tactile symbol could be employed; this could be simply a black circle with a red diagonal line through it. For a young person who can read, "don't want" could be printed or brailled on a card as a large print / tactile alternative.
Providing the young person with the means to communicate "don't want" is necessary but not sufficient: the young person must also be supported to use the means provided.
One way of doing this is to use what is, in effect, the PECS approach, as outlined in promoting the ability to initiate: the young person would be shown how to exchange the symbol in return for having the item / event / activity / change in routine withdrawn. It would be essential for the young person to have constant access to this symbol and to be supported to use it in naturally occurring situations. On each occasion that the young person presented the symbol to a member of staff, that practitioner would have to respond to the young person's rejection in a positive manner by immediately withdrawing the item / event / activity / change in routine. Once the young person had become familiar with communicating "don't want" and had experienced the item / event / activity / change in routine being withdrawn on many occasions, it may be possible for practitioners to modify their response to the young person: instead of withdrawing the item / event / activity / change in routine, they might be able to use the "now / next" approach.
Another approach to enabling a young person to communicate "don't want" is to adapt the finished box concept which is often used in the TEACCH approach. In this case, the box would become a "don't want" box, and would be the means for the young person to communicate "don't want".
Practitioners would have to support the young person to use the "don't want" box. The following is a strategy for demonstrating the use of the "don't want" box and for practising its use
Once the young person is reliably using the "don't want" box in this structured setting, an attempt should be made to generalise its use to everyday settings. Practitioners must ensure that the "don't want" box is always available to the young person, at least when the item / event / activity / change were presented (if not at all times). It may also be necessary to support the young person to generalise his / her use of the "don't want" box to several practitioners.
The "finished box" strategy described above focuses on presenting items to the young person. A modified approach is required for events, activities and changes in routine, as these cannot, of course, be placed in the "don't want" box. Events, activities and changes in routine need to be represented using some kind of augmentative system; this might be objects of reference, pictorial / tactile symbols, abstract / tactile symbols, or large print / tactile alternative.
There are significant difficulties with this approach. For example
If a particular item / event / activity / change in routine is known to cause significant stress / anxiety / overload, the most empathic approach is to avoid the trigger of presenting it.
Practitioners do not use any kind of "don't want" symbol or "don't want" box with any of the young people featured in the case studies in this guidance material.
No matter how a young person communicates "don't want" (i.e. rejects), it is essential that practitioners respond to his / her rejections in a positive manner.
Promoting the ability to initiate
Although it is essential to promote expressive communication, it can be very difficult to do so in young people with visual impairment and autism. This is because initiating – i.e. communicating spontaneously – is so challenging for them, and promoting the ability to initiate so challenging for practitioners. Yet the ability to initiate is absolutely fundamental to being a competent expressive communicator. Expressing needs and desires, and rejecting unwanted items / events / activities are crucial, basic reasons to communicate; but they require the ability to initiate, to be spontaneous.
Without the ability to initiate, to be spontaneous, you have little control over your life
Promoting the ability to initiate is therefore seen as an essential element of promoting expressive communication in young people with visual impairment and autism.
For practitioners, a crucial skill in promoting the ability to initiate is that of waiting. Many practitioners find it difficult to wait. This is because it can feel very abnormal. Some practitioners feel they are doing nothing while they are waiting, and therefore feel uneasy or embarrassed. The fact is that these young people require practitioners who wait; this is not doing nothing, this is promoting the ability to initiate. Waitingis also a crucial aspect of
An approach worthy of consideration is the Picture Exchange Communication System (PECS), which is an effective method of promoting the ability to initiate in sighted autistic young people. As the name implies, the standard PECS approach uses pictures. But PECS is something of a misnomer, as it can be employed with young people who use other means of communication. Thus PECS can be employed with young people who have visual impairment and autism, using objects of reference , TOBIs, pictorial / tactile symbols , abstract / tactile symbols or even large print / tactile alternative.
