Breaking Barriers and Making Progress: The Story of Kris Carrie Cherney, MA, CCCSLP

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Breaking Barriers and Making Progress The
Story of KrisCarrie Cherney, MA, CCC-SLP
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Kris Admission in 02/04

• -15 years and 5 months old
• -Dx CHARGE Syndrome, Severe Mental Retardation
  and Autism Spectrum Disorder
• -Nearsightedness
• -Profound Hearing Loss
• -Sleep Apnea
• -Feeding Disorder
• -Limited Reinforcers
• -Maladaptive Behaviors Non-compliance,
  aggression, self-injurious behaviors, elopement,
  dropping, property destruction, feces smearing
  and food stealing

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Communication Skills

• Strengths
• 3 signs eat, drink and finished
• Understanding of cause and effect.
• Most frequently got what he needed himself.
• Barriers
• Kris needed a minimum of one model to sign (more
  often needed multiple models).
• No response to verbal speech.
• No attention to picture symbols.
• No imitation of sound production.
• Infrequently took staff to what he wanted.
  Consistently waited for people to bring things to
  him.

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Goal of Speech-Language Pathologist

• The goal of the speech-language pathologist in
  this situation would be to continue development
  of a functional communication system for Kris.
• Because Kris is non-verbal, he needed an
  alternative communication system.

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Barrier High Rates of Maladaptive Behaviors

• Self-injurious behavior
• Classroom 112.3/day
• Home 33/day
• Physical Aggression
• Classroom 17.1
• Home 11.7
• Property Destruction
• Classroom 14.5
• Home 5
• Elopement
• Classroom 5.2/day
• Home6.5/day
• Dropping
• Classroom 13.4/day
• Home 17/day

• Cooperation
• Demonstrated cooperation 14 of the day in the
  classroom.
• Demonstrated cooperation 51 of the day in the
  home.

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Barrier Attention

• Kris resisted sit down at the table tasks and
  often slid out of his chair onto the floor to
  avoid work.
• Kris demonstrated poor visual scanning and did
  not attend to picture stimuli.
• Kris did not attend to verbal stimuli.

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Heartspring Support

• A Student Support Plan was developed to address
  behavior.
• Kris was required to work at the table.
• Kris followed a structured routine daily.
• Kris had consistent and clear expectations.

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Communication Supports in Place

• Object/Picture Schedule 3X3 digital photograph
  alongside an object representing the activity.
  When Kris finished an item on his schedule, he
  placed it in a finished box.
• Break Symbol Round, black plastic poker chip
  with velcro placed on his schedule. When Kris
  reached the poker chip on his schedule, he
  transferred and placed the chip on his break
  board and then selected a break.
• Eat/Drink Board 5X12 board with 5 digital
  pictures representing eat and drink with
  corresponding objects (spoon for eat and cup for
  drink.)

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Speech-Language GoalsMay, 2004

• Goal Kris will request preferred items using an
  augmentative communication system during
  structured activities to request preferred snack
  items.
• Obj 1.1 Given a choice of 3-4 object symbols
  representing preferred items, Kris will select a
  symbol, hand it to staff, and accept the item
  with 45 accuracy.
• Obj 1.2 Given a choice of 3-4 object symbols
  representing preferred items, Kris will select a
  symbol, hand it to staff, and accept the
  corresponding item with 80 accuracy.

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• Student Support Plan still being run..

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Speech-Language Goals May, 2005

• Kris made progress with choosing motivating items
  (food and drink) given a symbol/picture board.
• Next step Expand his ability to choose breaks
  when the break choices are not food items.
• Goal Kris will be able to choose between 6 items
  from his leisure choice board and accept his
  choice for a 5-minute break.

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Speech-Language GoalsMay, 2005

• Kris did not consistently choose breaks or
  communicate basic wants and needs using symbols,
  therefore use of sign was discussed.
• Goal Kris will independently use 10 signs to
  communicate basic wants and needs.

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• Student support plan still being run.

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May, 2006Present Levels of Performance

• Kris used 5 signs that were meaningful to him
  finished, break, shoes, eat and drink.
• Kris understood additional signs work, sit
  down, stand up and toilet.
• During structured trials, Kris demonstrated the
  ability to select a 4 digital picture to choose
  a highly reinforcing item from a field of 4
  pictures in 10/10 trials.
• Pictures used were placed within a colored
  border. Each picture had a different colored
  border.
• Board with pictures was placed six inches in
  front of his face.
• Picture of desired item was moved around the
  board.

