63 Communication Intervention in an Adolescent with Profound Cognitive Impairment and Autistic Features Ilze Pansegrouw and Erna Alant Department of Communication Pathology University of Pretoria ABSTRACT The service delivery model currently used with a large proportion of profoundly cognitively impaired (PCI) persons, results in the under-utilization of their potential and often contributes to social isolation. By providing communication and inde- pendence training the self-actualisation potential and the right to power and control, is recognised. This single case study describes the implementation of a communication intervention model with a PCI adolescent. His mother was trained in the use of picture symbol task analysis as well as positive reinforcement to promote change in the adolescent's communication skills and independence. Results indicated significant changes in the skills of both participants and highlighted the moth- er's need for support to meet the demands of change. OPSOMMING Diekenmerke van die diensleweringsmodel by 'n groot persentasie kognitief erg gestremde (KEG-) persone, resulteer dikwels in die onderbenutting van hul potensiaal en vir sommige in sosiale isolasie. Deur die voorsiening van kommunikasie- intervensie en onafhanklikheidsopleiding word in die selfverwesenlikingspotensiaal van die KEG-persoon voorsien en word sy/haar selfhandhawingsregte erken. Hierdie enkelgevalstudie beskryf'n kommunikasie-intervensiemodel wat by 'n KEG- adolessent toegepas is. Die moeder van die adolessent is in die gebruik van prentsimbooltaakanalises en positiewe versterking opgelei met die oog op verandering by die kommunikasievaardighede en onafhanklikheid van die adolessent. Resultate het betekenisvolle verandering in die doelstellings van die studie aangetoon en die ondersteuningsbehoeftes van die moeder ten opsigte van die eise wat verandering meebring, is beklemtoon. KEY WORDS: profound cognitive impairment (PCI), communication intervention, independence training. INTRODUCTION Due to limited provision of services and facilities the needs of a significant proportion of cognitively impaired persons (CIP) are not being met (Alant & Emmett, 1995). Services such as speech therapy are often not accessible due to beliefs that poor progress in therapy indicates that these persons do not benefit'from such therapy (Calcula- tor, 1988a). Consequently, a large percentage of CIP per- sons reside in segregated "special-care" units where total physical care is the only form of service provided (Lea, 1990). In addition, parents of those who reside at home report a lack of formal an informal societal assistance such as respite care to relieve caregiver stress (Singer & Irvin, 1991). The results of limited services to both parents and CIP Persons are far-reaching. It is known that the clinical pic- ture of a large proportion of these persons relates to the nature of service delivery and the intervention approach (Lea, 1990). The intervention approach to profound cogni- tive impaired (PCI) persons (I.Q. 20 and less) is clearly demonstrated in the categorisation of these persons as "untrainable" (Grover, 1990). The term "untrainable" im- plies that the person does riot have the ability to benefit from education or training and is therefore dependent on total physical care (Koordineringskomitee: Jaar van Gestremde Persone, 1987). These persons represent ap- proximately l%-2% of the cognitively handicapped popu- lation (Subcommittee on Mental Retardation, 1987a). Clinical features include the description of a high percent- age of self injurious and socially unacceptable behaviour, as well as low motivation relating to the development of independence skills (Sailor & Guess, 1983). Language and communication impairment represent the most pervasive problem of the majority of PCI persons and have been linked to the high incidence of severe behavioural prob- lems in this group of people (Durandt, 1990; Yoder & Villarruel, 1988). Due to frequent impairment in motor abilities, functional speech skills are often severely lim- ited (Sailor & Guess, 1983). Apart from the individual's inability to communicate, however, the inability to respond to the interaction attempts of primary caregivers often results in the gradual reduc- tion of primary caregiver attempts to interact with the im- paired person. This leads to low caregiver expectations re- garding communication from the impaired person, reduced opportunities to support the development of language, com- munication and social skills and results in severe difficulty Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 43, 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 64 Ilze Pansegrouw and Erna Alant in forming or participating in even the most basic social relationships (Kirchener, 1991). Primary caregivers often compensate and adapt to the impaired person in a way that contributes to the development of "learned helplessness" (Yoder & Villarruel, 1988). Learned helplessness is seen in the anticipation of all needs of the impaired person and results in low demands for communication and low partici- pation in domestic activities and household routines. These features result in reduced social environmental integration of the impaired person. One of the most important indicators of the quality of life, is the extent of a person's social integration (Haring, 1991). From the above discussion the following principles of com- munication intervention can be formulated. These princi- ples provide important criteria for successful intervention with PCI persons: - Quality of life is determined by the extent to which the person is socially integrated in his daily environment. Independence skills provide opportunities for active par- ticipation in daily activities and routines within the en- vironment (Haring, 1991). - The quantity and quality of communication interaction between the PCI person and the environment, relate closely to the communication skills of the impaired per- son. The PCI person cannot be viewed apart from his/ her daily environment; this person is viewed as one com- ponent of the environment in which he lives and spends most of his time (Gottlieb, 1988). - The above implies that the term "client" comprises both the impaired person and his environment. In the following, the application of the aforementioned principles to develop a model for communication interven- tion with a PCI person, is discussed. PROPOSED MODEL FOR INTERVENTION In this study a communication intervention model was developed to address the principles and important criteria I PRIORITY SKILLS Ψ SOCIAL SUB-SKILLS INDEPENDENCE SUB-SKILLS I I - Communication skills - * A.D.L. ALL FAMILY/OTHER ENVIRONMENTS CAREGIVERS I 4 DAILY ENVIRONMENT PRIMARY CAREGIVER I I PRIORITIES PRIORITIES AND SKILL I I PREDICTABILITY PSYCHOLOGICAL AND SECURITY SUB-SKILLS CONTEXT AND RESPONSIVENESS I SUB-SKILLS I I - Homeostasis - Social isolation and stress - Action and discourse - Skills related to communication and training ν PROGRAMPLANNING KEY: * A.D.L. = Activities of Daily Life * PCI PERSON = Profound cognitive impaired person FIGURE 1: Client approach: Communication intervention model The South African Journal of Communication Disorders, Vol. 43, 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) £ o i n i n u n i c a t i o n Intervention in an Adolescent with Autistic Features for intervention with PCI persons. This model is presented in Figure 1. Figure 1 provides criteria to identify the daily environment and the primary caregiver as well as priority skills that were identified for the client. Central to this model is the concept of quality of life, thus the facilitation of social interaction and the develop- m e n t of independence for active participation within this c o n t e x t . T h e functioning of the person is the product of in- t e r a c t i o n between the person and the environment ( E h r e n & Lenz, 1989). Figure 1 demonstrates a clear distinction between the family or other caregivers and the primary c a r e g i v e r as well as between the daily environment (where the person spends most of his time) and other environments w h i c h he might visit on occasion. The primary caregiver is identified as the person with whom the PCI person has a high frequency of contact, who elicits a high frequency of communication initiations and responses from the person and with whom there exists a strong affective bond (Owens & Rogerson, 1988). For obvi- ous reasons, this would be the most important starting point in intervention. Figure 1 demonstrates that for the PCI person, social integration, i.e., the acquisition of communication skills and becoming independent within this context, is a high prior- ity. The extent of the person's ability to develop stable so- cial relationships in order to achieve active social integra- tion within the daily environment, provides and indication of the needs for support of the person. The development and maintenance of active, social integration is dependent on functional communication skills which Eire prerequisites for the development and maintenance of social integration (Rustin & Ruhr, 1989). It follows that PCI persons, who often do not develop functioned speech production skills and who do not have access to AAC (Augmentative and Alter- native Communication) methods, will experience severe difficulty in forming and maintaining social relationships with others in the environment if support in the form of communication intervention is not provided. Similarly, skills related to Activities of Daily Living (ac- tivities occurring frequently and that Eire essential for the maintenance of hygiene arid order within the daily envi- ronment) determine the level of independence within the daily environment (Eshilian, Haney & Falvey, 1989). Homeostasis (see Figure 1) within the daily environment refers to environmental attempts which aim at creating predictability and security to maintain the existing struc- ture and order of the environment (Lund, 1986). Radical change of environmental homeostasis (such as change as a result of intervention) poses a threat to environmental pre- dictability and security and if not managed sensitively, can result in resistance to change (Conti-Ramsden, 1985). Ac- tion and discourse routines on the other hand, refer to fre- quently occurring, highly predictable action or conversa- tion events that, once they begin, unfold in the same man- ner each time they occur (Lund, 1986). Action routines thus refer to an event such as ball play where the action forms the main activity between the persons involved while dis- course routines refer to an event such as greeting where the conversation forms the main activity between the per- sons involved. Routines play an important role in the main- tenance of homeostasis and are equally important to the development of social and communication skills (Rowland & Stremel-Campbell, 1987). When looking at the primary caregiver, it can be seen in figure 1 that the psychological context, as well as skills Profound Cognitive Impairment and 65 n r i n i ? t ° . C a ; i ! g i v e : responsiveness training are deemed priorities in this intervention model. Socially constructed factors and processes are often the cause for the primary caregiver s social isolation and stress (Lea, 1990) Social isolation and associated stressors are found in the pres- ence of stigmatisation and limited support services (Lea 1990; Helm & Kozloff, 1986). Limited knowledge and skill can, amongst others, result in counter productive interac- tion patterns such as limited primary caregiver responsive- ness (Calculator, 1988b). Primary caregiver responsiveness is acknowledged as a key factor in the development of in- teraction and communication for the PCI person (Girolametto, Greenberg & Manolson, 1986). In consider- ing responsiveness, the skills of the primary caregiver in terms of how much communication is expected of the PCI person and whether utterances directed at the person are interaction and discourse orientated, are taken into account (Siegel-Causey & Downing, 1987). It is against this background that a study was conducted to explore the applicability of the above model of communi- cation intervention for a PCI person adolescent with autis- tic features. Specific priority skills and other skill areas were identified according to the model described in Figure 1. METHODOLOGY AIMS OF THE STUDY The main aim of the study was to develop a communica- tion intervention programme for a PCI person by means of identified priority skills. The sub-aims were three-fold: Firstly a pilot study was conducted to identify the needs of the subject and his mother relating to priority skills, to conduct an intervention trial and to develop relevant intervention materials. The second sub-aim was to implement the programme that was devel- oped by describing the communication of the mother and her skills at training the subject and to describe the com- munication and independence at performing action routines, of the subject. The third sub-aim was to describe the re- sults of identified priority skills of the subject and his mother during the six week intervention period as well as the ef- fect of the withdrawal of intervention during week six. RESEARCH DESIGN A quasi-experimental single case study with a multiple baseline (ABA) design with withdrawal was selected for use in this study. The multiple baseline design for the mea- surement of change in behaviour patterns is well suited to execute ABA comparisons (Kearns, 1986). The mother-sub- ject dyad was used whereby the behaviours of both were recorded. The research design is presented in Table 1. It is known that motivation plays a significant role in the learning process and that repeated failure most often results in a decrease in motivation as well as task avoid- ance (Haney & Falvey, 1989). The "feed the cat" routine was completely unfamiliar to the subject. Because both the "make the bed" and "set the table" routines were not com- pletely unfamiliar to the subject it was decided to intro- duce these before the "feed the cat" routine to make sure that success was highly likely with the first two routines. A withdrawal period could establish whether changes in the subject and the mother could be attributed to the interven- tion. The action routines which were introduced one after Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 43, 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 66 Ilze Pansegrouw and Erna Alant the other, were performed for the whole intervention pe- riod (not during withdrawal) because it is known that PCI persons forget learning material which is not reinforced regularly and on a daily basis (Brown, 1983). SUBJECT For the study, a fifteen (15) year old PCI subject was selected from nine possible candidates at a school for autis- tic children in Pretoria. The subject received individual speech therapy aimed at the development of speech pro- duction for the first six years in school. The production and imitation of a few single words are reported between the ages of two and four with a gradual decrease in vocalisations since then. The subject was introduced to AAC at the age of eleven years. During the initial training stages, photographs of highly motivational objects and actions for the subject were used and after six months, Makaton picture symbols (1985), were introduced. Table 2 provides the psychiatric diagnosis of the subject, formal assessment results as well as a description of the communication and independence skills of the subject. MOTHER The mother, who is the primary caregiver, took very good care of the subject. She has an honours degree in Biochem- istry but was not employed at the time of the study. Other family members included the father and an older non-im- paired brother. PILOT STUDY The pilot study consisted of two phases. Phase one aimed at needs identification and the gathering of information on the pre-intervention state of priority skills of the subject and his mother. The information gathered during phase one, was utilised to conduct phase two of the pilot study. Phase two was aimed at an intervention trial with the class teacher of the subject as well as the development of an instrument to measure change during intervention. Phase 1: Needs identified by the mother During phase one the mother expressed the view that increased independence in the area of A.D.L. was the sub- ject's main need and that she would like to see the subject become independent in setting the table at home (an action TABLE 1: Research design routine which he has been exposed to at school), making his bed (inconsistent attempts at this had been made pre- viously by mother) and feed the cat (to which he had no previous exposure). The mother expressed limited knowl- edge and self-confidence in training the subject. During video-recordings of two domestic action routines (loading the washing machine and unpacking the dishwasher), the subject indicated a strong need for positive reinforcement responses from his mother when he succeeded in certain parts of action routines. Significant features of the moth- er's communication included the introduction and repeti- tion of a limited amount of conversational topics with the subject, a high percentage of commands and low percent- age of responsive utterances/actions. It was noted that due to the under-utilisation by the subject of his AAC system (refer to discussion of PCI subject), his communication in- tentions were often not understood by his mother. At the end of phase one, two priority skills, namely com- munication skills and skills at training the subject, were selected for the mother. For the subject, communication skills and independence at performing those action routines that were selected by his mother (setting the table, making the bed and feeding the cat), were identified. Phase 2: Development of action routines and prelimi- nary testing During phase two a concrete positive reinforcement sticker chart (commercially available white, square, peel- off stickers) as well as three preliminary picture symbol task analysis charts were developed for each one of the three action routines that were identified by the mother. A task analysis is the "breaking down" (analysis) of a learning task into smaller, more manageable steps with the aim of intro- ducing the task as a "chain" of related steps. This task analy- sis method is an acknowledged strategy in domestic inde- pendence training of cognitively impaired persons (Sailor & Guess, 1983). Although three preliminary picture symbol task analy- sis charts were developed, only "set the table" was used in the intervention trial. The subject's teacher was asked to participate as "primary caregiver" in the trial with the aim of testing the usefulness and appropriateness of interven- tion materials. The teacher was trained to use the task analysis and positive reinforcement chart and the trial per- formance of "set the table" action routine was video recorded. For the purpose of this study only the primary caregiver WEEK 0 1 2 3 4 5 6 1 6 13/7 13/7-20/7 20/7-27/7 27/7-3/8 3/8-10/8 10/8-17/8 - 17/8-22/8 22/8 SET THE TABLE A Bl Bl Bl Bl A l A l Β Β Β MAKE THE BED A Bl Bl Bl Bl A l A l Β Β Β FEED THE CAT A Bl Bl Bl A l / A l Β Β KEY: A = Baseline measurements Β = Measurements Β1 = Performance of action routines A l = Withdrawal The South African Journal of Communication Disorders, Vol. 43, 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) u n i c a t i o n Intervention in an Adolescent with Profound Cognitive Impairment and Com"1 1 Autistic Features f r to discussion on proposed model for intervention) of tte subject was selected and the class teacher was only in- volved in the intervention trial. MEASUREMENT INSTRUMENT The measurement instrument was developed to record and describe information on the identified priority skills of the subject and his mother. (See introductory paragraphs 67 for the discussion and relevance of the selected priority skills). Skills selected for measurement were identified by analysing each priority skill into sub-skills. The selected behaviours for observation were supplemented by observ- ing video-recordings of week 0. Sub-skills were either marked + (positive) or - (negative). Positive behaviours (+) were those where an increase indicated a positive change and negative (-) behaviours were those where an increase indicated a negative change. TABLE 2: Subject: Psychiatric diagnosis, formal assessment results, communication and independence skills RESULTS DATE DESCRIPTION 1. PSYCHIATRIC DIAGNOSIS: 1979 (*C.A. 2 years) 2. FORMAL ASSESSMENT RESULTS: - Griffiths Developmental Scales: # Speech and Hearing: # Personal/Social: # Mental Age: # General Quotient: - Reynell Language Developmental Scales: # Receptive: # Expressive: - Peabody Picture Vocabulary Test: 3. COMMUNICATION AND INDEPENDENCE - Communication and interaction: * Requests: * Protest: (*C.A. 15 years) 1992 1992 1992 1992 : Use of picture symbols: - Independence: * Action routines: Selfcare: "Profound mental retardation in a brain damaged child with a few autistic features such as spin- ning of objects, stereotyped, repetitive movements and handling of objects as well as poor interper- sonal contact and relationships" 14 months 35 months 25 months 14 1 year 11 months Below 1 year 2 years 1 month -The subject indicated a need for communication and interaction with adults but no such need with peers. During this time an increase in the use of picture symbols to request objects at home and with selected adults was reported. * He pulled people by the hand towards required object, brought object to adult or established eye contact + noises + pointing at object * Pushed people and objects away or ignored re- quests, commands and communication of the part- ner * He used picture