ORIGINAL RESEARCH published: 06 July 2021 doi: 10.3389/fpsyg.2021.674755 Encouraging Emotional Conversations in Children With Complex Communication Needs: An Observational Case Study Gabriela A. Rangel-Rodríguez* , Mar Badia and Sílvia Blanch Department of Basic, Developmental and Educational Psychology, Universitat Autònoma de Barcelona, Barcelona, Spain Children with complex communication needs (CCN) regularly have barriers to express and discuss emotions, and have fewer opportunities to participate in emotional conversations. The study explores and analyzes the changes after a training program focused on offering an interactive home learning environment that encouraged and modeled emotion-related conversations between a parent Edited by: and a child with CCN within storybook-reading contexts. An observational design Silvia Molina Roldán, (nomothetic/follow-up/multidimensional) was used to explore and analyze the changes Universitat Rovira i Virgili, Spain in the communicative interaction around emotions between mother-child. Augmentative Reviewed by: Sherri Horner, and alternative communication (AAC) technologies were used to provide the child Bowling Green State University, access to emotion-related vocabulary. The training program resulted in the mother United States providing more opportunities to engage her child in emotional conversations, suggesting Kathryn Drager, Pennsylvania State University (PSU), that when opportunities and resources to talk about emotions were promoted, the child United States showed more engagement in emotion-related conversations using his AAC system. Anna Redford, The mother–child communicative patterns and behavioral relationships observed during Penn State University, United States, in collaboration with reviewer KD the phases are also presented. This case study illustrates the importance of a *Correspondence: primary communication partners’ role in facilitating emotional conversations, and the Gabriela A. Rangel-Rodríguez promising efficacy of a training program implemented in a storybook interactive learning gabriela.rangelr@gmail.com environment to promote conversations about emotion-related events while encouraging Specialty section: children with CCN to learn, explore, express, and discuss emotions. This article was submitted to Keywords: emotion, complex communication needs, augmentative and alternative communication, interactive Educational Psychology, learning environments, emotional education, family, parent–child interaction, home reading a section of the journal Frontiers in Psychology Received: 01 March 2021 INTRODUCTION Accepted: 17 May 2021 Published: 06 July 2021 Communication and language are essential to understand, express, and adaptively regulate and Citation: respond to emotions. Children with complex communication needs (CNN) may have impairments Rangel-Rodríguez GA, Badia M in language production and/or comprehension (Beukelman and Light, 2020), resulting from and Blanch S (2021) Encouraging different etiologies such as cerebral palsy, Down syndrome, developmental disabilities, or speech- Emotional Conversations in Children With Complex Communication language impairment. Recent studies have revealed some evidence that people with CCN often Needs: An Observational Case Study. face barriers in expressing and/or understanding emotions, and may have fewer opportunities Front. Psychol. 12:674755. to talk and learn about emotions (Na and Wilkinson, 2018; Rangel-Rodríguez et al., 2021; doi: 10.3389/fpsyg.2021.674755 Wilkinson et al., 2021). Frontiers in Psychology | www.frontiersin.org 1 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations The literature has shown that learning to express and them, and choosing appropriate ways to manage and respond communicate emotions linguistically and appropriately to different emotions they and their partners experience (Saarni, (according to socio-cultural and family norms) is related to 1999; Saarni et al., 2007; Beck et al., 2012). Suggestions have been adaptive emotional-behavioral outcomes. As an illustration, proposed to design interventions that promote opportunities individuals who are able to express their emotions linguistically to have conversations about emotions with children who (e.g., emotional vocabulary) are more likely to be aware of and could benefit from AAC. Na et al. (2016) suggested that recognize their own and others’ emotions, exhibit less intense initially, communication about emotions should occur during an and sustained emotions, present more emotional management enjoyable and meaningful activity with the child (e.g., storybooks, strategies, and display effective ways to self-advocate (Test et al., videos, movies, games, role-playing, TV programs, morning 2005; Cole et al., 2010; Roben et al., 2013; Doyle and Lindquist, conversations, etc.). Initiating emotional discussions amid a 2018; Torre and Lieberman, 2018). Children with CCN often heightened emotional state (e.g., in the course of a temper- present some challenges in expressing emotions, not only via tantrum) is not ideal (Wilkinson et al., 2021). These assumptions linguistic modes of communication (e.g., difficult to produce are consistent with studies that indicate the importance of speech or to access vocabulary that enables them to understand presenting a joyful and comfortable context in teaching practices and express emotions), but also in non-linguistic modalities (e.g., and its positive relationship in facilitating students’ learning motor and/or sensory difficulties). Thus, their communication (Schutz and Lanehart, 2002; Willis, 2007; Bueno and Forés, 2018). partners may face difficulties in identifying, interpreting, and Another key aspect for an effective interactive learning discussing emotions (Wilkinson et al., 2021) with a child and environment that supports the development of children with may over or underestimate the child’s emotional experience or without speech, language, or communication needs is the (Reed et al., 2020). As a result, emotional learning for children skills and performance of communication partners (Brinton with CCN can be challenging, restricted, or even ignored. and Fujiki, 2011; Romski et al., 2011; Kent-Walsh et al., 2015; There is a significant body of evidence on the benefits Mermelshtine, 2017; Biggs et al., 2018; O’Neill et al., 2018). of augmentative and alternative communication (AAC) in Partners must learn scaffolding strategies such as providing supporting the language and communicative development of opportunities to talk and learn about emotions (making children with CCN (Light and McNaughton, 2012). To have comments, asking questions, etc.), modeling the use of a effective communication through AAC, it is critical to offer child’s communication system, and offering feedback (Na and interactive and dialogic learning environments that support those Wilkinson, 2018; Wilkinson et al., 2021). Brinton and Fujiki who rely on AAC and their communication partners (Dattilo and (2011) illustrated the crucial role of communication partners’ Camarata, 1991; Kent-Walsh and McNaughton, 2005; Ogletree attitudes in children’s development by pointing out that “emotion et al., 2016; Beukelman and Light, 2020). Dialogic and interactive talk that is carefully constructed and timed to be most accessible learning environments must be created to maximize children’s to children can support the development of both emotional learning opportunities and outcomes (García-Carrión et al., competence and social communication” (p. 271). The role of 2018). In addition, encouraging conversations between children communication partners is essential to support children’s socio- and communication partners provides opportunities to interact, emotional and communicative learning. express, and share thoughts, opinions, emotions, knowledge, Additionally, to promote conversations about emotions in as well as create new learning (Vygotsky, 1962; Rogoff, 1990; children with CCN, it is essential to design AAC systems that Brinton and Fujiki, 2011). Interactive learning environments provide significant emotional vocabulary and a diverse range that promote conversations are also beneficial for supporting of emotion-related communication tools that are culturally social, emotional, and communicative learning outcomes for sensitive to the child and the family’s linguistic and cultural children with special needs (Gottman et al., 1997; Jenkins et al., context (Blackstone and