But I can't afford speech therapy!

As an SLP, I get asked questions about speech and language development time and time again from parents, friends and, many times, even strangers.  Unfortunately my advice tends to be the same regardless of situation:  when in doubt, get an assessment.  Often, I receive reluctance to follow through with this recommendation, but the truth is and assessment IS necessary. Allow me to explain.

Disorders and Delays are Complicated

Any speech, language, or even reading disorder/delay is highly complicated as there are number of underlying issues that could manifest itself as simple speech or language delays or the very ambiguous report of "difficulty with school work".  Unfortunately, I cannot diagnose your child or determine need for therapy services from a 10 minute conversation where symptoms are freely shared.  This is the reason comprehensive assessments are highly recommended as there is no other way to determine if a disorder or delay truly exists.

Response:

"But I don't have the money for this?" is often the response with the expectation that for some reason, I, or any other professional, should wave or discount our assessment/treatment fees.  Unfortunately, this cannot be done.  Allow me to further explain.

Comprehensive Assessments are Costly

A good comprehensive assessment of speech, language and literacy skills is costly for a number of reasons.  It takes time to assess all areas of communication (not just areas of concern) face-to-face with the child.  However, in addition to the assessment period or periods, depending on how long the assessment takes, time is spent scoring tests, analyzing the results, determining underlying deficits and writing the report.  A good comprehensive assessment, will not simply report test scores but will explain how those scores impact various communication areas.  The report will identify underlying disorders and diagnose the child appropriately.  This report, which takes several hours to write (even if a therapist uses a basic template they've created), will share clinical impressions and make recommendations which lend itself to the creation of an individualized treatment plan for your child.  This report is highly detailed and will provide much more to a parent than most medical reports, in which thousands of dollars are charged for very less time consuming procedures.

Response:

"Well maybe I'll just get a tutor. They aren't so expensive." is another fun response I tend to encounter.  It is of course, any parents right to decided what type of help they would like their children to receive but allow me to explain why a tutor won't close the gap for your child.

Closing the Gap, Takes Time AND Specialized Training

Here's the hard truth.  You get what you pay for.  If you pay a tutor, guess what you are going to get?  Tutoring.  That's it.  You'll get your child help with the subjects he/she is struggling with academically.  This will not close the gap because what your child requires is neurological development in the affected areas.  Only a trained professional knows how to facilitate neurological growth in these areas using evidenced based approaches.  Does a tutor know how to improve word retrieval skills so a student can retell a narrative in the classroom or for a book report?  Does a tutor know how to train compensatory strategies to aid in executive function skills to improve organization, initiation, and completion of academic tasks or projects?  Does a tutor know how to improve motor planning for correct production of speech sounds then teach the child how to use those speech sounds to blend and segment words in order to read and spell accurately?  The answer, I can assure you, is NO.  

So the next time you want to question the need for speech and language services, the next time you want to ask an SLP to discount their services, the next time you want to make an SLP feel as if their services are overrated, ask yourself:  Can my child afford to not get the right help?  Can my child go to college if he/she continues on this track?  Because I can assure you, if you do not get the correct treatment, anything else to try will be a band-aid and that wound, will only grow deeper and wider, affecting all areas of your child's development.  So...can your child afford that?

ASHA 2016: Executive Function Skills and Task Management

Anthony Bashir, Ph.D. and Bonnie Singer, Ph.D. presented on a simple way SLPs, teachers and other school staff can think about, document and support the five core executive function (EF) processes in the school setting.

Note: This blog post is not to replace the presentation of Drs. Bashir and Singer, but to simply share with you some of the information I found helpful and important for my own clinical practice.  If you would like hear Drs. Bashir and Singer speak on this subject at your school you can contact them here.

What is an executive function?  EF is a brain based process dedicated to: 1) inhibit an automatic response (or action), 2) plan (figuring out "the WHAT" to do), 3) organization ("the HOW" to do it), 4) hold those plans in one's working memory (WM), and 5) maintain self-regulation (of emotions, behavior, cognition, language and learning)

1. Inhibition

2. Planning

3. Organizing

4. Working Memory

5. Self-Regulation

Note: Although these skills all develop over time from birth through to mid-20s (as seen by myelin growth), they do NOT develop in sync (thus supporting that EFs are actually multiple separate functions rather than one large function as previously thought years ago).  Rather they develop differently over time.  Therefore it is imperative to determine which EFs will inhibit a student's success for individualized tasks in order to address them effectively.