symbols only for request pur- poses when the aforementioned request strate- gies were not successful or when he was reminded to use his symbols. His picture symbol system comprised of ten symbols which were a combina- tion of Makaton (Walker, 1985) and PICSYMS (Carlson, 1985) picture symbols. He used one Makaton sign (Walker, 1972) namely "thank you/ please". This sign was used spontaneously to re- quest permission (often when he was refused a request) and was also used to indicate confusion * He enjoyed domestic action routines such as un- packing the dishwasher or loading the washing machine and spontaneously participated. Adult assistance was, however, required * Although he was mainly independent regard- ing selfcare, he needed assistance with dressing, bath and tooth brushing KEY: * C.A. = Chronological age D i e Suid-Afrikaanse Tydskrif vir Kommunikasieafwy kings, Vol. 43, 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 68 Appendix 1 provides the grouping of sub-skills of prior- ity skills of the subject and his mother. Appendix 2 pro- vides the grid which was used to record and analyse data regarding sub-skills of the mother's skills at training the subject. The sub-skills of the other three priority skills, i.e. sub-skills of the mother's communication skills and the sub- skills of the independence and communication skills of the subject, were recorded onto three other grids. Ilze Pansegrouw and Erna Alant RESULTS OF PRELIMINARY TEST Results of phase two not only indicated the effectiveness of procedures but also highlighted the need for minor changes. A"theme symbol" was added as well as a separate column on the task analysis chart for positive reinforce- ment stickers. The mother suggested the use of "Spot", "Donald Duck" and "Ladybug" commercially available stick- TABLE 3: Picture symbol task analysis of action routines ACTION ROUTINES Size of task analysis chart Sub-components of task analysis and picture symbol systems used Size of symbols Colour of carton to which picture symbols are attached Size of coloured carton background Placement of symbols on task analysis chart * Other symbols in * Other symbols in sequence: sequence: 1. Plate (M) 1. Pillow off (S) 2. Placemats (S) 2. Duvet off (S) 3. Knife (M) 3. Smooth (S) 4. Fork (M) 4. Pillow on (S) 5. Glass (M) 5. Duvet on (S) 6. Serviette (S) SET THE TABLE 34 χ 64 cm * Theme symbol: Set the table (S) 9 x 8 cm Yellow 10 χ 9 cm Theme symbol Set the table 1. 2. 3. 4. 5. 6. MAKE THE BED 34 χ 42.2 cm * Theme symbol: Make the bed (S) 9 x 8 cm Pink 10 χ 9 cm Theme symbol Make the bed 1. 2. 5. FEED THE CAT 34 χ 64 cm * Theme symbol: Feed the cat (S) * Other symbols in sequence: 1. Bring the milk-bowl (M&S) 2. Bring the food-bowl (S) 3. Bring the milk (M) 4. Fork (M) 5. Bring the cat food (S) plus wrapper of cat food tin 6. Fill with milk (S) 7. Food in bowl (S) 8& 9. Put down (S) 9 x 8 cm White 10 χ 9 cm Theme-Symbol Feed the cat 2. 3. 4. 6. 8. 9. * Each picture symbol was covered with Desifix and attached to the chart with Prestik. Prestik was used so that the mother could, when necessary, change the sequence of the symbol arrangement on the chart Placement Inside of the kitchen cupboard door where the plates and the glasses are stored Inside of the subject's clothes cupboard in his room Inside o f kitchen cup- board door where the cat food is stored Key: (M) = Makaton (S) = Self-developed symbols The South African Journal of Communication Disorders, Vol. 43, 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) o u n i c a t i o n Intervention in an Adolescent with Autistic Features e r s because the subject was familiar With these icons from watching animated videos and indicated enjoyment when- ever he saw them. The mother of the subject was consulted regarding the size and placement inside the family home of the task analysis charts. These suggestions were combined with the results of the trial intervention to determine the features and application of training materials used in the main study. THE MAIN STUDY Training materials l&ble 3 provides information on the picture symbol task analysis charts of the three action routines and Table 4 pro- vides the features and placement of positive reinforcement stickers that were used as training material for the adoles- cent. More detail on the development of these materials can be obtained in Pansegrouw (1994). The implementation of action routines were video re- corded in the family's home during time slots when these activities would normally take place. "Set the table" action routines were recorded at 19:00, "make the bed" at 07:00 and "feed the cat" at 10:30. Profound Cognitive Impairment and 69 Measurement recordings (B-phase; see Table 1) were done at the same time in which these action routines would normally take place in the family's home. The first meas- urement video recording was made of the "set the table" routine seven days after the introduction thereof. On the same day the task analysis chart, instructions for use and training for the "make the bed" action routine was intro- duced to the mother. She received instructions to continue the "set the table" action routine during the following week. Seven days after the "make the bed" action routine was introduced, this action routine was measured for the first time and the "set the table" routine measured for the sec- ond time. On the same day the "feed the cat" action routine was introduced to the mother. She received instructions to continue with the "set the table" and "make the bed" action routines in the following week. After seven days, the "feed the cat" action routine was measured for the first time and the "make the bed" routine for the second time. The mother received instructions to continue with the performing of the three action routines for another seven days and then to withdraw intervention for two weeks. On the last day of the two week withdrawal period, the third measurements of the "set the table" and "make the bed" as well as the second measurement of "feed the cat" routine were done. PROCEDURES Data collection Baseline video recordings (Α-phase; see Table 1) of the three action routines were done at the family home on the first day of the experiment (week 0). The mother was asked to introduce the subject to the three selected action rou- tines one after the other. For the baseline recordings the mother received no training or task analysis charts. After the baseline recordings, on the same day, the mother re- ceived the task analysis chart, instructions for use and rel- evant training for the "set the table" action routine. ί Training procedures and instructions Training procedures included detailed instructions to the mother on how to perform and train action routines once a day. Typed, as well as verbal instructions, specified utter- ances to be used an non-verbal guidance (such as pointing, gesture, physical guidance) to attract, direct and maintain the attention of the adolescent during the action routine. Instructions to pause regularly in order to create opportu- nity for the subject to initiate communication and to dem- onstrate independence development, were given to the mother. She was also instructed to respond to all communi- cation attempts and other noise/sounds that the subject TABLE 4 : Concrete