Wilkins, 2009; Na et al., 2016; Wilkinson 2003; Schmidt and Stichter, 2012; Fleury and Schwartz, 2017). et al., 2021). For example, vocabulary that serves to explain However, research on the possible benefits of AAC strategies why a person feels the way they feel (e.g., “I’m irritated to support children’s emotional development remains scarce because it’s too noisy”), and some possible responses to those (Wilkinson et al., 2021) and “desperately needs direct attention” emotions (e.g., “I need a break and go somewhere else”). The (Na et al., 2016, p. 447). AAC system must be functional for the child to communicate Emotion talk refers to having conversations about emotion- about emotions and useful for the child’s partners to model related events. Emotional conversations are a medium to foster emotional communication. Interviews can be critical to gather emotional learning, which means that children must understand the information that guides intervention decisions that support words that describe emotions and also have access to emotion- communication about emotions. The Early Development of related vocabulary. Through dialogue, communication partners Emotional Competence (EDEC) is a semi-structured interview can discuss and teach the language of emotions, and they can developed to meet this purpose (Na et al., 2018). suggest strategies for managing and understanding emotional Evidence concerning the use of AAC systems in conversations experiences (Eisenberg et al., 1998; Eisenberg and Morris, about emotions provides some insight about the promising 2003; Morris et al., 2007; Tenenbaum et al., 2008; Aznar benefits of supporting children who have CCN. Na and Wilkinson and Tenenbaum, 2013; Harris et al., 2018). Hence, children (2018) developed the Strategies for Talking about Emotions can learn skills such as recognizing and labeling emotions, as PartnerS (STEPS) program and examined it with three comprehending their causes and consequences, talking about parents and their children with Down Syndrome, conducting a Frontiers in Psychology | www.frontiersin.org 2 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations single-subject multiple-baseline across participants design. They settings. Therefore, a paradigm that allows an integrative and selected storybook time as the context to foster conversations complementary study was needed. A pragmatic epistemological about emotions. Interactive storybook reading has the advantage framework and mixed-method approach were used to allow for of involving the child in an active role and provides a rich the coexistence, integration, and/or combination of quantitative and natural setting for emotional and language development and qualitative elements in the study and enable the use of (Bedrosian, 1999; Drummond et al., 2014; LaForge et al., 2018). analytical techniques in either sequential or parallel phases The STEPS program focused on supporting communication (Teddlie and Tashakkori, 2010; Anguera et al., 2020). For the partners to implement communicative strategies for encouraging present study, an observational methodology was employed. conversations about emotions with children with CCN. The This case study was carried out by an observational design, STEPS training (see Na, 2015; Na and Wilkinson, 2018; which was configured based on three dichotomous criteria Wilkinson et al., 2021) consists of three steps: Step 1: provide and (Anguera and Izquierdo, 2006): model emotional vocabulary (label the emotion); Step 2: validate and discuss emotions (talk about the reason for the emotion); • Unit of study: one unit or individual (idiographic) or a Step 3: communicate about appropriate responses to emotions group of units/participants (nomothetic) studied. (talk about the possible responses/coping strategies to emotion). • Temporality: one session (point) or several sessions (follow- These steps, in combination with other communication partner up) observed over time. strategies (e.g., ask, wait, provide feedback) and the design of • Number of dimensions: one (unidimensional) or several emotional-communication boards resulted in parents providing (multidimensional) behaviors considered to study. more opportunities to discuss emotions using the AAC system, Hence, this study employed a nomothetic/follow- and the children increasing their utterances referring to emotions up/multidimensional observational design (N/F/M) for the using different communication modes (including AAC). Even following reasons: though further research is needed, the STEPS program appears to be a beneficial resource to initiate conversations about emotions • Nomothetic: a parallel and independent analysis of the with children who have CCN in natural settings. behavior of the child and the mother was conducted. Giving children with CCN access to key and meaningful • Follow-up: intra and inter-sessional recordings analyses emotion-related vocabulary, as well as encouraging its usage, is between the 4 phases of the program (13 complete critical to support effective conversations between the children storybook reading sessions) from the collected and their communication partners (Rangel-Rodríguez et al., data were performed. 2021; Wilkinson et al., 2021). Nuclear family members are • Multidimensional: several dimensions of interactive life partners and the primary communication partners in the responses from the child and the adult in each child’s social networks (Blackstone and Hunt-Berg, 2012); its session were recorded. engagement in children’s healthy development, learning, and emotional well-being are fundamental (Mandak et al., 2017; The observation was direct through video recordings of Lehrl et al., 2020). Therefore, families are certainly “children’s storybook reading sessions that the mother shared with the first and most important teachers, advocates, and nurturers” researcher, allowing the researcher full auditory and visual (U.S. Department of Health and Education and Human Services accessibility of the interaction. and U.S. Department of Education, 2016, p. 1). Supporting families in promoting learning environments is essential to aid Participants children’s learning (Lehrl et al., 2020) and thus reduce or prevent A mother–child dyad participated in this study. They were behavioral, social, or emotional conflicts in the future (Sanders, recruited through convenience sampling. The inclusion criteria 2008; Dishion et al., 2014). were (1) have a child who has functional hearing and vision per The current study describes and analyzes a program designed parent report and CCN, with previous or current exposure to to increase and encourage conversations about emotions during aided AAC systems; (2) parents who have no speech, language, or a storybook reading activity with a child who has limited hearing impairments; and (3) have an internet connection. The speech using a case study approach. The goal of the program mother participated in the study and although the father could is to facilitate interaction skills that encourage emotional talk. not participate, he was also interested in the study. This study is part of a larger research project carried out by The mother was 44 years old, and the child was 7 years the first author. old. The child had a medical diagnosis of dyskinetic and dystonic cerebral palsy that affected the ability to control muscle movement, posture, and coordination; specifically, characterized MATERIALS AND METHODS by slow unintentional writhing movements (dyskinetic) and varying patterns of muscle tone (dystonia) (Center for Disease Design Control and Prevention (CDC), 2020). The child’s speech This study highlights the importance of the sociocultural intelligibility was severely impaired. The mother stated that her context, communication, language, and experiences generated child “understands everything and can sound most of the words, from the intervention, as well as examining the efficacy of the but the sound level is very faint (lots of air in the sound),” so he program through the behaviors of its participants in natural also communicates via gestures (e.g., eyes up for yes, eyes down Frontiers in Psychology | www.frontiersin.org 3 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations or stick his tongue out for no), facial expressions, and through an the emotion; and (c) propose possible responses or coping AAC electronic device. The child has used a speech-generating strategies to these emotions. The communication board