Task Management:

In order to manage a task (either daily living or school/academic activity), we need to use BOTH our EFs AND Self-Regulation (SR) skills SIMULTANEOUSLY in order to achieve success.  Yet, what are the EFs and SR skills we need to manage and complete a task?  They are not as simple as one might think.

Task management with Core EFs + Self-Regulation skills= Academic Success!

But what do we do for children with poor self-regulation skills? We need to teach our students to do the following:

1. establish attainable goals to complete the task
2. choose and use effective strategies to reach the goal
3. self-monitor, evaluate, mediate one's performance with self-talk (positive)
4. maintain motivation (either with internal loci of control or external--outside help from SLP/staff)
5. seek support from other resources

When teaching our students effective self-talk, first we much know what type of self-talk they use.  Ask them "what's going on in your head right now?" or "what are you thinking?".  This will give you a glimpse of where they fall on the self-talk continuum.  We will likely have to spend much time on teaching our student's how to use positive self-talk in order to problem solve and reason through situations.  In fact, some children need to learn positive self-talk so they can initiate a project/task/activity.  The goal being that positive self-talk can assist them in initiating, maintaining and completing the realistic goal.

                                                         Self-Talk Continuum

<----------------------------------------------------------------------------------------------------------------------->

Negative                                                                                                                         Positive

Counter Productive                                                                                                      Facilitating

Bashir and Singer shared what I like to call three rules that should govern our thinking when working with children and adults with EF difficulties.

The Rule of Reciprocity:

The Rule of Rapid Deterioration:

The Rule of Demands vs. Capacities:

Stay tuned for the next post where I'll share with you a bit about Bashir and Singer's suggestions regarding treatment for children and adults with EF deficits.

Happy Talking!

ASHA 2016: Word Finding Difficulties: Assessment and Treatment

If you missed the first post explaining the 3 types of error patterns exhibited by adolescents and adults with word finding deficits based on Dr. Diane German's work, click here.  Today we will be addressing Dr. German's suggestions for assessment and treatment for these deficits.

Please keep in mind, this information is only a small portion of the information presented by Dr. German.  I highly recommend you look into her work on word finding deficits and if you have a chance to hear her speak, to do so as it will be worth your while.

Dr. German suggests you can use both formal and informal assessment measures to analyze error patterns.   If you are interested in a formal standardized test, you may want to look into the Test of Adolescent/Adult Word Finding-Second Edition (TAWF-2).

However, if you are also interested in informally assessing word finding skills Dr. German recommends analysis of the following:

1.  Target Word Comprehension:  does the child/adult understand the concept of the target word?  (comprehension can be demonstrated receptively or expressively by pointing or labeling pictures)

2.  Delayed Response Time:  any word retrieval that is >3 secs. is considered an error (regardless of whether the word retrieved was correct).

3.  Responsiveness to Phonological Cues:  determine if the child is responsive and can retrieve the word with a phonological cue (either initial sound or syllable).  If word is retrieved it is still considered in error but this information will provide diagnostic information regarding the type of error pattern that exists.

4.  Ability to Imitate Segmented Word:  if the child/adult could not retrieve the word but could imitate the word segmented into syllables, this suggests it is more likely a word finding deficit rather than a motor planning issue.

5.  Nature and Target of Substitutions:  nature of the substitutions used will lead you to determine the type of error pattern (EP) (e.g. semantic substitutions-EP 1,  withdrawal/refusal (IDK)-EP 2,  phonological substitution-EP 3).

6.  Manifestation of secondary characteristics:  determining if secondary characteristics exists and what types are used will help also determine the type of EP the child/adult exhibits.

Note:  Knowing the word finding EP exhibited will guide our treatment in the strategies we will use as well as the types of curriculum terms/words we will practice with out students.

Treatment:

Goal:  a)  help the child with automatic retrieval of curricular vocabulary, b) decrease word finding behaviors (to typical range ~19% of the time) using strategies.

Error Pattern 1:

Teach:  EF Strategies:  1) self-monitoring, 2) self-correcting, 3) strategic pauses (i.e. pauses before content words, before the noun in a noun phrase, before the object in a prepositional phrase, etc.)

Choose to target:  high frequency words, that are short and have more common phonological patterns or combinations, such as words with large word families (Dr. German labels them as words "in dense neighborhoods").  For example words like "fan, man, pan, Stan, can, tan" is considered a "dense neighborhood".

