Santino was brought in by his mom today and was in good spirits. We put his book bag away in the classroom and used the communication board to demonstrate the activity line up of the day. Santino assembled puzzles that contained items that were in the story. He was prompted to pick up the puzzle piece that corresponded to the animal, item, or object mentioned in the story. His favorite puzzle continues to be the one corresponding to The Three Little Pigs. Santino will play that one repeatedly and occasionally repeat words or phrases. He is afforded high fives and thumbs up for such elicitations even though they are random and arbitrary. We also followed the lines to The Wheels on the Bus, with Santino mimicking some of my movements, such as turning a wheel or the swishing of windshield wipers. His performance as yet remains dependent on the provision of physical prompts to meet this objective. We got some playtime in on the playground, which Santino greatly enjoys, following which we washed our hands thoroughly in the sink. During this activity, I presented Santino with a Dixie cup full of water with a small rim, and I brought it to his lower lip. After breaking the task down into smaller steps (task analysis), I proceeded to tip the cup so that a small amount entered his mouth and he closed his lips to retain and swallow the water. Although Santino did not hold the cup with his hands, he demonstrated the correct oral steps necessary to appropriately draw water into his mouth and swallow. I then placed the cup on the table and stated that it was there if he wanted to drink more. We practiced this exercise 6 times, with Santino drinking from the cup without protesting each time. He did not pick up the cup himself, but the fact that he drank water from a cup held to his lips was a significant advancement. When his nanny, Ingrid, arrived to pick him up, I showed her one of the three videos I had taken and we both lavished Santino with praises, hugs, high fives, and thumbs up signs for the performance and milestone he achieved. Santino was demonstrably happy. Today was an extremely productive and gratifying day.

Santino continues to work on greeting me with a hug, embracing his arms around me as I kneel to be eye-level with him and afford him minimal physical and verbal prompts. He has been doing well achieving this goal and prompts have been gradually fading as he has grown more familiar with expectations and the skill sets needed for achievement. His nanny, Ingrid, has been working on this as well so efforts both at school and program have been consistently reinforcing this behavior across different areas of his functioning. Santino did well working on an alphabet activity using the circular mat in the classroom; he has been articulating the letters more clearly and audibly. Today, after we performed our hand-washing routine at the sink in the kitchen, I gave Santino a cup of water, and brought the lip of the cup to his lips. In the past, Santino never drank from the cup, but today, he matter-of-factly and easily took a sip from the dixie cup as if he had been doing so all along. This demonstrated that he has the oral motor development and mouth muscle control needed to successfully achieve this goal and was a significant milestone that was accomplished. This will be practiced in future sessions in the hopes of consolidating greater gains and achieving greater mastery and independence in self-feeding and daily living skills.

Santino came in from playing outdoors and initially laid on the floor. I thought he might be tired, but when he saw my open bag, he grew interested, and examined some items in it. He closely examined a clementine orange, but when I offered it to him and began to peel it, he turned away. However, when he saw my cell phone, Santino picked it out of my bag and handed it to me. I held it from him and repeated the word 'please,' indicating to him that he needed to say the word to obtain the item. After repeatedly doing so, but pulling my hand away if he just reached for the phone without uttering the word, he said what appeared to be a reasonable approximation to it. I handed him the phone, opened an app, and he was clearly happy with the outcome. This is done in the hopes that he will understood the connection between the word, object, expectations, and contingenices. I began playing a shape and color song, and Santino selected a story about pigs which we had viewed the other day. I brought him a puzzle with farm animals and asked him to show me the pig; he did so. Santino replayed the story several times, occassionally verbalizing some of the words and phrases he heard. He received high fives and thumbs up for imitating speech. We concluded the session with a hand-washing activity and Santino accompanied me back to the classroom to begin his next session.