design device since he was 2 years old. Currently, he accesses his device page contained a table to write the book page, the emotion through eye-gaze. The mother commented that he has functional selected to talk about, the trigger for that emotion, and the hearing and vision level, uses glasses, and attends a 1st grade class possible responses when that emotion appears. in a mainstream school program. Communication board example Ethical approval was obtained from the Ethics Committee According to the child’s AAC communication, the clinician from the Autonomous University of Barcelona prior to designed an example of pages to explain how the boards starting the research. could be created in the child’s current AAC system (see Supplementary Material 2). Materials Storybooks were selected for the program, specific materials Video-demonstrations of storybook reading activity were used to illustrate the training session conducted with Five short videos, around 1 min each, were presented to the the mother, and communication boards were designed in mother in the training session. Each video showed a role-playing conjunction with the mother to provide the child access to situation between two individuals (one acting like a child and emotion-related vocabulary. the other as a parent) in a storybook reading activity. Each video explained the different parts of the training. Storybooks The selected storybooks had to fulfill the following criteria: (a) Communication Boards being an illustrated book, (b) with text appropriate to the child’s Once the mother filled in the material “communication board characteristics, interests, and cultural background, (c) showing design page” for each book, suggestions were made by the at least two different emotional categories (e.g., sad–happy), and researcher and agreed upon by the mother. The researcher (d) a length of at least 20 pages. The selection criteria taken then created the communication board pages using the child’s was proposed by Na and Wilkinson (2018), who adapted the communication system (Snap-Core First App, a system that guidelines from Kent-Walsh et al. (2010). permits dynamic display pages), and shared it with the mother. Vocabulary was added to the emotion page in his AAC Instruction Session Materials system, as needed. Also, new communication pages were created STEPS instruction page throughout the program: (a) one page per book to talk about The STEPS instruction page contains a detailed description of the possible causes of the emotion, and (b) one section with each step proposed in the training to encourage communication vocabulary to talk about possible responses to emotions. As the about emotions during the storybook-reading activity mother suggested new words that enabled her and the child to (see Supplementary Material 1). The mother received a discuss emotions, the child’s access to emotion vocabulary grew. copy of the instruction page as support. This page was an An example of the child’s AAC emotion-related pages used is adaptation of the handouts suggested by Na and Wilkinson presented in Figure 1. (2018; Wilkinson et al., 2021), where suggestions to encourage mother–child communication were included. Instruments Observation Instrument Communication board design page To analyze the data collected in an interactive natural context To create communication boards that were culturally and family between communication partners and children with CCN, appropriate, the researcher asked the mother to read the selected an observation tool was constructed ad hoc to fully adapt books and (a) choose the emotions with which she could feel to the interests of the research (Anguera et al., 2021), comfortable talking with her son; (b) identify the causes for based on the data obtained from preliminary interactions FIGURE 1 | Example of emotion communication dynamic display page [emotions, causes, and responses to emotions]. The Picture Communication Symbol R and Boardmaker by Tobii Dynavox R All Rights Reserved. Used with permission. Frontiers in Psychology | www.frontiersin.org 4 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations observed (15 mother–child with CCN dyads in a storybook- study, which includes 6 dimensions (out of the 15 dimensions reading activity), and previous theoretical and empirical work included in the full-version) that allowed for the capturing (Girolametto et al., 2007; Kent-Walsh et al., 2010; Girolametto of mother-child emotional interaction in the storybook and Weitzman, 2011; Rowland, 2011; Parish-Morris et al., reading activity. 2013; Poyatos, 2015; Na and Wilkinson, 2018). Therefore, the instrument combined a field format with category systems: “this Recording and Analysis Instruments combination is possible when some or all of the dimensions in All the video-recording sessions were recorded and coded the field format have a theoretical framework and the object of according to the full-version observation instrument using the research is atemporal” (Anguera et al., 2018, p. 7). software LINCE 1.4 (Gabin et al., 2012). The data obtained The full-version observation instrument is presented were time-based and concurrent, categorized as type IV; that is, as Supplementary Material 3. Figure 2 only presents the “the observer notes the duration of events, but different events dimensions and units analyzed for the purposes of the present can overlap and occur together” (Bakeman, 1978, p. 65). FIGURE 2 | Observation instrument. Frontiers in Psychology | www.frontiersin.org 5 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations For data analysis, different software were employed: GSEQ videos also served to identify behaviors that might contribute new 5.1 (Bakeman and Quera, 2011) to conduct the intra- categories in the observation instrument. The last three sessions observer reliability and lag-sequential analysis, HOISAN 1.6.3.3.6 were taken for analysis. (Hernández-Mendo et al., 2012) for the polar coordinate analysis, and the R program to obtain the graphic representation on polar Online Training Session coordinate analysis (Rodríguez-Medina et al., 2019). One online training session was offered and lasted about 1 h 20 min. Throughout the session, the clinician encouraged the Procedures mother to share her ideas, doubts, or questions. This session The study procedures consisted of an interview and exploratory consisted into four stages presented below. observations of a video-recorded storybook reading activity at home, followed by a training session and post-observations of videorecords of the storybook interactive learning environment Conversation and commitment suggested during the program. The session started with a conversation about the interaction Once the mother and child were selected for participation, a and emotional communication obtained through the EDEC semi-structured interview called EDEC, the Early Development interview and exploratory phase observations. In this stage, of Emotional Competence tool (Na et al., 2018), was conducted the researcher promoted a discussion about the importance between the researcher (the first author) and the mother. The of emotional development and its relationship with language purpose of the interview was to identify the current child’s and communication, as well as the importance of fostering emotional state and communicative characteristics, as well as emotional learning by creating environments to talk about some caregivers’ emotional and communicative socio-cultural emotions, using the storybook reading activity as an opportunity aspects, in order to support the family better (Rangel-Rodríguez to pursue this matter. The clinician also shared the purpose et al., 2021). In this meeting, the researcher explained the study of the training session, which is to receive suggestions and and the importance of recording the storybook reading sessions strategies to implement in the storybook reading activity with throughout their participation. The mother provided informed her son to foster conversations about emotions that can continue consent and agreed to participate in the study. supporting her child’s emotional learning and development. The As part of the interview, the mother was asked to share stage finished with asking the mother if she would like to commit her son’s favorite storybooks. As the sessions progressed, other to the training. storybooks were suggested based on the research’s criteria, family values, and the child’s