Will teaching my baby to sign delay his speech?

By Nicole Hess MS, CCC-SLP

Fridays Column Focus on Language by Nicole Hess.

I get this question ALL the time. In fact I just gave a talk to a group of preschool teachers and this question came up: Can teaching sign language to my baby delay his talking? Lets look at what the research tells us about using signs with babies. In an article published in the American Journal of Speech Language Pathology Elizabeth Crais, et al. provided an overview of the research on gestural communication and its effect in language development. For years, actually since I began practicing, I have used gesture development in early intervention. However, only recently has this practice been actively researched. This is in part due to the expanding research on Autism. Yet, most parents when told that the use of gestures helps verbal development fear that gestures will replace words. It seems that the research does not support that fear.

A review of: Crais, E., Watson, L., & Baranek, G. (2009). Use of Gesture Development in Profiling Childrens Prelinguistic Communication Skills American Journal of Speech-Language Pathology, 18 (1), 95-108 DOI: 10.1044/1058-0360(2008/07-0041)

The authors first provided a summary of gestures and their developmental course. There are two types of gestures: deictic and representational. Deictic gestures are either contact or distal and they are used by the child to refer, call attention to, or indicate and object or event. Contact gestures require contact between the child and adult (pushing away an adults hand for “no”) but distal gestures do not require contact (pointing or reaching). Representational gestures are semantic in nature. They can be object-related or culturally defined gestures that refer to a cultural or social action or concept (for example shushing). Deictic gestures emerge first around 7-12 months and representational gestures emerge closer to 12 months.

The authors discussed research showing that the use gestures by infants is a good indicator of later language development. Gestures can differentiate between typically developing children and those with language delays at the age of 9-12 months. And later, they can differentiate between children with different developmental delays such as Down’s Syndrome and Autism. Children with good prelinguistic gestural communication at 14 months usually have better comprehension at 24 and 42 months than those who do not. Thus, assessment of gestures can help differentiate a “late-talker” from a true language delay. Furthermore, symbolic play (which requires gestures) is not only associated with cognitive skills, but it has also been shown to predict later language skills. Gestures play a large role in symbolic play from pretending to drink to indicating night-night by closing eyes and putting hands against the head.

The authors then discussed the developmental trajectory of gestures and the number of behaviors within the use of gestures that are important. Typically 12-month-olds use one gesture per minute, 18-month-olds use two, and 24-month-olds use five gestures per minute. The type of gesture also changes with development. Twelve month-olds use mostly vocalizations or gestures, 18-month-olds begin to ad words, and 24-month-olds use mostly words. There are also specific gestures that are important markers or predictors of normative development. For example, pointing has been linked to better language development, especially receptive vocabulary. The extent to which a gesture has communicative function plays a role as well, so that the more intent is embedded in the gesture, the better the outcome for language development. Another important landmark in communication is when gestures are paired with eye gaze and vocalizations. In fact, in normative development we expect a child to move from eye gaze and vocalization to gestures and vocalization, and then to gestures and words. As you can see, just as language follows a developmental path, so do these prelinguistic sounds and motor movements.

So how do speech therapists assess gestures? Currently there are two assessment tools with specific focus on gestures; the Communication and Symbolic Behavior Scales Development Profile (CSBS-DP; Wetherby and Prizant, 2002) and the MacArthur-Bates Communicative Development Inventories, Words and Gesture Form (CDI; Fenson et al., 2002). The Rossetti Infant-Toddler Language Scale also has a strong focus on gestures but does not have normative data. Essentially though, gestures are assessed informally and are an integral part of an assessment and goal development.

Ok, so we know that the use of gestures by children is associated with better outcomes. But does this also mean that teaching gestures is associated with good outcomes? Most of the research says yes. For example, the teaching of gestures has been found to promote language development in children with autism (see for example Communication Intervention for Children with Autism: A Review of Treatment Efficacy). In addition, teaching gestures to infants has been associated with better language development in a number of studies (see for example Impact of Symbolic Gesturing on Early Language Development). And although there is still some controversy about this issue (a meta-analysis conducted by Johnston et al -DOI 10.1177/0142723705050340- concluded that the evidence for the benefits of teaching signing was inconclusive), to my knowledge there is no empirical evidence suggesting that teaching your child to sign will delay his speech.