It should be stressed that PECS is not a means of communication – it is, essentially, an approach for providing opportunities to initiate communication for requesting. In the early stages, this is achieved by making the young person aware that an item he / she finds very motivating is available, and then demonstrating that he / she can obtain that item by exchanging a picture (or non-visual alternative) for it.
Some research focussed on the use of PECS with visually impaired people has been published; see Ali et al. (2011), Finkel et al. (2004), Lund and Troha (2008) and Parker (2009).
Promoting the ability to initiate is necessary, but not sufficient. Alongside this, it is vital to
Jasper initiates during music lessons: he requests songs, using objects of reference. In each lesson, he has access to several objects of reference which he uses to communicate expressively. These objects include
The young people in Jasper's class are encouraged to request songs and are given turns to make their requests. Jasper requests songs using his objects of reference when he is asked which song he would like. In addition, he sometimes spontaneously presents a member of staff with one of his objects of reference, even when it is not his turn. As Jasper spontaneously uses the objects of reference and shows gratification when the song he has requested is sung, it is assumed he has made the link between the object and the song.
Providing a responsive environment
The most essential factor in successfully promoting expressive communication is the provision of a responsive environment. It is vital to respond positively to the young person in order to convey the message that communicating is worthwhile – in other words, that it works. In the current context, a responsive environment is one in which the young person
For more information on responsive environments, see Ware (2003).
Following the discussion here are several sub-sections covering additional key elements of providing a responsive environment. These deal with
Many young people with visual impairment and autism are passive. When supporting a passive individual, there is a tendency to believe that the young person will only learn by being stimulated as much as possible. But, as far as communication is concerned, frequently encouraging, stimulating or prompting the young person is counter-productive. This is because it removes the very things that are essential: the opportunities to take the initiative, to communicate spontaneously. Rather than frequently encouraging, stimulating or prompting the young person, practitioners should wait.
Waiting is a crucial strategy but one which many practitioners find difficult. This is because it can feel very abnormal. Some practitioners feel they are doing nothing while they are waiting, and therefore feel uneasy or embarrassed. The fact is that young people with visual impairment and autism require practitioners who wait; this is not doing nothing, it is a crucial aspect of
An effective strategy that involves Waitingand contributes to provide a responsive environment is to ALLOW.
ALLOW =
Observing the young person (by looking and listening carefully) enables the practitioner to gain knowledge about the individual's behaviours. This knowledge can then be used to decide which behaviours are communicative and thus require a response. It can also be used to decide which behaviours, whilst not currently communicative, could become so. These behaviours also require a response.
Observing the young person involves constantly monitoring the individual. It is important to monitor the young person's behaviour and moods in order to identify raised levels of stress and anxiety and thus to promote emotional wellbeing, and to promote positive behaviour. Having identified raised levels of stress and anxiety, it is essential, of course, to respond appropriately. In other words, it is essential to provide a responsive environment. Both monitoring the young person and responding appropriately require the practitioner to know the young person really well ; this enables the practitioner to view the world from the young person's perspective.
Practitioners need to view all the young person's behaviours and changes in mood as potentially communicative; practitioners should continuously ask themselves the questions
Staff must agree about the meaning (or potential meaning) of the young person's behaviours and moods and ensure their responses are consistent.
All the young people featured in the case studies in this guidance material are provided with a responsive environment. This is illustrated here with reference to the following young people: Jivan, Ali, Winnie, Sarah, Archie and Bob.
Staff provide a responsive environment for Jivan by responding to all his behaviours that appear to be communicative
Jivan is also provided with daily interactive music sessions based on Intensive Interaction.
Ali experiences a responsive environment. This means, for example
However, even staff who are expert at providing a responsive environment are not always able to interpret a young person's behaviour or moods. This is the case with Winnie. Her intentional expressive communication skills are very limited, consisting only of her producing the sign "me". She uses this to convey a variety of meanings. On any particular occasion, it is necessary for the practitioner to interpret what she means; for example, depending on the context, Winnie is thought to use this sign to
Winnie only initiates to seek attention; when the teaching assistant (TA) responds to Winnie on these occasions, she often feels Winnie is trying to express a need or desire and attempts to establish what she wants by asking her questions such as:
The TA always asks Winnie first if she wants to eat as she becomes very irritable when hungry; this can escalate into biting or hitting herself, and, occasionally someone else.