interests and preferences. STEPS description The training program was an adaptation of Na and This stage aims to explain the Strategies for Talking about Wilkinson’s (2018) protocol and consisted of four phases [(1) Emotions as Partners (STEPS) and their communicative exploratory, (2) strategy implementation, (3) iteration, and (4) components, including the design and use of AAC systems. maintenance]. One additional training session was carried out Graphic materials supported the training (see section after the exploratory phase. The book reading sessions in all “Materials and Methods”) to explain the steps for fostering phases took place in the participants’ home and were video- conversations about emotions (name-cause-response): (1) recorded by the mother, who used her own videocamera device. Discuss the name of the emotion, (2) Discuss the possible causes The child was informed and agreed to be filmed too. Before for that emotion, and (3) Discuss possible responses to the the first recorded session, a filming tips handout was provided emotion. The communication strategies suggested that in each to ensure the whole interaction was captured. The filming tips step (name-cause-response), the parent: (a) Asks an open-ended were (a) use a room with good light and no noise; (b) leave the question (e.g., How does Louis feel?), (b) Waits for child’s camera in a fixed place; (c) make sure to have enough memory response (at least 5 seconds), and (c) Responds and provides on your card and enough battery; (d) in case of recording feedback using the child’s communication system (e.g., “you’re with a cellphone, turn off the mobile data to avoid calls or right, Louis needs to ask for help,” selecting at the same time the notifications while recording; and (e) verify the interaction scene words in his AAC device). is in focus. The mother shared the videos online with the The researcher gave other types of suggestions to promote researcher for later analysis and, depending on the program’s and model communication with the child. For instance, if the phase, for providing feedback. child does not respond after an open-ended question, provide a double-choice question by pointing to the word-choices in Exploratory Phase the child’s communication system (e.g., “Do you think Louis is After the storybook selection, the mother was asked to record the angry because his friends went away or because he doesn’t like storybook reading activity with her child in their home. The only Kelly?”). If the child still does not answer, give the correct answer instruction for this phase was: “read the storybook the way you while modeling the communication using the child’s device (e.g., always do with your child.” “Louis is angry because he doesn’t like Kelly”). The researcher also The mother sent a total of seven videos in this phase. The encourages the mother to have the child’s communication system first four videos were used to minimize reactivity bias, give a available at all times during the session and make comments period for camera sensitization, and optimize recordings’ quality using the AAC device to model and encourage communication (e.g., camera angles, background noise, etc.). These first four without requiring it. Frontiers in Psychology | www.frontiersin.org 6 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations Subsequently, an example of how to design an emotional Iteration Phase communication board that includes the steps (label-cause- Three different storybooks were used in this phase. Therefore, response) was presented (see section “Materials and Methods”). new vocabulary, if needed, was added to the AAC pages. Three It was explained that the vocabulary added in the communication sessions of the storybook reading activity were recorded in this boards must coincide with the vocabulary used in the family phase, and the mother was encouraged to continue fostering and child’s context. Therefore, it is emphasized that it is of the opportunities to talk and learn about emotions. The researcher utmost importance that the mother gets involved in the AAC gave less support; nevertheless, the mother was still encouraged board design, that is, to scan in the storybook selected, choose to express her ideas, doubts, or questions about the interaction the situations to talk about, and write down the vocabulary she with her son. For example, she asked how she can encourage more would like to discuss with her child (using a template to write it discussions about her child’s emotions during the storybook. down according to the STEPS). The mother had the freedom to choose whatever emotion she would like, and in which she felt Maintenance Phase comfortable, to discuss with her son. The mother asked the child which storybook he would like to read, with the possibility of choosing all the storybooks Strategy demonstration used in the program. Three storybook-reading sessions were After the STEPS description, short video demonstrations (see recorded. In the maintenance phase, the researcher did section “Materials and Methods”) were presented with the not give feedback about the participants’ performance. The purpose of modeling and illustrating the strategies presented. objective in this phase was to identify communicative changes Discussions on the strategies were encouraged, and the generated by the program. researcher gave in-depth explanations about the interaction and strategies performance. Data Quality Control Before data analysis was carried out, a data quality control was Verbal practice and feedback performed through intra-observer agreement using GSEQ 5.1 The mother was asked to describe the three steps suggested software (Bakeman and Quera, 2011). The first author recoded for discussing emotions she just learned, including the fifteen percent of the sessions, with at least 3 weeks of difference communication strategies to encourage emotional conversations between the first and second codification. Cohen’s Kappa (Cohen, in children with CCN (ask, wait, respond, comment, model 1960) resulted in a satisfactory agreement average of 0.87. The AAC). This stage aimed to affirm and ensure the mother’s sessions used for data quality control were selected randomly and learning in the training session and give feedback. using different extracts from different sessions from each of the phases in the program. Commitment to employing the strategy At the end of the training session, the mother was asked if she Data Analysis would like to continue with the program and try the strategies. A total of 13 storybook reading sessions held over a period of She responded, “yes, absolutely, it’s really fascinating and sounds 11 months were analyzed. The average observation sessions lasted so nice.” Nevertheless, she expressed possible difficulties in 18 min, 7 s. All videos were imported and coded through Lince having the time to make the activity and record it due to software (Gabin et al., 2012). The first author observed and coded different family situations. The researcher commented that the each of the behaviors included in the observation instrument. program would adapt to their needs and family time (one of The coded data considered the frequency, order, and time of each the benefits of using observational designs is its applicability behavior observed. in natural settings and everyday life). The mother agreed to Two data analysis techniques were used: (1) lag-sequential fill in the communication board design page and sent it to the analysis and (2) polar coordinate analysis. These techniques have researcher. Moreover, once the pages were created, she could start proven efficacy in different research areas, including individuals implementing the strategies suggested. with special needs, such as clinical psychology (Arias-Pujol and Anguera, 2020), education (Escolano-Pérez et al., 2019), communication (Rodríguez-Medina et al., 2018), and AAC Strategy Implementation Phase (Todman et al., 1994; File and Todman, 2002). Data were also Once the AAC pages were designed, and the mother was satisfied analyzed descriptively (frequencies of communicative turns and with them, the mother video-recorded four sessions of the emotional content in each phase). storybook reading activity with her child while implementing the training session’s strategies suggested. The researcher watched Lag Sequential Analysis the recordings and gave feedback and suggestions. In this phase, This technique is used to identify how one