No More, More
By Tracy Vail, MS, CCC-SLP, Autism Consultant and Heather Forbes, MA, CCC-SLP, BCBA
There is currently a great deal of debate in the field of speech-language pathology about the kinds of words that should be taught first to nonverbal (or minimally verbal) individuals with communication impairments. This debate mainly surrounds whether interventionists should first teach a broad range of specific, concrete words or a small set of abstract words that can be used across items and environments.
Clinical decisions like choosing first words should not be made randomly or based on practitioner preference. Important factors to consider include the values of the learner, his/her family, and community as well as and evidence from high quality research. A third critical factor to consider is the nature of the communication disorder itself. What are the baseline skills (and missing skills) of the individual we are trying to teach?
No diagnosis highlights the importance of this third factor more than autism spectrum disorder (ASD). As a well-known saying jests: “If you’ve met one child with autism, you’ve met one child with autism.” ASD presents with high variability both across children and within children, as children with autism may not develop skill sets in the same sequences as peers (Sundberg, Galbraith, & Miklos, 2007). However, the paramount deficits across children diagnosed with ASD are in social communication and social interaction—what SLPs would typically call pragmatic language (American Psychiatric Association, 2013). For instance, a child with autism may learn to say many things, but those utterances may simply be scripted from a favorite TV show and have no communicative purpose at all. Or a child with autism might learn to label many things in his/her environment, but the child might not know how to ask for those same items when he/she wants them. Therefore, when analyzing factor three, we cannot simply look at the forms of the skills missing in a child’s repertoire—especially for children with ASD. We must also observe whether or not the child has all of the foundational skills necessary to use the target skill effectively across all relevant social contexts.
Laura Mize, a pediatric speech-language pathologist, wrote a blog entitled In Defense of More—10 Reasons I Still Teach the Sign “More” First. The purpose of the blog was to support the continued teaching of the sign “more” as a first word to children receiving speech and language intervention. To that end, we will consider each point highlighted in Ms. Mize’s blog and specify why her rationale may not be validated by research or applicable to many children with communication impairments, especially those with ASD. This response is not meant as a personal attack against Ms. Mize, as we have read her blogs and feel that she has made important contributions to the field of speech-language pathology. Rather, this response is one way—in the age of “electronic conversations”—for offering a different viewpoint.
1. “The sign for ‘more’ is easy.”
Ms. Mize claimed that the sign for “more” (i.e., signing “o” with both hands converging at midline) is a relatively easy motor movement and relatively easy for the clinician to physically prompt. While the sign “more” may be easy in comparison to more complex signs, research does not support “more” being the easiest sign to emit. In fact, there are earlier-developing motor movements than those required by the sign “more.” Bonvillian and Siedlecki (1998) noted that movements involving hands on either side of the body occur before converging hands together, bringing hands in contact with a broad surface (e.g., torso, leg) occurs before bringing hands in contact with a narrow surface (e.g., fingertips), and the hand movements involved in holding up five fingers, pointing with the index finger, and signing “b” or “a” all occur before the hand movements involved in signing “o.” In other words, there are many other signs available to clinicians that may both be easier to prompt and easier for children to physically produce than “more.” Furthermore, given that many early signs in typically-developing infants and toddlers are approximations (Bonvillian & Siedlecki, 1998), it seems feasible that clinicians can teach modified forms of even complex signs initially, and shape complexity as the child’s motor skills improve. All-in-all, the sign for “more” might be easy, but research does not support that it is by any means the easiest.
2. “The sign for ‘more’ is fast.”
Here, Ms. Mize was referring to both speed of acquisition and speed of emission of the sign. Her argument for rate of acquisition was related to her first point—easily prompted and easily produced motor movements will be acquired faster. Because she relates those arguments, we encourage the reader to please see the response above negating the relative simplicity of “more” in comparison to other signs.
