How can you tell me where it hurts? Part II

Go Here if you missed Part I

My Bratty was in the dental ward in the hospital yesterday, having what we hope will be the last 2 extractions under General Anaesthetic that she has to go through.

Due to problems with her babyteeth, her second teeth have come in a bit crowded and they had to make space.

But the Dental Surgeon said that all the others were perfect and we were doing a great job.

That was not the case 5 years ago.

On that visit she had 7 extractions under G.A. and we had obviously not done "a good job."

Poor Bratty had a bad diet, oral defensiveness and decay in her baby teeth that had obviously been painful.

But at the time I didn't know. When it was discovered and I made the necessary changes to her oral hygiene routine and lifestyle - (I was the worlds least popular mummy at the time) - I swore I would find a way to teach her to: "tell me where it hurts"

This is really hard because you are teaching someone to Comment on something Abstract.

Commenting is not naturally rewarding - you have to structure it with tangible rewards in order to make it rewarding.

You say "I see dog" And child thinks "Who the hell cares?"

But if you get a picture book and teach them to say:

"I see dog" then - "here have a chocolate button."

- you will eventually get the child saying:

"I see a cat, elephant, starfish, look there's an aeroplane"

because you have paired that purely social "sharing" with a tangible reward.

Then pair the tangible reward with praise - and eventually you can just praise them for sharing. (and ditch the chocolate buttons)

All the above works just as well with picture communication. You set up the opportunity, you prompt, reward, praise and when it is repeated, reward and praise again.

So for "feelings" you create your "talking about pain cards" (or in my case buy them on ebay)

and then wait for a natural opportunity, such as a fall in the playground or a bumped elbow, to prompt the child to say where it hurts because you can actually see where it hurts.
It isn't an abstract concept as the child is actually feeling the pain as you show them.

The problem is of course, that the "pain cards" are probably back home in the cupboard when they fall off the swings and graze their knee. Leaving them in the dirt crying while you go get them is not exactly ethical, or caring.

And this is where Grace App on iPhone comes in.
While you may have left the picture cards back in the press at home. You always have your phone when you are out - so the final version of Grace App includes a section called "My Body"

When the pain happens, Grab the phone and select "My Body" Hand over Hand so the child is selecting the category picture with you

Then prompt them to choose "Sore"and "knee"

And as I said in Part I, give them a lot of care and attention around that poor sore knee. Saying "Sore Knee" and pointing to the pictures and the actual knee, a lot.

In a separate exercise; (when they are no longer in pain) you teach all the other body parts using flashcards or standard picture exchange requests.

How do you request a body part? Try using our friend Mr Potato Head as a 3D teaching tool.

Set up a mirror and the potato man and keep hold of the body parts. They can request "I want nose" and "I want eyes" using the phone.

At the same time do a little "show me your eyes" and prompt a nice point at eyes looking in the mirror together. So it is real, not abstract.

They will associate the picture of "eyes" on the phone with their eyes.

We also play a drawing game with Bratty. She requests a Teletubby or Muppet using her words and a colored crayon or marker. I draw the outline, then she requests "circle face", eyes, mouth, ears, aerial and "square tummy". Okay, people don't have aerials, but you get the rest of the idea. The important thing is that the game is based on their favourite character. Not some boring picture of a face.

You could also print off and make 6 x 8 flashcards (ugh) and do the standard; Point to, Give me, Show me, What's this? direct teaching. (or find someone else to do that bit!)

And from that, practice naming their real body parts with tickle or massage games, looking in a mirror together, or putting shaving cream on in the bath. Keep it fun and look for lots of opportunities to repeat the game during the day. From that you will hopefully create good body awareness, and recognition that they can then generalise into understanding. And when they have a hurt you don't know about - tell you.

Grace App was developed by Grace, Me and Steve Troughton-Smith (the Tech Wizard) with the support of O2. Mary Moroney did the original drawings we use.
If you want to make a set of those cards: email me and I will send you the images.*

But consider this a copyright, mmokay?