Error Pattern 2:

Teach:  1) word meaning and metalinguistic reinforcement (number of syllables in word, etc.), 2) phonological mnemonic cues, 3) rehearsal of targeted word in isolation, phrases, sentences and discourse

Phonological Mnemonic Cue:  you are going to allow the child to come up with a familiar phrase with the 1st syllable of the word being the phonological cue in order to recall the word.   Example provided during the presentation was a boy trying to recall the word "density" so he made a phonological mnemonic cue that meant something to him "Denver city".

Choose:  less frequent, less familiar words in "sparse neighborhoods" (less common phonological combinations or fewer number of members in a word family).

Error Pattern 3:

Teach:  1) metalinguistic reinforcement, 2) phonological mnemonic cue, 3) rehearse target word (isolation, phrase, sentence, discourse)

Example of phonological mnemonic cue:  for the word "paradox", the cue is "pair of socks".

Note: same techniques as EP 2 

Choose:  multisyllabic words, that have unfamiliar/atypical/infrequently used phonological patterns/sound combos, from "sparse neighborhoods".  

Remember: for any and all error types, the goal is always to teach the child which type or types (there can be a combination) of error patterns they use AS WELL AS their strategies.  The goal is not to eliminate word finding difficulties but to teach strategies so as to reduce these difficulties to those of typical peers (i.e. word finding deficits are exhibited ~19% of the time). For more information regarding this incidence, please refer to Dr. German's work.

Stay tuned for more posts from specific sessions I attended at ASHA 2016.  Remember, if you are looking for more posts regarding my ASHA16 experience, to look under the label "ASHA 2016" by scrolling down to the labels section on the right side of this page.

Happy Talking!

ASHA 2016: Word Finding Difficulties: 3 Error Patterns

This is the first official post recapping specific sessions I attended during the ASHA 2016 Convention.  You can access more posts labeled "ASHA 2016" under the labels section found in the right tool bar of this page (you'll need to scroll down) once they are published.

Diane German, Ph.D., presented a session on word-finding difficulties.  Just for a little background information for those of you unfamiliar with Dr. German, she’s a professor at National Louis University, Chicago and has done some wonderful work in the area of word-finding and word-retrieval deficits.  Her research has lead to the creation on the Test of Word-Finding-Third Edition (TWF-3) and just this year, the publication of the second edition of the Test of Adolescent/Adult Word-Finding-Second Edition (TAWF-2).  So to hear her speak was a great pleasure for me.  I recommend that you take advantage of hearing her if you ever get the chance.  What I will share will you in this and a follow up post is the basic information I took away from her presentation but it is far from everything she discussed.

Although I could never do justice to Dr. German's presentation, I will share with you the things I learned during her session and why they are important to me as a clinician.

What I learned from Dr. Diane German:

1.  Is word-finding deficit a language delay?:  Although Wallach (2008) was able to determine that word-finding deficits can co-occur with language deficits, Dr. German reports that they can also occur independently and that it’s extremely important to use in-depth assessment and error analysis to determine the types of word-finding difficulties present in order to treat effectively.  Keep in mind in-depth assessment is much MORE than picture naming.
2.   3 types of word-finding error patterns (EP) and Interventions: 

    Next post I'll share a bit about assessment and intervention Dr. German recommends for each error pattern type.

  

    Happy Talking!

The Big Picture: Top Three Things I Learned at ASHA 2016

I had the wonderful opportunity to attend the ASHA 2016 convention in Philadelphia, PA this year.  I had a great time meeting up with old friends from graduate school, making some new SLP friends and attending some really great sessions.  The thing I find the most interesting is seeing "the big picture".  I enjoy listening to speakers explain information from their area of expertise and research, of course, but what I find the most fascinating is the fact then when I take a step back, I can see how each session's information fits into the very big puzzle of that thing we all label as "communication".  Standing on the outside looking in, is so advantageous as we can see where links exist between each individual area and how these links support, aid, and assist other areas of communication.  With that concept of "big picture" in mind I'd like to share with you a list of some of my take-aways from this conference.

