Santino had been up several hours so when his mother brought him in, she already had a bottle prepared and asked that he be allowed to sleep, if he needed to, and to convey this message to his teachers. Santino did seem a bit tired initially, but he perked up when he entered the classroom. I brought out a magnetic educational activity in which he had shown interest the previous day; however, today, he showed little to no interest in tracing the magnetized alphabet letters, even when afforded prompts. Next, I selected two books to read to Santino; one was the Velveteen Rabbit, and the other was Clifford's Happy Easter. We chose the latter, as Santino gravitated towards it with his eyes and repeated the word, "purple." Afterwards, Santino was provided with a squishy sensory gel toy which he enjoyed squeezing and watching as several colorful objects inside came to the surface. I narrated which objects appeared as they came to the surface when he squeezed the toy. Santino then took the bottle with Pediasure and lay down with the toy on the carpet, absorbed in tactile play and engaged in interactive tactile stimulation and proprioceptive input. Santino appeared comfortable and happy with this arrangement.

We worked on a lot of indoor activities today. Santino was in good spirits, giggling and loudly vocalizing his pleasure throughout the session. When I said "let's go put your book bag away," Santino repeated, "let's go!" He also repeated the word "fish" when we looked at the Beta fish in the classroom. I next read Santino two Easter books and he looked at some of the pictures as I read aloud. Santino enjoyed holding and stroking a balloon and stuffed animal I had given him earlier to better focus and sustain his attention. Next, Santino traced the alphabet using an educational magnetic game. Given hand-over hand instruction to guide him, Santino traced the curves of lowercase letters following directional arrows using a magnetic stylus which pulled the beads up visually to create a sensory-based learning experience. He delighted in erasing the magnetic pull, by using the tip of his finger or the opposite side of the stylus, to make the the beads disappear. We finished the session assembling a new and colorful number puzzle. Santino sustained attention to this activity for at least ten minutes, demonstrating good visual perceptual skills, eye-hand and bi-manual coordination as he looked from the model to the puzzle pieces to figure out how to assemble them correctly. This concluded a rewarding, engaging, and productive session.

Santino appeared happy to see me and smiled. He approached me, reached for my hand, and reciprocated my hug after I initiated it. He seemed jovial, smiling and vocalizing often. I planned the session's activities using pictures from his visual communication board, but he did not seem interested and looked away. We worked on a matching game for the initial few minutes of the session, and then walked over to the Beta fish in the classroom. Santino repeated the word, 'fish' after me and was interested in watching it swim. We stayed in and played some instruments and listened to some songs: Santino repeated a few words he heard from the story and manipulated some objects found in the classroom which piqued his interest. I narrated his actions as he examined and manipulated them in efforts to stimulate associative connections and speech. Santino drank from an 8 oz. water bottle I provided him and knew to wash his hands when we went to the kitchen as he approached the sink on his own, independent of my direction. He also drank more water from the faucet, and said, 'let's go' after he had finished and I turned off the water. Overall, Santino has demonstrated he is comfortable with the routine we’ve established at the School and has been more engaging and vocally interactive.

I engaged Santino in playful activities that promoted social interaction. We sang together, and Santino occasionally followed by repeating a few parts of the melody. I also recited some nursery rhymes, positioning myself in front of him and close to eye level, so I was sure he heard and saw me. If Santino's attention waned, I requested a high five, placing my hand just above my eyes so he would make eye contact. Gestures and eye contact build a foundation for language, so I always try to encourage Santino by modeling and responding to behaviors. I imitated a lot of his sounds, verbalizations, and positive play behaviors as a means by which to encourage increased vocalizations and interaction. It also tends to encourage Santino to copy me and take turns. For example, when Santino rolled a car, I did the same, and when he hopped around the room, I copied him. He enjoys this interaction and it fosters increased interaction. As usual, I followed Santino's interests. Rather than interrupting his focus, I followed along with words and narrated whatever it was he was doing. Today, when he was playing with a shape sorter, I repeated the word “in” when he put a shape in its slot, and said the shape and the word 'shape’ (e.g., ‘circle shape’), whenever he held up the shape, and I said “dump circle shape” when he dumped them out to start over. Talking about and narrating activities in which Santino is engaged associates vocabulary to functional speech. I also gave Santino an opportunity to enjoy some outdoor time and he washed up when we returned indoors. Santino drank a sip or two from a cup; however, once inside the classroom, he became upset when we could not find any Pediasure to pour in his bottle. He kept handing it to me and grew frustrated when he took sips and found only water. I mentioned this to Ingrid when she came to pick Santino up, and she’ll include some in his book bag tomorrow. Santino left in good spirits, and was interested in looking at the Beta fish that was a new addition in the classroom.

Today, Santino was invited to join in a birthday celebration held in the kitchen for a student turning 9; however he showed little interest and indicated he wanted to leave by pulling me towards the door. I had him reciprocate giving a few high fives to students along the way and we proceeded outside where we enjoyed a session of outdoor gardening and nature discovery. I sprayed Santino with insect repellent before taking a gardening box filled with various digging tools outdoors to the garden where we planted some seeds and watered some plants. Santino enjoyed examining the different tools and digging holes when given hand-over-hand instruction and guidance to do so. He also enjoyed using the spade to dig a small hole into which water was poured and he appeared fascinated watching the water fizzle as it soaked in the soil. When indoors, we sang songs as we flipped through a book, and Santino repeated a few words and phrases that he heard me speak. Santino was permitted a few minutes with my cell phone after he repeated an approximation to the word 'please,' following several verbal prompts I gave it to him while holding it within his sight but out of his reach. It is hoped that functional language will become an understood prerequisite in his verbal language repertoire with repeated practice and reinforcement. Santino washed his hands in the sink, lathering effectively; he is becoming more adept at drying his hands when given the towel. Santino also drank some water out of a cup and an 8 oz. bottle, but he proceeded to hand me his bottle when he was lying down with my phone as he likes to drink out of it when lying down. The phone was switched seamlessly to an I-pad with the transition to his next teacher.

Santino has continued to be more receptive and responsive as we continue working together. Today, he clearly said "hello, in a melodic sing-song voice, upon entering the school. It set the tone for a vocally responsive day, which was chock full of activities, with each planned out on the visual communication board. First, working with puzzles, Santino chose two alphabet puzzles, which he assembled. We then moved on to music. Santino followed my lead using a baton to strike a tambourine, and we repeated one another's actions producing sounds. Santino enjoyed feeling the instruments and both listening and feeling the vibrations produced utilizing them in different ways. Santino led me to his book-bag, which was by his cubby, and indicated through gestures that he wanted something. I removed a few food choices, including cereal and pudding, and he took them to the area in which he was seated and assembled a puzzle. He then went to my bag and tried to unzip it. I asked him what he wanted. After a while waiting to hear if he might respond, I said, "Ah, I think I know - you want my cell phone. Do you want my phone, Santino? Say please"...after again repeating the word and waiting, I had his attention and emphasized the 'p' sound repeatedly. Santino watched, listened, and after a few trials of doing this while keeping my phone within sight but out of reach, Santino repeated the 'p' sound a few times, imitating me. I responded by giving him an enthusiastic high five and I allowed him to have my phone. I put on an app I know he enjoys and he was allowed to watch a few stories (e.g., Peppa Pig/Mickey Mouse) as we repeated some phrases and words ('pig,' 'Mickey Mouse'). I also blew some bubbles as Santino tried to catch a few, giggling throughout his pursuit of them. Santino did not eat any of the foods left out for him, but I informed his next tutor that he might change his mind and to leave them out on the table. It was a productive day with several reciprocal actions and functional verbalizations engaged in throughout the session.

We continued to work on activities aimed at initiating and developing effective expressive language by creating opportunities for Santino to approximate words. When Santino wanted a chair, I sat on it and waited till he indicated he wanted it through gestures. I then stated, "Oh, you want the chair?" Please say 'chair,' and I said the word repeatedly till I heard him attempt to repeat, or sound out an utterance approximating the word. This method has been beneficial as a means by which to elicit functional language when delays are evident. We used the communication board as an alternative augmentative communication device by which to familiarize Santino with our planned activities for the day. The visual language icons on the board (signs and pictures) represent specific linguistic units and utilize Santino's visual processing skills to help in the acquisition of functional speech and assist him to generate spoken language. Santino enjoyed it when I repeated his speech patterns, actions, and behaviors; it generated an interesting exchange in which he became engaged and amused. We listened to songs and rhymes, and Santino was reinforced if he repeated a word. Puzzle pieces helped sustain his attention and provided another modality by which to sustain interest. We finished the day by washing our hands and drying them with a towel. Santino was offered a drink of water out of a cup and drank from it effectively. He also drank out of the faucet, with long sustained gulps and was well hydrated before his next session.

Santino and I explored the properties of a half-filled/slightly deflated yoga ball today. We examined its surface texture, rolled it, squished it, threw it, rolled it down and off objects, sat on it, cradled it, and used it as a recliner. Santino enjoyed all the sensory-motor information he gleaned from manipulating and engineering the ball in various positions and operations. Throughout the discovery phases as he engaged with the ball, I narrated and repeated all the various terms and concepts that applied to our actions and operations. Santino repeated a few words and clearly enjoyed the stimulation received; he enjoyed the freedom to manipulate the large ball as he wished. At one point, as Santino reclined in it and it cradled him. Santino interacted with the same student with whom he engaged the other day during one part of our session as well. I intend to introduce it on our visual communication board if this is pre-planned in the future. After washing our hands towards the end of the session, I offered Santino a drink of water from a Styrofoam cup, and he drank from it twice when it was held to his lips. He pushed my hand away when he was done and lay down for a few minutes as I read him a book and we awaited his next teacher to arrive. Santino walked outside with me but was re-directed by his next teacher and returned to the classroom for his next class.

