Early interaction

Talking hands
A year ago Amanda Baxter was sitting on the baby signing fence, but practical experience in an Early Start context has persuaded her of its use in enhancing carer-child communication skills.

he use of symbolic gestures and signs with babies has been popularised by such programmes as Something Special on BBC2. While gesture is a natural part of communication, and official signing systems such as the BSL derived Makaton and Signalong are an established part of a speech and language therapists toolkit, the profession is divided on the issue of formal signing with babies in the absence of an identified need (Clarke, 2004; Grove et al., 2004; Garrett et al., 2005). This controversy is based on whether the use of structured signing interactions actually impedes caregiver communication at the expense of language stimulation activities (Slonims, 2005) and also whether there is any need to use signs with typically developing children receiving appropriate environmental stimulation. The validity of symbolic gesture programmes and their role in language development has also been questioned. Research has focused on evaluating the impact on early communication skills, for example increased attempts at initiation, impact on joint attention and onset of expressive language development (Acredolo & Goodwyn, 1985). Parents using symbolic gestures (whether iconic or part of an established signing system) have reported lower distress for both them and their child attributed to their childs ability to communicate their needs pre-verbally (Allen, 2004; www.literacytrust.org.uk). Acredolo & Goodwyn (cited by Allen, 2004) also comment that when caregivers are using symbolic gesturing they are automatically using other language stimulation strategies such as following their childs interest, using simple language and labelling at their childs language level. However, it is difficult to attribute the latter effect solely to the use of symbolic gestures (whether iconic or part of an established signing system) or the general communication environment. As with many other interventions in the profession it is difficult to measure impact due to the lack of randomised control trials (Cyne Johnston et al., 2005). However, baby signing is used within Sure Start programmes (Allen, 2004) and in equivalent programmes in Canada and the United States (Early Headstart) as a means of preventative intervention. The aims are to reduce childrens distress cues (and, by association, parental anxiety) and enhance interactions between parents and young children, by promoting communication strategies such as following the childs focus of interest, making eye contact and using simple key words. It is also used as a means of 22

promoting inclusion in diverse communities. In Newham we have Early Start, created by merging funding from Early Years and Sure Start. This enables families of children under 5 throughout Newham to access a range of services. Carers are offered a programme of support from the antenatal stage going on to include postnatal groups, baby massage courses and then baby signing groups. Speech and language therapists are involved in ante and postnatal groups and some therapists have trained in baby massage so they can promote the importance of early attachment as a foundation for early communication skills. Baby signing groups (Talking Hands) are offered in a variety of community locations and most recently at Baby Clubs in different programmes across Newham. Baby clubs can be attended by carers with babies under 12 months. Numbers vary but there have been up to 20 parents at a recent Talking Hands group. The groups are usually facilitated by a speech and language therapist and a speech and language therapy assistant. Parents attend with their babies (up to 18 months) and older children, as they can learn and model signs for their younger siblings.

READ THIS IF YOU ARE INTERESTED IN EARLY INTERVENTION ENHANCING CAREGIVER / CLIENT INTERACTION HEALTH PROMOTION GROUPS

Themes

The groups focus on a number of signs derived from the Signalong system and run for a block of 5 or 6 weeks. The first week gives an overview of the philosophy behind keyword signing and introduces the BSL alphabet to make name signs. Each week signs are introduced around the following themes: My family and home Mealtimes Going out Bathtime (incorporating getting ready) Bedtime and storytime. This enables us to teach and use a range of signs that broadly reflect early language development (nouns and verbs) and relate to environmental language use. We introduce signs with objects (where possible), songs and stories to make the sessions as interactive as possible and to give parents ideas for activities to carry out at home. In the Bathtime session we have items such as bubbles to try out, and objects such as towel, soap, sponge and duck which are introduced with the word and the sign. We then sing songs like This is the way we wash our hair / brush our teeth and Five Little Ducks. We also have simple stories that incorporate bathtime activities. The intention is to introduce signs to parents so they can use them at home during everyday routines in a more naturalistic setting.

These groups also enable us to discuss early communication activities with carers and to facilitate idea sharing among the group. By getting carers to play with bubbles, for example, they can see how their babies respond and track the bubbles. We can discuss principles of positive carer-child interaction such as observing, waiting and listening to their baby (Manolson, 1992). Working with one carer enabled her to wait to see how her baby would respond to bubbles, which then gave him the space to respond by moving his arms, initiating eye contact with her and vocalising. Informal observation and parental report have shown us that the children initiated, attended and listened for longer periods and showed reduced distress cues when symbolic gestures (signs, iconic signs and actions for songs) were used. However, we wanted to do a more formal evaluation of the impact of symbolic gesture on a range of early communication skills: Eye contact Attention Response to symbolic gesture Joint attention Copying gestures. Initially we used an observation form (figure 1) in groups to look at carers skills and babies responses. We adapted this from a form used in carer-child interaction groups. Each skill / aspect is given a score (the grid numbers), depending on its perceived difficulty. We attempted to measure observable carer behaviour / learning (in relation to symbolic gesturing) and the childs communication. We encourage hand over hand signing / gestures in songs to promote kinaesthetic learning. We graded childrens communication skills in a roughly developmental hierarchy. We also gave out a pre-group questionnaire which we had used with previous groups. This looked at strategies being used at home to help communication development and whether carers had any concerns. The language stimulation strategies mentioned included watching CBeebies, reading books and singing songs. In terms of outcomes, we used data from the five parents who attended consistently. Change in their behaviour is in figure 2. All could produce signs in the group and use hand over hand with their children in songs. They