or more behaviors the mother was also encouraged to ask questions and express her work and presents, if any, a sequence of statistically significant ideas about the mother–child interaction; the clinician offered actions (not due to chance) connected to specific given behaviors a space for listening and addressing her needs, concerns, and (i.e., the behavioral triggers that may initiate or promote a thoughts. For example, in the beginning, she commented that it behavior pattern along time; Bakeman and Quera, 2011; Anguera was awkward to discuss while reading “because that breaks the et al., 2021). In other words, this analysis provides a measure rhythm of the book.” of how likely is that one behavior (i.e., the “given” behavior) Frontiers in Psychology | www.frontiersin.org 7 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations is followed by another [i.e., the “target” behavior(s)], either lag-sequential analysis was applied to each of the program phases immediately (i.e., lag 1) or after two (i.e., lag 2) or more (i.e., lag to identify communicative patterns among them. 3, lag 4, etc.) successive behavioral events. The analysis, adequate for the identification of patterns of Polar Coordinate Analysis social interactions, consists in proposing the given behavior(s), Polar coordinate analysis (Sackett, 1980) is performed to identify the conditioned or target behavior(s) (i.e., the actions that could a representative map that explains the type of relationship be significantly associated with the given behavior), and the between a focal behavior (i.e., the behavior of interest) and lag (i.e., the distances or place of order within the conditioned the selected conditioned behaviors (i.e., actions that could be behavior in relationship with the presence of the given behavior). associated with the focal behavior). This technique employs the Once these criteria are defined and based on the given behavior, adjusted residual values obtained in the lag sequential analysis. It the matched frequencies are calculated, which is a parameter integrates both prospective (e.g., lag 0 to +5) and retrospective that is comprised of the number of times that a certain (e.g., lag 0 to –5) perspectives, which are used to calculate conditioned behavior appears before (if the lag is negative), the Zsum scores (prospective and retrospective), as well as the after (if the lag is positive) or concurrently (if lag = 0) with vectors (length and angle) for each conditioned behavior. For the specific given behavior. From the matched frequencies, the this analysis, the genuine retrospectivity proposed by Anguera expected and conditional probabilities are calculated for each (1997) was used. Each conditioned behavior can be represented lag, and adjusted residuals are obtained (Allison and Liker, graphically; depending on the quadrant in which the vector 1982), revealing the likelihood of occurrence/co-occurrence is located, the relationship between the focal and conditioned of each conditioned behavior in association with the given behavior is interpreted (activation vs. inhibition): behavior. Z scores are statistically significant (p < 0.05) for values >1.96 (i.e., the association between behaviors is activated) • Quadrant I: Both behaviors (focal and conditioned) are or <–1.96 (i.e., the relationship is inhibited). To decide mutually activated (prospective and retrospectively). when the behavioral pattern ends conventionally, the following • Quadrant II: The focal behavior inhibits the conditioned interpretative guidelines were considered (Anguera et al., 2021): behavior, whereas the conditioned behavior activates the (a) when there is an absence of statistically significant behaviors in focal one (prospective inhibition/retrospective activation). the lags; (b) when there are two successive empty lags; or (c) when • Quadrant III: The focal and conditioned behaviors in two consecutive lags, various statistically significant behaviors are mutually inhibited (prospective and retrospective appeared, if so, the first of these lags is defined as the MAX inhibition). LAG. Considering these guidelines are only recommendations • Quadrant IV: The focal behavior activates the conditioned (not compulsory criteria), when various statistically significant behavior, whereas the conditioned inhibits the focal one behaviors appear, but the significant lags after the MAX LAG (prospective activation/retrospective inhibition). were considered illustrative in understanding the mother–child The behaviors that were suggested to be implemented in the communicative sequences, it was decided to incorporate the training session to the mother, and that showed a frequency > 4 subsequent lags’ significant behaviors. at least in one of the phases, were identified as the focal behavior: The mother’s communicative behaviors concerned with ask, make comments, respond, model AAC communication; implementing the strategies suggested in the training session while the child’s communicative behaviors: answers, makes were selected as the given behaviors. Hence, the mother’s comments, asks questions, expressing with conventional gestures behaviors related to asking open-ended questions, waiting, giving or AAC were selected as the conditioned ones. the answer, providing feedback, and making comments were considered to be of special interest. Both responses from the child and mother were chosen as the conditional behaviors to identify Social Validation Mother and child satisfaction surveys were completed at the significant interactive patterns during the conversation about end of the maintenance phase to evaluate the program’s emotions. A particular interest in the analysis was the child’s social validity. The questionnaire included multiple-choice and behaviors in discussing emotions: answering, making comments, open-ended questions about their ideas and opinions about and asking questions. The analysis only deemed the units from the program’s process and participation. The child answered the observational instrument with a frequency > 4 at least in one with his AAC device. of the phases. Values lower than 5 are considered not significant in observational methodology (Sackett, 1980). The search for associations between the given and the conditional behaviors was made prospectively (lag 1 to lag 5) and RESULTS retrospectively (lag –1 to lag –5). Concerning the retrospective analysis, only the given behaviors expected, in theory, to be Development of Emotion-Related the next part of a conversational sequence already begun Conversations (e.g., providing feedback, giving the answer) are presented in Figures 3 and 4 illustrate the interactive communication progress the results section. The child and mother’s utterances and (frequencies) per phase, between the mother and her child, their simultaneity with the type of emotional content discussed regarding their participation and emotional content discussed and method of expression were also analyzed (in lag 0). The (emotional label, causes, and responses to emotions) in the Frontiers in Psychology | www.frontiersin.org 8 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations FIGURE 3 | Development of the mother’s conversational utterances about emotions [closed-ended questions, open-ended question, comments] and type of emotional content discussed [label, reason, and responses to emotion]. FIGURE 4 | Development of the child’s conversational utterances about emotions [answers, asks questions, comments] and type of emotional content discussed [label, reason, and responses to emotion]. storybook-reading activity. It can be noticed that in the appearance of the selected behaviors. The results revealed exploratory phase, there is little stimulation in both participants highly significant concurrences (>1.96, p < 0.01) between about having an emotional talk. The sessions that followed these dimensions (Figure 5), demonstrating that discussions the training session showed maintained progress by both the richer in emotion-related content and about different referents child and mother, concerning their active participation in appeared as conversations developed over time. Additionally, conversations about emotions. it is noticeable that, after the training session, the mother To examine the participants’ utterances in conversations about showed AAC models while commenting about emotions, and the emotions, the type of emotional content (i.e., emotion label, child participated in emotional