Sometimes, having worked her way through all the questions she can think of, the TA still does not know what Winnie wants; she is then left with the impression that she has not asked the right question. This, of course, is very frustrating for the TA and, sometimes, for Winnie.
However, despite the difficulties described here the provision of a responsive environment has been successful. In providing her with a responsive environment, staff use Intensive Interaction. Observations show that Winnie has made progress during these sessions.
Staff support Sarah's expressive communication by providing a responsive environment. They observe Sarah closely and aim to respond to as many as possible of Sarah’s behaviours that are, or have the potential to be, communicative. For example when Sarah:
Sarah apparently engages willingly in sessions which promote sensory understanding using Tacpac®. During these sessions, Sarah frequently communicates with the member of staff supporting her, using single words and short phrases. For Sarah, it is possible to view the provision of TacPac® sessions as being an element in providing a responsive environment to promote expressive communication.
In effect, Archie is provided with a responsive environment as part of the strategy for responding positively to his repetitive questioning which is described in responding to the young person's questions in a positive manner.
It is essential that the practitioners working with Bob understand when it is not appropriate to initiate communication with him. They no longer speak to him when he is
They are thus providing Bob with an appropriately responsive environment. It is particularly important that staff monitor Bob's levels of stress and anxiety. His behaviour provides a reliable way of doing this
Providing a responsive environment not only requires practitioners to monitor the young person's behaviours and moods; it is also necessary to monitor the environment and respond appropriately.
Using Intensive Interaction
For young people in the very early stages of acquiring communication, Intensive Interaction can make an important contribution to the provision of a responsive environment. Intensive Interaction is an approach to promoting the acquisition of the pre-spoken language fundamentals of communication.
One aspect of the responsive environment provided for Winnie is sessions in which staff use Intensive Interaction. These sessions enable staff to focus on interacting and communicating with Winnie. Staff believe the use of Intensive Interaction has resulted in Winnie now engaging in brief turn-taking "conversations" of up to three turns.
On occasions, a resonance board has been used in these interactive sessions. A resonance board is a slightly raised platform on which young people and practitioners can sit, lie, or place a hand, arm, foot or leg. The board can be tapped, or a musical instrument can be played on it. The vibrations provide young people with additional sensory information which many really enjoy. The staff who support Winnie believe the use of the resonance board has helped to raise her awareness of her peers, and has encouraged her to respond to them. This is described in using a resonance board to promote peer relationships.
Jivan is provided with daily interactive music sessions in the school's music studio. As described elsewhere, these are individual sessions with the teaching assistant, and are provided when his peers have assembly.
Using Intensive Interaction can contribute considerably to
Intensive Interaction is typically provided in sessions set aside specifically for the purpose. However, there are some drawbacks with this approach, which are discussed in the following two paragraphs.
Intensive Interaction sessions can only be effective if the young person is receptive and is able to participate. Many young people with visual impairment and autism experience wide mood swings. This means there are times when it is inappropriate to provide an Intensive Interaction session, as the individual will be unable to participate. Considerable flexibility may be required with regard to the timing of Intensive Interaction sessions. Practitioners should monitor the young person closely, providing Intensive Interaction sessions as often as possible when the individual’s mood indicates that he / she will be communicative. Practitioners should not go ahead with planned Intensive Interaction sessions if the young person’s mood indicates that he / she is not likely to be communicative. Practitioners should also be prepared to terminate a session if it becomes clear that the young person is not communicative, or if the young person communicates a wish to terminate the session.
The skills promoted during Intensive Interaction sessions are appropriate at all times, in all situations and with all other people. Unfortunately, young people with visual impairment and autism do not readily generalise what they learn in one situation to other situations. Practitioners therefore need to ensure that they use the strategies employed in Intensive Interaction sessions as much as possible at other times and in a wide variety of other situations. It is also advisable for all members of the team to employ Intensive Interaction strategies, to reduce the risk that the young person only communicates with one person, and to promote the generalisation of skills across as many people as possible.
