The 200-Mile Drive

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This is our “thinkaboutable” blog, but I find that when I post, I’m usually trying to present fully explored, finished ideas. In this post I’m going to try putting out a barely sketched, unpolished hypothesis, and see where it goes.
My husband and I were driving home from northern Minnesota a couple of weekends ago, on a route that we take many times a year. It’s a 200-mile drive, and we were somewhere near the towns of Cotton and Canyon when I realized that I only had a vague guess of what landmark was coming up next.

It made me wonder, what is it like to have extreme difficulty following a “simple” routine like preparing a snack, washing your hands, or playing a board game? This is the case for some people with autism. Does it feel like being on a 200-mile drive, and even though each landmark is somewhat familiar, it’s just hard to remember what’s coming up next?

What is the difference, for me, between the 200-mile drive and a routine like washing my hands?

- Repetition. I wash my hands more often than I take the drive.
- Length. Washing my hands happens faster than the drive.
- Complexity. Washing my hands requires coordinating 5 things: water, soap, scrubbing, rinsing, and drying. The drive has hundreds of landmarks, like towns’ names, billboards, restaurants, rivers, roads, and freeway exits.
- Engagement. When I’m washing my hands, I’m in charge of the task, but when I take the drive, I only really have to remember about four different roads. The rest of the landmarks just pass by the window as I drive in a straight line.
- Logic. The steps to washing my hands feels meaningful. I know the reason why I do each step in a certain order. But the landmarks on the drive are in an arbitrary order. The Laurentian Divide just happens to be north of Cotton and Canyon. ...or is it south?

So for someone who has autism and also has extreme difficulty learning a new activity, does washing your hands feel just like that 200 mile drive? Not repetitive enough to memorize? So long and drawn out that it’s hard to remember the beginning by the time you get to the end? Infinitely complex? Unengaging, like it’s just passing by the window? Not meaningful? And if it does feel that way, what can we do to best support learning?

That is the end of my musing for now, but Hannah read a draft of this post and the idea in her response fascinated me, so I wanted to share it as well:

 

"Do you think it is harder or easier for kids to learn routine actions if there are minor changes in the context in which it occurs?  It seems reasonable to state that for kids whose attention may become acutely focused on certain components of a physical space (e.g., the pump on a soap dispenser-- which may vary according to context), the landmarks are continually changing and/or vary in how remarkable they are to the kid and therefore, contextual changes become that much harder (and maybe don't outweigh the potential benefits of theoretically easier/faster generalization)."

Summing Up Summer

As the summer comes to end and I look forward to the new academic year, I would like to consider the past few months.  Over the summer, I worked on balancing research and clinical practice. I will be the first to state that it was not easy. However, it was not because these two arts are particularly different from one another. 

I realize that as a clinician, I often think like a scientist. I test hypotheses about how a specific approach may work for a client.  As a scientist, my best (read: most interesting, not necessarily most executable) questions are informed by my clinical experiences. This works for me because I am interested in both ways of engaging in our field. I wonder though, how can clinicians and researchers better speak the same language? Or at least see that although their daily practices are quite distinct, the critical thinking they do is quite similar. Would this get clinicians more invested in research (a noble task)?

The intersection between research and clinical practice is critical. As I consider these two arenas, I realize though, that intersection is perhaps a misnomer. An intersection is a static, clearly defined space. However, I think the basic and applied research that drives Speech-Language-Hearing Sciences (as a field) and the daily practice of speech and language pathology interact dynamically in a space that includes education, psychology, social work, and other rehabilitative sciences. I am excited to keep thinking in this space and hope to find others who inhabit it.

Hypotheses about language disorder classification

As Hannah and I talked today about some of the speech and language disorders that we have observed over the years, a particular point really caught my interest.  Morphosyntax disorders (a subset of expressive language disorders) can manifest so differently in different children.  We talked about some children we have known who had very similar language disorder presentations as one another, and other children, who also have language disorders but who seem share a different set of symptoms.

I'm writing this post in order to sort out my thoughts and hypothesize about some different classifications of morphosyntax disorders. I'll stick with describing children at about age four for ease of comparison.

Language disorder hypothesis: "Quiet Type"

At age four, these children play quietly. They have a short mean length of utterance (MLU) and low lexical variety (Type-Token Ratio; TTR). When they make grammatical mistakes they seem to be shortening and simplifying adult forms. Gestures and sound-effects replace some words when they are trying to get an important idea across even though they don't have the right word. When these children receive speech and language therapy, they are slow to learn specific conceptual or grammatical language targets, but they do make progress in overall communication.

