Augmentative communication

Shereen Idiculla is the creator of “Learning through Movement” and “Whole body to speech program”. A SLP by profession, she is Hanen certified. She is also a feeding therapist and an AAC coach.

 

In this interview, we have discussed the following topics:

 

1.    The importance of movement in brain development.

2.    Primitive reflexes.

3.    The terrible twos and brain development.

4.    Reflex integration followed by motor and sensory integration.

5.    Integration of the right and left hemispheres of the brain.

6.    3 phases of the LRM program and Shereen's roadmap to speech.

Congratulations on REALIZE! I gather it is a holistic approach towards communication rather than a piecemeal approach. Bottom-up rather than a top-down approach. 

This is actually the first time I'm talking about Realize. It's been a passion of mine for a long time. This thought has been in my head for years. But I never did anything about it. When working towards speech, communication and language, we work at the top tier of the learning hierarchy. For me, I never knew I had to work below that. When I passed out of college, or when I started working, there was no conversation about, how much the body contributed to developing speech? As SLPs, we work on speech; somebody else does OT and PT. It was not something that I could connect to. This concept of movement and brain activation came a few years ago when I was invited to speak at a conference in Kolkata. I heard Joanne Lara, another speaker, talk about Autism Movement Therapy. And for me, it was like, oh, okay, this is a whole area that I need to look into. I love to dance. That's how I got hooked on it. She had a demo class during the conference. And it just sounded so interesting to me. I told her that the next time you teach this course, please let me know because I'd like to participate. She had come down to Kolkata, and conducted the AMT course. And I'm so grateful even now that I got to attend it. Unfortunately, she is no more. But AMT really started driving this whole concept of how movement is so important for the brain to get to speech and language. That's when I started ‘connecting the dots’. I started exploring music and movement. I created my program, “Learning through Rhythm and Movement” (LRM), which I do online. I started this with parents online over 2 years ago and now I have many groups running for children below 6 (TOTS Group) and for children above 6 years. My goal was to explore movement as much as possible in a fun way. But as I explored, I started getting a little stuck, because some of my children were having extreme difficulty in moving, be it creating movement in the different planes or coordinating their upper and lower body or their right and left side. The parents were also finding it difficult.

And so, I started researching to see what next? By then I had started with Movement Based Learning (MBL), a course which again changed my life. The way I work with children also changed. As time passed, I tried everything I could get my hands on in terms of movement that speech therapists could do. Not an OT/ PT program. That would have gone above my head. But I started looking for what could be holistic, and I explored every movement training that came to India or online. And I started understanding the importance of movement in brain development. Another change maker for me was Dr. Robert Melilo’s certification courses. That's when I understood the importance of primitive reflexes and its effect on brain development This is something that should be checked but unfortunately, is not, by professionals.

What do you mean by primitive reflexes?

 Primitive reflexes are these automatic movements that we are all born with. And it builds the precursor for us to develop controlled voluntary movement. For example, you have a primitive reflex of the baby where when you touch the palm of a baby, she immediately closes her fingers around your finger. It's a reflexive movement. It's not because they're showing love at that point of time. And this reflexive movement helps the brain to understand that it can do this movement. And then, as they gain more control, that is when they learn to grasp, they reach out for things voluntarily. Another example, right now if someone tries to hit you, you turn away. It's a reflex, right? We are born with those reflexes for survival. So primitive reflexes start in-utero. And it continues to grow for another six to eight months. There are different reflexes, and they get integrated by about one year. When I did the Melillo certification course, I realized there's a lot of research now showing children with neurodevelopmental delays, have retained primitive reflexes. So when these reflexes do not go away, it begins to affect brain growth. I started exploring, asking parents to go and check with professionals. They were turned away, with the explanation that it was only done for babies. But that's not the case. I think they do not give primitive reflexes its due. I'm not sure what it is. But I'm hoping that changes. Because I know a lot of professionals who are now learning about it. I am crossing my fingers that it will benefit more people and families. All my children, without fail, have 1 or 2 primitive reflexes, or some of them had pretty much all of them. And that's why they struggle with movement. So I learned a little more, did more research around that. I started with a few families saying, you know, let's try some things together and just see what works. When I started seeing things work. Then I expanded it. I started a parent group training program, for a three-month period. The training would equip them to carry on with the program for a year. Reflexes will take one year to one and a half years to fully integrate. It's not a one day process. 

We started to observe changes somewhere between 2 weeks - 3 months. And within those three months, we had a pre and post study kind of thing, a basic one. We kept scores through checklists. The scores started changing, and so did the sensory profile. So it was not just movement getting affected, but also awareness, focus, understanding, behaviour, emotional development and academics. The biggest one was that it affected speech without speech intervention even starting. That was a big “aha-moment”! Because in three months, especially for my little ones (below five and six years), they started using speech more effortlessly. I realized that by just by working on the reflexes consistently, the parents and I were seeing huge leaps when speech therapy was not even in the picture!

