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(#49)  CI:  The BEST Strategy to Teach Imitation [By Mary Lou B. Johnson, Guest Blogger]

Greetings, SLP!

We covered “imitation” a few weeks ago, and I thought we were moving on.
 
But immediately after the#45 Therapy Matters blog on Imitation was published, I received an email that blew my socks off.
 
The intriguing email was from Mary Lou, an experienced, and from what I could tell, a highly competent SLP.
 
I had posed a question in #45: “What’s a therapist to do if the child doesn’t readily imitate and he doesn’t produce speech sounds?”
 
She answered it brilliantly. Her technique is simple and effective. She says she’s able to get most low-verbal children to imitate quickly with her systematic strategies. She has used this method extensively and has taught it to others with great success.
 
I couldn’t pass up this opportunity to share it with you. I asked her to write a guest blog describing her imitation technique, and bless her, she did. In her own words, here’s Mary Lou B. Johnson detailing how to doConditioned Imitation (CI).
 
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Hello! It’s a treat to contribute a technique to Char’s substantial and supportive posts.
When I read Char’spost #45, I felt something was missing from the list of six methods presented in the literature review article. I immediately thought of the method I’ve used for decades to elicit imitation directly. This method has not been the subject of a research project, and I doubt there’s published evidence for it. All I can suggest is you treat it as a single-subject experiment and decide if it is sufficiently productive to use with individual children.
 
I call this methodConditioned Imitation (CI). The wordconditioned comes from operant conditioning, first described by B.F. Skinner, an American psychologist. Operant conditioning is used to strengthen a desired voluntary behavior or weaken an undesired voluntary behavior. In CI, we use reinforcement to strengthen the child’s attempts to vocalize and move his articulators to shape speech sound production.
 
When evaluating young children under 4 years of age, how often have you heard a parent say her child does not imitate or uses no words or very few words? When I heard this, I always wondered if it was speech production (articulation) difficulty that was inhibiting the child’s ability to demonstrate his expressive language skills. Using CI during treatment as well as assessments often exposes possible motor planning difficulties. A child’s responsiveness to the method also gives an indication of his attention skills, developmental level, and cognitive abilities.
 
I use the CI method with children at least 24 months of age. I will sometimes try it with especially aware/alert 18 to 24-month-olds. However, if the younger ones can’t “get” their imitative role, I tell the parents their child is not ready yet for this direct imitative task.
 
I view the training of elicited imitative behavior, especially verbal imitation, to be a bridge to shaping spontaneous imitation in a young child. Following are a few benefits of CI I’ve witnessed through the years:
  • For a child who has not become a natural (spontaneous) imitator, the CI method can give a valuable nudge.
  • For a child who uses his voice infrequently, his productions during CI help him realize that he can vocalize at will.
  • For a child who is tentative about “getting started” in a session, CI can be a productive ice-breaker activity.
  • For a child, such as a child with autism, who prefers to control everything, CI can become a routine, accepted shared activity. For parents observing this method during an evaluation or treatment visit, a child’s productions of previously unheard sounds, syllables, or words can convince the parent that something therapeutic is happening, and it can provide a beginning glimmer of hope that the child will learn to speak or speak better.
 

Instructions

Please note:TIMING is a critical piece to the success of this technique.
 
Sit close to the child, face-to-face, on the floor; enlist the parent’s help
If you want the parent’s help and/or the child needs to have the parent close, ask the parent to sit beside and slightly behind the child. If a parent wants to hold her child on her lap, I gently request that the child sit independently on the floor. The child will be more open to engaging with me. Ask the parent to be your assistant in the task.
 
Have materials ready
You need a toy that has many pieces or parts. I prefer to use “pop beads” that have pieces that connect. Fisher-Price calls them Snap-Lock Beads. There are other brands, too. You might choose to use other toys, such as an open can for a shape sorter and have the child simply drop in the blocks. Or, a child could use blocks with holes and put them onto posts.
 
Whatever you use, the child receives the toy, then gives it up fairly quickly so he is ready for the next item. To maintain interest, make sure the activity moves along at a good pace.
 
Also, have ready a pre-made list of stimuli(click here for my CI Checksheet-Chart) you plan to present and elicit. Of course, have a pen or pencil handy. It’s best to be prepared to plunge in and keep the activity going without interruption to keep the child “in the groove.”
 
Smile and begin engaging the child
Entice the child to want the toy. Keep the item in view but out of easy reach, so she can’t grab it. You don’t want a tug of war, but you also don’t want the child to think you are intentionally withholding the toy.
 
To start the activity, I hold a section of about 8 pop beads and lightly shake it so the top bead wiggles.
 
Important: Here comes the first timing issue—as soon as the child begins to reach for the bead—and not before—give the first stimulus. Always wait for the child to reach toward the object. If this doesn’t happen, giving a stimulus to imitate is useless. The child must show interest in the item so you know he is focused on you and the task. Wait for engagement.
 
The first presentation is a “freebie” without any condition for performance. This simply rewards the child for being interested in the task and reaching for the object.
 
Prompts are always stated as, “Do this”
Always say the generic prompt, “Do this,” rather than telling the child specifically what to do.
 
