MORE Common Sense PLEASE!

As the title reflects, we as Speech-language Pathologists (SLP) and other educators need to apply more common sense when suggesting or teaching the use of universal, multiple meaning request words to young multiply handicapped children and young adults. Children with speech and language delays continue to be identified at earlier ages. As more children are identified our role as the speech and language expert becomes increasingly important. The argument exists for the teaching of generic request words such as “More” and “Please” to cognitively impaired children and young adults.  In this article, I will focus on the opposing view, which is to teach cognitively impaired children concrete and functional words or gestures with specific meanings and outcomes.

As I reviewed the literature regarding the use of universal or generic request words, I was unable to locate any articles or current research related to the use of universal, multiple meaning request words (“More” and “Please”). For the purpose of this article, the term “cognitively impaired” refers to children or young adults with multiple handicaps to include mental, physical, and speech-language disabilities.   The following are a few examples of how I have observed cognitively impaired children use universal request words.

Example #1

A four-year-old girl with Down Syndrome requested chocolate milk by signing “more”. As she was given the glass of milk she smiled and quickly drank all the milk. The next day at snack she was presented with vanilla wafers, and again she signed “more”. She was given three cookies and she ate each cookie. A week later I observed her again and this time pretzels were the snack. The girl signed “more” and was given a pretzel. She smiled as she put the pretzel in her mouth. As she started to chew she made a horrid face and spit the pretzel out onto the table, pushed her glass of milk away, spilling it as she vocalized in protest.  The teacher quickly gained control of the situation and asked the young girl what she wanted. The girl vocalized with strong communicative intent as she pressed her short, stubby fingers together signing a variation of “more”.  The teacher gave her another pretzel and again the young girl protested. The teacher removed the young girl from the table and she missed her snack.

Example #2

A young boy with visual, physical and cognitive disabilities was on a large therapy ball. The professional assisting him was very attentive. When she stopped bouncing him, she immediately responded to his vocal protests by grasping his hands and physically assisting him to sign “more”, at which time she would bounce him again. Again stopping, she would cue him with “tell me more bounce” and physically assisted him with signing “more”. The professional later reported to me that he learned to spontaneously request to be bounced (by signing “more”) after three sessions.

Example #3

A young girl was sitting in her wheelchair in the classroom play area listening to music.  She bounced in her wheelchair and smiled as the music played. When the tape stopped, she started rubbing her chest (signing “please”) as the teacher assistant approached her saying, “You want me to turn on the music?” The assistant then turned the music on and walked away to attend to other students in the room.  While the assistant was busy in another area of the classroom another student started pushing the buttons on the tape player and turned off the music. The girl again started rubbing her chest but no one was attending to her this time. She then started to pat her chest with frustration showing in her face.  Minutes passed and she continued to pat her chest. She added vocalizations to express her frustrations. This time the teacher approached her saying, “If you want a book you need to ask me appropriately”.  As the teacher waited the girl signed “please” by rubbing her chest.  The teacher responded by saying “Good asking for a book” and took the girl’s favorite book from the shelf and gave it to her. The girl opened the book and started looking at it. Later that morning, during snack, the same girl requested “juice” by signing “please”.

These are only a few examples of how “More” and “Please” are used by cognitively impaired children to make requests. If you have worked with cognitively impaired children, then you can relate to one or more of the above examples. Some professionals would say these children are demonstrating functional communication skills. I would judge their communication skills as functional only to the listener and not to the child.

I would like to suggest the following exercise to help make a point. Pretend I am standing in front of you right now and said the word “banana”. What did you visualize when said banana? I would assume a picture of a yellow banana. Now do the same with “chocolate milk”. Some of you would visualize a carton of milk and others a glass. Now try “cracker” and again, depending on your past experiences, you would have visualized a variety of cracker you have eaten. Now, what do you see when I say “more”? Most likely you saw nothing at all. What do you think a child with cognitive and language delays visualizes when they hear “More”? My interpretation is that children will visualize whatever they associated with the word “More”. They might associate the object or activity they were involved with when “More” was taught to request an object or continuation of an activity.

I have had many discussions over the years with parents, caregivers, teachers and other professionals regarding the use of universal communicative responses. I encourage teaching cognitively impaired children specific words for the item or action the child wants. This makes the most sense and has been successful.  Use of the universally understood gesture of “pointing/ reaching”, is by far more acceptable and meaningful than teaching abstract multiple meaning words.  In some situations, as in example #2, the sign representing the activity of “bounce” (one hand) requires a less complex motor movement than the sign for “More” (two hands). If cognitively impaired children have the ability to make requests using “More” and “Please” then they have the ability to learn the word, sign or point/reach for the item they are requesting.

If the above examples were describing children with age commensurate cognitive and language skills, they would not have been expected to use such abstract words as “More” and “Please” to express something they want. Typical children would be expected and encouraged to use specific words that represented what they wanted (chocolate milk, cookies, bounce, music and juice).

Research supports the need for specific labels of objects to be taught to developmentally delayed children in the context in which the child experiences the use of the object (Kouri, T., 1994, Lexical Comprehension In Children With Developmental Delays, American Journal of Speech-Language Pathologist, 3 (1) 79-88). Kouri states that new object terms are learned much faster than new action words. Kouri attributes this to object referents being more concrete. The article indicates the success for generalized use of the new concrete vocabulary terms is greater when learned in context. This research supports the teaching of specific and concrete words for the items cognitively impaired children are requesting. At this time, there was no research available to support the use of multiple meaning words.

My professional philosophy related to the use of “More” and “Please” is simple. I do not agree with the use of generic or abstract all-purpose request words with cognitively impaired children. I disagree even more when these words are taught to cognitively impaired children as their primary means to express wants and needs to others. The words “More” and “Please” are an important part of children’s language and should be taught when developmentally appropriate. I oppose their use when taught to cognitively impaired children as the child’s only means to communicate immediate wants and needs. I encourage the use of the universally understood gesture of pointing/reaching and use of specific and concrete words representing the desired item or action.

The use of a “pointing/reaching” gesture by the child provides an immediate bridge to communicate in multiple environments. As professionals, we need to focus on using common sense in our decision-making process as it relates to teaching functional communication to our cognitively impaired children.

Richard Hood, MS, CCC/SP