Category: Executive Function

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Have I Got This Right? Developing Self-Questioning to Improve Metacognitive and Metalinguistic Skills

Image result for ambiguousMany of my students with Developmental Language Disorders (DLD) lack insight and have poorly developed metalinguistic (the ability to think about and discuss language) and metacognitive (think about and reflect upon own thinking) skills. This, of course, creates a significant challenge for them in both social and academic settings. Not only do they have a poorly developed inner dialogue for critical thinking purposes but they also because they present with significant self-monitoring and self-correcting challenges during speaking and reading tasks. Continue reading Have I Got This Right? Developing Self-Questioning to Improve Metacognitive and Metalinguistic Skills

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Improving Executive Function Skills of Language Impaired Students with Hedbanz

Those of you who have previously read my blog know that I rarely use children’s games to address language goals.  However, over the summer I have been working on improving executive function abilities (EFs) of some of the language impaired students on my caseload. As such, I found select children’s games to be highly beneficial for improving language-based executive function abilities.

For those of you who are only vaguely familiar with this concept, executive functions are higher level cognitive processes involved in the inhibition of thought, action, and emotion, which located in the prefrontal cortex of the frontal lobe of the brain. The development of executive functions begins in early infancy; but it can be easily disrupted by a number of adverse environmental and organic experiences (e.g., psychosocial deprivation, trauma).  Furthermore, research in this area indicates that the children with language impairments present with executive function weaknesses which require remediation.

EF components include working memory, inhibitory control, planning, and set-shifting.

  • Working memory
    • Ability to store and manipulate information in mind over brief periods of time
  • Inhibitory control
    • Suppressing responses that are not relevant to the task
  • Set-shifting
    • Ability to shift behavior in response to changes in tasks or environment

Simply put, EFs contribute to the child’s ability to sustain attention, ignore distractions, and succeed in academic settings. By now some of you must be wondering: “So what does Hedbanz have to do with any of it?”

Well, Hedbanz is a quick-paced multiplayer  (2-6 people) game of “What Am I?” for children ages 7 and up.  Players get 3 chips and wear a “picture card” in their headband. They need to ask questions in rapid succession to figure out what they are. “Am I fruit?” “Am I a dessert?” “Am I sports equipment?” When they figure it out, they get rid of a chip. The first player to get rid of all three chips wins.

The game sounds deceptively simple. Yet if any SLPs or parents have ever played that game with their language impaired students/children as they would be quick to note how extraordinarily difficult it is for the children to figure out what their card is. Interestingly, in my clinical experience, I’ve noticed that it’s not just moderately language impaired children who present with difficulty playing this game. Even my bright, average intelligence teens, who have passed vocabulary and semantic flexibility testing (such as the WORD Test 2-Adolescent or the  Vocabulary Awareness subtest of the Test of Integrated Language and Literacy ) significantly struggle with their language organization when playing this game.

So what makes Hedbanz so challenging for language impaired students? Primarily, it’s the involvement and coordination of the multiple executive functions during the game. In order to play Hedbanz effectively and effortlessly, the following EF involvement is needed:

  • Task Initiation
    • Students with executive function impairments will often “freeze up” and as a result may have difficulty initiating the asking of questions in the game because many will not know what kind of questions to ask, even after extensive explanations and elaborations by the therapist.
  • Organization
    • Students with executive function impairments will present with difficulty organizing their questions by meaningful categories and as a result will frequently lose their track of thought in the game.
  • Working Memory
    • This executive function requires the student to keep key information in mind as well as keep track of whatever questions they have already asked.
  • Flexible Thinking
    • This executive function requires the student to consider a situation from multiple angles in order to figure out the quickest and most effective way of arriving at a solution. During the game, students may present with difficulty flexibly generating enough organizational categories in order to be effective participants.
  • Impulse Control
    • Many students with difficulties in this area may blurt out an inappropriate category or in an appropriate question without thinking it through first.
      • They may also present with difficulty set-shifting. To illustrate, one of my 13-year-old students with ASD, kept repeating the same question when it was his turn, despite the fact that he was informed by myself as well as other players of the answer previously.
  • Emotional Control
    • This executive function will help students with keeping their emotions in check when the game becomes too frustrating. Many students of difficulties in this area will begin reacting behaviorally when things don’t go their way and they are unable to figure out what their card is quickly enough. As a result, they may have difficulty mentally regrouping and reorganizing their questions when something goes wrong in the game.
  • Self-Monitoring
    • This executive function allows the students to figure out how well or how poorly they are doing in the game. Students with poor insight into own abilities may present with difficulty understanding that they are doing poorly and may require explicit instruction in order to change their question types.
  • Planning and Prioritizing
    • Students with poor abilities in this area will present with difficulty prioritizing their questions during the game.