Santino and I had several 'WOW' moments today! He started out in an excellent, jovial mood and was exceptionally engaged with me. He was particularly demonstrative, expressive, and communicative of his mood and desires by sustaining eye contact, and through vocalizations, and gestures, and he was very responsive to my imitations of his speech and vocalizations – giggling and repeating after me while holding my gaze. He also gave me a hug and laid his head against my chest, smiling the whole while. Santino grabbed my arms and placed them around him, embracing me in a hug. This then turned into a tickling interaction, which he initiated by uttering some vocalizations, which I repeated, he found funny and repeated, and waited for me to then repeat it. This dynamic was an incredibly engaging, interactive and responsive means of communication and was witnessed by his previous tutor, who was equally excited to witness his significant gains. I was very happy to see Santino dressed in light long pants today, as had been requested, and his bites looked much less irritated. It seems that the antibiotic cream helped, and we will keep applying the insect repellent if outdoors. After using the visual communication board to plan out and communicate the plan for the day, Santino and I began with a musical activity involving instruments. Santino examined a guitar, plucked its strings, examined it from different angles, and held it appropriately. I strummed a few chords and paired words with them, making every effort to mimic the cadence of his vocalizations and connect them to words phrases repeatedly used (e.g., hello, thank you, etc.). After exposing Santino to certain words repeatedly, I set up temptations to encourage him to elicit the word. For example, I placed the guitar out of Santino’s reach so he can see it but not reach it. When Santino reached for it, I said, “What? What do you want?” and then gave him a sufficient amount of time to say it himself. After the wait, I modeled the word as a question, and asked, "Do you want the guitar?" while pointing to it and to a picture of a guitar. Although Santino did not request the guitar verbally, I modeled the word again and gave it to him. Since I’ve heard Santino say the word ‘guitar’ it’s not a question of poor speech production. With time and patience, I anticipate seeing more gains in functional language, especially as his receptivity to following directives and responsiveness has been showing such marked signs of improvement. The last 15 minutes of the session, we proceeded outdoors with another student who has been engaging nicely with Santino. They’ve established greeting one another with a high five, and they share equipment together (e.g., the see saw). Santino finished up the day by washing his hands with soap and water. He used the towel more efficiently to dry his hands. He also enjoyed when I put some water on his lips and indicated he wanted me to do this more. I complied with his request and our session ended on as happy a note as which it began. I shared our success with Ingrid and Santino gave her a warm hug, a high five and huge smile. It simply made my day!

I applied antibiotic cream supplied by mom onto Santino's mosquito bites, which are primarily on his legs, and sprayed the exposed area of his skin with OFF insect repellent spray. By the end of the session, this seemed to have alleviated the itching and the bites did not appear as irritated as when he had arrived. I am suggesting that Santino bring a pair of light pants to the program to prevent him from being bitten. Today, we worked with large, colorful pieces of sidewalk chalk. Santino initially expressed interest and made a few parallel lines on the sidewalk; however it did not sufficiently engage his interest to continue the activity for longer than approximately 5 minutes. I afforded him physical prompts to help him write his name in chalk before moving on to physical activities using a forward roll wedge and a large punching bag that contained water in its base with which to support it. Santino greatly enjoyed manipulating these two pieces of equipment and imitated the movements shown to him. He was delighted to have his legs supported as we attempted forward rolls, and he then performed the forward roll himself, independent of prompts. If he needed assistance, Santino guided my hand and led me to the apparatus he wished to use. He observed me push over the punching bag with my body and attempted to do likewise, taking my hand and placing it on the punching bag in a clear indication that he wished to topple it over. We did this repeatedly to squeals of delight. Once, when it rolled on top of another piece of equipment, Santino said "Whoa," using the phrase appropriately at the right time. He often uses this phrase at other appropriate times involving physical activities; however, it does not dissuade him from completing the activity. He enjoys using props found in the classroom or outside, experimenting with them as he examines their properties. He pressed his face against the badminton racquet after we used it to bat around a birdie, and he peered through its webbed grid inquisitively; he balanced a chair on different sides, rocking and then jumping off it; and he used a balloon I had given him today, pushing it down the slide, both with and without him sliding down behind it, and observed as it was caught in the wind. These activities and opportunities provide him with information about the properties and applications of objects. We finished the session watering some plants in the garden before washing our hands. Santino drank a bottle of Pediasure and lay down on a mat at the end of the session. I read him a book as he relaxed and finished the bottle.