positive reinforcement ACTION ROUTINE 1 SET THE TABLE MAKE THE BED FEED THE CAT I Sticker j Spot (Otto) Donald Duck Lady bug Colour of carton background Yellow Pink White Size of stickers 2,5 χ 2,5 cm 2,5 χ 2,5 cm 2,5 χ 2,5 cm Placement Vertically in 4 cm column on the right side of the chart Vertically in 4 cm column on the right side of the chart Vertically in 4 cm column on the right side of the chart Placement on task analysis chart 1 Placement on task analysis chart 1 * Theme symbol ~ Picture symbol # Positive reinforcement stickers 1 # 1 1 Placement on task analysis chart 1 * Theme symbol ~ Picture symbol # Positive reinforcement stickers Placement on task analysis chart 1 * Theme symbol ~ Picture symbol # Positive reinforcement stickers ~l 1 # 1 1 Placement on task analysis chart 1 * Theme symbol ~ Picture symbol # Positive reinforcement stickers Placement on task analysis chart 1 * Theme symbol ~ Picture symbol # Positive reinforcement stickers ~l 1 # 1 Placement on task analysis chart 1 * Theme symbol ~ Picture symbol # Positive reinforcement stickers Placement on task analysis chart 1 * Theme symbol ~ Picture symbol # Positive reinforcement stickers ~ ι ι ~i * 1 1 Placement on task analysis chart 1 * Theme symbol ~ Picture symbol # Positive reinforcement stickers Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwy kings, Vol. 43, 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 70 produced during the performance of action routines. Instructions for the performance of the "set the table" action routine were as follows: - Mother was asked to place four each of plates, knives, forks, glasses, placemats and serviettes alongside each other in the cupboard where these objects are kept. She was asked to show the subject where the objects were placed. - Mother said "S. it is time now to set the table; we are going to eat." - Mother directed/physically cued subject to the task analy- sis chart. - Mother pointed to the theme symbol and said: "Look, it is time now to set the table" (she directed the subject's attention to the theme symbol.) - Mother looked at the subject, pointed to the theme sym- bol and said, "S. please get the plates from the cup- board." - Mother directed the subject's attention to the plate pic- ture symbol and pointed to the cupboard where the plates were kept. - If he understood the instruction and performed the ac- tion without any trouble, mother said: "Put a plate on the table for dad, put a plate down for Α., a plate for me and a plate for yourself." - Mother was encouraged to compliment verbal instruc- tions with gesture and facial expression. - Should the subject experience difficulty with any in- struction, mother repeated the instruction and physi- cally cued him through the action. After all the plates were placed on the table, the other utensils (forks, knives, placemats, glasses and serviettes) were placed on the table by using the same procedures and instruc- tions. Instructions for the use of positive reinforcement were as follows: After the performance of a correct action by the subject the mother was requested to do or say the following: - "Very good!" (positive reinforcement: verbal); - smile (positive reinforcement: smile); - squeeze his hand/shoulder (positive reinforcement: physical) and - to place a sticker (positive reinforcement: concrete) in the left upper corner of the appropriate picture sym- bol. - After the attachment of the sticker, mother pointed to the sticker and repeated: 'Very good!" Data analysis and statistical processing Verbatim transcriptions of video material of the inter- action between the mother and subject during action rou- tines were done. Due to the fact that the subject did not communicate verbally, his communication was described by recording occurrences of pointing, smiles, gesture, eye contact as well as communicative sounds and noises on the relevant recording sheets. (Appendix 2 provides an example of a recording grid). Recording was done by count- ing each occurrence of a sub-skill on the transcriptions. Tallies were recorded onto the four different grids (see Appendix 2). The Friedman Variance Analysis (Hollander & Wolfe, 1973) was applied to the data to indicate P-val- Ilze Pansegrouw and Erna Alant ues (significance of change) of the sub-skills of the prior- ity skills over the six week intervention period. The P. value indicates significance of change of the difference between week 0 and any other measurement between week 0 and week 6. Raw scores were processed to tallies p e r minute and the average percentage change in relation to week 0 (baseline), calculated. The percentage change re- fers to the percentage change in relation to week 0. For equivalence of action routines, interpolation· was done to determine percentage change for week three of "set the table". In this way the change in priority skills for week 2 for both "set the table" and "make the bed" as well as week 3 and 6 (in relation to week 0) for all action routines, could be presented. At the comparison of the sub-skills for all action routines only the percentage change at weeks 3 and 6 are presented. This was done because the "feed the cat" action routine was only introduced in week 2 and meas- ured one week later (see Table 1). Through these proce- dures, changes in sub-skills of priority skills at weeks 0 , 3 and 6 could be calculated for all action routines. RESULTS AND DISCUSSION The results of intervention, i.e. a description of identi- fied priority skills of the subject and his mother during the six week intervention period as well as the effect of withdrawal of intervention during week six, follows. Figure 2 represents the overall results of the percent- age change of the two priority skills of the mother (com- munication skills and skills at training the subject) and the two priority skills of the subject (communication skills and independence at performing action routines) in weeks three and six. From Figure 2 it is evident that positive changes were seen in the results of the priority skills of the subjects. The subject benefitted from and developed new skills dur- ing the six week intervention period. At the time of the study, the chronological age of the subject was fifteen. He then was found to have a M.A. (Mental Age) of 25 months 4 0 0 3 5 0 3 0 0 2 5 0 2 0 0 1 5 0 100 5 0 0 % Change 0 0 | 0 0 Week 0 4 7 53 1 W3(TBC) W6(TBC) M/C IH s / c EES M/S Μ s/i Key: (TBC) = Set the table; Β = make the bed; C + Weed the cat M/c = Mother: communication skills S/c = Subject: communication skills / M/s = Mother: skills at training the subject S/i = Subject: independence at performing action rou- tines y FIGURE 2: Change of priority skills at weeks three and six X The South African Journal of Communication Disorders, Vol. 43, 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) £ , o n u n u n i c a t i o n Intervention in an Adolescent with Autistic Features and a G.Q. (General Quotient) of 14. According to existing y c h o m e t r i c categorisation the subject would be " u n t r a i n a b l e " which implies an inability to benefit from education/training and consequently being dependent upon physical care (Grover, 1990; Koordineringskomitee: Jaar van G e s t r e m d e Persone, 1987). Results of this study sup- port the view that