Flowspoon said…
I know I will get flack for this, but here goes. While this is very ingenious, I feel it is enabling. Yes, autism holds the most challenging conundrum for facilitating communication with your child. But constantly combining alternatives to verbalization with Pavlovian rewards has the potential to create patterns of dysfunction even worse than the lack of verbalization. Sign language is effective, interactive communication, as well as an excellent motor coordination exercise.
And training a tiny child to interface with electronic devices instead of humans...well that is just so ironically the opposite of what is the ideal...and quite frankly, messed-up.
Anonymous said…
I disagree Flowspoon, use of technology has it's place. Up to now many non verbal children have to labour with PEC's books, perhaps not always having the right combination of pictures available to communicate effectively ( as outlined in the article). It makes them even more different in social situations and by God they have enough challenges. This technology is being promoted with children who already have a command of PECS so they learn the referencing first and to use technology later.

I agree that sign has it's place too but many of our children would also be challenged with poor co-ordination and motor planning issues. As far as I understand with sign language (and my knowledge is limited as I last researched it when my son was NV at 2.5) in order to be an effective communication partner, one needs to understand the gestures, where with PECS the pictures are fairly self explainatory. While we personally do not need PECS now,I know others that see this app as a godsend for their NV children .
Lisamaree said…
Dear Flowspoon,

As you are promoting a commercial enterprise - I cant tell what your background is for such a comment, but I will do my best to answer it based on what I know others might think.
Grace app is not an "alternative to verbalisation. It is ALWAYS to be used with prompted or attempted verbalisation.
However from a speech therapy or autism therapy point of view, the most important thing to do with a "tiny child" is to give them a means to communicate based on interacting with a "listener".
This can be sign or picture based, the choice is usually made on the basis of visual processing, gross motor ability and the access to training.
The child's ability to produce babble and imitate is also a deciding factor. I know this because my children both attend a school that uses both, based on the individual child's ability.
Your premise that Sign Language is an "excellent motor coordination exercise" is ignorant of the fact that many kids with autism have great difficulty with motor planning and co-ordination" - it is part of the diagnostic process.
So for those kids the frustration with being misunderstood is more likely to result in "patterns of dysfunction" as you describe it. Or inappropriate behaviors as I prefer to say.
These behaviours such as self harm or aggression or tantrums can be very effectively reinforced and rewarded as everyone tries to figure out what the child needs in order to make the behaviour stop.
The problem is that it is NOT universally understood by the wider community and if the child does not start speaking, they are dependent on an interpreter who understands Makaton or Lamh - the simpler "special needs" sign languages.

Picture exchange in hard copy however is easily taught in a 2 day course and can expand expotentially to encompass the child's growing vocabulary.
It is always used in CONJUNCTION with emerging speech. To begin with the listener speaks each word with the child, but as the child's vocalisations develop, the listener just prompts or points to each picture and waits for the child to say it.It works well when there is difficulty with motor planning and co-ordination - you just use bigger cards. And it is universally understood, I have used it myself in southern italy and therefore consistently rewarded - which helps reduce behavioural issues associated with frustration.

Most children using hard-copy of picture exchange move on from it within 3 - 6 months as their articulation grows and they naturally fade using the picture back-up.
However, a number of children don't move on and their picture vocabulary can expand to the point where the book used to store it is no longer very portable or convenient.
That is where Grace App comes in. It replaces the large hard copy book that is kept at home, when you are out and about. Grace App is never intended for "tiny children" as you say because their vocabulary is still very portable.
To be cont
Lisamaree said…
As for "talking for the child"

Picture Exchange is never intended to replace speech. On the contrary, I strongly disagree with so called "voca" machines and apps for autism as they discourage the speaker from attempting to speak themselves - and breaks the "contract" of verbal behaviour, where the speaker is encouraged to interact with a listener in order to have needs met.