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Speech-Language GoalsMay, 2006

• Goal Kris will demonstrate the ability to choose
  a picture from a field of 8 and exchange it to
  request a desired item, object or activity.
• Obj 1.1 Field of 5
• Obj 1.2 Field of 6
• Obj 1.3 Field of 7
• Obj 1.4 Field of 8

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Barriers within Picture Exchange Goal

• When doing multiple trials, Kris initially
  selected a picture, pulled it off and attempted
  to exchange it without looking at it. When he was
  given the item he selected, he immediately signed
  done.
• It was discovered that if the board was held in
  front of his face for 3-5 seconds after he pulled
  off a picture, he often continued to scan during
  that time. When he spotted the picture he really
  wanted, he put the picture back on the board and
  pulled off the picture he really wanted.
• Kris impulsivity and impatience with the
  activity affected his ability to scan.
• During this process, Kris ability to scan
  gradually improved and his attention to pictures
  gradually increased.

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• Student support plan still being run..

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May 2007Present Levels of Performance

• Kris demonstrated the ability to select a 4
  picture from a field of 8 and accept his choice
  in over 95 of opportunities throughout his day,
  across environments.
• When the same pictures with the same color
  backgrounds were used, Kris demonstrated the
  ability to select 3 pictures, given a field of
  8, to choose a preferred item.
• Kris attention to pictures and scanning ability
  had improved dramatically.

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Speech-Language GoalsMay, 2007

• Goal Kris will use a point-and-carry
  communication book to request desired items,
  objects and activities during unstructured
  activities, across environments.
• Obj. 1.1 No more than one prompt, in structured
  activities
• Obj. 1.2 No prompts, in structured activities
• Obj. 1.3 No prompts in unstructured activities

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Communication Book

• Kris communication book includes the same
  pictures that were on his choice board in a 3X3
  size.
• There are two pictures per page.
• His book includes the highly preferred activities
  that Kris enjoys doing when has a break.

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Current Performance

• When Kris is given his book and told to choose a
  break or asked what do you want, Kris is
  making choices and accepting them with over 90
  accuracy.
• Staff report that Kris has independently picked
  up his book, walked to staff and pointed to a
  picture representing something he wants to do on
  several occasions.
• Kris often uses signs paired with his
  communication book to request (for eat and drink)

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Other Gains

• Kris very consistently responds to simple and
  clearly stated verbal directives.
• Kris continues to use and understand functional
  and meaningful signs throughout his day.
• Instead of waiting for people to bring things to
  him, Kris often asks for them or pulls staff to
  what he wants.
• Though Kris does not functionally use verbal
  speech, he has demonstrated the ability to
  reciprocate vocalizations during play-type
  activities with a tube. He can be very playful
  and has slightly improved in play skills.

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Current Rates of Behavior

• Self-injurious behavior
• Classroom 3.28/day (112.3)
• Home 11.18/day (33)
• Physical Aggression
• Classroom 7.04 (17.1)
• Home 30.36 (11.7)
• Property Destruction
• Classroom 3.88 (14.5)
• Home 14.29 (5)
• Elopement
• Classroom .24 (5.2)
• Home 1.18 (6.5)
• Dropping
• Classroom .6 (13.4)
• Home 4.97 (17)

• Cooperation
• Demonstrates cooperation 86 of the day in the
  classroom. (14)
• Demonstrates cooperation 79 of the day in the
  home. (51)

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Conclusions

• High rates of behavior and decreased ability to
  attend affected his ability to perform to his
  full communicative potential.
• Without the help of his psychology team
  developing a Student Support Plan and classroom
  and home staff implementing it, his behaviors
  would have continued to inhibit his progress.
• Without the help of classroom and home staff
  requiring that he sit and complete tasks, his
  attention would not have improved.
• Without the help of classroom and home staff
  running communication goals throughout his day,
  he would not have made the gains that he has.
• When working with students with high rates of
  difficult behavior, a team effort is crucial.
• --------------------------------------------------
  -----------------------------------------
• When Kris came to Heartspring, he was 15 years
  old and in middle adolescence. It is sometimes
  concluded that the abilities that a student
  demonstrates by this point in their life are the
  full potential that can be reached.
• Kris is a reminder to never give up!