The first imitative targets are non-verbal motor tasks
If need be, physically assist the child to move him through the non-verbal motor tasks. Non-verbal motor tasks are used first, prior to verbal tasks, because they are bigger, more tangible, more visible, and can be guided physically, unlike most oral tasks.
 
IMMEDIATELY REWARD an assisted or volitional attempt at compliance
Reward the child by quickly handing the toy to the child. Smile and offer approval, such as, “Yay!” “That’s it!” or “You did it!”
 
Continue the task progression
Establish volitional clapping first. Some children will understand right away. When the child succeeds, repeat the clap stimulus for 3 trials to be sure the child really understands what is expected. Then, move on to the next one, head patting. Some children will clap again, thinking that’s the only task, or they clap to receive the toy. You may have to physically assist them one or more times to note the change. Next, provide the third non-verbal target.
 
Advancing from physical movements to oral movements
After the first three physical movements, the stimuli advance to the mouth: Blow air. If you have pop beads, blow into the little hole on top to make an enticing sound. Then hold the bead close to the child’s mouth to imitate blowing. Also, use the top connected pop bead as a simulated microphone to signal to the child that it’s his turn. If this input is insufficient, hold the back of the child’s hand in front of your mouth so he can feel the air. Then hold his other hand in front of his mouth to feel his own airflow. This also indicates it’s his turn.
 
The next stimulus, the voiceless prolonged “h” is prompted with an open palm in front of your mouth, not blocking the child’s view. Please note: Donotpresent this as “ha”; it dramatically changes the task. It adds a voiced vowel to a voiceless consonant, which may be too difficult for a child to sequence at this point. Keep it a voiceless “h.” Take the same precaution as you say other voiceless consonants on your list.
 
If the child is able, move on to the voiced lax vowel “ah.” Place your fingers lightly against your throat over your larynx. Guide the child to feel your vibrations and his, if needed. At this point, many children do not need the additional tactile cues.
With a responsive child, continue to present the items on your list, just one time each, moving along to accomplish as many targets as possible before the child fatigues.
 
Maintain attention and focus; or conclude
To keep the child interested in this activity for as long as possible, have fun with it. Make a big deal about the “pop!” when the bead is pulled off. Fake groan if one bead is hard to pull off, and so on. Make the task a fun engagement, not a dull drill.
 
If you detect the child is losing interest, such as taking longer to reach for the next toy, stop the task before the child turns away. In other words, end the activity on your terms, if possible. Try to get “just one more” compliant act, such as by returning to an easy item, like clapping. Offer a big smile and praise for the child’s accomplishments. Let him wear the full hoop of beads as a necklace, or momentarily play with the blocks, or simply move on to another toy or activity.
 
Additional suggestions and ideas
Some children will not figure out the first imitation task of clapping. Ask the parent to help the child clap with full hand-over-hand assistance. Reward immediately, as indicated above.
 
Guide the parent to offer less and less help over the trials by just tapping the child’s elbows or wrists to nudge movement. Also, reward the child even if he barely touches his hands together. Keep in mind “successive approximations.”
 
If the child hasn’t figured out the task after about ten presentations, consider stopping and present the task another day. Try to figure out why the child is not performing the CI task. Does he look confused? Is he inattentive? Is he not capable? What is the reason?
 
What to do when he stops after the first three tasks
A child—even a very young child—may be aware that his mouth isn’t working well. He may resist trying anything that involves his mouth. If he balks at progressing past the first three non-verbal tasks, try anything: lip smacks, a hum-like sound (/mmmm/), or a sound or phonation you know he is able to do.
 
If he turns away, suggest he do “just one more” and give the clapping stimulus. Always try to end on a positive note so he wants to do it next time.
 
The parent’s role in spontaneous imitation
Personally, I like to preserve the CI method for use in therapy. The success of this method is highly dependent on keen observations of the child’s behaviors and the timing of the tasks. Because of these parameters, I typically ask parents not to try to replicate this activity at home.
 
Instead, I then teach parents how to elicitspontaneous imitation. I guide parents to:
  • Make interestingcomments in statement (declarative) form.
  • Significantly reduce the number of direct questions they ask their child.
  • Pause and wait to give the child a chance to speak.
  • Take turns talking!
It takes several sessions to shape changes in parental language.
 
I hope you will give the CI method several tries. See if you like it and if it works for you and your kids. I hope you make it a part of your tools to help children vocalize and verbalize. It is a valuable technique for eliciting new speech sounds, syllables, and words.

 

About Mary Lou B. Johnson, M.S., CCC-SLP

Mary Lou earned her M.S. in Speech & Hearing from the professional training program at Central Institute for the Deaf (CID) which was affiliated with Washington University in St. Louis.
 
She learned the Conditioned Imitation method from Frank R. Kleffner, Ph.D., who was the director of the speech clinic in the program, as well as a master clinician, and, eventually, an ASHA president.
 
When she graduated, she became a CF at Children’s Hospital Colorado, and remained within that system for the next 42 years. She used the CI method with great success while working in seven different locations of outpatient clinics.
 
After “retiring” a year ago, Mary Lou continues to work with children in private practice. And in a few months, she proudly launches an online course for parents called, “Parents: Power Up to Boost Your Child’s Speech.” The coursewill go live this springatwww.help-your-child-speak.teachable.com. Also, friend her new Facebook page when it launches soon: Help Your Child Speak.

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