Another thing we saw when the integration process started was “behaviour” that you normally see when children turn 2 years old. The opposition, the manipulation, the tantrums, understanding of self… all of this typically happens at 2 years and goes on to roughly 4 years of age. For children who missed these milestones, these “behaviours” come in when reflex integration starts. It’s not a bad thing… in fact it’s a very good thing! It indicates changes in the brain and should have happened, but didn’t.

Typically, the “terrible twos” involves a big brain development jump. Autism is commonly diagnosed at this age. This is because the big brain change causes an imbalance between the right and left hemispheres of the brain. According to Dr. Robert Melillo, the left brain gets stronger and the right brain gets weaker at this time for children with autism, and this imbalance causes all the “symptoms” to appear. If you look at the triad of symptoms of autism (deficits in social-emotional reciprocity, nonverbal communicative behaviours used for social interaction & deficits in developing, maintaining, and understanding relationships) – all of these are right brain functions.

The right brain is the social brain while the left is the logical & analytical brain. The right brain looks at the big picture; the left brain looks at details. I’m sure we have seen those on the spectrum noticing the smallest of details, like the stapler having moved even an inch from its position - this is an overactive left- brain function. You also have children who can read but not really understand what they're reading all the time. Reading is a left brain function while comprehension is a right brain function.

So if any kind of imbalance occurs, it makes it difficult to connect the dots. And that's why we see those on the spectrum being able to memorize information by rote but not use it in a social context. They might have a vocabulary of 20,000 words, but they are not able to use it. Because that's a right brain function - to be able to use words and language for a social reason. This is what we need to interact or develop relationships with peers or parents or others.

But, now what happens when the right brain is weak, when there is an imbalance? - Well hemispheric integration doesn't happen and social communication and other skills get affected!

I like to use this visual when explaining this to parents. It's a learning hierarchy which shows the bottom-up processing of the brain.

 This is a pyramid of learning that I use. It shows that the foundation of learning starts with the integration of primitive reflexes. Sensory processing and sensory integration can only happen if these reflexes are integrated. Traditionally, for children with autism, ADHD, dyspraxia, and other neurodevelopmental disorders, traditional therapy works on the superficial skills – and this is why integration doesn’t happen for a social and dynamic purpose.

I will continue to do speech therapy and oral placement therapy. But I have been getting such wonderful feedback from parents after they worked on reflex integration, that now I have started insisting on it. I have also been concurrently building a proper data model. The checklist that we had showed us that scores have changed, where the imbalance could have been 50; the imbalance now is at a 35, for example. The imbalance is reducing. If the imbalance reduces, that means the brains are getting more into balance. And when the brains balance, that's when integration happens. It's fascinating right now for me! I'm at the top of the world exploring this, as this is what I have been missing all these years.

I continue to explore kinesiology - the study of movement and how it affects brain development – which I feel has not been given its due importance. I'm on a personal mission to figure out how to break these movements so that parents can understand it and use them effectively with children. So I'm working with students and parents alike to see if we can create a balance, a positive environment where the children are learning naturally rather than being just told to “sit down”, “look at me”, “do this”, learn this, “pick this up”, “show me that”, etc.

What is the neural pathway that connects all of these?

 Essentially, we have three types of brain‌. The primitive brain, which is what we're all born with, for survival, it takes care of all the survival skills, like breathing, our heart rate, digestion, etc. and teaches us that we are safe; the emotional brain, where we learn about emotional regulation, how to connect with the environment, and how to be social; and the thinking brain, which helps us make decisions, learn concepts, think on our feet, etc. So we need neural connections from here to here (Shereen moves her hand from the back of her head to the front). But, traditionally we start working directly here at the neocortex (pointing at the forehead). If you look at most of the therapy approaches, we focus only on the neocortex. That's why the children struggle, because the right connections haven’t been established.

 When babies are born, they learn about the world around them by moving. They start to explore their body, their senses and create different movement patterns. They learn to crawl, which helps them understand their right and left coordination and get both hemispheres of the brain to talk to each other. Gradually they learn to stand against gravity, learn to walk and by the end of the year, that is when meaningful speech develops. So what this tells us is that its MOVEMENT, purposeful and mindful movement that triggers development and maturation of the brain. And as a speech and language therapist – this is what will help me get towards my goal of speech, language and communication.

Just as an observation, we skip writing as the child can type; accommodations that benefit the child immensely. In a phased approach to motor development ‌are we overlooking a fine motor skill; which may be beneficial in the longer run?