clinical features are dynamic and often r e f l e c t the extent and nature of the service delivery model (Lea, 1990). Physical care as the only form of service de- livery to the subject, would most certainly have resulted in the under-utilisation of potential. THE SUBJECT'S COMMUNICATION AND INDE- PENDENCE SKILLS When looking at Figures 2, 3 and 4 a significant differ- ence in results between weeks nil to three (during inter- vention) and weeks nil to six (after intervention with- drawal) in the priority skills of the subject, is seen. Re- sults in Figure 3 indicate that in weeks nil to six inde- pendence skills either increased or remained nearly the same. From the same figure it can also be seen that com- munication skills (apart from picture symbol communica- tion which he used to indicate that he wanted to termi- nate routines) decreased from weeks nil to six. From these results it seems that the subject did not lose/forget skills during intervention withdrawal but instead presented poor motivation and unwillingness to co-operate. It is known that regular, consistent practice of skills with a familiar person in the environment, as well as the provision of ex- ternal structure to facilitate productive functioning are important requirements for intervention success with PCI persons (Siegel-Causey & Downing, 1987). During the withdrawal period provision of external structure and regular performance of action routines de- creased significantly. For this reason it becomes clear that so called generalisation problems often reflect a situation where behaviour has generalised but where reinforcement Profound Cognitive Impairment and 71 Key: P/c = Picture symbol communication; R/r/c = Requests for recognition/confirmation; S/r = Smiles for rec- ognition; I/c = Intentional communication; C/w/ a/ = Performs commands without assistance from mother; Sc/i = Performs sub-components of action routines independent/without com- mand from mother; A/c/pr = Anticipates concrete positive reinforcement FIGURE 3: Subject: Selected sub-skills of communi- cation skills and independence (all action routines) for the regular use of the behaviour, was insufficient (Johnson & Koegel, 1982). Increases were seen in the re- sults of the subject's requests for and smiles for recogni- tion, as well as anticipation of concrete positive reinforce- ment. These results indicate that the subject's related needs were addressed by providing his mother with posi- tive reinforcement training. It also suggests that the of- ten described clinical feature of poor inner motivation of the PCI person to develop skills that would decrease de- pendence of persons in the environment, could be changed by providing motivation (positive reinforcement) as the first step in the learning process (Sailor & Guess, 1983; Haney & Falvey, 1989). When looking at increases in the results of the commu- nication skills of the subject (Figures 2, 3 and 4), it seems that the provision of picture symbol task analysis charts to introduce action routines, provided the context in which communication between the mother and the subject was encouraged through the provision of common, specific themes that facilitated interaction (Lund, 1986; Rowland & Stremel-Campbell, 1987). Task analysis charts provided the subject with the opportunity to acquire new informa- tion slowly and to be provided with small amounts of in- formation at a time required by most PCI persons during the introduction of learning tasks (Wilson, 1981). THE MOTHER'S PRIORITY SKILLS Figure 2 results represent increases between weeks nil to three and weeks nil to six in the priority skills of the mother. When comparing overall percentage increases, the increases in the priority skills of the mother were not as high as those of the subject. However, Figure 5 results, which represent high increases in both positive responses (identification, recognition and positive response to com- munication attempts of the subject) and concrete and ver- bal positive reinforcement, are significant. Increases in positive responses and concrete and ver- bal positive reinforcement suggest that the training of the mother in the use of positive reinforcement was not only effective, but most likely contributed to increases in posi- tive responses. The use of positive responses were not di- rectly trained and could therefore possibly be viewed as a "spill-over" effect of positive reinforcement training. The significance of these results is underlined by the view that for the PCI person, partner responsiveness is known to encourage and facilitate interest in and willingness to participate in communication interaction (Girolametto et al., 1986). % C h a n g e 2 0 0 - -107- 17 W e e k 0 W e e k 2 W e e k 3 W e e k β —— S e t t i n g t a b l e ~ ^ M a k i n g b e d - * — F e e d i n g cat FIGURE 4: Subject: communication skills trends Die Suid-Afrikaanse tydskrif vir Kommunikasieafwy kings, Vol. 43, 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 72 Ilze Pansegrouw and Erna Alant COMPARISON IN PRIORITY SKILLS : THE SUB- JECT AND THE MOTHER Significantly fewer overall increases in the priority skills of the mother, when compared to those of the sub- ject, are seen in Figure 2. When adding the overall in- creases of the mother as presented in Figure 2 (47% in weeks 0-3 and 53% in weeks 0-6 for communication skills and 105% in weeks 0-3 and 99% in weeks 0-6 for skills at training the subject), only a slight change (50%) in moth- er's communication behaviour over the six week interven- tion period is seen. The slower tempo of change of the mother could be viewed against the backdrop of the "set" of table management strategies that have developed over years in order to meet and cope with the daily demands of the PCI person. Due to limitation in formal and informal societal assistance, families develop rigid/stable strategies which are instrumental in maintaining environmental pre- dictability, security and familiarity (see discussion of homeostasis under proposed intervention model). During the study a few of the family's rules and strategies were observed and mentioned by the mother. It follows that despite mother's willingness to participate in the study and to implement intervention strategies, demands to change management and coping strategies that have pro- vided security and predictability over years, would require a much longer period of professional and social support. However, when looking at Figure 2, it is seen that the communication skill of the mother was the only priority skill that showed an increase in week nil to six (after in- tervention withdrawal). A possible explanation for this could be found when comparing Figure 4, 5 and 6. In Figure 4 the highest scores during weeks nil to three for the three selected action routines are seen for "set the table" (in which the subject had most prior intervention experience), second highest for "make the bed" (less prior experience than setting table) and third highest for "feed the cat" (least prior experience). After withdrawal of in- % C h a n g e — 86 - — 6 0 - 47 47 SSTL Ν • H I -4 C . p / r V . p / r P / r L / 8 " W I 9 _ 8 0 r P / c T / u Η W e e k 3 S i ! W e e k 6 Key: C.p/r = Concrete positive reinforcement; V.p/r = Verbal positive reinforcement; P/r - Positive