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).

Searching

It seems reasonable to state that Speech & Language Pathologists who use the Internet as a resource are likely to encounter loads (a very technical word) of information. I was curious about general search terms, so I recently did a quick search. “Speech and language goals” revealed 2,790,000 results. “Articulation goals” revealed 6,720,000 results. SLPs may also search for activities targeted toward specific age groups (e.g., “preschool”) or themes (e.g., “dinosaurs”). Combining these two terms (“preschool + dinosaurs”) reveals 2,630,000 results. One could imagine pairing many different age groups with many different themes/ideas to yield even more results.

Given the quantity of information available, I am curious about how SLPs select resources. Do they return to websites because activities from those sites have been interesting to kids? Do they return to websites because the resources are free? What information do SLPs find when they search for activities to target goals that are commonly addressed? Are there better ways for SLPs to share information?

Asking Questions and Listening to Answers

I'm still thinking about Reggio Emilia, and using a Reggio-Inspired approach when teaching children. This isn't an approach that I have ever heard Speech & Language Pathologists (SLPs) discussing, but Reggio Emilia is an educational approach that values learning through thoughtful contemplation, conversation, and translation of ideas. Children learning from a Reggio-inspired teacher might translate their ideas from conversation, to drawing, to sculpting, to dancing, to writing. Translating ideas like this make the ideas come alive in many different ways. So, even though SLPs aren't currently using Reggio Emilia, it feels appropriate to attempt to translate its ideas into my own SLP language.

Today I have been thinking about the questions I can ask the kids I work with, in order to inspire them to reach their speech or language goals using thoughtful contemplation, conversation and translation of their ideas. Of course, the act of asking kids questions is a commonly used method of teaching. For example, I hear adults ask kids:

- "What color is this?"
- "Is whispering loud or quiet?"
- "What should you do when you have a problem? Should you give up or ask someone for help?"
- "Can anyone think of what you should say when you meet someone for the first time?"

But with this type of question, in the adult's mind and in the child's mind, there is going to be a right answer and a wrong answer. The adult knows what the right answer is, and the child hopes to get it right. I wouldn't call this thoughtful contemplation, an invitation for conversation, or a chance to translate ideas. I think a more apt term for this type of question is a test, or a chance to practice recalling previously learned information.

So I am trying to come up with some examples of question-types that might serve a more thoughtful purpose:

- "Can we find things that are as green as this bug?"
- "Is anything quieter than a whisper?"
- "What kinds of things might help you get that to open?
- "What will happen if you go up to her and say, 'honk honk honk?'"

Of course, if you ask this set of questions with a "right answer" in mind, they could end up being just like the "test" questions in the first section above. So if the goal is a Reggio-Inspired approach, there is much more to do than just changing what you are asking. But it's an interesting place to start wondering about what type of conversational interactions serve the purposes you want them to serve.

A second step that is coming to mind is to accept the child's answer to a question like this as a hypothesis, and then invite the child to test their hypothesis. So perhaps the adult's response to a child's answer to a question is just as key: Instead of a "yes," or a "no," or an "actually," how about a response like, "Let's try it out," or, "Which idea do you want to try first?" or "Would you like to use these markers to draw a picture of that idea?"

So do these question-types serve a more thoughtful purpose? It's a hypothesis that I'm enjoying testing.

Try, try again.

If you have read our past few blog entries, you know that Alaina and I attempted another 'conversation' format.  However, as we wrote, neither one of us had been particularly jazzed about adding to the conversation (as indexed by the lack of content/progression of the idea).  Instead of pushing through the series, we discussed why it was not working.

We considered that perhaps the format does not work for all topics, or perhaps the format does not work given our current preferences for adding content to the blog.  Perhaps it did not work for another reason.  This small failure  (although I hesitate to label it a failure) reminded me of a piece of commentary I recently read (see Next Time, Fail Better by Paula M. Krebs).  For me, the article highlighted how difficult it is to value failure.  Specifically, Krebs discusses how some fields (i.e., computer science) lend themselves to repeated failure; failure is expected and is an integral part of the process of getting something right.  But for some, as  Krebs explains, failing can be humiliating and this may be because they have not learned to focus on the process. They have not learned to use the failure to be better in their chosen pursuit.    Krebs goes on to to describe how professors should teach this. I am still considering whether or not this can be explicitly taught or if there just needs to be room for multiple attempts as one approximates a goal (and THAT should be explicit).

As a Speech & Language Pathologist, I am still learning that I may not choose the right approach for a specific client the first time.  I may incorrectly assess a behavior pattern.  I may be too technical or too hurried in a conversation with a parent.  Through the experience of these small failures, I am able to reflect and refine my clinical skill set.   I guess I could say I am getting better. . . at failing.

A Quick Think About Being a Speech & Language Pathologist Part 3

Hannah: I think ideally I would want to capture the breadth of speech & language pathology but still make sure I have the opportunity to speak specifically about at least one population or one area in which I am developing my clinical expertise. That second part is important to me because it seems it would be a point for authentic advocacy. Time is a mitigating factor, at least in the context of the situation we are discussing. So, I wonder if it is better to spend the (short) amount of time speaking more generally? This would perhaps allow the greatest potential for connecting with your interlocutor based on their experience. Or perhaps providing a specific example . . .