expressive/receptive language mismatch ... musing on what next

[graciousenid]

we've just had ds's (4.5 ASD & language delay) most recent SALT assessment back (CELF).

Expressive language in the normal range (all >35th centile) up from 5th 6 months ago & 0.4th a year ago.

Receptive language is still severely delayed though - 5 centile - 6 months ago it was 0.1st & a year ago untestable. He scored really badly on sentence structure 0.1st centile :(

He's been doing a part time (i.e about 16/20 hours a week) VB programme for 15 months (before than he had 4 months of Hanen type therapy with a very small amount of ABA) & has 9 hours in mainstream nursery (this will continue for another 6 months). His biggest problem has always been the language issues & his prognosis was poor. He now has lots of spontaneous & social language & is conversational but still this huge receptive delay.

We can't fund the ABA indefinitely & will have to start reducing his hours (VB-MAPP is pretty much complete) in 2012. I really want to make the most of the next 6 months. He is going through a developmental leap atm - huge progress very quickly - I'm aware this isn't likey to continue. He is extremely good at disguising the receptive delay, nursery etc are shocked at how poorly he scored (I'm not tbh :( ).

He doesn't get direct SALT - we include her recommendations in our programme but she has never suggested anything that we're not already doing iykwim. Is there something a SALT could offer that VB can't with these sort of issues? Would it be worth swapping ABA hours for direct SALT?

when my DS was very young, he also had an expressive/receptive mismatch - not quite as big as with your DS. my DS was using a lot of echolalia, both functional and telly talk./stimmy. IME SALT didn't have a great deal to offer re:receptive language after diagnosis, other than common sense - about using visual prompts/signs etc to help communication - a fresh pair of eyes can sometimes be helpful, so no harm in seeing what an experienced private SALT would propose doing - but I wouldn't be in a hurry to swap VB for SALT.

what bits in particular are you looking to address?

I know, overall, you want ot improve receptive language, but I would approach it (initially) situationally. work on it a bit at a time.

what is causing problems most of all? you say he disguises it at nursery - by being smiley and charming, and everythign washing over his head, or by disengaging and tunign out?

Being smiley, charming & chatty - whenever he's in a situation where they language/demand is too complex he'll start talking about something completely different & bring the conversation around to his terms. We do a lot of 'we're not talking about X ds, I said ' but unless you're really aware of what he's doing it is easy to go along with an irrelevant story about robots or whales etc.

He'll follow 2 & 3 step instructions (get your fish book & give it to daddy in the bedroom etc) - but in the test he repeatedly failed the 'first show me the then find the _' questions (we're doing self echoics to try and improve his working memory for that kind of stuff).

We've done quite a lot of sequencing work with him with visuals & orally, but he didn't do well with first/next/last, before/after in the test.

He had problems with picking out the picture from a group of similar ones when there was more than one difference - so find the big & black dog, the girl under the bush, the boy not running etc - only listening to the first part of the sentence.

He had trouble with concepts like empty, dry, on the bottom, different which he uses expressively & appropriately & are generalised (he loves which one is different puzzles) - which really surprised me, I can ask him to empty the box/dry the animals etc & he'll do it.

We don't use visuals in a big way at all - he has a weekly calendar - I'm not sure how they would help really ... in daily (routine) life it doesn't seem to cause major difficulty - he copes fine with 'we're going shopping, then Grandma is coming, then we're going to nursery' etc. Obviously there is a big problem though - perhaps less apparent than it should be because we're only doing NET atm, no sit down or academic stuff at all

the trouble with concepts (dry/empty etc) - how were the questions phrased? is it wh? that he is having problems with? so he knows the concept of empty, but when asked "which one is empty" doesn't know what it means, so is randomly guessing?

for all the before/after/first/next: when dd1 was struggling with this, we implemented a new bedtime story, about "two little girls" who (entirely coincidentally ) have the same names as dd1 and dd2.

we went over what they ahd doen in the day, and what they would eb doing the next day. slowly, it has become dd1 tellign us what she has done with her day (my sneaky way of getting to know what she has done at school )

she loves it, adn it gave us a very conversational way to use first/then temporal relations, before/after - both as statements, and to test ehr understading of the questions.

completely get where you are coming form re: chatty and charming though - dd1 is the same. and you do need to be constantly on your guard, as otherwise she is happily rattlign on about somehtig entirely different!

I think he needs a way to tell you the demands are too complex, as he is communicating this but as you say it would be easy for someone unfamiliar to miss. Maggie Johnson has a programme called Active Listening for Active Learning with lots of barrier games to teach explicit clarification requests e.g. "say that again" or "I'm not sure"/distinguish between knowing and guessing etc. It's a good strategy for us all.. we all need to clarify,

In terms of the assessment, "empty" in "empty the box" has a different meaning to "point to the one that is empty".

The first is a verb - it involves an action, it's probably in a routine etc. "Point to the one that's empty" is pointing at nothingness, absence. So a bit different. Same for dry in your example.

The others need systematic work too.

I would probably teach a lot of these as you have taught everything else but as he has completed VB-MAPP you might just need to increase the demands. One of the things I think can be poor in some ABA programmes is that programmes like RFFC need to be perpetually done with new materials rather than "ticked off" as done because a certain critical mass has been achieved for a period of time.

If I showed you a new object, say an electronic gadget of some sort, you would quickly extrapolate RFFC information for it to support it in your memory. Depending on how "techie" you are this could range from quite basic information (has an mp3 player and a camera, use it to communicate, a communication device) to ludicrously numeric (has 12.6 .exe features and can tranfer data at a rate of 36000 whatsits etc etc). I love RFFC, I think it is a fabulous programme, but it needs to be revisited as things change and vocabulary/language demands increase to ensure that your child is developing solid understanding of words etc.. this is how it works for all of us, we are constantly adding to and refining words. Hopefully, when he is older it will be automatic but he is still young and the assessment suggests there is work to do. Similarly with concepts, they may need to be used in different contexts etc. At secondary, empty might be a word you use to describe someone's laugh, their soul, as a foundation for other words like vacuous etc.

just to add..with regards to the 2-3 step instructions and the example you have given, it seems he is ok with familiar instructions/expectation

DS follows excellent go upstairs in your brother room and bring me socks from the drawer and pijamas from the wardrobe but gets stuck when I say first touch your nose, then clap your hands then give me a kiss or anything random like that. And he also failed point to the girl on the table when he had a choice of a girl on a bed and a girl on the table (certainly the girl on the table wasnt expected in his logic, well mine too :))

this is really helpful - thanks everyone - need to get kids to bed but will be back!

Working Thank you so much for that post. I think it has solved a good number of my problems wrt the next steps for ds.

Thanks everyone - really appreciate the input :)

We've been working on mainly expressive, OT (he's almost caught up! Should be discharged soon :) ) & social skills recently - a lot of the receptive stuff has gone by the wayside (particularly RFFC - working you're absolutely right we got to critical mass & shelved it); I've emailed consultant & tutors suggesting we refocus a bit

continue with self echoics
more temporal sequencing
2 and 3 step instructions ? gross motor and object manipulation
give him a way of saying ?I don?t understand? (he already uses I don't know but needs more work)
test basic concepts - check he's solid on all of them
more RFFC