responses to communication of subject; L/s = Looks at sub- ject; U/s = Uses symbols; I/r = Ignore responses to communication of subject; P/c = Physical con- tact; T/u = Total utterances tervention (weeks nil to six), except for "feed the cat", re- sults show a decline. Figure 6 results indicate that, ex- cept for "set the table", mother's communication skills in- creased from weeks nil to six. Sub-skills of mother's com- munication skills that increased at weeks nil to six (Fig- ure 5) were "looks at subject", "physical contact" and "to- tal utterances". Ignore responses were significantly less in weeks nil to six. These results indicate that for the sub- ject and his mother a relationship existed between the subject's extent of experience and independence at action routines and the communication skills of the mother. It seemed that, as could be expected, increased independ- ence of the subject at performing action routines, lessened the need for "supportive" communication from the mother and vice versa. CONCLUSIONS The PCI population is distinguished by it's hetero- genicity and differences are the rule rather than the ex- ception (Yoder & Villarruel, 1988). A single case design was selected and no generalisations on the basis of these results, can be made. However, it appeared that overall increases in the results of the priority skills of both the mother and the subject could be ascribed to the implemen- tation of communication intervention. A significant de- crease in the results of three of the four priority skills af- ter the withdrawal of intervention, strengthens the afore- mentioned presumption. When taking into account that the results of the PCI subject showed the highest increases overall, the most important conclusion points to the dy- namic (vs static) nature of the subject's clinical features. When comparing results at the different measurements, motivation seemed to be a key determinant of the features of the priority skills of the subject as well as the commu- nication skills of the mother. Results indicated the neces- sity to target and provide positive reinforcement as well as consequent opportunities to perform skills together with a familiar person in the environment, in order to main- tain the PCI subject's motivation and willingness regard- ing intervention aims. The use of domestic action routines and the introduc- tion and representation thereof by means of picture sym- bol task analysis charts, seem to have succeeded in the facilitation of interaction between the mother and the sub- ject. Results which indicated that increased subject inde- pendence (at action routines) reduced the need for "sup- portive" communication from the mother, point to the need for flexibility regarding the selection and period that the % Change W e e k 6 FIGURE 5: Mother: Selected sub-skills of communi- cation skills and skills at training the subject (all action routines) • S e t t i n g table * M a k i n g bed " Feeding c a t FIGURE 6: Mother: communication skills trends The South African Journal of Communication Disorders, Vol. 43, 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Communication Intervention in an Adolescent with Profound Cognitive Impairment and Autistic Features subject is expected to perform each action routine. Al- though in this study the action routine choice of the mother was used, mother's choices should be alternated with those of the subject. Additionally the possibilities of increasing the number o f routines (alternating familiar and less fa- miliar routines) or shortening the period of performance of each to less than a week per action routine, could be considered. Due to the widely accepted acknowledgement of respon- siveness as the facilitator of motivation and willingness to interact, increases in the mother's use of positive re- sponses to the communication o f the subject (possibly in- dicating a side-effect of positive reinforcement training), are viewed as significant. However, the slower tempo of change in the communication skills of the mother high- lighted the need for a realistic and sensitive attitude to- wards social and historical aspects, daily stressors and general needs of the mother. Demands to change coping strategies and communication behaviours that were de- veloped over years, necessitates a prolonged period of pro- fessional and social support. Additional sources of support could include the active involvement of other family mem- bers as well as societal support. Results of communication intervention with the PCI subject indicated that these persons cannot be denied com- munication intervention on grounds of clinical features , or psychometric classification alone. Poor progress during intervention does not indicate that the person is unable to benefit from intervention and therefore requires only physical care. To provide for the right of the PCI person to develop and maintain a quality o f life equal to that of mainstream society, communication intervention must be aimed at the development o f social integration through the facilitation of functional communication and independ- ence skills. The PCI person forms one component of the environment in which he spends most of his time. For this reason primary caregiver skill development and sensitiv- ity towards the environment cannot be overemphasised. REFERENCES Alant, E. & Emmet, T. (1995). Breaking the silence: Commu- nication and education for children with severe handicaps. Human Sciences Research Council, Pretoria. Brown, L., Nisbet, J., Ford, Α., Sweet, M., Shiraga, B, York, J. & Loomis, R. (1983) The critical need for non-school instruction in educational programs for severely handicapped students. Journal of the association for the severely handicapped, 8 (3), 71-77. ! Calculator, S.N. (1988a). Teaching functional skills in non- speaking adults with mental retardation. In S.N. Calculator & J.L. Bedrosian (eds). Communication assessment and intervention for adults with mental retardation. Boston, Mass : College-Hill. Calculator, S.N. (1988b). Promoting the acquisition and genera- lisation of conversational skills by individuals with severe disabilities. Augmentative and Alternative Communication. 2(4), 94-103. Carlson, F. (1985). PICSYMS categorical dictionary. Baggeboda Press, Rhode Island. St., Lawrence, K.S. Conti-Ramsden, G. (1985). Mothers in dialogue with language- impaired children. Topics in Language Disorders, 58-67. U u n n , L.M. (1965). Peabody Picture Vocabulary Test. Circle Pines, Minn.: AGS. Durarit, M. (1990). Severe behaviour problems. New York, The Uuilford Press. khren, B.J. & Lenz, B.K. (1989). Adolescents with language disorders: Special considerations in providing academically relevant language intervention. Seminars in Speech and language, 3 (10), 192-203. 1 Eshilian, L., Haney, M. & Falvey, M.A..