Consequently, all of the above executive functions can be addressed via language-based goals.  However, before I cover that, I’d like to review some of my session procedures first.

Typically, long before game initiation, I use the cards from the game to prep the students by teaching them how to categorize and classify presented information so they effectively and efficiently play the game.

Rather than using the “tip cards”, I explain to the students how to categorize information effectively.

This, in turn, becomes a great opportunity for teaching students relevant vocabulary words, which can be extended far beyond playing the game.

I begin the session by explaining to the students that pretty much everything can be roughly divided into two categories animate (living) or inanimate (nonliving) things. I explain that humans, animals, as well as plants belong to the category of living things, while everything else belongs to the category of inanimate objects. I further divide the category of inanimate things into naturally existing and man-made items. I explain to the students that the naturally existing category includes bodies of water, landmarks, as well as things in space (moon, stars, sky, sun, etc.). In contrast, things constructed in factories or made by people would be example of man-made objects (e.g., building, aircraft, etc.)

When I’m confident that the students understand my general explanations, we move on to discuss further refinement of these broad categories. If a student determines that their card belongs to the category of living things, we discuss how from there the student can further determine whether they are an animal, a plant, or a human. If a student determined that their card belongs to the animal category, we discuss how we can narrow down the options of figuring out what animal is depicted on their card by asking questions regarding their habitat (“Am I a jungle animal?”), and classification (“Am I a reptile?”). From there, discussion of attributes prominently comes into play. We discuss shapes, sizes, colors, accessories, etc., until the student is able to confidently figure out which animal is depicted on their card.

In contrast, if the student’s card belongs to the inanimate category of man-made objects, we further subcategorize the information by the object’s location (“Am I found outside or inside?”; “Am I found in ___ room of the house?”, etc.), utility (“Can I be used for ___?”), as well as attributes (e.g., size, shape, color, etc.)

Thus, in addition to improving the students’ semantic flexibility skills (production of definitions, synonyms, attributes, etc.) the game teaches the students to organize and compartmentalize information in order to effectively and efficiently arrive at a conclusion in the most time expedient fashion.

Now, we are ready to discuss what type of EF language-based goals, SLPs can target by simply playing this game.

1. Initiation: Student will initiate questioning during an activity in __ number of instances per 30-minute session given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

2. Planning: Given a specific routine, student will verbally state the order of steps needed to complete it with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

3. Working Memory: Student will repeat clinician provided verbal instructions pertaining to the presented activity, prior to its initiation, with 80% accuracy  given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

4. Flexible Thinking: Following a training by the clinician, student will generate at least __ questions needed for task completion (e.g., winning the game) with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

5. Organization: Student will use predetermined written/visual cues during an activity to assist self with organization of information (e.g., questions to ask) with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

6. Impulse Control: During the presented activity the student will curb blurting out inappropriate responses (by silently counting to 3 prior to providing his response) in __ number of instances per 30 minute session given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

7. Emotional Control: When upset, student will verbalize his/her frustration (vs. behavioral activing out) in __ number of instances per 30 minute session given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

8. Self-Monitoring:  Following the completion of an activity (e.g., game) student will provide insight into own strengths and weaknesses during the activity (recap) by verbally naming the instances in which s/he did well, and instances in which s/he struggled with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

There you have it. This one simple game doesn’t just target a plethora of typical expressive language goals. It can effectively target and improve language-based executive function goals as well. Considering the fact that it sells for approximately $12 on Amazon.com, that’s a pretty useful therapy material to have in one’s clinical tool repertoire. For fancier versions, clinicians can use “Jeepers Peepers” photo card sets sold by Super Duper Inc. Strapped for cash, due to highly limited budget? You can find plenty of free materials online if you simply input “Hedbanz cards” in your search query on Google. So have a little fun in therapy, while your students learn something valuable in the process and play Hedbanz today!

Related Smart Speech Therapy Resources:

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Assessing Behaviorally Impaired Students: Why Background History Matters!