 We can and should give accommodations to children so that we give them a platform to always succeed and not fail. Failure demotivates us and brings down our confidence. Learning will never move forward if we our confidence and self-esteem is poor.

Some skills take time to develop, it’s not going to happen overnight. So we need to give them enough accommodations till those skills develop.

If children have difficulty writing, we got to go back and ask – why the difficulty? What movements have been affected? Where in the foundational level did things go haywire. Are the presence of reflexes causing postural, balance, sensory processing and/or writing difficulties? Are the movement patterns they have created rhythmic? This, again is important because it’s not just about creating a movement pattern, but about creating a coordinated rhythmic sequenced movement. This is your fine motor control. Children can probably run, skip and jump, but can they coordinate their body to play a sport? This a big indication that movement patterns in the body have been affected, which could affect a variety of other skills.

In autism, the earliest indicator for autism is movement. At six months of age, you can figure out there is an asymmetry in the movement. Movement is a huge thing. I'm discovering more and more that we've just not given it enough importance.

My goal is to let my fraternity know that we should not just sit at the table and teach them anymore. It doesn't work. Get up, move around, dance around, do something that involves movement and integrate this with learning. That's when you'll actually see effective changes. I'm not saying you won't achieve goals because children will still learn. That's how plastic their brain is, but integration is not going to happen easily.

And to be apply this knowledge to learning?

Dynamicity of thinking and learning should always be our goal. Because that’s how we deal with the world. This can happen only if there is an integration of both hemispheres.

If there is an imbalance, we have to find ways to understand where the imbalance is (right or left) and start working on it from the foundation up. For example, when children have vocal tics, or severe immunity issues, it indicates an hyperactive left brain. The right brain is supposed to inhibit and control the left brain function. But if it is too weak, it cannot do its job, which can make the left brain go hyperactive, causing OCDs, vocal tics, anger outbursts, food allergies and sensitivities, sleep difficulties, sensory processing difficulties, etc.

Apart from movement, what are other factors that can have a high impact on learning?

 I've created my roadmap to speech because at the end of the day, I'm a speech and language therapist. I'm trying to get towards that speech-language-communication component, which then integrates into social situations. That's the ultimate goal. For a speech & language therapist, this is what we all work towards. 

So, for my roadmap, I look at going into primitive reflex integration, sensory motor integration, body movement with music, co-regulation, naturalistic and play based interactions, AAC, oral sensory and motor stimulation, and finally speech.

One foundation of my LRM program was based on the idea that our brain is a predictable brain; so using music and movement enabled the building up of motor movements, sequencing, coordination and, specifically, motor memory. If we do not activate those areas in the brain (the cerebellum) that retain our motor memory, every time we do a task, it will seem like a new task. We need to activate these areas of the brain so that these memories get stored and become automatic for us. When I reach here and then work on interaction and language stimulation, things start happening faster and more effectively. The speech that develops becomes something that is meaningful and not just parroted or repeated blindly. This is when any traditional speech therapy approach will work.

So I have Phase One, which is primitive reflex integration, Phase Two, which goes into interaction and communication, and finally Phase Three, which goes into speech. All these phases are combined with body movements. This is how I have broken it down. Again, it could be wrong. I don't know, I'm exploring!

 

How does this approach work for young adults?

 The brain can pick up at any age. It's a long process, but may not be that long either. We saw changes in 3 months. There's one adult I've been working with for many years, where we struggled with speech. But now, after working on integration of reflexes a little more, his sounds are smoother, more effortless.

For a third person, hearing about this might not be a great thing. For me, it's a huge improvement! We've struggled to get a sound. Now I'm getting a sound and you're moving to combinations. So, for me, that's like magic. Because I know how hard the parents work with the child and how hard the child worked for so many years to get a single sound out. 

 For the older ones, we immediately put in accommodations – we start AAC, be it using devices, letter boards, etc. 85% of my population are children with a Mind-Body disconnect. They cannot move their body the way they want to. So that is why I explored movement because that was the population I was mainly working with. Motor coaching them through the motor patterns of using AAC effectively before moving on to cognitive components is what I have seen work wonders again and again. We follow a language ladder that helps us move up the cognitive communication skills, and our goal is to ultimately get to, in a year or two, to open-ended communication between us touching their hand or prompting them.

 

What's the Plugged Into Series all about?

 I started this series called “Plugged Into” on my official Instagram page to share my professional “Aha” moments - Moments that changed things for me as a professional. I would love to collaborate with both professionals and parents on this, but I think that will take some time. So, whether you're a professional, or a parent, can you get plugged into what is needed and what could help? That was the idea behind the series.

Thank you, Shereen, for explaining in great detail how movement impacts learning.