Regarding the ability to emit “more” quickly, we would argue the relevance of this point. We could find no research to support that “more” is the speediest sign to emit. Nearly all signs can be emitted equally as quickly. Furthermore, let us consider what might be the advantages of emitting a sign quickly. Ms. Mize (correctly) pointed out that the quicker the sign is emitted, the quicker the child gets what he/she wants. This is exactly where a sign for “more” fails—particularly in the ASD population. When the average person says or signs “more,” it is only under the conditions in which he/she already had something and the listener knows what, in fact, he/she wants more of. The irony (and danger) of teaching the sign for “more” first is that the child has not been taught to request the original item he/she desires! Most typically-developing children who use “more” have other skills such as leading, pointing, and even speech—all of which they can use to communicate desired items to their listeners (Bates et al., 1994; Tardif, Fletcher, Liang, Zhang, & Kaciroti, 2008). But some studies show that early social communication skills such as “pointing” are lacking more often in the ASD population when compared to both typically-developing children (Osterling & Dawson, 1994) and children with developmental delays and language impairments (Stone, Ousley, Yoder, Hogan, & Hepburn, 1997). When these and other skills are lacking, teaching the sign “more” first can actually slow access to reinforcement, since signing “more” does not indicate to caregivers exactly what the child wants. Even when the child can lead and point, reinforcement is often more delayed than if the child said or signed the name for the specific item right away, since pointing alone is not always effective. (Consider if a desired item is in a high or well-stocked cabinet.) For these reasons, research demonstrates that training a child to ask for specific items actually reduces problem behavior better than generalized signs like “more” (Kahng, Hedrickson, & Vu, 2000).
3. “The sign for more is popular.”
While many listeners might know the sign for “more,” as indicated above, knowing that a child wants something does not specify to that listener exactly what the child wants. Furthermore, this point is only relevant if it is conversely difficult to teach listeners other signs at the rate in which the child is learning them. This is almost never the case. It typically takes little more effort than telling listeners what to do one time before they learn how to appropriately respond to specific signs of early communicators. Certainly, competent adults should be able to learn a sign just as quickly if not quicker than the learners we are trying to teach. Even siblings and peers can learn signs fairly quickly and easily. In fact, typically-developing infants as young as 8.5 months have learned to sign and respond to sign without explicit teaching (Bonvillian, Orlansky, & Novack, 1983). If clinicians cannot speak to family members and members of the community in-person, it is also quite easy nowadays to snap a picture or video of a child’s sign and send it via an e-mail/text, or print it out to hang on a ring. Given the downfalls explained above of teaching the sign for “more” first, clinicians are cautioned about making decisions about best practice based mainly on what is easiest for the clinician. Program decisions should by and large be based on what is best for the child.
4. “The sign for ‘more’ is functional”
Ms. Mize defined the term “functional” as “[enabling] you to ‘function’ better and more consistently in everyday life.” Given this definition, in our 43 years of combined practice, we have not encountered a less functional word to teach first than “more”—particularly for a child with ASD. Yes, many toddlers say “more juice” or “more cookie.” Some might even just say “more.” However, as indicated above, typically-developing and even some language delayed children have existing communication skills that allow them to discriminate that they only use “more” when they have already had some of something (and their listeners know exactly what they want). Tardif et al. (2008) analyzed the first 20 words to develop in a sample of 865 children in the United States (n=264), Bejing (n=367), and Hong Kong (n=336). “More” did not show up on any of the lists for any of the languages studied. Bates et al. (1994) analyzed language development in 1,803 infants. They found that “closed-class words” (including quantifiers like “more”) did not appear in the children’s vocabularies until they developed at least a 50-word vocabulary of specific nouns and verbs. It appears to be conceptually, developmentally, and functionally problematic to teach a child to ask for “more” of something before he/she can ask for the thing itself. Let’s consider an example in which an interventionist taught a child to sign “more” in a therapy session in order to be bounced on the therapist’s knee, to receive a snack of crackers, to get a drink of water, to be rolled on a scooter, and to get the therapist to blow bubbles. Let’s say that interventionist even communicated to the child’s parent what the child was taught that day (as a good interventionist should). What happens when the child goes home and spontaneously signs “more” to his/her parent without any other clues? Will the parent immediately know what the child wants? Is the sign really enabling the child to “’function’ better and more consistently in everyday life?” For communication to be functional, it has to be clear to both the speaker and the listener. This is often not the case with “more.”
5. “The sign for ‘more’ is multi-purpose.”
In her blog, Ms. Mize encouraged that the sign for “more” be introduced “for lots of things the child might want—snacks, toys, activities.” She indicated that introducing “more” in this way makes the sign “multi-purpose.” However, when the sign for “more” is taught to access everything a child might want, we would argue that it only has one purpose: to inform adults that the child wants something. Teaching “more” as a single-purpose request like this can be a problem—and not just because it can lead to problem behavior as indicated above (Kahng et al., 2000). Ms. Mize encouraged parents to begin fading in new signs only after the child has learned to use the sign “more” “in many contexts, for many reasons throughout the child’s day.” Unfortunately, research shows that behaviors become more resistant to change if they are strongly practiced initially, followed by variable practice later (Cooper, Heron, & Heward, 2007). In other words, evidence shows it may be more difficult to introduce specific signs if a single-purpose sign like “more” is taught first than if specific signs were taught from the beginning. Ms. Mize acknowledged that children sometimes “get stuck” if they are taught the sign for “more,” but she implied the reason for “getting stuck” was the failure of adults to “move the child along to other signs after learning the sign for ‘more.’” We would argue that a child “getting stuck” has less to do with the failure of adults to move on and more to do with the nature of teaching a single-purpose sign like “more” first. Children “get stuck” because the laws of behavior take effect, whether or not adults are aware of them.
A second problem with teaching a single-purpose sign like “more” first is the child does not receive the benefits that research shows come with teaching specific signs. In fact, evidence shows that teaching specific signs to request specific things can actually support the development of other skills, including using those signs in other appropriate social-communicative contexts (Arntzen & Almaz, 2002; Drash, High, & Tudor, 1999).
6. “The word ‘more’ is easy to say.”
We agree with Ms. Mize that a spoken approximation of “more” is easy for early communicators to say. However, for that matter, any combination of early developing sounds (e.g., “bah” for ball) is going to be just as easy for a child to say as “more.” The problem is, if the clinician or parent is just teaching one sound combination, he/she has missed out on the opportunity to teach many other sound and syllable combinations. Research shows that sign training combined with speech training can increase vocalizations better than speech training alone (Barrera, Lobato-Barrera, & Sulzer-Azaroff, 1980; Barrera & Sulzer-Azaroff, 1983; Carbone et al., 2006; Carbone & Sweeny-Kerwin, 2010). Sundberg and Partington (1998) offered an explanation for this advantage of sign-plus-speech training: “Once the motor movements are learned, specific vocalizations can be matched with [specific] signs. This sign-vocalization prompt can help…a child to prompt his own vocalizations (p. 77).” In other words, when the specific motor movements of signs are matched with the specific motor movements of speech, the sign acts as a “built-in” prompt for speech. This unique process can only occur if the clinician is teaching more than one sign at a time.
7. “The word ‘more’ is evidence based.”
Ms. Mize referenced a 2011 study at Bryn Mawr College that listed 25 words that 2-year-olds should know—one of which was “more.” While a list of words known by most typically-developing 2-year-olds may be interesting, this kind of list in no way supports teaching the sign for “more” first. Typically-developing 2-year-olds have many, many more communication skills than simply saying or signing the word “more,” including a minimum of a 50-word vocabulary (Bates et al., 1994). It does not seem to be sound clinical judgement to imply that a child with communication skills of a nonverbal infant should immediately start working on skills at the level of a typically-developing 2-year-old, especially when research shows that words like “more” are likely not among the first to develop in the general population (Bates et al., 1994; Tardif et al., 2008).
8. “AAC experts include ‘more’ as a first option for pictures systems and speech-generating devices too.”
A child learning to push a button that says “more” for everything he/she wants can have the same detrimental effects as saying or signing “more.” In addition, if the practitioner is not careful to teach the child with an AAC device to approach a listener, the end result may be a child sitting in the corner by himself/herself pushing many buttons, including “more.” We have seen such situations in action, and instead of analyzing problems with teaching procedures, the “AAC experts” claimed these children were not “ready” for an AAC device. Being titled an “expert” does not inherently make a professional correct in his/her clinical decisions. An argument from authority tends to be an empty argument if that “expert” cannot back his/her claims with sound evidence and analysis.
9. “Asking for ‘more’ is an early form of requesting and requesting is one of the earliest pragmatic functions to develop.”
Here we wholeheartedly agree with Ms. Mize that requesting is one of the earliest (and most important) functions of communication to develop. Early language training should be filled with teaching the child to request! We also wholeheartedly agree with Ms. Mize’s statement that “signing is more complex and more purposeful than other less-mature forms of requesting such as when a younger baby uses crying or reaching.” But where we strongly disagree with Ms. Mize is in her decision to teach “more” as a first signed request—particularly in the ASD population. In fact, we do not believe that “more” should be taught at any point in the single word stage until the child can request many specific things (through sign and/or speech). Research does not only link the practices we recommend with fewer problem behaviors, but these practices also more closely follow the developmental sequences of typically-developing children. Some of the evidence supporting our clinical decision-making has already been elaborated above (e.g., Arntzen & Almaz, 2002; Barrera et al., 1980; Barrera & Sulzer-Azaroff, 1983; Bates et al., 1994; Carbone et al., 2006; Carbone & Sweeny-Kerwin, 2010; Drash et al., 1999; Kahng et al., 2000; Sundberg & Partington; 1998; Tardif et al., 2008).
10. “I’ve seen success with the sign.”
We have no doubt that this is true. If one were to work only in early intervention, we are sure it would be easy to assume that the teaching of abstract vocabulary is working because the child is using it. The problem is that we often see these same children when they are 5, 6, 7, 8 years old and beyond—when they are banging their heads against the wall, pounding their knees to their heads, and falling on the floor because they have no functional way of getting their specific needs met. Their parents often report to us that they “tried signs” and that signs “don’t work” for their child. When probed, we have come to find that the signs they “tried” were single-purpose signs like “more, please, and want.” The literature shows these signs were likely ineffective because they never resulted in the child immediately getting the specific things he/she wanted.
On the topic of overgeneralization: We do not feel that it is fair or accurate to equate teaching a child “more” in the way that Ms. Mize described with overgeneralization seen in the typically-developing population. First, when we traditionally talk about overgeneralization, we are typically referring to a process that occurs when a child erroneously emits a previously-learned (specific) word in the context of an item that shares a similar physical property/use. Hence, as Ms. Mize noted, “many babies call every man they see ‘Daddy,’ every round object ‘ball,’ and all four-legged animals ‘doggie.’” But, past the crying and reaching stage, we have never heard of any typically-developing child call everything he/she wanted by the same name—solely based on the property of “wanting.” This likely does not happen because science shows “wanting” does not affect our communication and other behaviors in the same ways as physical properties (Cooperet al., 2007). Second, when typical children erroneously overgeneralize, they are often immediately corrected by an adult. If a toddler sees a cow and shouts “Doggie!,” his/her parent is likely to say something like, “I see! It’s a cow!” You cannot compare this process to an instructor deliberately choosing to teach a child only one name for a countless number items he/she might want. In the latter case, the clinician has purposely instructed a child to use “more” erroneously under a context in which typically-developing children do not error, and then (rather than gently correcting the child) the clinician reinforces the error. Teaching the sign “more” is not an accidental mishap; it is calculated.
The lack of clarity from the adults in the environment, the ensuing maladaptive behaviors, the difficulties of teaching new signs after teaching “more,” and the total breakdown in communication can all be avoided by teaching clear, concrete requests for a child’s favorite things right away. Abstract language such as “more, please, yes/no, want” makes it difficult for a child to communicate independently and a challenge for those in the environment to reinforce. Teaching effective communication is the least we can do for these children who already have so many struggles to overcome.
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