So no - the user is not going to "interface with electronic devices instead of humans" the need won't be met unless the user interacts with a listener. And to begin with the Listener - a carer, teacher, parent etc, will have instructional control of the iTouch or iPhone. The user must approach the listener and request the device which is worn on a lanyard or clip on their belt.

If successful, you could get a device that "belongs" to the child. But this would be a longer term consideration.

Grace app does NOT have a voice card attachment. The user points to the picture and the listener prompts the user to attempt each word. The App vocabulary expands to suit the individual using their own photographs and an agreed "name" for each item based on the users phonemic development.

These can be shared via SMS or Email with all the carers and teachers in the child's community, and therefore consistently prompted.

And finally, expecting a child to "sign" when they have a stomach ache, toothache, earache or sore throat, is messed up. You want to create a means for finding out if something more serious is going on - quickly. And that is why I created it.
Jen said…
As someone who has used the original PECS folder and pictures and tried sign language I can agree with everything Hammie has said.

My son started PECS 6 months ago. PECS encourages my child to ask for what he wants, interacting with us in a healthy, productive way.He also tries to verbalise when using PECS. He has started attempted one word requests verbally while using 3 part sentences in PECS. When he can talk he will already know how to construct and ask for something, it is just a case of the words following at this stage.

In that same six months we have managed to introduce ONE sign. Sign language has it's place, but not necessarily for children with autism.


Will be emailing you Hammie:)
Make Do Style said…
I think these are fab and as you know I've instigated picture cards at nursery to help young kids vocalise their needs with out need for verbals, particularly when their requests have been ignored in the past. Cards are great for all xxx
I think you are brilliant and it is a fantastic tool to expand communication. You, dear Hammie, never cease to amaze me. Your children are lucky to have such a brilliant, bold and incredible mummy.
Jean said…
Grace is peachy. I guess everyone is entitled to their opinion, but it works. It's that simple. Hats off to our lisa and steve xxx
Petunia said…
Flowspoon, you obviously don't understand the intricacies of Verbal Behaviour and the excellent results PECS have had in encouraging verbalisation. I have the Grace application and can see huge potential for many disabilities, not only for autism. Yes, sign language can be highly effective, but unless the person the child is signing to is trained in Lamh or Makaton, they may as well be "talking" to someone in Russian. Last time I looked, pictures are globally understood. The Grace app can be successfully used in an Echoics program to encourage vocalisation with the "listener" prompting and rewarding the child.

I had a quick look at the product you are promoting on your website... Do you not think its confusing for a child to have a mutant cross between a spoon and a bottle/breast? Will this not confuse them more and make them dependent on a "spoon" not widely recognised around the world... quite frankly, I think thats messed up!
Sister Wolf said…
Flowspoon has some weird agenda and should be ignored.

I love you so much, Hammie. Sorry about the dental situation, xo
Irish Mammy said…
I think this app sounds fantastic I have a cousin with Austism and I will be sharing this idea with her mom.
jazzygal said…
Well done Hammie. Grace, the app, is a wonderful, innovative creation that will help many, many children. I say this without any bias whatsoever, if I had any reservations I'd say it.
Grace, the child, is gorgeous! xx Jazzy
Grace is great, well done Hammie!
Clive said…
Enjoyed the comments!!

Grace is a fantastic tool - you will always get detractors - but no better person than you Lisa for dealing with them!
WendyB said…
I don't feel I can speak to the issues raised above but I wanted to send my sympathies to Bratty. I'm having another stage of root canal this week and feel her dental pain!
Arushi Khosla said…
You are brilliant. Kthxbai.
Casdok said…
I think i understand (but dont agree with) where Flowspoon is coming from as when C was small 'they' used to say the same about teaching children sign language, that children would then not verbalize. But we now know this not to be true.
And now all kids interface with electronic devises - why not our kids its how society works these days.
I think is brillient. And when the day comes that C decides PECs is the way to go i wont have to lumber big PECs books round hoping i have the right symbols with me.

Hope Bratty is ok :)