As a speech language pathologist (SLP) who works in an outpatient psychiatric school-based setting, I frequently review incoming students previous speech language evaluation reports.  There are a number of trends I see in these reports which I have written about in the past as well as planned on writing about in the future.

For example, in the past I wrote about my concern regarding the lack of adequate or even cursory social communication assessments for students with documented psychiatric impairments and emotional behavioral deficits.

This leads many professionals to do the following: 

a. Miss vital assessment elements which denies students appropriate school based services and

b. Assume that the displayed behavioral challenges are mere results of misbehaving. 

Today however I wanted express my thoughts regarding another disturbing trend I see in numerous incoming speech-language reports in both outpatient school/hospital setting as well as in private practice  – and that is lack of background information in the students assessment reports.

Despite its key role in assessment, this section is frequently left bare. Most of the time it contains only the information regarding the students age and grade levels as well as the reasons for the referral (e.g., initial evaluation, triennial evaluation).  Some of the better reports will include cursory mention of the student’s developmental milestones but most of the time information will be sorely lacking.

Clearly this problem is not just prevalent in my incoming assessment reports. I frequently see manifestations of it in a variety of speech pathology related social media forums such as Facebook. Someone will pose a question regarding how to distinguish a _____ from ____ (e.g., language difference vs. language disorder, behavioral noncompliance vs. social communication deficits, etc.) yet when they’re questioned further many SLPs will admit that they are lacking any/most information regarding the students background history.

When questioned regarding the lack of this information, many SLPs get defensive. They cite a variety of reasons such as lack of parental involvement (“I can’t reach the parents”), lack of access to records (“it’s a privacy issue”), division of labor (e.g., “it’s the social worker’s responsibility and not mine to obtain this information”) as well as other justifications why this information is lacking.

Now, I don’t know about you, but one of my earliest memories of the ‘diagnostics’ class in graduate school involved collecting data and writing comprehensive ‘Background Information’ section of the report. I still remember multiple professors imparting upon me the vital importance is this section plays in the student’s evaluation report.

Indeed, many years later, I clearly see its vital role in assessment. Unearthing the student’s family history, developmental milestones, medical/surgical history, as well as history of past therapies is frequently the key to a successful diagnosis and appropriate provision of therapy services.  This is the information that frequently plays a vital role in subsequent referrals of “mystery” cases to relevant health professionals as well as often leads to resolution of particularly complicated diagnostic puzzles.

Of course I understand that frequently there are legitimate barriers to obtaining this information.  However, I also know that if one digs deep enough one will frequently find the information they’re seeking despite the barriers. To illustrate, at the psychiatric hospital level where I work,  I frequently encounter a number of barriers to accessing the student’s background information during the assessment process. This may include parental language/education barrier, parental absence, Division of Child Protective Services involvement,  etc.  Yet I always try to ensure that my reports contain all the background information that I’m able to unearth because I know how vitally important it is for the student in question.

In the past I have been able to use the student’s background information to make important discoveries, which were otherwise missed by other health professionals. This included undocumented history of traumatic brain injuries, history of language and literacy disabilities in the family, history of genetic disorders and/or intellectual disabilities in the family, history of maternal alcohol abuse during pregnancy, and much much more.

So what do I consider to be an adequate Background History section of the assessment report?

For starters, the basics, of course.

I begin by stating the child’s age and grade levels, who referred the child (and for what reason), as well as whether the child previously received any form of speech language assessment/therapy services in the past.

If I am preforming a reassessment (especially if it happens shortly after the last assessment took place) I provide a clear justification why the present reassessment is taking place. Here is an actual excerpt from one of my reevaluation reports. “Despite receiving average language scores on his _______ speech language testing which resulted in the  recommendation for speech therapy only, upon his admission to ______, student was referred for a language reassessment in _____, by the classroom staff who expressed significant concerns regarding validity and reliability of past speech and language testing on the ground of the student’s persistent “obvious” listening comprehension and verbal expression deficits.”

For those of you in need of further justification I’ve created a brief list of reasons why a reassessment, closely following recent testing may be needed.

  1. SLP/Parent feels additional testing is needed to create comprehensive goals for child.
  2. Previous testing was inadequate. Here it’s very important to provide comprehensive rationale  and list the reasons for it.
  3. A reevaluation was requested due to third party  concerns (e.g., psychiatrist, psychologist, etc.)