(1989). Domestic skills In M.A. Falvey (ed.). Community-based curriculum. Baltimore, Maryland: Brookes. Girolametto, L.E., Greenberg, J. & Manolson, H.A. (1986). Developing dialogue skills: The Hanen Early Language Parent Program. Seminars in Speech and Language 4(7), 367-379. Gottlieb, M.L. (1989). The response of families to language dis- orders in the young child. Seminars in Speech and Language 9(1), 47-53. Griffiths, R. (1984). Griffiths Mental Developmental Scales. Bucks: Association for Research in Infant and Child Development. Grover, V. (1990). Psycho-educational aspects of mental handicap. In S. Lea & D. Foster (eds). Perspectives on mental handicap in South Africa. Durban: Butterworth. Haney, M. & Falvey, M.A. (1989). Instructional strategies. In M.A. Falvey (ed). Community-based curriculum. Baltimore, Maryland: Brookes. Haring, T.G. (1991). Social relationships. In L.H. Meyer, C.A. Peck & L. Brown (eds). Critical issues in the lives of people with severe disabilities. Baltimore, Maryland: Brookes. Helm, D.T. & Kozloff, M.A. (1986). Research on parent training: shortcomings and remedies. Journal of Autism and Developmental Disorders, 16(1), 1-16. Hollander, M. & Wolfe, D.A. (1973). Nonparametric statistical methods. New York: John Wiley & Sons. Johnson, J. & Koegel, R.L. (1982). Behavioural assessment and curriculum development. In R.L. Koegel, A. Rincover & A.L. Egel (eds). Educating and understanding autistic children. Calif.: College-Hill. Kirchener, D.M. (1991). Using verbal scaffolding to facilitate conversational participation and language acquisition in children with pervasive developmental disorders. Journal of Childhood Communication Disorders, 14(1), 81-98. Koordineringskomitee: Jaar van Gestremde Persone. (1987). Gestremdheid in die Republiek van Suid-Afrika: Behandeling. Vol. 3. Pretoria: Departement van Nasionale Gesondheid en Bevolkingsontwikkeling. Lea, S. (1990). Psycho-social aspects of mental handicap. In S. Lea & D. Foster (eds). Perspectives on mental handicap in South Africa. Durban: Butterworth. Lund, N.J. (1986). Family events and relationships: Implications for language assessment and intervention. Seminars in Speech and Language 7(4), 415-429. Owens, R.E. & Rogerson, B.S. (1988). Adults at the presymbolic level. In S.N. Calculator & J.L. Bedrosian (eds). Communica- tion assessment and intervention for adults with mental retardation. Boston, Mass.: College-Hill. Pansegrouw, I. (1994). Kommunikasie-intervensie by 'n kognitief erg gestremde adolessent met outistiese trekke. Ongepubli- seerde M.Log verhandeling,.Universiteit van Pretoria. Rowland, C. & Stremel-Campbell, K. (1987). Share and share alike; conventional gestures to emergent language for learners with sensory impairments. In L. Goetz, D. Guess & K. Stremel- Campbell (eds). Innovative program design for individuals with dual sensory impairments. Baltimore, Maryland: Brookes. Rustin, L. & Ruhr, A. (1989). Social skills and the speech impaired. London: Taylor & Francis. Sailor, W. & Guess, D. (1983). Severely handicapped students: an instructional design. Boston, Mass.: Houghton Mifflin. Siegel-Causey, E. & Downing, J.E. (1987). Nonsymbolic com- munication development: Theoretical concepts and educational strategies. In L. Goetz, D. Guess & K. Stremel-Campbell (eds). Innovative program design for individuals with dual sensory impairments. Baltimore, Maryland: Brookes. Singer, G.H.S. & Irvin, L.K. (1991). Supporting families of persons with severe disabilities: Emerging findings, practices and questions. In L.H. Meyer, C.A. Peck, & L. Brown (eds). Critical issues in the lives of people with severe disabilities. Baltimore, Maryland: Brookes. Subcommittee on Mental Retardation. (1987a). DSM-III-R Classification: Axes 1 and 2 Categories and codes. In The American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (3r d ed., rev.). Cambridge: The Press Syndicate, University of Cambridge. Walker, M. (1972). Signs for Makaton. EARO. Walker, M. (1985). Symbols for Makaton. EARO. Wilson, A. (1981). Curriculum selection for the deaf-blind; Severely/profoundly handicapped. In S.R. Walsh & R. Holzberg (eds). Understanding and educating the deaf-blind I severely D l e Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 43, 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 74 Ilze Pansegrouw and Erna Alant and profoundly handicapped: an international perspective. the severely handicapped child. In N.J. Lass, L.V. McReynolds, Springfield, Illinois: Charles C. Thomas. J.L. Northern & D.E. Yoder (eds). Handbook of speech- Yoder, D.E. & Villarruel, F. (1988). Effective communication for language pathology and audiology. Philadelphia: B.C. Decker. APPENDIX 1: Grouping of sub-skills of priority skills of the subject and his mother 1. Mother: 1. Total utterances (+) Communication skills 2. Total commands (+) 3. Repetitive commands (+) 4. Average repetitions (+) 5. Physical contact (+) 6. Looks at subject (+) 7. Response to communication of subject: 7.1 Positive (+) 7.2 Negative (-) 7.3 Ignore (-) 8. Uses symbols (+) 9. Positive reinforcement: 9.1 Concrete (+) 9.2 Physical (+) 9.3 Verbal (+) 9.4 Smile (+) 2. Mother: Skills at 1. Uses symbols (+) training the subject 2. Positive reinforcement: 2.1 Concrete (+) 2.2 Physical (+) 2.3 Verbal (+) 2.4 Smile (+) 3. Subject: 1. Looks at mother (+) Communication skills 2. Smiles (+) 3. Smiles for recognition (+) 4. Initiates physical contact (+) 5. Intentional communication (+) 6. Picture symbol communication (+) 7. Requests recognition/confirmation during action routines (+) 8. Protests (-) 9. Anticipates concrete, positive reinforcement (+) 10. Ignores commands (-) 1 11. Distractible (-) 4. Subject: Independence 1. Performs commands without assistance from mother (+) | 2. Performs sub-components of action routines independent/ without commands from mother (+) ι 3. Looks at symbols (+) > 4. Communicates through symbols (+) 1 5. Requests recognition/confirmation for performance of action routines (+) 6. Protests (-) 7. Anticipates concrete positive reinforcement (+) 8. Ignores commands (-) 9. Distractible (-) 10. Mother performs own commands (-) χ The South African Journal of Communication Disorders, Vol. 43, 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Communication Intervention in an Adolescent with Profound Cognitive Impairment and Autistic Features APPENDIX 2: Grid for recording and analysing data of the mother's skills at training the adolescent Task Se ; the ta ble Make the bed Feed the cat Average Week 0 1 2 3 6 0 2 3 6 0 3 6 3 6 Measurement Β 1 2 3 Β 1 2 3 Β 1 2 Time (min) 8 9 9 10 2 12 4 2 4 9 5 Mother Mother Mother (*) 1 Use Symbols 16 11 6 5 12 5 7 2 11 7 3 1.1 Count/Minute 2 1.222 0.666 0.5 6 0.416 1.75 1 2.75 0.777 0.6 1.2 % Change 0 -38.8 -66.6 -93 -75 0 -93.0 -70.8 -.83.3 0 -71.7 -78.1 -78 -79 2. Positive reinforcement 2.1 Concrete 0 7 5 6 0 5 5 5 0 9 7 Revised Count 1 8.3 6.13 7.25 1 11 7 6 1 11.25 8.25 Count/Minute 0.125 0.903 0.681 0.725 0.5 0.916 1.75 3 0.25 1.25 1.65 306 513 % Change 0 622.6 444.8 267 480 0 83.33 250 500 0 400 560 2.2 Physical 1 2 3 2 1 1 2 0 1 1 0 Count/minute 0.125 0.222 0.333 0.2 0.5 0.083 05 0 0.25 0.111 0 % Change 0 77.77 166.6 257 60 0 -83.3 0 -100 0 -55.5 -100 67 -47 2.3 Verbal 2 8 10 7 1 3 5 3 1 4 3 Count/Minute 0.25 0.888 1.111 0.7 0.5 0.25 1.25 1.5 0.25 0.444 0.6 % Change 0 i 255.5 344.4 433 180 0 -50 150 200 0 77.77 140 220 173 2.4 Smile 1 1 1 0 0 1 2 0 1 1 0 Revised Count 1 • 7 4 1 Count/Minute 1 0.125 0.111 0.111 0 0.5 0.583 1 0.5 0.25 0.111 0 % Change 0 | -11.1 -11.1 -11 -100 0 16.66 100 0 0 -55.5 -100 11 -66 Average 0 ' 181' 176 171 109 0 -25 86 103 0 59 84 105 99 D e Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 43, 1996 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2)