discussions using his AAC and cause, response), ways of expression (i.e., method of expression conventional gestures. in the child and communication model in the adult), and The exploratory phase was characterized by the child’s to whom the emotional discussion was addressed (i.e., the gestural responses to the mother’s questions about the emotional child, storybook characters, or other people), a lag sequential label from the storybook’s characters and the child. After the analysis was performed in lag 0. Lag 0 indicates a simultaneous training session, the mother and his child showed engagement Frontiers in Psychology | www.frontiersin.org 9 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations FIGURE 5 | Adjusted residuals showing significant concurrences (lag 0) between emotional conversations utterances from the mother and child, and their modes of expression, and type of emotional content discuss (content and related to). in discussions related to more than just labeling emotions the storybook-reading activity in each phase. Only the patterns (they discuss the reason and responses to emotions) about the that showed activation (i.e., Z > 1.96, p < 0.05) between the given storybook and the child. In the iteration and maintenance phases, (the mother’s behaviors that encourage emotional conversations) the child’s interest in asking questions about emotions referring and conditioned behaviors (the child’s behaviors in emotional to himself (e.g., what can I do?) and his mother (e.g., how do conversations, as well as the mother’s behaviors that encourage you feel?) emerged. emotion-related conversations) are presented. Encouraging Child’s Participation Openly Behavioral Sequential Patterns of Even though the closed-ended questions were not part of the Mother–Child Interaction When Fostering training sessions’ suggestions, it was considered important to Conversations About Emotions present them in the results section as closed-ended questions Figures 6–8 present the statistically significant sequential are part of the communication flow during any conversation. communicative patterns related to the dyad interaction during Yes-no questions about emotion-related events were followed Frontiers in Psychology | www.frontiersin.org 10 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations FIGURE 6 | Sequential communicative patterns obtain in each phase during the storybook reading with the mother’s closed-ended and open-ended emotion-related questions as given behavior [M, Mother; C, Child]. by a stable behavior pattern of the child’s response, succeeded C: Looks up [gesture for yes], confused [selected via AAC] by another mother’s query in all of the phases (Figure 6). One M: Yes, and he is confused. exception to this appeared in the implementation phase, which was followed by the mother’s feedback and then another closed- A considerable difference before and after the training session ended question or comment about emotions. In the exploratory can be seen when the mother asked emotion-related open-ended phase, the mother showed a pattern of asking more than one questions (Figure 6). In the exploratory phase, even though closed-ended question at a time, followed by the child’s response. the mother asked open-ended questions, it was immediately A significant change in the pattern was shown in the maintenance followed by a closed-ended question (e.g., What do you do phase where the child, after a second closed-ended question, when you are scared? Can I see a face that you think is tended to respond with also a spontaneous comment: scared?). Nevertheless, in the phases following the training session, significant combinations of conversational turns about [Talking about character’s feelings] emotions were observed when the mother asked an open-ended M: Mmm, I wonder why, do you know why? question: (1) the child engaged actively in the conversation C: Stick tongue [gesture for no] by responding (answers), and this behavior was followed by M: Or do you think he is gonna be angry? the mother’s feedback; (2) The mother, after questioning, Frontiers in Psychology | www.frontiersin.org 11 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations answers immediately, and (3) Repeats the question, which in patterns observations from the retrospective (e.g., lag –1 to – turn could finish the sequence with the child’s response. The 5) and prospective (lag + 1 to 5) analysis were included in this following clinical vignette, taken from the implementation phase, section (Figure 7). demonstrates the first sequence explained above: Feedback providing utterances significantly changed and were maintained after the training session. In the M: So, when somebody is so sad, what they can do? exploratory phase, this behavior related to emotional content C: Need a hug [AAC] was not observed, whereas in subsequent phases it was M: Oh, need a hug, yes, he was so sad that he preceded by the child’s emotional comments and responses, needs a hug, ok. and feedback, in turn, activated another child’s emotional comments: An example of the behavioral sequence of open-ended question – mother’s comment – repeat question – child answers [Discussing character’s emotions] observed in the iteration phase would be: C: Overwhelmed M: Overwhelmed, yes, it’s too much [for the character] M: And when you feel stressed, what should you do? C: Surprise M: Cause when you feel stressed your body tenses up M: Yes, he is probably surprised, because he lost his M. M: So, if you feel stressed, what should you do? In other cases, offering feedback activated another mother’s C: [child smiles] Cheer up mate! play [AAC] query or emotional comment (the mother’s comment was only M: Oh, I know, you want someone that says cheer up! significant in the implementation phase). And you wanna play. The mother’s expression of answering her questions was not directly associated with the child’s response, neither Answering and Giving Feedback retrospectively nor prospectively. In phases 3 and 4, after Answering and giving feedback are behaviors expected to be the mother answered, she made another open-ended question contingent on previous actions; thus, significant behavioral encouraging the child’s conversation: FIGURE 7 | Sequential communicative patterns obtain in each phase during the storybook reading with the mother’s providing feedback and answers as given behavior [M, Mother; C, Child]. Frontiers in Psychology | www.frontiersin.org 12 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations [discussing storybook] lag 0, Figure 3). During the phases 1 and 2, the mother’s M: They were what? personal comments about emotions were not prospectively M: Maybe there is not an emotion, but they were safe associated with a significant child’s communicative behavior, C: Looks up [gesture for yes] whereas, by phases 3 and 4, the mother’s emotional opinions M: So, they are now rescued. How do you think they felt? were followed by the child’s comments about emotion- C: Glad, happy [AAC] related events: M: Absolutely, yes, that’s great. So, they were so happy now because they were safe. [Talking about what the child can do when he feels sad because his body tenses up] Commenting to Encourage Child’s Participation M: Maybe you can “wait” [AAC] a little bit and “breathe” The mother’s emotional comments were observed in all [AAC] phases (Figure 8), with a simultaneous mother’s use of C: Try again [AAC] AAC in the phases after the training session (remember M: Yes, you can also try again. FIGURE 8 | Sequential communicative patterns between mother–child during storybook reading with the mother’s emotion-related comments as given behavior [M, Mother; C, Child]. Frontiers in Psychology | www.frontiersin.org 13 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations In phases 3 and 4, the mother’s emotional comments were mother’s closed-ended questions and the child’s answers significantly preceded by child’s questions: through gestures. The child’s AAC mode of expression in the maintenance phase was also significant and located in [Talking about what can the child do if he were the book’s quadrant II, indicating that closed-ended questions inhibit the character] child’s use of AAC, whereas this expression activates mother’s M: What can you do? closed-ended questions. C: I need a break [AAC] Concerning open-ended questions (Figure 10), a stable M: Yes, sure, you will need a break from all these crayons mutual stimulation with the