Secondly, it is important to document all relevant medical history, which includes: prenatal, perinatal, and early childhood diseases, surgical interventions and incidents. It is important to note that if a child has a long standing history of documented psychiatric difficulties, you may want to separate these sections and describe psychiatric history/diagnoses following the section that details the onset of the child’s emotional and behavioral deficits.

Let us now move on to the child’s developmental history, which should include, gross/fine motor, speech/ language milestones, and well as cognitive and socioemotional functioning.  This is a section where I typically add information regarding any early intervention services which may have been provided to the child prior to the age of three.

In my next section I discuss the child’s academic functioning to date. Here I mention whether the student qualified for a preschool disabled eligibility category and received services from the age of 3+.  I also discuss their educational classification (if one exists), briefly mention the results of previous most recent cognitive and educational testing (if available) as well as mention any academic struggles (if applicable).

After that I move on to the child’s psychiatric history. I briefly document when did the emotional behavioral problems first arose, and what had been done about them to date (out of district placements, variety of psychiatric services, etc.)  Here I also document  the student’s most recent psychiatric diagnoses (if available) and mention any medication they may be currently on (applicable due to the effect of psychiatric medications on language and memory skills).

The following section is perhaps the most important one in the  report. It is the family’s history of genetic disorders, psychiatric impairments, special education placements, as well as language, learning, and literacy deficits.  This section plays a vital importance in my determination of the contributions to the student’s language difficulties as well as guides my assessment recommendations in the presence of borderline assessment results.

I finish this section by briefly discussing the student’s Family Composition as well as Language Knowledge and Use.

I discuss family composition due to several factors.  For example, lack of consistent caregivers, prolonged absence of parental figures, as well as presence of a variety of people in the home can serve as significant stressor for children with psychiatric impairments and learning difficulties.  As a result of this information is pertinent to the report especially when it comes to figuring out the antecedents for the child’s behavior fluctuation on daily basis.

Language knowledge and use  is particularly relevant to culturally and linguistically diverse children. It is very important to understand what languages does the child understand and use at home and at school as well as what do the parents think about the child’s language abilities in both languages. These factors will guide my decision making process regarding what type of assessments would be most relevant for this child.

So there you have it.  This is the information I include in the background history section of every single one of my reports.  I believe that this information contributes to the making of the appropriate and accurate diagnosis of the child’s difficulties.

Please don’t get me wrong. This information is hugely relevant for all students that we SLPs are assessing.

However, the above is especially relevant for such vulnerable populations as children with emotional and behavioral disturbances, whose struggle with social communication is frequently misinterpreted as “it’s just behavior“. As a result, they are frequently denied social communication therapy services, which ultimately leads to denial of Free Appropriate Public Education (FAPE) that they are entitled to.

Let us ensure that this does not happen by doing all that we can to endure that the student receives a fair assessment, correct diagnosis, and can have access to the best classroom placement, appropriate accommodations and modifications as well as targeted and relevant therapeutic services.  And the first step of that process begins with obtaining a detailed background history!

Helpful Resources: 

 

 

 

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Assessing Social Communication Abilities of School-Aged Children

Recently, I’ve published an article in SIG 16 Perspectives on School Based Issues discussing the importance of social communication assessments of school aged children 2-18 years of age. Below I would like to summarize article highlights.

First, I summarize the effect of social communication on academic abilities and review the notion of the “academic impact”. Then, I go over important changes in terminology and definitions as well as explain the “anatomy of social communication”.

Next I suggest a sample social communication skill hierarchy to adequately determine assessment needs (assess only those abilities suspected of deficits and exclude the skills the student has already mastered).

After that I go over pre-assessment considerations as well as review standardized testing and its limitations from 3-18 years of age.

Finally I review a host of informal social communication procedures and address their utility.

What is the away message?

When evaluating social communication, clinicians need to use multiple assessment tasks to create a balanced assessment. We need to chose testing instruments that will help us formulate clear goals.  We also need to add descriptive portions to our reports in order to “personalize” the student’s deficit areas. Our assessments need to be functional and meaningful for the student. This means determining the student’s strengths and not just weaknesses as a starting point of intervention initiation.

Is this an article which you might find interesting? If so, you can access full article HERE free of charge.