Language disorder hypothesis: "Unmonitored Type"

At age four, these children are very talkative. They talk quickly and assume that you can understand them, even though you are having difficulty following their conversation. They have a typical MLU and typical lexical variety, but they make many grammatical deletions and substitutions that follow their idiosyncratic rules consistently. When these children receive speech and language therapy, they are quick to learn how to produce standard grammatical forms in structured activities, but have difficulty producing newly learned forms in conversation. When you point out an error, they sometimes know how to fix it, but at age four, they do not yet self-monitor or self-correct.

Language disorder hypothesis: "Memorizing Type"

I've talked about these children before in the post, Receptive Language Disorders and Memorization.  At age four, these children love to recite scripts to themselves, and sometimes to other people.  Their MLU is longer when you take into account their scripts, and shorter when you only measure creative utterances.  Similarly, their grammar is more complex in their scripts, and less complex in their creative utterances.  If they don't know what words or grammar to use, they use jargon to create their desired intonation patterns.  They use few communicative gestures, although they often use scripted gestures to act out a memorized scene.  When these children receive speech and language therapy, they are highly motivated to participate in language routines, but seem to get lost when you talk using regular child-directed language, because it is not predictable enough.

These three categories don't capture every morphosyntax disorder.  This is the first time I have tried to put this idea down on paper, so I know there are more types than just these three and the descriptions within these categories are just preliminary.  I'll be thinking about this more.

(positive) Negative Findings

In the July, 2012 issue of Language, Speech, and Hearing Services in the Schools, there was a letter from the editor (Marilyn Nippold) titled, The Power of Negative Findings. This summer, I have been trying to focus my reading toward articles about early communicative development, more specifically gesture development in children with autism. But Nippold’s article caught my attention.

It is not a particularly lengthy article (and even if it was, I would still recommend investing the time in it). You can read it, or not. At first take, it seems as though, Nippold’s main audience is not clinicians, but rather researchers. This makes sense as she forms her argument for the importance of publishing negative findings (e.g., results of an intervention study that imply the particular treatment was not successful). As Nippold suggests, this allows us to further the science that drives our intervention practices.

As I think about it, this idea is also really important for clinicians. I think we consider negative results in the sense that we try a particular therapy technique, obtain data on how successful the kid is, and if it is not working, we know to move on to something else. This seems like one great way to think about an unsuccessful session (or series of sessions). When we find certain techniques or strategies or reinforcers that do not work, I think we are more closely approximating what will be successful. That feels positive to me.

This post reminds me of an earlier post. In it, I thought about the idea that we can use failure to get better at our chosen pursuit. I guess sometimes I need to be reminded that there is something in the negative space and in order to find it, I may have to shift my perspective just a bit. In doing this, I think I am becoming a stronger clinician and learning how to be a better researcher.

Receptive Language Disorders and Memorization

I recently wrote a post about supporting the receptive language of children who have language disorders. The last two ideas in that post are specific to a subset of children with language disorders that I find especially compelling: children who can readily memorize and recite lines from picture books and movies, but have significant difficulty with everyday language when they are trying to listen or express themselves.

Do you know these children? You hear them reciting memorized language (both at expected and unexpected times). When they are happy, they may walk around reciting their favorite show. When you ask them a question, they may not answer, but recite their favorite show instead. And when they are stressed, they might pull away from your interaction and...recite their favorite show. Their intonation is usually right on, although their articulation of speech sounds is sometimes unintelligible. Many are diagnosed with autism. You might call what they are doing "scripting," or "delayed echolalia," and you may have felt the way I once did - like it was a big problem. A loud, distracting, exhausting, inappropriate, unstoppable problem. A hindrance to social communication and interaction.

But I like to reframe things, and in my practice I have reframed the recitation of memorized language as a usable, available, robust, functional, unstoppable skill. What an amazing skill these children have! Memorizing whole episodes of TV shows and picture books, and reciting them with great intonation...these children have a fascination and enthusiasm for language that I love to see. The memorization skill makes this group of children highly motivated to pay attention to language that is repeated the same way each time. It makes them highly motivated to participate in language routines. They listen to and process intonation cues. Language is a source of pleasure for them, and they love to make an effort to recite things correctly.

The bold words in the above paragraph do are not generally used to describe people with autism and language disorders, but there they are. When we tailor our language output for these children who love to memorize and are often on the autism spectrum, we may gain the chance to communicate and socially interact with them in a way that helps them pay attention, participate, listen, process, and take pleasure in making an effort to be correct. Who could ask for anything more in a language learner?

Supporting Families and Saying Goodbye

 Alaina’s recent post about supporting receptive language got me thinking about all the different ways we support language and communication for our clients. Specifically, I started thinking about different ways in which we support families. Clinicians are educators as we teach a family about communication and language. We are listeners as we consider a family’s specific needs, cultural and linguistic background, and preferred style of interacting with us as professionals. We are also advocates as we collaborate with other professionals to best support our client’s readiness to learn.

I have supported families as they are discharged from therapy many times but I have not really considered how we best support them through this process. It seems reasonable to state that having a child with a communication disorder may be a very emotional experience. For those clinicians who may be interested, David M. Luterman’s Counseling Persons with Communication Disorders and their Families, is a nice reference. As I write and think, I can see how it would be difficult for a family to be done with therapy (and thus, perhaps, why they may require a different kind of support). I want to help families focus on the positives (e.g., celebrating their child’s success) and look forward to the extra time and resources that they will no longer be putting into therapy.

As I consider ways to support a family as they transition out of therapy, here are some strategies I am practicing:

1. Consider scheduling a time for a bigger conversation, one that is set apart from the child’s regular therapy time.
2. Ask parents to talk about their child’s communication. It seems likely they will reference how much progress the child has made which will be helpful as they begin to consider being discharged.
3. Use different media to celebrate the child’s success, and to remind parents how far a child has come.
3. Organize information about the child’s progress and current level of performance in a few different ways. Some parents may appreciate tables with standard scores, percentile ranks etc. This may not be as meaningful or helpful to other parents. Providing some written narration about the child’s progress could also be helpful.
4. Find a balance between listening to the parent while still being the expert. (This one is difficult for me!) We know parents are the expert on their child, but as clinicians we are the expert with respect to communication and language.
5. Provide tips for parents for ways they can continue to support their child’s communication at home and in the community.

What strategies do you find helpful for families as they transition out of therapy?

Five Receptive Language Supports

As I was thinking about how to start this post, I considered Hannah's recent post about how Speech & Language Pathologists (SLPs) search the internet for information. Since I'm writing this post about how to support children who have a severe receptive language disorder, I'm guessing that this post might come up for SLPs who are doing searches for "receptive language disorder" or "receptive language goals" as they are writing their students' IEPs or their patients'/clients' plans of care. However, this post doesn't have goal ideas as much as ideas about the support that we, as communication partners, can give as we are communicating during our therapy sessions.

Receptive language disorders can make it hard for children to pay attention. What would it be like to have a receptive language disorder? It is impossible, as an outsider, to know what that experience is like, but second-language learning might be a good simulation. When I spend time listening to people speak in Spanish, a language in which I am proficient, it becomes very clear why someone with decreased receptive language skill would lose focus after a while and want to take breaks to do something easier. I know that as I take part in a Spanish-language conversation, it becomes almost painful as the conversation continues and I try to maintain comprehension.

A supportive Spanish-speaking partner goes a long way to help me participate in conversation, so I can empathize with why support is so helpful to children with receptive language disorders, too. One way that I structure speech and language goals is to include a phrase like "...with moderate support." I don't conceive of this support as a process of giving hints that lead the child to an answer that I have deemed correct. Rather, I look at support as a way to diminish the communication barrier so that a child can take part in a natural process of communicating and making connections. Here are five ideas for what this support, whether it's "mild," "moderate," or "maximal," might look like.

Five Supports for a Child with a Receptive Language Disorder

1. Slowing down and pausing to allow processing time.

2. Writing while speaking, and giving the child the opportunity to practice reading/repeating each sentence that you have written. This support is potentially appropriate for any children interested in written words, even if they do not yet read. Writing while speaking serves to slow the adult waaaay down, and gives the child visual indication of word boundaries.

3. Acting out, drawing, or showing pictures while speaking.

4. Repeating the exact same sentence (same words, word-order, and intonation) multiple times.

5. Using language that the child has already learned through her interests (the sentences she can recite from her favorite TV shows, movies, and books, modified to fit the context).