With prompts to guide him, Santino placed his arms around me and greeted me with a hug. He then accompanied me to his classroom where he was afforded physical prompts to put his book-bag in its proper place. I utilized the communication board to show Santino what activities I had planned for the day. Eventually, I hope that Santino will select his preferred activities from the options presented, but for now, I chose the activities and order. First we worked on alphabet and letter identification and then moved onto puzzle assembly. Santino's favorite puzzle currently appears to be a 5-piece animal puzzle which we pair with reading a story about the Three Little Pigs, and/or a video. After engaging Santino in cooperative and enjoyable play, I let him take the 'you lead and I will follow' approach and began to hear some delayed imitations of words and phrases. Santino learns best from experiential play. He will examine objects and learn about their properties, function, and capabilities through observation. Allowing Santino to problem solve is critical to stimulating his overall cognitive development which, in turn, affects and shapes speech and language. Presenting him with developmentally appropriate activities that involve thinking and figuring out of how to get X has been an invaluable strategy that is likely to result in desirable outcomes in time.

We used the communication board created by the OT to show Santino the sequence of events and activities that would be occurring in today's session and help him learn to communicate and acquire information (Florida State Standard SP.PK12.US.4.2). As we did not go out the other day due to inclement weather, I showed him a picture of the two sliding ponds on his board. He gazed at it a while as if processing the information. I then added the word play and affixed it to the board with the velcro tab provided. When I took his hand, Santino readily and gladly accompanied me out to the playground where we reinforced spatial concepts such as up, down, over, under, and added the word 'through." To reinforce this concept, we used a hula hoop that Santino went through as he slid down the sliding pond. He clearly enjoyed doing this and repeatedly handed me the hoop to repeat the action. When he wanted assistance going up the slide, I repeated the word 'hand' as I offered him an outstretched hand. Santino seems to be making an association between the word and the corresponding action. Additionally, it sounded as if he might have approximated the verbalization of the word, and was therefore given a high five and thumbs up sign. Santino also reached for a ball as he watched another teacher playing ball with a student in the play area. While he did not continue reciprocating the play, it is encouraging and beneficial to see him relate to and initiate positive interactions with others. Santino appears increasingly comfortable with expectations and we will continue practicing a consistent routine and perform routine activities daily (eg., hand-washing) in efforts to elicit and facilitate communication skills, functional language, and task acquisition. Santino has also been starting to put his arms around me upon greeting me, when given physical and verbal prompts to guide his behavior, and he is afforded reinforcement techniques to consolidate gains.

Santino arrived to the program refreshed, having slept through the night and eaten a good breakfast and snack prior to arrival. We placed his book bag on the table and took out his food options in the event he got hungry during the session. When he does get hungry, Santino will select his choice from the array of options available and hand the food item or beverage to me to open it or pour into a bottle, respectively. Next, Santino worked on an animal puzzle, and he independently assembled the 5 pieces without difficulty, demonstrating the visual perceptual skills and eye-hand coordination necessary to complete the task satisfactorily. Our next activity was related to animals as well. Santino listened to the Old McDonald Song and was prompted to show me the animal puzzle pieces mentioned. Although physical prompts remained necessary, Santino did say "oink" when the pig was mentioned in the song. When Santino's OT, Kirsten, arrived, she was shown into a smaller classroom in order to help Santino sustain attention and better focus on acquiring the skill sets necessary to eat and to feed himself with a minimum of distractions.