Helpful Smart Speech Resources Related to Assessment and Treatment of Social Communication 

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Improving Emotional Intelligence of Children with Social Communication Disorders

Our ability to recognize our own and other people’s emotions, distinguish between and correctly identify different feelings, as well as use that information to guide our thinking and behavior is called Emotional Intelligence (EI) (Salovey, et al, 2008).

EI encompasses dual areas of: emotion understanding, which is an awareness and comprehension of one’s and others emotions (Harris, 2008) and emotion regulation, which are internal and external strategies people use to regulate emotions (Thompson, 1994).

Many students with social communication challenges experience problems with all aspects of EI, including the perception, comprehension, and regulation of emotions (Brinton & Fujiki, 2012).

A number of recent studies have found that children with language impairments also present with impaired emotional intelligence including impaired perception of facial expressions (Spackman, Fujiki, Brinton, Nelson, & Allen, 2005), prosodic emotions (Fujiki, Spackman, Brinton, & Illig, 2008) as well as abstract emotion comprehension (Ford & Milosky, 2003).

Children with impaired emotional intelligence will experience numerous difficulties during social interactions due to their difficulty interpreting emotional cues of others (Cloward, 2012).  These may include but not be limited to active participation in cooperative activities, as well as full/competent interactions during group tasks (Brinton, Fujiki, & Powell, 1997)

Many students with social pragmatic deficits and language impairments are taught to recognize emotional states as part of their therapy goals. However, the provided experience frequently does not go beyond the recognition of the requisite “happy”, “mad”, “sad” emotions. At times, I even see written blurbs from others therapists, which state that “the student has mastered the goals of emotion recognition”.  However, when probed further it appears that the student had merely mastered the basic spectrum of simple emotional states, which places the student at a distinct disadvantage  as compared to typically developing peers who are capable of recognition and awareness of a myriad of complex emotional states.

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That is why I developed a product to target abstract emotional states comprehension in children with language impairments and social communication disorders. “Gauging Moods and Interpreting Abstract Emotional States: A Perspective Taking Activity Packet” is a social pragmatic photo/question set,  intended for children 7+ years of age, who present with difficulty recognizing abstract emotional states of others (beyond the “happy, mad, sad” option) as well as appropriately gauging their moods.

Many sets contain additional short stories with questions that focus on making inferencing, critical thinking as well as interpersonal negotiation skills.  Select sets require the students to create their own stories with a focus on the reasons why the person in the photograph might be feeling what s/he are feeling.

There are on average 12-15 questions per each photo.  Each page contains a photograph of a person feeling a particular emotion. After the student is presented with the photograph, they are asked a number of questions pertaining to the recognition of the person’s emotions, mood, the reason behind the emotion they are experiencing as well as what they could be potentially thinking at the moment.  Students are also asked to act out the depicted emotion they use of mirror.

Activities also include naming or finding (in a thesaurus or online) the synonyms and antonyms of a particular word in order to increase students’ vocabulary knowledge. A comprehensive two page “emotions word bank” is included in the last two pages of the packet to assist the students with the synonym/antonym selection, in the absence of a thesaurus or online access.

Students are also asked to use a target word in a complex sentence containing an adverbial (pre-chosen for them) as well as to identify a particular word or phrase associated with the photo or the described story situation.

Since many students with social pragmatic language deficits present with difficulty determining a person’s age (and prefer to relate to either younger or older individuals who are perceived to be “less judgmental of their difficulties”), this concept is also explicitly targeted in the packet.

This activity is suitable for both individual therapy sessions as well as group work.  In addition to its social pragmatic component is also intended to increase vocabulary knowledge and use as well as sentence length of children with language impairments.

Intended Audiences:

  • Clients with Language Impairments
  • Clients with Social Pragmatic Language Difficulties
  • Clients with Executive Function Difficulties
  • Clients with Psychiatric Impairments
    • ODD, ADHD, MD, Anxiety, Depression, etc.
  • Clients with Autism Spectrum Disorders
  • Clients with Nonverbal Learning Disability
  • Clients with Fetal Alcohol Spectrum Disorders
  • Adult and pediatric post-Traumatic Brain Injury (TBI) clients
  • Clients with right-side CVA Damage

Areas covered in this packet:

  1. Gauging Age (based on visual support and pre-existing knowledge)
  2. Gauging Moods (based on visual clues and context)
  3. Explaining Facial Expressions
  4. Making Social Predictions and Inferences (re: people’s emotions)
  5. Assuming First Person Perspectives
  6. Understanding Sympathy
  7. Vocabulary Knowledge and Use (pertaining to the concept of Emotional Intelligence)
  8. Semantic Flexibility (production of synonyms and antonyms)
  9. Complex Sentence Production
  10. Expression of Emotional Reactions
  11. Problem Solving Social Situations
  12. Friendship Management and Peer Relatedness

This activity is suitable for both individual therapy sessions as well as group work.  In addition to its social pragmatic component is also intended to increase vocabulary knowledge and use as well as sentence length of children with language impairments. You can find it in my online store (HERE).