child’s emotion-related answers C: What would you do? [AAC] was identified during all of the phases. Nevertheless, changes M: If I were him, I would say, “good job” guys, “thank were found in terms of the child’s modes of expression. In the you” for your service, and then I will say I will “think of exploratory phase, the mother’s open-ended questions inhibit a strategy” [AAC]. the child’s gestures, but this behavior, in turn, activates the mother’s questioning. A different pattern was observed after Relationships Between Mother–Child the training session, where the child’s AAC use mutually activate Interactive Communication About the mother’s open-ended questions in phase 2 and 4. In contrast, Emotions in phase 3, the child’s AAC use is situated in quadrant IV, Figures 9–14 show the vectorial graphs from the polar indicating that the mother’s open-ended questions activate the coordinate analysis in each phase. Those graphs present the child’s AAC expressions, but the AAC use inhibits the mother’s relationships between mother-child interactive emotion-related open-ended questioning. conversations. Behaviors taken as focal were mother’s closed- ended question, open-ended question, multimodal feedback, Mother’s Emotional Comments and Child’s give answer, emotional comment, and AAC model. The child’s Engagement in Conversations answers, comments, questions, and modes of expression were No relationship was found in the exploratory phase between selected as the conditioned behaviors. In this section, only the the mother’s emotional comments and the child’s behaviors vectors with significant results will be discussed (i.e., with a (Figure 11). Phase 2 presented a mutual excitatory association length > 1.96, p < 0.05, are represented in purple; vectors with between the mother’s comments and the child’s emotional a length > 2.58, p < 0.01 are represented in red). Vectors in blue comments. However, in phase 3, the reciprocal activation was are not significant. between the mother’s comments and the child’s questioning. By phase 4, this communicative link changed to quadrant II, Mother’s Questions and Child’s Engagement in implying that the child’s inquiry about emotions stimulates the Conversations mother’s comments but not vice versa. A similar relationship Similar to what was found in the lag-sequential analysis, was observed with the child’s gestures (quadrant II) in phases 3 Figure 9 shows the significant stable mutual activation and 4; that is, the mother’s comments inhibit the child’s gestures, (Quadrant I) in all of the program phases between the but those gestures activate the mother’s comments. Finally, the FIGURE 9 | Vectors corresponding to the mother’s emotion-related closed-ended question as focal behavior, and the child’s emotion-related communicative turns [answers, comments, asks] and methods of expression [AAC, conventional gestures] as conditional behaviors. Frontiers in Psychology | www.frontiersin.org 14 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations FIGURE 10 | Vectors corresponding to the mother’s emotion-related open-ended question as focal behavior, and the child’s emotion-related communicative turns [answers, comments, asks] and methods of expression [AAC, conventional gestures] as conditional behaviors. FIGURE 11 | Vectors corresponding to the mother’s emotion-related comments as focal behavior, and the child’s emotion-related communicative turns [answers, comments, asks questions] and methods of expression [AAC, conventional gestures] as conditional behaviors. AAC child’s mode of expression was significantly associated session (Figure 12). Feedback was strongly mutually activated with the mother’s comments in the iteration phase (quadrant with the child’s emotional comments in all phases, and with the IV), where the focal behavior stimulates the child’s AAC use child’s responses to questions in phases 2 and 4. In phase 3, but not conversely. the mother’s feedback inhibited the child’s answers, but this response activated the mother’s feedback. Mother’s Feedback/Answer and Child’s Engagement Concerning the mother’s answering of her questions in Conversations (Figure 13), in phase 2, the child’s AAC use and the mother’s A significant relationship was found between the mother’s giving the answer inhibited each other (Quadrant III). At multimodal feedback and the child’s behaviors after the training the same time, the child’s gestures activated the mother’s Frontiers in Psychology | www.frontiersin.org 15 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations FIGURE 12 | Vectors corresponding to the mother’s providing multimodal feedback as focal behavior, and the child’s emotion-related communicative turns [answers, comments, asks] and methods of expression [AAC, conventional gestures] as conditional behaviors. FIGURE 13 | Vectors corresponding to the mother’s giving of the answer to her own questions as focal behavior, and the child’s emotion-related communicative turns [answers, comments, asks] and methods of expression [AAC, conventional gestures] as conditional behaviors. giving the answer (a similar association was also observed in Mother’s AAC Modeling and Child’s Engagement in phase 3). In addition, significant excitatory association was Conversations noted in the iteration phase between the child’s response and In the exploratory phase, no AAC model was presented the mother’s answering. Phase 4 did not present a significant (Figure 14). Nevertheless, in the implementation phase, relationship between the focal behavior and the child’s behaviors the mother’s use of AAC, while discussing emotions, or expression methods. involved mutual activation with the child’s gestures and Frontiers in Psychology | www.frontiersin.org 16 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations FIGURE 14 | Vectors corresponding to the mother’s AAC modeling as focal behavior, and the child’s emotion-related communicative turns [answers, comments, asks] and methods of expression [AAC, conventional gestures] as conditional behaviors. prospective activation with the child’s emotional answers to the How are you? To answer like fantastic. To communicate.” He mother’s questions. also shared that he “absolutely” likes to talk with his mom using By the iteration phase, modeling AAC showed a reciprocal his AAC device, and what he likes the most about the emotion- activation with the child’s answers, questions, and AAC use to related AAC pages is “to be able to express I like, I love,” whereas communicate emotion-related events; and a unilateral activation what he like the least was “dizzy – too many choices.” When asked with the child’s comments. However, these relationships were not to complete the sentence “I want to say that. . .,” he commented, sustained in the maintenance phase. It was observed that the “Ready and sharing – Enjoyed.” child’s questions stimulated the mother’s AAC model, and the mother’s AAC model activated her child’s AAC use, but none of them conversely. DISCUSSION The present study highlights the importance and promising Mother–Child Social Validation implications of providing interactive learning experiences in A written satisfaction survey was sent to the mother and her child natural settings to encourage emotional conversations in children by the end of the maintenance phase to evaluate the training and with CCN. Similar to the findings presented by Na and Wilkinson program’s social validity. (2018), participating in the program resulted in improvement The mother expressed feeling extremely satisfied with the in the communicative exchanges between mother–child about support provided during the program and considered it helpful emotion-related events. and very easy to learn emotional communication strategies. She During the exploratory phase, the child rarely had commented that participating taught her: opportunities to discuss emotions, and his participation was how to have a deeper conversation with my son. To be mindful mainly summarized in answering yes/no questions. Although of the characters in the books and use them as a tool to talk to the mother occasionally promoted a richer emotional discussion my son (. . .) this [the emotion communication strategy learned] (asking open-ended questions), this was followed by a closed- enables otherwise a superficial, two-dimensional conversation to ended question. Research has shown that asymmetries between be more interesting. I got to learn more about how my son feels. discourse