Santino readily accompanied this teacher to his classroom. He is aware of the routine and if directed elsewhere, or to a place he does not wish to go, he will express his displeasure via gestures (pulling his hands away) or through vocalizations that increase in frequency or intonation depending on the degree of his discontent. Today, Santino was agreeable when introduced to a magnetic game, and he experimented making different shapes. However, efforts to get him to identify some of the shapes upon request remained largely unsuccessful; Santino only verbalized the word 'cicle' during self-directed play and not following verbal prompts. Santino enjoyed working with a hangman board flipping over letters. While he has been observed saying letters, colors, shapes, and numbers when engaged in self-directed play, he rarely engages with teachers if uninterested in what is being presented to him. This activity sustained his attention for over 5 minutes but he resisted my attempts to intervene or guide his attention or focus. Santino has been encouraged and reinforced if he follows single-step directions. We continued working on his requesting my help to obtain a desired object or engage in an activity by saying the word 'hand' (offering my outstretched hand) or 'help'. At this point, however, we have just begun establishing the connection between word and action. It will require repeated trials to accomplish this as there are a limited number of acitivities Santino finds reinforcing enough to affect behavior change. Santino participated in performing the steps of hand-washing before the session concluded, and he enjoyed a big drink of water from the faucet to quench his thirst and hydrate him.

The goal in today's session was to help Santino discriminate, identify, and produce suprasegmental elements of speech, including pitch, loudness, and duration (Florida State Standard SP.PK12.SA.1.1). We used musical instruments to vary the loudness, pitch, and duration of sounds produced, and Santino was afforded hand-over-hand guided instruction to reproduce the sounds following my lead. Next, I drew some long and short lines on paper with dots and dashes using crayons and markers and again assisted Santino in connecting and tracing the lines. He had limited attention on this task, so we moved to a movement exercise. Santino was to imitate me walking in a straight line pattern, heel to toe, on a chalk outline. He seemed to enjoy mimicking me and giggled and remained engaged on the task. We spent some time on the playground following these exercises. Santino requests my assistance climbing up a steep slide and I am trying to get him to verbally request my assistance by repeating the word 'hand' or 'help.' He has not as yet verbalized the request but does gesture or motion for my hand when he wants assistance. It is hoped that repeated practice demonstrating the association between my hand and the offer of assistance will facilitate the elicitation of desired speech in time. The session ended with a hand-washing exercise. Santino is getting better at at initiating the prerequisite steps to dispense soap, but he as yet requires assistance to obtain a towel and dry his hands. Santino did not gesture to eat any of the food options left out on the table, or request a drink; however, he drank from the faucet for a good amount of time and was well hydrated by the end of today's session.

I began today's session by reading aloud to Santino and encouraging him to engage non-verbally with both the book and me, the reader. Without relying on spoken language, I guided Santino to follow along with me as I placed my finger just under the text as I read. I also guided his finger along with me as I physically prompted him to turn the pages at the right times. Story props were used to help Santino make the connection between the words and objects, whenever possible. We read a story about animals, using puzzle pieces of animals to help narrate the story as it unfolded. We also made the sounds the animals make as we read. To consolidate these gains, a video, Peppa Pig was used (via assistive technology) and Santino was reinforced with high fives when he repeated a word from the story; he clearly articulated 4 words. These activities and strategies help engage Santino with books without relying on spoken language. When we next moved onto an alphabet activity, Santino was asked to put the letter 'X' back in its spot on the puzzle board. When he failed to comply with my request at first, I told him that I would play the video again if he followed my directive. In other words, playing the video was made contingent upon his putting the letter 'X' in its proper place on the puzzle board as requested. Santino did as requested and was afforded high fives and thumb up signs as well as enthusiastic verbal acknowledgement following compliance with the directive. We finished up the session with our hand-washing activity. Santino is making progress in this area and is becoming increasingly familiar with the steps necessary for successful task acquisition.

Today was Valentines Day, and Santino participated in a fun and festive activity with other students in the lunchroom celebrating both the day and Miss Judie Batt Yarnell's birthday. He enjoyed navigating around the room and observing the other children as they interacted with one another, sang happy birthday, and delivered several sweet birthday messages to Miss Judie. I explained to Santino what was going to happen and what to expect would happen next. For example, I said “After we finish singing happy birthday, it will be time to work on our puzzle." Santino had no difficulty transitioning to the next activity. We also played with several musical instruments producing sounds and counting aloud to the beats. I afforded Santino hand-over-hand instruction to facilitate successful engagement and participation in this activity. It was a fun and productive day.