The top THREE things I learned at ASHA 2016:

1.  It's all about LANGUAGE:
     It doesn't matter WHAT the diagnosis is, the research is supporting our crucial role in language intervention as the KEY to unlocking so many other areas of language.  We all knew this right?  Well now we have the research to support it!  For example:

• Bashir, Gillam, Montgomery and Singer shared the NEED for more treatment targeting language comprehension for children with SLI who also exhibit WM (working memory) capacity limitations.  They explained how research is showing there is NO VIABLE way we can actually INCREASE one's working memory capacity, therefore our shift in treatment should be to make other skills automatic, which are currently using up a lot of working memory resources.  If we cannot increase a child's WM capacity, we can at least help the child master linguistic skills to the point of automaticity so as to free up WM to learn novel information.
• Katz and Fallon discussed how to we can effectively assess written language skills, and guess where they began?  Comprehension of both spoken and written language (a.k.a. reading).  To fully assess written language abilities we need to first know how the child understands spoken language and comprehends reading in order to determine how those skills relate to their verbal expression, both in oral expression and in writing.
• Mirasala, Jagla, and Knapp shared the invisible obstacles (impacts on behavioral, academic, social, executive function skills) adolescents with SLI experience and how they manifest as children get older.
• Camarata and Lancaster are asking us to reconceptualize SLI as a continuum rather than a specific entity due to the nature of the symptomology and numerous subtypes we currently see exist under this diagnosis.  Moving toward a continuum approach could completely change the way additional services in the school setting can be provided.  If we determine a spectrum of severity, would that not lend us to provide treatment and support according to severity level rather than simply diagnosis? 
• Diane German shared her research regarding the three types of word finding issues, their characteristics, and assessment and treatment.  Once we take note of which word finding subtype(s) the child demonstrates we can build our treatment around the effect techniques her research currently supports.
• Kahmi, Vermiglio and Wallach, shared their support for the need to understand the linguistic underpinnings that lie unearthed in many children diagnosed with (C)APD.  Their research suggests if we can adequately identify the underlying language issue, this population could be treated far more effectively and efficiently than current practices.
• Bashir and Singer (again?! I KNOW but they are great!) explained how improvement in language skills can effectively enhance the 5 core EFs (executive functions) students require for daily living and academic success.

      I'd love to go on and on but just looking at this list ALONE supports my new motto "It's all about the Language, 'bout the Language, no trouble"! (influenced of course by the lovely Meghan Trainor)

2.  Be META:

     I wonder if we, as SLPs, are so focused on trying to reach our goals (data=proof=progress...but does it? Hmmm.) and teach specific skills that we forget probably the most important part of language intervention, teaching our children strategies that will generalize to novel experiences, unfamiliar classroom assignments and new daily life situations.  There is empirical support for teaching our students to use language (internal-self talk, or external-self talk) to THINK about THINKING, to THINK about LANGUAGE for numerous populations (EF deficits, WM difficulties, SLI, ASD, anxiety, depression, etc.).  We call these skills metacognition and metalinguistics.  We not only see the use of metacognition and metaglinguistics skills improving executive function skills BUT there is also some evidence supporting the use of these skills to teach ToM (Theory of Mind), or now the newest "fancy schmancy" term I heard at the conference, ISL (Internal State Language...um...ok. Whatev's you know what I'm talking about either way) for children with ASD (Autism Spectrum Disorders).  In fact, I did attend an interesting discussion on ToM which reviewed a very small scale study (2 subject single case design comparison) which compared the use of repeated book reading as a method to facilitate ToM in a child with SLI and a child with ASD.  The findings suggested repeated book reading was a very good technique for the child with SLI, as the child improved in answering various types of ToM questions over time with repeated exposure.  The child with ASD, demonstrated more resistance and for some question types, even negative trends rather than improvements, based on this one study.  Of course we cannot throw out the baby with the bathwater here based on one study but it may help us to begin thinking about how important teaching and modeling metalinguistic and metacognitive skills can be for our ASD population with regards to ToM/ISL facilitation.   Interesting stuff, nonetheless.  So, don't forget to be meta and teach these very necessary skills to our students. 

3.  Success takes TIME and HARD WORK: 

     If you are an SLP with a huge caseload or a parent with a child struggling reading this, please understand that NONE of the improvements happen over night.  Many of the presenters expressed that these types of deficits and delays take a lot of time and hard work for the child to achieve success.  Note that I did not say "achieve remediation" or "achieve typical functioning", or "achieve all A's on their report card".  The idea of success for ANY of our students/clients should be synonymous with the terms "functional" and "independent" (to the degree they can be).  There is no magic cure, no pill, no computer program, no app, no one-size-fits-all technique that can ever substitute for hard work and individualized instruction.  So be patient with yourselves and with your students/clients.  See the real functional progress you are making, and be sure to get the most bang for your buck.  Use the strategies what will facilitate this "success" by giving the child the skills to use and generalize to other settings.  You know the old adage "Catch a fish, a man eats for a day.  Teach him to fish he eats for a lifetime."  So, let's teach our kids to fish!