So when a parent or teacher asks me if teaching gestures and signs in conjunction with verbal development is a good idea I say yes. One caveat though. Sign language is a language just like Spanish or English. If a parent takes teaching signs to an extreme and incorporates syntax and use the signs in lieu of speech the child may use more signs than speech. Just like when a child learns more than one language in a home. And remember, there is a time of silence before both languages emerge.
Here is a very cute video of a 12-months-old using signs:

[youtube=http://www.youtube.com/watch?v=7gSZfW4gVhI]

Mirtazapine for the treatment of public masturbation and inappropriate sexual behaviors in autism

By Nestor Lopez-Duran PhD

The issue of public masturbation in kids with autism is probably one of the most uncomfortable topics for parents to discuss with their clinicians or pediatricians. I usually can sense when a parent wants to bring up the topic, and the parents are usually relieved when I address the issue directly. Inappropriate sexual behaviors (public masturbation or nudity, sexually touching of strangers, etc) are actually not that uncommon among children with a variety of developmental disorders, including autism.
Usually clinicians recommend behavioral modification techniques, similar to the techniques used to decrease the rates of any other undesirable behaviors (please note that in this post I am not talking about masturbation as an undesirable behavior. I am instead talking about public masturbation or other type of public sexual behaviors that are considered in most societies to be inappropriate). But often, when the behaviors are not responsive to behavioral interventions, many children show improvements from the use of specific medications.

A review of: Coskun, M., Karakoc, S., Kircelli, F., & Mukaddes, N. (2009). Effectiveness of Mirtazapine in the Treatment of Inappropriate Sexual Behaviors in Individuals with Autistic Disorder Journal of Child and Adolescent Psychopharmacology, 19 (2), 203-206 DOI: 10.1089/cap.2008.020

In a study published in the journal of Child and Adolescent Psychopharmacology, a team of researchers from Turkey examined the effectiveness and safety of Mirtazapine (Rameron) for the treatment of inappropriate sexual behaviors in autism. The study included 10 children with a diagnosis of autism (8 boys and 2 girls, ranging in age from 5 to 16). These children had received behavioral and psychoedcucational interventions for their inappropriate sexual behaviors but these interventions did not reduce these problems. The authors described the percentage of the children who engaged in the different concerning behaviors: non-private masturbation (100%), touching people inappropriately (50%), disrobing in public (20%), sexual interest in particular body parts or nonhuman objects (20%), and observing people bathing or undressing (10%). Two of these children had a co-morbid diagnosis of ADHD and two others had a co-morbid diagnosis of depression.

The children were treated with an initial dosage of 7.5-15mg per day and this was increased according to response and side effects to a maximum of 30mg per day.

The results:
Based on the excessive masturbation item from the Clinical Global Impressions-Improvement Scale, the authors found that:

50% of the subjects showed very much improvement
30% showed much improvement
10% showed moderate improvement

The researchers then concluded that the study provides support for the effectiveness of Mirtazapine in the treatment of inappropriate sexual behaviors in children with autism.

But why Mirtazapine?

Mirtazapine is relatively old anti-depressant that is still commonly used. In clinical practice Mirtazapine is often used used because (instead of despite of) some of its side effects (in specific cases desirable side effects). For example, Mirtazapine is associated with significant weight gain, thus it is commonly used for the treatment of depression in people with anorexia. Likewise, Mirtazapine is associated with severe drowsiness, thus it is often used for individuals with depression and insomnia. Thus, the selection of Mirtazapine for this study was also related to another side effect. While SSRI antidepressants (such as Prozac) are associated with sexual dysfunction (for example erectile dysfunction), Mirtazapine has been found to reduce libido (reduced sexual desire). Thus, it is sensible to expect that this medication, by reducing libido, would be effective in the treatment of inappropriate sexual behaviors.