Helpful Smart Speech Resources:

References:

  1. Brinton, B., Fujiki, M., & Powell, J. M. (1997). The ability of children with language impairment to manipulate topic in a structured task. Language, Speech and Hearing Services in Schools, 28, 3-11.
  2. Brinton B., & Fujiki, M. (2012). Social and affective factors in children with language impairment. Implications for literacy learning. In C. A. Stone, E. R. Silliman, B. J. Ehren, & K. Apel (Eds.), Handbook of language and literacy: Development and disorders (2nd Ed.). New York, NY: Guilford.
  3. Cloward, R. (2012). The milk jug project: Expression of emotion in children with language impairment and autism spectrum disorder (Unpublished honor’s thesis). Brigham Young University, Provo, Utah.
  4. Ford, J., & Milosky, L. (2003). Inferring emotional reactions in social situations: Differences in children with language impairment. Journal of Speech, Language, and Hearing Research, 46(1), 21-30.
  5. Fujiki, M., Spackman, M. P., Brinton, B., & Illig, T. (2008). Ability of children with language impairment to understand emotion conveyed by prosody in a narrative passage. International Journal of Language & Communication Disorders, 43(3), 330-345
  6. Harris, P. L. (2008). Children’s understanding of emotion. In M. Lewis, J. M. Haviland-Jones, & L. Feldman Barrett, (Eds.), Handbook of emotions (3rd ed., pp. 320–331). New York, NY: Guilford Press.
  7. Salovey, P., Detweiler-Bedell, B. T., Detweiler-Bedell, J. B., & Mayer, J. D. (2008). Emotional intelligence. In M. Lewis, J. M. Haviland-Jones, & L. Feldman Barrett (Eds.), Handbook of Emotions (3rd ed., pp. 533-547). New York, NY: Guilford Press.
  8. Spackman, M. P., Fujiki, M., Brinton, B., Nelson, D., & Allen, J. (2005). The ability of children with language impairment to recognize emotion conveyed by facial expression and music. Communication Disorders Quarterly, 26(3), 131-143.
  9. Thompson, R. (1994). Emotion regulation: A theme in search of definition. Monographs of the Society for Research in Child Development, 59(2-3), 25-52

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Teaching “Insight” to students with language, social communication, and executive functions impairments

One common difficulty our “higher functioning” (refers to subjective notion of ‘perceived’ functioning in school setting only) language impaired students with social communication and executive function difficulties present with – is lack of insight into own strengths and weaknesses.

Yet insight is a very important skill, which most typically developing students exhibit without consciously thinking about it. Having insight allows students to review work for errors, compensate for any perceived weaknesses effectively, and succeed with efficient juggling of academic workload.

In contrast, lack of insight in students with language deficits further compounds their difficulties, as they lack realization into own weaknesses and as a result are unable to effectively compensate for them.

That is why I started to explicitly teach the students on my caseload in both psychiatric hospital and private practice the concept of insight.

Now some of you may have some legitimate concerns. You may ask: “How can one teach such an abstract concept to students who are already impaired in their comprehension of language?” The answer to that is – I teach this concept through a series of concrete steps as well as through the introduction of abstract definitions, simplified for the purpose of my sessions into concrete terms.

Furthermore, it is important to understand that the acquisition of “insight” cannot be accomplished in one or even several sessions. Rather after this concept is introduced and the related vocabulary has been ‘internalized’ by the student,  thematic therapy sessions can be used to continue the acquisition of “insight” for months and even years to come.

"The Beginning" Road Sign with dramatic blue sky and clouds.

How do we begin? 

When I first started teaching this concept I used to explain the terminology related to “insight” verbally to students. However, as my own ‘insight’ developed in response to the students’ performance, I created a product to assist them with the acquisition of insight (See HERE).