Practitioners who become skilled at using Intensive Interaction learn how to embed the strategies in all their practice and use them at all times.
Practitioners who provide Intensive Interaction successfully are, in effect, providing a responsive environment.
Responding to the young person's requests in a positive manner
It is important to understand that providing a responsive environment does not mean always giving the young person what he / she wants. However, it can be difficult to explain to an individual with visual impairment and autism why it is not possible to grant his / her request. Practitioners are advised to avoid the use of negatives. This is because words such as "no," "don't," and "can't" only tell the young person what not to do; this is unhelpful. Young people with visual impairment and autism need very clear information about what they should be doing. This is explained more fully in providing clear boundaries which inform the young person of what is acceptable behaviour. Examples are given there of rules which are expressed in positive terms, avoiding the use of negatives.
In fact, the word "no" should also be avoided because it is a trigger for some young people with visual impairment and autism; it can result in the individual going into crisis. For some young people, this may result from associating the word "no" with unpleasant past situations, such as being reprimanded, or denied a favourite activity or item.
Using the "now / next" approach (see next section) is often very useful in responding to the young person's requests in a positive manner.
Using the "now / next" approach
Young people sometimes request something that the practitioner does not wish to, or cannot, provide at that time. For example, Bob likes to use the stapler in the school office, but cannot do so if it is already in use or when he has a lesson. On such occasions, the member of staff redirects Bob, using the "now / next" approach.
If someone else (e.g. Jo, the school administrator) is using the stapler, but will very soon finish, Bob is told, for example, "Jo now, Bob next."
If the other person needs to use the stapler for some time, and Bob would have to wait too long (he cannot wait for more than about a minute), he may be directed to another activity which he likes, or at least tolerates; for example, he is told "playground now, stapler next."
However, if Bob has a lesson, he is told "work now, stapler next."
If Bob is told "playground now, stapler next " or "work now, stapler next," the member of staff must ensure that Bob can use the stapler as soon as "playground" or "work" has finished: it is important to ensure than all events the young person is informed of in advance do actually happen.
Staff avoid responding "no" to Bob's requests because this does not give him sufficient information: it does not tell him when he can use the stapler. (See further responding to the young person's requests in a positive manner above.)
In addition, Bob associates the word "no" with unpleasant situations, such as being reprimanded in the past. (He is never reprimanded now.)
Staff also avoid giving Bob non-specific answers such as "later". Again, this does not really inform Bob of when he can use the stapler: "later" is non-specific and fluid; it could mean two minutes or two hours.
Because of Bob's literal understanding, practitioners also avoid saying "in a minute". If a young person requests an activity that is to occur later in the day, it may be appropriate to use his / her timetable to explain when that activity will occur. If the young person's understanding of time is such that he / she cannot conceive of an activity occurring several hours in the future, the most appropriate strategy might be to simply redirect him / her to the current task: e.g. "Literacy now."
The "now / next" approach is useful when the young person refers to the activity which follows the current one. For example, if snack time follows a literacy lesson and the individual communicates "snack" during the literacy lesson, it may be helpful to respond "Literacy now. Snack next." If possible, this should be augmented as appropriate. For example, if spoken language is augmented with objects of reference, the object representing "literacy" could be presented, quickly followed by the object representing "snack." If spoken language is augmented with tactile versions of abstract symbols, these could be used in conjunction with a Now / Next card; the symbol representing "literacy" would be placed on the "Now" side, with the symbol representing "snack" on the "Next" side.
When using the "now / next" approach, it is important to refer to activities in the sequence in which they occur: for example, "Maths now. Play next". Mentioning activities in reverse order might be very confusing to the young person. Thus "Play next. Maths now" should be avoided.
There are variations of the "now / next" approach, including
The use of "first / later" should be avoided; as noted above, "later" is non-specific and fluid; it could mean two minutes or two hours.