However, the authors correctly discussed the most obvious limitation of this study: no control condition. Since there was no control group taking a placebo pill, it is impossible to tell for sure whether the improvements observed were due to the medication or to the placebo effect (e.g., the expectation by the parents that the medication was supposed to work). Thus, although the study provides some preliminary evidence of the potential effectiveness of Mirtazapine for the treatment for excessive non-private masturbation, there is a need for placebo-controlled studies using larger sample sizes.

Children with Psychopathic traits may have difficulty hearing the victim

By Nestor Lopez-Duran PhD

A study examining the perception of victim distress signals among children with psychopathic traits indicates that these children have the capacity to identify and respond to the victims distress, but these children may have their distress radar turned to low.

A review of: van Baardewijk, Y., Stegge, H., Bushman, B., Vermeiren, R. (2009). Psychopathic traits, victim distress and aggression in children Journal of Child Psychology and Psychiatry DOI: 10.1111/j.1469-7610.2008.02023.x

Yesterday, in my review of an article examining shame and guilt in preschool depression, I commented on a interesting unrelated finding: children with high levels of disruptive behavior problems displayed low levels of guilt and guilt reparation. According to their parents, these kids simply didnt feel bad about their actions and did not feel a need to seek reparations (e.g., say Im sorry). I mentioned that this was consistent with views on conduct disorders and psychopathic traits. Children with these type of conduct problems appear to have a deficit in their ability to respond to other peoples distress. But a common question regarding such psychopathic traits is Do these children recognize the distress and just dont care? Or do they simply dont even see that the victims are in distress?

In a recent study published in the Journal of Child Psychology and Psychiatry, a Dutch team of researchers reported the results of an ingenious experimental study that examined whether children with psychopathic traits were able to recognize and respond to the distress of others.

In the study the authors had a group of 228 children (mean age 10) complete a measure of psychopathic traits and play a competitive computer game against a simulated opponent (the children believed that the opponent was a real person but in fact the opponent did not exist). The kids were told that they were playing a game against another kid from a different school. During the game, the children had the opportunity to send a blast of loud noise to the opponent after winning. Half of the kids received a written message from the opponent indicating that the noise was distressing. The other half received a message from the opponent, but there was no mention of distress.

The results:

There was a main effect of psychopathy. Those children with higher level of psychopathy were more aggressive during the game (sending more intense noise blasts) than kids with lower levels of psychopathic trait. There was no main effect of distress message. That is, the presence of a distress signal by the opponent (mentioned that he/she was distressed by the noise) did not affect the average noise intensity used by the entire group. However, this was not always the case, because there was a strong interaction between psychopathic traits and the distress message.

As you can see above, in the absence of the distress message, children with more psychopathic traits were more likely to use higher intensity noise than children without psychopathic traits. In contrast, when the distress message was present, psychopathic traits was not associated with noise intensity. That is, when providing with a clear distress signal, these kids were not more likely to be aggressive than kids with lower levels of psychopathic traits. The authors state:

We can thus conclude that children with psychopathic traits are indeed prone to act aggressively, but also that this aggression is dynamic and is dependent upon circumstances. In fact, aggression can be attenuated in children with psychopathic tendencies if they are stimulated to focus on their victims pain and discomfort.

This last sentence by the authors is key because it raises a number of issues. First, a unique feature of this study is that the authors manipulated the nature of the distress signal so that the children could not avoid it or miss it. The distress was presented in writing as part of the game procedure. So it is possible that kids with psychopathic traits can respond to these distress signals but only if these signals are salient enough during very controlled conditions. It may be that during the chaos of real life (a school yard for example) these kids have too many distractions during a transgression to be able to attend to the distress signals. While this is encouraging, in that it suggests that interventions focused on enhancing these kids sensitivity to stress signals could impact aggressive tendencies, there is one item of bad news. The kids with psychopathic traits were more likely to be aggressive overall. Although these kids were able to regulate these aggressive tendencies when presented with salient distress signals from the victim, this regulation happened after the initial offense. That is, at best, these kids seem to regulate aggression in response to stress signals. This is certainly an adaptive skill, as many times we are unaware that we are hurting someone and we change our behavior in response to indications of distress. But most often our regulation occurs in the absence of stress signals. That is, we usually regulate our frustration and anger before we hurt someone; before we have the opportunity to hear the distress from the victim.