Happy talking and fishing!

Progress Monitoring: Baselines and Beyond

The Frenzied SLPs are discussing data collection now that school is back in full swing!  Today I'll be sharing one way I like to take daily data quickly when I have a client with several goals in a 1:1 therapy setting.  If you'd like to see how I took data in the school setting click here.

Firstly, when working in private practice, I like to create a basic treatment plan, a course of action in which I would like to see progress.  Below is an example of a basic treatment plan.

Then I take the goal sheet and create a daily data sheet:
1.  I align the goal #s from the treatment plan to the goal sheet so I know which goals I am targeting without having to re-write them for each session.
2.  I can simply take data only on the goals I target each session.
3.  I also add a place for additional notes.
4.  I would typically hand write on this form, rather than type.  So if I would need additional lines for notes, I would simply continue to the next like and so on until I finished the note.  Then simply add the date of the next session on the next fully clear line.

And that's it!  I can use one sheet of paper for numerous therapy sessions without having to write re-write goals or other excessive information.

How about you?  Do you have a quick data collection system too?  Feel free to share!

Happy Talking!

An InLinkz Link-up

Colleague Question #1: ASD client swallows pool water. What do I do?

Often times, I will receive questions from colleagues via email or FB private messages regarding specific cases they are dealing with.  I tend to shoot back an email but I have been thinking lately that it might help to share these responses with you too.  Maybe they will help or maybe they will spurn a few additional great ideas from you that you can share with your fellow colleagues.  So here is the first post in this "Colleague Question" series.

A fellow colleague writes:

"I have a client with ASD and SPD...he loves swimming but can't stop swallowing the pool water. He also struggles with swallowing instead of spitting during teeth brushing.  His parents have suspended his swimming lessons even though he so enjoys them because he can become ill from all the water he takes in...Any suggestions?"

Some of you reading this question may be asking yourselves "What does this have to do with speech therapy or communication?", yet, the reality is, as SLPs, we may be the only service provider for some children and therefore, the only source of guidance and education for parents.  It's important for us to fully understand sensory needs in our ASD population and how we can assist parents in providing effectively for those needs.

For this particular case, let me first say that it is important to keep safety at the forefront of decision making for our clients so I can understand why the child's parents would suspend swimming lessons at this time. However, for children who have sensory needs it is almost painful for me to hear a child not being able to participate in such an enjoyed activity.  I'm sure swimming provides some wonderful sensory input as well as a wonderful social opportunity for this child and my hope would be to find a way to get this child back to swimming lessons as soon as possible.  As this is a safety issue, we cannot encourage this behavior even if it provides some sensory feedback for the child.  What I would suggest is possibly finding a way to appropriately replace this behavior with something safer that the child can do in the water while still providing some type of sensory input.

An acceptable compromise would be to try and replace drinking the pool water with blowing bubbles with lip trill (sounding like a "motor boat") or humming with child's lips sealed while in the water (nose and eyes above water).   Either of these options will still provide sensory input to the child's face but will encourage water to be blown away from lips, or in the case of "humming", total lip closure.  These activities can be practiced at home during bath time so that the child can master one or both of these replacement behaviors initially, then transferred to practicing them in the pool during non-lesson times first, following by adding them during swimming lessons.

To aid in decreasing swallowing of saliva during teeth brushing, it might help child to have a visual goal to encourage a replacement behavior.  Possibly parents can teach the child to spit often (every few brush strokes) into a small disposable bathroom cup.  They could make a game out of it by brushing their teeth together with the child, modeling how to brush and spit often.  Parents and child can each have their own cup in which they draw a large line on the outside of cup indicating a stopping point.  Whomever fills up the cup to that line first wins the game.  This encourages spitting often while making this activity, hopefully a bit reinforcing, creating excitement and fun!  Of course it doesn't sound very appealing to be spitting into a cup and having to look at it for us as adults, but the visual may provide the child with a concrete goal so that he can learn how to spit rather than swallow during teeth brushing.  Over time this activity can be modified to see who can spit in the sink a certain number of times, and so on, so that the cup gets faded out and typical teeth brushing remains.

I hope these suggestions help.  Have any suggestions of your own you'd like to add?  Feel free to comment below.

Look for more posts in this new series to come over the next few weeks.  If you have a specific question you'd like answered feel free to email me at communicationstationspeechtx@gmail.com.  You just might see your question pop up in this series.  (Note: all identifiable information will remain confidential.)

Happy talking and swimming this summer!