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

early interaction
Figure 1 Observation form Week No 1 2 3 4 5 6 Figure 2 Parent behaviours

Parent
Produces sign in group Uses hand over hand with child in songs Spontaneous approximation to sign/gesture

Parent total Child

Looks at parent Responds to sign (coos, smiles, moves, vocalises) Copies gestures / signs Produces sign spontaneously Imitates noises Imitates word Spontaneous 1 word (not verb)

7 6 5 4 3 2 1 0

score

week 1 week 5

3 PARENT

Figure 3 Naming language stimulation strategies

number of strategies

Child total

7 6 5 4 3 2 1 0

pre post

3 PARENT

also increased in spontaneous approximation to signs and gestures by week 5. In future we would extend the observation form to include carer-child interaction strategies. The number of language stimulation strategies that parents could name had increased (figure 3). These included answers from reading books and singing songs to using gestures, using simple language, watching what hes interested in and waiting for her to respond. Carers were able to name targeted, specific strategies to promote and enhance language development. Overall we found that the basic observation form was not sufficiently specific or sensitive enough to measure the aspects we were looking at. We wanted to see if there was an increase in the number of times babies made eye contact with carers and also to see if there was a change in the duration of eye contact, as this would suggest enhanced interaction between carer and child.

Baseline

A future direction for this group is to obtain a baseline in the first session, record when signs are being used and use a tally count analysis. This would enable us to compare the babies responses to carers to find out, for example, whether duration and frequency of eye contact increased when the carer used these in speech or whether babies responded by cooing / smiling

more when gesture / sign was being used. Comments from parents have been very positive. Three have said that their 10 month old babies have been making approximations to signs requesting food items. Other parents have commented that various signs are useful for signalling aspects of everyday routines, such as finished or bath time, and that this has helped in reducing tantrums and distress. Carers using two or more languages have also reported that they have found signing a useful way for reinforcing vocabulary items when presented to their children in different languages. We spoke to three parents from a previous baby signing group to see if they were using signs with their babies. One had gone on to take a Signalong course, as Talking Hands had developed her interest in signing. She uses signs to signal everyday routines and early concepts such as more. Two other parents said they use signs when singing. Baby signing is a very popular group in Early Start and feedback from parents is positive about enhancing carer-child interaction and promoting the development of early language skills. We will continue to develop our outcome measures. When I began running baby signing groups a year ago I didnt know which side of the baby signing fence I stood on, as much of the focus has been about promoting the longitudinal effects of baby signing such as the age of first

words and size of vocabulary. However, I have become a convert to the effects of signing and symbolic gesture as a means to enhance early communication skills, as my own observations have shown the frequency and duration of eye contact from babies increases, ensuring a longer period of attention. Parents report reduced frustration or anxiety (for both themselves and their children) with babies who have been introduced to signing and symbolic gesturing as part of everyday routines. They also report that they feel signs and symbolic gestures add to songs and books and develop their babys ability to copy, join in and request preferred activities or items. At the time of writing Amanda Baxter was a speech and language therapist with Early Start Newham. She is now working as a speech and language therapist for childrens centres in Waltham Forest PCT, e-mail Amanda.Baxter@wf-pct.nhs.uk.

References

Allen, T. (2004) Signing the way, Speech and Language Therapy in Practice Winter, pp.4-6. Acredelo, L. & Goodwyn, S. (1985) Symbolic gesturing in language development: A case study, Human Development 28, pp.40-49. Clarke, J. (2004) Hope you can see what Im saying, Bulletin of the Royal College of Speech & Language Therapists 631 (Nov), pp.10-11. Cyne Johnston, J., Durieux-Smith, A. & Bloom, K. (2005) Teaching gestural signs to infants to advance child development: A review of the evidence, First Language 25 (2), pp.235-251. Garrett, S-A., Owens, E., Ford, J. & Spooner, F. (2005) Your views on baby signing, Bulletin of the Royal College of Speech & Language Therapists 633 (Jan), pp.10-11. Grove, N., Herman, R., Morgan, G. & Woll, B. (2004) Baby signing: the view from the sceptics, Bulletin of the Royal College of Speech & Language Therapists 631 (Nov), pp.12-13. Manolson, A. (1992) It Takes Two To Talk. Toronto: The Hanen Centre. Slonims, V. (2005) To sign or not to sign? That is the question, Bulletin of the Royal College of Speech & Language Therapists 637 (May), pp.12-13.

REFLECTIONS DO I SEEK TO UNDERSTAND WHY PEOPLE ARE CRITICAL OF AN APPROACH BEFORE I DECIDE WHETHER AND HOW TO TEST IT OUT? DO I RECOGNISE THE IMPORTANCE OF DEVELOPING OUTCOME MEASURES THAT GO BEYOND HOW MUCH SOMEONE HAS ENJOYED THERAPY? DO I FIND OUT HOW PEOPLE ACTUALLY USE THE INFORMATION PROVIDED AT A GROUP ONCE IT IS FINISHED?
How has this article been helpful to you? Have you changed your views on baby signing? Let us know via the Summer 08 forum at http://members.speechmag. com/forum/.

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