The precise words employed probably do not matter; the essential features of the approach are
Responding to the young person's rejections in a positive manner
Rejecting items, events activities and changes in routine that you do not want, do not like or cannot tolerate is an extremely important skill. It is essential that practitioners respond in a positive manner when young people with visual impairment and autism communicate that they are rejecting something.
However, this is not always easy; many young people in this group have very significant difficulty rejecting
Those who resort to challenging behaviours probably do so because, in the past, their attempts to reject have not been understood, or have received negative responses.
Young people with visual impairment and autism cannot readily understand or predict the behaviour of other people. It is essential, therefore, that practitioners build close relationships with each young person so that he / she comes to trust them. A key element of this is being consistent, predictable and responsive; responding in a positive manner to the young person's rejections is part of this.
In order to promote positive behaviour and promote emotional wellbeing, practitioners need to respond positively to the young person's behaviour and moods. This requires practitioners to identify the young person's attempts to reject items / events / activities / changes, especially when these attempts are very idiosyncratic; this means practitioners need to know the young person really well.
Practitioners must respect the young person's rejections by immediately withdrawing the item / event / activity / change in routine concerned. Not withdrawing the item / event / activity / change in routine is equivalent to giving the young person the idea that communication is not worthwhile; the likely outcome is a frustrated young person who escalates his / her behaviour until it is impossible to ignore it.
On occasions, the young person may be very stressed / anxious / overloaded when rejecting an item / event / activity / change in routine. When this occurs, it is essential that the practitioner withdraws the item / event / activity / change in routine immediately. This should be followed as soon as practicable by employing a calming strategy (see promoting emotional wellbeing).
If a particular item / event / activity / change in routine is known to cause significant stress / anxiety / overload, the most empathic approach is to avoid the trigger of presenting it.
Sometimes a young person rejects an educational activity or a care routine; it is very difficult for practitioners to respond in a positive manner to such rejections, as these events / activities are regarded as being in the best interests of the young person.
Using the "now / next" approach may be effective in such situations. When employing this approach, the event / activity presented "next" should be one the young person finds very motivating. An educational activity that the young person rejects should last for only a very short period and should always be followed with a space before any other educational activity is presented.
If possible, practitioners should enable the young person to communicate "don't want" in an acceptable way that can be readily understood. Responding to the young person's rejections in a positive manner will still be important once he / she has a clear and acceptable means of communicating "don't want".
Responding to the young person's questions in a positive manner
It is particularly important that practitioners respond truthfully and consistently to the questions of a young person with visual impairment and autism. This is because it will help to them to become predictable for the young person and will contribute to building the young person's trust.
Responding in a positive manner to questions also requires practitioners to take account of the individual's receptive communication skills by adjusting the language used. Key elements of this are
Repetitive questioning is quite common amongst verbal young people with visual impairment and autism, but facilitating more functional skills in these individuals can be very difficult. In addition, repetitive questioning can be very irritating for the practitioners involved, and for the young person's peers; they may hear the same question or set of questions very many times over the course of each day. Identifying the reason(s) a young person asks questions over and over again can be very difficult. Yet this may be an important first step in reducing, or even eliminating, this behaviour.
For a more detailed discussion of repetitive questioning, see Kehoe (2012).
Archie has a history of repeatedly asking staff questions about the next activity. This infuriates his peers who constantly tell him to be quiet. The practitioners who support Archie believe his repetitive questioning is related to anxieties about what will happen next. To reduce Archie's anxiety about forthcoming events, he now has a tactile timetable , a component of the TEACCH approach. This seems to have resulted in a reduction in Archie's repetitive questioning.
In addition, staff only respond to Archie’s first question about the next activity. They do so by physically prompting him gently towards his timetable whilst saying "Check timetable". The member of staff provides as little physical prompting as possible and says "Check timetable" quietly. The intention is to fade these prompts completely in time, to avoid prompt dependency, and to promote independence. In addition, staff make a particular point of giving Archie positive attention when he initiates a conversation about other topics: they respond conversationally to him and attempt to maintain the conversation.