Hierarchy of Visual Supports

Research and experience have shown us that many people benefit from visual supports.  As a Speech Therapist who works with children with significant communication deficits, I use visual supoorts daily.  Visual supports come in many forms, as I will discuss below, and are used for a variety of purposes.  Visual supports can be used to aid learning a new concept, understanding a new and upcoming event, completing a sequence of daily life, completing a job sequence or communicating non-verbally.  But where do we start?  What type of visual should we use?  I have found the hierarchy presented below to be very helpful.  I will observe the individual and see what communication strategies they are currently using and start from there.  However, many caregivers do not naturally use visuals.  In these cases, I will start very simply and increase the complexity from there.

So, let's jump right into it and I will provide some examples from my experiences to help apply the principles.  The list progresses from the most basic to the most complex form of visual support (the original list was presented in the Wisconsin Assistive Technology Initiative of 2000).

• Physical Communication: the individual takes their communication partner to the desired item or prompts them with their hand to request a desired action.  A child comes to you, takes you to the fridge, puts your hand on the handle and points to the carton of milk once you open the door.  This example highlights using physical communication to request an item (milk from the fridge) and an action (opening the refrigerator).  This is a very common way for toddlers to communicate.  If an older child or adult uses this method, the importance of this stage is sometimes overlooked.  It is a good indicator for communication success, much more effective then screaming or throwing tantrums.  Much more intentional. 

• Real Objects: the individual uses real objects to communicate their wants and needs.  For example, a child may bring their coat to an adult to ask to go outside.  Additionally, an individual may hand their  communication partner a container they can't open to request help.  Like physical communication, real objects are generally easy to connect to the desired item or action.

• Miniature Real Objects: the individual uses a miniature version of the real object to request the object or related action.  A piece of towel could represent taking a bath or a small cup could represent getting a drink.  I find that this works well for visually impaired individuals with lower level cognition.  We have attached Velcro to the objects and put them on a Velcro-accepting fabric on a board (lying flat) or 3-ring binder (standing up).

• True Object Based Icons (T.O.B.I.s): These are larger line drawings or photographs of the real objects, cut out in their  shape.  For instance, a 3 inch picture of a bubble container cut into the shape of the container used to request to play bubbles.  I prefer photographs as they are much easier to understand than line drawings.  I like to present these on a black background.  It draws the individual's attention to the T.O.B.I.  Also, I start with only a few pictures, sometimes only one, to ensure that the individual understands the cause and effect of choosing the picture then receiving the item or action.  The use of T.O.B.I.s help to lay the foundation of understanding that 2-dimensional pictures represent an item or action.
• Photos: the individual uses photographs to communicate.  These can be any size, though the smaller the photograph, the more can be used on a communication board at the same time.  I use a lot of pictures for schedules and sequences.  I try to include the individual in these photographs whenever possible and the real objects or locations.  For example, a photo of the therapist or teacher may be a representation of it being time to go to therapy or school.  In a visual support of a job sequence, it would be very helpful to photograph the individual doing the task(s).

• Color drawings: the individual uses cartoon-type, color drawings to represent a desired item or action.  Mayer-Johnson symbols are the most well known, but other picture systems exist that work just as well.

 

• Line Drawings: the individual uses similar pictures, just without the color.  
• Written Words:  the individual who can read or even identify a limited number of written words, uses these to represent a desired item or action.  Some individuals may even write or type to communicate.  This is the most advanced and most flexible of visual supports.  One child I have worked with has progressed through these levels (starting with photographs) and now uses a written schedule during therapy so he knows what to expect and when his reward is coming.  

The goal is to progress through the hierarchy, but not every individual will.  Some individuals are limited by their cognitive skills, physical abilities or vision.  This hierarchy is a great tool to know where to start and were to go from there.  The further down on the hierarchy, the more independent and individual can be.  Having to take people to objects is not very efficient sometimes and having to carry around a bunch of objects is difficult.  To use photographs or drawings takes much more preparation and is not as flexible.  I must first make sure I have the correct picture or find/print it out.  It is difficult to change the schedule as needed.  With the written schedule, it takes only a few moments to write each task down (keeping their reading level in mind) and it can be changed easily on the fly.  During our last session, the child requested to play a game instead of using the iPad and we were able to change the schedule accordingly.  In fact, the child wrote in the change on the schedule himself.