Intended Audiences:

  • Clients with Language Impairments
  • Clients with Social Pragmatic Language Difficulties
  • Clients with Executive Function Difficulties
  • Clients with Psychiatric Impairments
    • ODD, ADHD, MD, Anxiety, Depression, etc.
  • Clients with Autism Spectrum Disorders
  • Clients with Nonverbal Learning Disability
  • Clients with Fetal Alcohol Spectrum Disorders
  • Adult and pediatric post-Traumatic Brain Injury (TBI) clients
  • Clients with right-side CVA Damage

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This thematic 10 page packet targets the development of “insight” in students with average IQ, 8+ years of age, presenting with social pragmatic and executive function difficulties.

The packet contains 1 page text explaining the concept of insight to students.

It also contains 11 Tier II vocabulary words relevant to the discussion of insight and their simplified definitions. The words were selected based on course curriculum standards for several grade levels (fourth through seventh) due to their wide usage in a variety of subjects (social studies, science, math, etc.)

Language activities in this packet include:

  • Explaining definitions
  • Answering open-ended comprehension questions
  • Sentence construction activity
  • Crossword puzzle
  • Two morphological awareness activities
    • Define prefixes and suffixes
    • Change word meanings by adding prefixes and suffixes to words
  • Self-reflection page in written format contains questions for students to assist them with judging their own strengths and weaknesses related to academic performance

And now a few words regarding the lesson structure…

I introduce the concept of “insight” to clients by writing down the word and asking them to identify its parts: ‘in‘ and ‘sight‘. Depending on the student’s level of abilities I either get to the students to explain it to me or explain it myself that it is a compound word made up of two other words.

I then ask the students to interpret what the word could potentially mean. After I hear their responses I either confirm the correct one or end up explaining that this word refers to “looking into one’s brain” for answers related to how well someone understands information.

I have the students read the text located on the first page of my packet going over the concept of insight and some of its associated vocabulary words.  I ask the students to tell me the main idea of each paragraph as well as answer questions regarding supporting text details.

Once I am confident that the students have a fairly good grasp of the presented text I move on to the definitions page. There are actually two definition pages in the lesson: one at the beginning and one at the end of the packet. The first definitions page also contains word meaning and what parts of speech the definitions belong to.  The definition page at the end of the packet contains only the targeted words. It is now the students responsibility to write down the definition of all the vocabulary words and phrases in order for me to see how well they remember the meanings of pertinent words.

The packet also includes comprehension questions, a section on sentence construction several morphological awareness activities, a crossword puzzle and a self-reflection page.

The final activity in the packet requires the student to judge their own work performance during this activity.  I ask students questions such as:

  • How do you think you did on this task?
  • How do you know you did ________?
  • How can you prove to me you understood ________?

If a student responds “I know I did well because I understood everything”, I typically ask them to prove their comprehension to me, verbally. Here the goal is to have the student provide concrete verbal examples supporting their insight of their performance.

 This may include statements such as:

  • I know I did well because you said: “Nice Work!”
  • I know I did well because you didn’t correct me too much
  • I know I did well because you  kept smiling and showed me thumbs up as I was talking

As mentioned above this activity is only the beginning. After I ensure that the students have a decent grasp of this concept I continue working on it indirectly by having the students continuously judge their own performance on a variety of other therapy related activities and assignments.

You can find the complete packet on teaching “insight” in my online store (HERE).  Also, stay tuned for Part II of this series, which will describe how to continue solidifying the concept of “insight” in the context of therapy sessions for students with social pragmatic and executive function deficits.

Helpful Smart Speech Resources:

 

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What if Its More Than Just “Misbehaving”?

Frequently,  I see a variation of the following scenario on many speech and language forums.

The SLP is seeing a client with speech and/or language deficits through early intervention,  in the schools, or in private practice, who is having some kind of behavioral issues.

Some issues are described as mild such as calling out, hyperactivity, impulsivity, or inattention, while others are more severe and include refusal, noncompliance, or aggression such as kicking, biting,  or punching.

An array of advice from well-meaning professionals immediately follows.  Some behaviors may be labeled as “normal” due to the child’s age (toddler),  others may be “partially excused” due to a DSM-5  diagnosis (e.g., ASD).   Recommendations for reinforcement charts (not grounded in evidence) may be suggested. A call for other professionals to deal with the behaviors is frequently made (“in my setting the ______ (insert relevant professional here) deals with these behaviors and I don’t have to be involved”). