Augmentative communication

 Namrata Pai is the founder director @ Magpie speech therapy and co-founder at Magpie think labs. She is a certified speech language pathologist, with over 15 years of hands-on clinical experience in communication paediatric disorders. A gold medallist, in the Hanen program, she is well versed with Oral Placement Therapy, Play Therapy, Structured Teaching, social thinking, LAMP (language acquisition with motor planning), PROMPT (Prompts for restructuring oral muscular phoenetics targets) and PECS ( Picture exchange communication system). Some of her main areas of interest include; Social communication issues in children with ASD, ADHD and LD, AAC,  and naturalistic intervention approaches.

                    During the interview, the following points were discussed.

1. Dynamic and domain specific assessments
2. The powerful Test, Teach and Test again concept
3. Executive functions in the context of an SLP
4. Goal setting for young adults on the spectrum
5. Bridging the gap between performance and expectations
6. Naturalistic intervention  techniques; RDI and Declarative language.

A lot of your work is based on dynamic assessment and goal setting. Could you please elaborate?

 My background is in speech language pathology. When I started working, I realized that a lot of the standardized assessments for speech and language in autism, do not support the intended purpose. What is the child's current communication level. What might be ways in which we can support it? That information was not, coming across as it should, through these standardized tests. These tests assumed a lot of times that the child will be verbal, or we'll be able to respond verbally, maybe also in a particular format, or detail, which, of course, we know, is difficult for children. And since it's the spectrum, we are looking at children with very different abilities in terms of speech, and language. I think the first couple of years, while in my practice, I realized that, these were not leading me anywhere to how I can exactly help the child and the family. Also, that we are looking only at the child. When we administer the test, a lot of times we thinking about the challenges, and the weaknesses. But are we looking at the strengths?

           Second, would be the family. The family is approaching you for help. How do we make sure the family is a big part of that communication process? How do I make sure that I identify factors related to the family in terms of their conversation style, routines, priorities. As a SLP, I might have a certain lens I'm looking through, however, the parent might find a different situation more distressing than just the speech aspect. With all these challenges, I felt that let me see what I can do around the assessments.  I started documenting a lot of my sessions, and making notes of it, as I would finish. I realized, it was falling into a very simple methodology of test, teach, and test again. I realized that every time if I went in with this mindset for a session; I have a particular goal, and some takeaway for the family on how they can generalize it, in a span of maybe six to seven sessions, we should be able to reach a point where the family, self and the child feels more independence in the communication. This was a completely contrasting approach to IEP,  where you're planning for a year, and one has this whole vision that this is where the child will be in a year.  Practically, there are a lot of challenges and failed benchmarks in the timeline.  When I started implementing this model of test, teach, re-test, I realized there is literature supporting it. I started reading up more, realizing that this is a form of dynamic assessment. The Dynamic Assessment principle comes from the Psychology background. It was Lev Vygotsky who initially proposed it and  have used to see how to mainstream children with special needs into inclusive classrooms c using DA. The research began there, but it has now been adopted by many other professions, including SLPs.

 

You have also spoken about domains?

Domains is something that is close to my heart. Because, as I previously stated, when I first started, my lens was really focused on speech, and perhaps language in general, but then parents asked me how I could help them with these behaviours. Why is my child flapping his hands? Or why is it that it is difficult for him drink water from a glass? Such specific questions, which do not come under any standardized assessment. I understood that if I was going to actually assist, I needed to answer these questions. I had to equip myself to understand how I could best assist them based on the a) information provided by the parents, b) what I observed in the child, and c) what I read or researched. Putting all three together is when I started coming up with domains, and I realized that it can be made into really small parts because language is vast like an ocean. When it comes to language, joint attention can be one component, and emotional expression can be another. Yet another could be being able to hold a conversation. We can have different domains within what we are assessing, so that we become more and more specific. And, in many cases, with this domain-centred approach, the family and child may offer me feedback on the domain they believe we should proceed with.

You said at one point that you are viewing communication through a particular lens, and then the family finds something else disturbing… At some point, did you think, executive functions also come under the realm of an SLP? Especially when working with the family as well.

You have pointed out a very big aha. Executive functions really govern a lot of our independence. A lot of our mainstreaming is about taking up jobs or just being, contributing to a routine and a family structure. And what happens is, these executive functions generally are addressed from all by a psychologist, a lot of its background comes from psychology. But the same time how I felt, I wanted to add executive functions.

For children below eight years, a lot of executive function is just about how are they able to plan their day-to-day routines, participate independently, or with help depending on the child's motor planning and facets related to the child’s strengths? While if we are looking at a child who's maybe about eight, then we are looking at function from a bigger perspective of; Am I able to read the information around me? How do I use this information to make myself heard/ seen or advocate for myself? Or look at how do I express what I'm thinking in a manner that makes sense to the other person. Yes, it plays a huge role, and incorporating that, in our early intervention program has been a focus.

For example, I have parents who come in with a four-year-old and telling me that, I want my child to learn maybe 50 new words, as part of you being a speech therapist. But I ask them, is your child independent in using the toilet, or feeding himself. These are not questions they expect a SLP to ask. So how am I going to help in this executive function aspect? I think the narrative of telling parents that we can contribute to it because a daily routine is also a time when you're communicating a lot.  It's, a lot of back and forth, which happens and it can be used in a way to not only build executive function, but also some communication, which can eventually get to that final goal of those 50 words you want your child to learn. Explicitly telling parents that our program at Magpie, covers these aspects, keeping language and communication in mind is something which I had to give examples to parents, because they might not realize that they can actually take help for this from SLP.

 

Goal setting is another major area of focus. How do you do that for teens and young adults?

This is our process. If the child can communicate in any form, we ask the child why he has come to our place at Magpie. What are the things which he feels he needs help with? One part of this is because I feel a child himself telling me that, this is easy for me, or this is difficult for me, sometimes it can be that they are echoing what they have heard their parents talk about. And that definitely gives me insights about the parent as well, because they are surprised when I first talk to the child. How do you think I can help? Some children completely deny they need therapy. They state I am absolutely fine. I'm here because my parents got me here. Then we try a different approach. I would ask them what are some things which you like to do, or you are good at. So, our conversation might start from there. 

The first part is trying to look at the child as an individual, and not as somebody who's been brought by his parents for fixing. Just supporting in terms of skills, this is his weakness, we are going to support him through this. That's the first thing, which is a drastic change from a child below eight years where, maybe I'm talking to the parent mainly. The second thing is, when I'm talking to parents, most of the times the child is not there, whether the child is pre-verbal or verbal. I feel most children on the spectrum are able to understand and I feel what is happening around them. They are so stressed with, meeting so many professionals, and maybe going through the whole routine. Parents concerns revolve around the child’s inability to make friends, making him comfortable in a classroom setting. These are some common concerns of parents whether they walk in with an older child or a young adult.

The second focus is, a lot of emotional regulation. Because what happens is we have children who are either very expressive in their emotions, their buckets get too full too soon, which means we see them express their anxiety, express their anger or disappointment very often, in ways which sometimes can be very difficult for a parent to understand or manage. It can be very stressful for the parent as well.   It can be that or it can be completely the other extreme, where the parent is really struggling to figure out what my child is feeling. What is he going through in a particular situation?  The very amazing thing about emotional regulation is it's nothing related to the severity of the spectrum. We say mild, moderate, severe autism, but I think there is no connection between the severity and emotional regulation. It's just so independent. A so-called severe autistic can have a beautiful bond with his parent and be emotionally regulated through his parent; yet I can have a so-called mild autistic child who nevertheless struggles with emotional regulation. I believe that the piece where I see emotional regulation leading is the child's ability to connect and feel comfortable. He doesn't feel threatened that often; he can connect with his environment, can maybe connect with adults or peers. This child now needs support with how do I express what I like or what I dislike or what I want to do? And how do I keep myself together in spite of rejections? Social rejections, because then we are looking at a child who is trying his best to adapt and make friends and be in this mainstream classroom. Maybe inclusive classroom, where he's made some initiation towards his peers, but he has been maybe at times, rejected unknowingly, at times ridiculed or bullied, knowingly. So, there can be different situations, which can make this child very sceptical and not ready for peer interaction. Though they want to, they might find it very intimidating. And it's not a fear of failure. And in that case, we are definitely looking at the peace of having one companion, one friendship, or a small group of peers where the child can share and, feel comfortable. Understand that there can be bridges built with peers, and where we are looking at some group support.

 We hold paired sessions in which we attempt to match children based on this social emotional learning component. We try to understand how the child can feel good and comfortable in a social interaction without being judged, or without being constantly corrected. It’s not therapy. I feel its more of coaching to impact on a lifetime of opportunities. We are there to just moderate. 

 

This is something you have been hearing a lot from parents; expectations. How do you bridge the gap between expectations and reality? “How much improvement has the child shown”. It finally comes down to that.

It’s a process. Families are at various phases of acceptance, depending on how much they have accepted the fact that their child is neurodiverse. Not only accept, but accommodate around it?  I believe that what happens in this path is that the gap between expectation and reality can be very large for some families, where they are frequently looking for neurotypical means of affirmation?  He needs to go to a mainstream school, he needs to be good academically, he needs to be able to build friendships. There's nothing wrong with this expectation, because I think every parent definitely deserves to expect and has all the right to think about the best for their child.

Autism being very complex neurological condition, where do I set my expectation? Where do I set my boundary? I think one part is definitely when parents are in touch with a lot of other parents who have a similar background. I think that really helps a lot more than even meeting a professional. We have different kinds of people, professionals, kid enthusiasts, quacks and not all of them have an ethical practise. The first few years, the emotional aspect takes its toll on the parent and nobody looks into it. It is a lot of assessments, reports etc. Then they decide to step forward for the intervention part. As a professional, how do I tell my parents that this is something which we can achieve versus this is something which is difficult? I think that clarity is something which parents’ ought to be given?  I have learned this after many years of practice that some things which are difficult, I believe you need to tell the parent that this is really difficult, this is not possible. And why is it not possible, I think trying to gather being a detective and gather those clues with the parent. It is my responsibility as a professional.

I think if parents get logical answers to their questions, they also start settling into the process. And they realize that this is why it's hard. It's not that I can make the child do it. It's not that he's stubborn or intentional. It's not that he's lazy. So, I think that piece of knowledge if they get from one professional, if we have a bunch of individuals who think the same way or support the child in the same way, it just makes it so much simpler for the parent. What happens is, there might be a child who comes to Magpie and we are really trying to normalize the process of self-stimulation. A kinder word maybe enthusiasm, with neurodivergent affirming practises. What matters is the intent with which we are talking to the parent and the child. And the parent might hear these different things. One professional says it has to stop, it's bad. While another professional says, It's okay. This can again widen that gap of expectation and reality.

Speaking specifically about our practice, we are very particular about bridging the gap. When I take in families, I explicitly have this question for families that, where do you see your child in the next three months? Where do you see your child in the next one year?  I'm just trying to gauge the expectations, and then, start from there. It's a process, a journey for both the therapist as well as the family.

I take up any two goals. I always have one goal, which is the parents’ priority, which we might try to, discuss and come down to an achievable goal. It is because the parent is totally invested in it, then I know I'm going to get a lot of support in achieving it. Versus we might take one from a professional perspective or just looking at the bigger picture of the child and decide another domain  to  balance the action plan.

 

You recently met Linda Murphy. How does it overlap with your existing practise. And what have been your takeaways?

When I started my practice, I really didn't have any colleagues who followed a similar methodology in Bangalore. As in it being child -centred, family- centred, naturalistic. We were looking at traditional speech therapy. Flashcards based approach, tabletop approach, or the medical model. Second, I was kind of figuring out my path with dynamic assessments, and making it as research backed as possible, collecting clinical evidence. Assessments, Documentation, the challenges… I travel every alternate year, to different places to gather information, knowledge, exchange ideas, keep myself and my team motivated, bring in new practices. I came across Linda’s work. They followed something called RDI (Relationship development intervention). At that point in time, Linda was mainly doing only RDI.

During the pandemic she actually worked a lot on co- regulation, and declarative language. This is one space where she has done amazing work and I totally loved it. It was a whole new outlook on neurodiversity affirming practise.

It’s about looking at the child from the social emotional learning perspective, looking at it from making it achievable through group dynamics, rather than having the child on a one is to one where we trying to teach a skill, but rather doing it through a paired/ group activity, in the moment learning through activities, which look very natural.  As simple as sharing about, what they had for breakfast. It can give a lot of insights into sharing perspectives, thinking in alternatives or possibilities, giving time or just listening to the other peer.

Her team also is a mix of professionals.  She has a mix of speech language pathologists along with educators and psychologists. I felt that apart from being interdisciplinary on paper, can we have professionals who are maybe working in their own ways with children on the autism spectrum, but still can contribute and collaborate so that we are looking again at the child's overall growth in communication, social and emotional skills. These aspects are something which really have made me stay in touch with Linda, and as generous and warm as she is, every time I go, I get to observe sessions or be with her during her sessions. There is so much experiential learning happening.

 

Thank you, Namrata Pai for sharing your ideologies and thoughts. It was wonderful talking to you.