patterns between partner-individual with CCN are (. . .) Got to understand more about the importance of discussing frequently expected (Todman et al., 1994) and that there is the emotions and how to deal with the emotions. (. . .) [the “how a tendency to engage individuals with CCN through yes/no to respond” page] has helped my son to also think deeper. [this questions in communicative exchanges as it speeds up the program] opens up many more opportunities to use AAC and talk about more abstract issues (not just factual questions). interaction. Nevertheless, asking closed-ended questions limits their experience and opportunities to learn, discuss and interact The child indicated that he enjoys talking about emotions actively (Light et al., 1985; Beukelman and Light, 2020). in the storybook reading activity “a lot” and that he learned After the training session, a considerable improvement something new about emotions: “(I learned) to ask questions like in the child and mother’s utterances and communicative Frontiers in Psychology | www.frontiersin.org 17 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations patterns was observed. The mother’s prompts to encourage in the present study allows intensive research, being inversely the child’s involvement in conversations about emotions, as related to the extensiveness required by other methodologies. well as the proper culturally sensitive AAC system design, Moreover, single case studies are the best path to follow facilitated the child’s active participation during the storybook- when the topic to be studied is emerging (Swanborn, 2010). reading activity. The availability of emotion-related vocabulary The analysis used illustrates a novel approach for conducting contributed to the child’s ability to sustain and start conversations single case studies in the field of communication (including about emotions. The behavioral patterns obtained permitted AAC), psychology, and education. Polar coordinate analysis analyzing the communicative change over time between and lag sequential analysis provide an innovative way to mother–child emotional conversations. Maintaining the model the conversational pathways that change over time after mother’s prompting to foster emotional talk helped increase an intervention in everyday contexts. These analyses offer the child’s conversational contributions substantially in terms information on the relationship and sequences between behaviors of making spontaneous comments rather than just responding that cannot be understood through other conventional analyses, to questions, asking questions about emotion-related events such as those that measure the frequency of appearance of a to others, and talking about himself rather than only the target behavior. storybook’s characters. Further research is needed to continue validating the The analysis carried out allowed for the identification of intervention and involving more children with CCN, from what types of the mother’s behavior encourage or inhibit different socio-cultural backgrounds and linguistic levels. particular behaviors by the child. For example, it was noticeable Additional work is warranted to identify the generalization of how the conversational sequence and relationship with the the emotion conversational abilities obtained in other settings child’s behavior changed during the program phases around outside the storybook-reading activity. The mother commented the mother’s emotional comments. Even though the mother they had conversations about emotion-related events outside made emotional comments during the exploratory phase, the storybook-reading sessions, where the child accessed his the child did not show any conversational response. In AAC emotional communication pages to discuss specific contrast, in the following phases, when she commented about events. Further studies are relevant to adapt the program in emotions, concurrently with modeling the use of AAC, the other contexts, such as including both parents, siblings, or child showed interactive behaviors that were significantly group settings (e.g., at school, group therapy); and in other connected to that mother’s prompt. These findings are activities, such as role-playing, watching movies or series, consistent with the literature that highlights the importance playing games, etc. of supporting communication partners in providing models To sum up, significant communicative changes between the and opportunities, deliberately, to foster interaction and mother and child occurred in the interaction when the mother development of emotional and communicative competencies encouraged opportunities to discuss emotions in a storybook- in individuals with CCN (Biggs et al., 2018; O’Neill et al., 2018; reading activity. The present findings support the promising Wilkinson et al., 2021). outlook of providing interactive home learning environments The present case study sheds light on the promising to foster emotional talk in children with CCN who may efficacy of supporting communication partners online in benefit from AAC. creating interactive learning environments at home to encourage emotional and communication skills to discuss emotions, while respecting the family conditions and cultural background. At DATA AVAILABILITY STATEMENT the beginning of the program, the mother expressed some concerns about engaging in the intervention due to specific The datasets generated for this study are available on request to family situations and difficulties in having the time to make the corresponding author. the activity and record it. Despite the family time barriers to engaging in the program within a brief period [e.g., less than 3 months as in Na and Wilkinson (2018)’s multiple-baseline ETHICS STATEMENT research design], the intervention still showed positive results. The study was reviewed and approved by the Ethics Committee Sometimes, family effective engagement in interventions may of the Universitat Autónoma de Barcelona. Written informed be hindered by logistical barriers like parents’ work schedules consent to participate in this study was provided by the (Brotman et al., 2011). Being flexible to the context and participants’ legal guardian/next of kin. understanding the child with CCN, family, and socio-cultural needs and interests are essential in creating appropriate and sensitive interventions that support children’s learning (Rangel- AUTHOR CONTRIBUTIONS Rodríguez et al., 2021). Systematic observation approaches provide the flexibility needed to studying natural settings GR-R documented, designed, developed the project, carried out and everyday life without losing rigor in the investigation the study, and wrote the manuscript. MB and SB made direct (Anguera et al., 2018). contributions to the work, revised the manuscript, and approved An evident drawback of the study was the limited number of it for publication. All the authors contributed to the article and participants. However, the observational methodology employed approved the submitted version. Frontiers in Psychology | www.frontiersin.org 18 July 2021 | Volume 12 | Article 674755 Rangel-Rodríguez et al. Children With CCN: Emotional Conversations FUNDING their suggestions and comments. Special thanks to the participants in this study. A research grant by the Mexican National Council of Science and Technology (CONACYT, reference: 692379-440601) to GR-R supported this study. SUPPLEMENTARY MATERIAL The Supplementary Material for this article can be found ACKNOWLEDGMENTS online at: https://www.frontiersin.org/articles/10.3389/fpsyg. 2021.674755/full#supplementary-material The present work has been carried out within the Supplementary Material 1 | STEPS Instruction Page (adapted). framework of the UAB-UB (Universitat Autònoma de Barcelona-Universitat de Barcelona) interuniversity Supplementary Material 2 | Example of AAC emotion-related boards. Doctorate in Psychology of Communication and Change. Supplementary Material 3 | Observation Instrument for interactions between The authors would like to thank Dr. Maria Teresa communication partners and children with CCN during a storybook-reading Anguera, Dr. Sarah Blackstone, and Jacob Rieker for activity (full version). REFERENCES Biggs, E. E., Carter, E. W., and Gilson, C. B. (2018). Systematic review of interventions involving aided AAC modeling for children with complex Allison, P. D., and Liker, J. K. (1982). 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