I am happy to answer any questions, offer suggestions or even help you create a visual support.  I am a major "speech-nerd" who makes visual supports for everything from work to home!  Check out my posting on Organizing Art Supplies (http://7isperfection.blogspot.com/2012/11/organizing-art-supplies.html) to see just how much I love visual supports.

10 Things Every Parent Wants from Their Child's Therapist

In my nearly 17 years as a pediatric Speech Therapist, I have tried to learn as much as I can from my patients and their families.  In a recent discussion about a newer patient's previous therapy experiences (trying to understand what they worked on/what methods they used), her mother said something that has stayed in my mind ever since.  "There are therapists and then there are good therapists."  She went on to explain that her daughter had multiple therapists in various disciplines.  Some of them just came and did their job, while others she deemed as "good therapists".  So I started thinking about other parent comments throughout my tenure and even asked some of the families about what makes a good therapist.  Then I stumbled upon this article: http://parentingspecialneeds.org/article/54.  It really got me thinking.

The following list is in no particular order as I would not presume to know what is most or least important to each family.  My hope is that this list will serve to be an inspiration for those of us who are blessed to work with special children and their extraordinary families.  Inspiration to be better, to be exceptional, to be a blessing to all we have the pleasure to work with.  I also hope it puts into words the desires of the hearts of all who love a person with a disability.  I hope you will listen to your heart and advocate for the special person in your life who needs extra help to reach their full potential.  Help the "experts" in your life to understand your child, their needs, your hopes and dreams for them and how you and your family want to be involved in this process. 

10 Things Every Parent Wants From Their Child's Therapist:
1. Care about my child.  Be happy to see them.  Smile.  Greet them.  Give a high 5.  Let them hug you.  Hug back.  Be genuinely concerned when we get bad news and genuinely happy when we have a victory.  Remember my child's birthday.  None of us are guaranteed another year, but it is especially precarious for some children.
2. Care about my family.  Remember things that are important to us.  Know me by name (not "mom", "dad", "grandma") and my other children's names.  Talk to my other children too, it's not always fun for them to go to the numerous appointments we have each week.  Remember doctor's appointments and ask about them after.
3. Be good at what you do...know your stuff.  Take the time to research things you haven't seen before.  Pick courses to attend that will help you better meet my child's needs.  Share what you learned with me.
4. Admit what you don't know...then look it up.  I won't think you are less of an "expert" because you don't know it all.  I want to know that you are willing to learn, that's all.
5. Push my child to succeed.  Expect him to.  Don't give up on my child.  Don't accept that she can't learn.  Look past the behaviors.  Look past the attempts to distract you.  Realize it's hard for my child, but keep trying.
6. It may be your job, but it's my child.  Be passionate about what you do.  My child knows when you aren't.  We know when you aren't.  
7. Give me reasonable things to do at home.  Seek to understand my home situation.  Realize that I have other children or a sick parent I am taking care of.  Understand that I have multiple appointments in my week for my child.  Give me things to do so that I can feel successful and not defeated.  Watch my body language, listen to my stories of the week we just had and tailor the homework accordingly.  
8.  Resource me.  Help me find other resources for services, funding, supplies, parenting help, respite care, family counseling, etc.  Send stuff home with me.  Whether it's copies of what you are using at therapy or things you make (daily schedules, social stories), I appreciate it all.  I realize you don't have to anything outside of our session.  Go above and beyond my expectations.  
9. Appreciate the small steps my child makes, as well as the major breakthroughs.  Verbalize the small steps my child is making toward his goals.  It helps me to see them and to know that you see them too.
10. Take into account what is important to us when making your goals.  It may be toilet training, wearing her seat belt, saying his phone number, interacting with children at school or church, saying family members' names, writing her name, being able to go up and down the slide at recess, or being able to eat with the family.  I appreciate all that you know about my child's development and progressing through skills, but I also appreciate you asking what is important to us.

For professionals, I want to thank you for taking the time to read this.  That speaks a lot about you and your desire to meet the needs of the children and families we serve.  I hope this motivates you to be every improving how we do what we do.  So pick the thing that stood out to you and work on that.  For me, I have trouble remembering names.  So a colleague of mine passed along that she had written the parents' names in red marker on the outside of the chart.  I copied her idea and have been practicing using their names in our conversations during therapy.  It really is the little things that make the difference.  I also set up a parent resource bulletin board in the waiting room which we stock with articles about parenting classes, special diet recipes, advocating for your child, financial planning, support groups and many more relevant and timely topics.  Please post any ideas you have found that really worked for you in the comments section.


For parents, I hope this resonates with you.  I hope it validates how you are feeling.  Please feel free to comment below and add your experiences.  I have tried to speak positively about what parents want and not  focus on what therapists are not, so please phrase your comments that way.

Social Stories

As a pediatric Speech Therapist that works primarily with children with Autism or other social disorders, I use social stories often. 

What is a social story? 
A social story is a  tool created specifically for a child or adult to address a behavioral concern, help with transitions or prepare the them  for a new experience.  I have written stories to help children wait in line at the store, only eat their own lunches, prepare for having a new bus and driver, and learn what to expect during their field trip to the zoo.  I have even written stories to help children understand what is happening in their bodies (i.e. wounds healing, puberty) to prepare them or diffuse any anxiety they may have.

How do you write a social story?
A social story should be positive, a list of "do's" not "don'ts" or rules.  Talking about what a child should do allows them to focus on the desired behavior(s) and not on the undesired ones.  For example, if the story says "I shouldn't hit my sister", it may cause the child just to focus on hitting his sister.  Conversely, if the story says "When I get mad at my sister, I can say 'stop it' or 'no'.  I can say 'I'm mad' or 'Leave me alone'.  I can talk to mom or dad about what happened.", it gives the child alternatives to hitting his sister without even mentioning hitting.

I write these stories in first person.  "I" refers to the child.  Making the stories personal makes reading them more fun!  The story should also talk about feelings.  How the child and others feel about the situation and resolution.  An example of the problem: "I get tired of waiting in line at the store.  I want to touch everything or look at things away from where mom is.  This makes mom upset.  She worries if she can't find me.".  The solution: "When I stay by mom and wait patiently with my hands in my pockets, mom is very happy.  She is proud of my behavior.  I like when mom is happy."  Also, I am careful to use language that the individual can understand...on their level.

I use lots of photographs in the stories.   Anyone who spends time with the individual may read the social story.  When possible, I like to use photographs of the actual individual and surroundings.  The best case scenario would be to photograph the child or adult in the actual situation.  This is not always possible.  When it is not, I try to at least have a photograph of the individuals involved in the story.  Google Images is a great resource for free photographs.  For example, if the child is going to a public place like the zoo or firehouse, you can find specific photos or really close photos of the destination.  I have also found some really good pictures of people experiencing different emotions.  You can search very specifically (i.e. hispanic angry girl, crying toddler boy) and find some really nice photos that will show what the story is talking about.

Who uses a social story?
Anyone who needs extra practice in positive social interactions.  They may or may not have Autism.  The child or adult does not easily learn to navigate the social jungle.  They do not understand common social standards and cannot read peoples emotions or intentions.  By rehearsing the positive social interactions portrayed in the social story, they can more easily learn the appropriate behaviors.  I am actually considering a social story about using a kleenex for my nose-picking 4 year old!

How do you use a social story?
Social stories are to be read many times.   Anyone who spends time with the individual may read the social story: a parent, grandparent, sibling, instructional aide, therapist, or friend.  Limiting the number of social stories to 1 or 2 at a time will help the individual to keep the information straight and not confuse the stories.  I learned at a conference that an individual with Autism needs up to 4 weeks to learn a new skill.  The repetition of the social story allows the child or adult to really learn the information presented as well as affording them opportunities to implement the information.

So, in a nutshell, my process is as follows: determine the targeted behavior to extinguish or encourage, write out the text of the story, add pictures and edit it so it is easy to read.

The link below takes you to an example of a social story.  Please feel free to ask any questions in the comment section.  Happy writing!

https://docs.google.com/viewer?a=v&pid=gmail&attid=0.1&thid=13c3a193d5557bcc&mt=application/vnd.openxmlformats-officedocument.wordprocessingml.document&url=https://mail.google.com/mail/?ui%3D2%26ik%3Df328575db5%26view%3Datt%26th%3D13c3a193d5557bcc%26attid%3D0.1%26disp%3Dsafe%26zw&sig=AHIEtbQ5WDcFyleuGQf_TO8CQgFYkyifpw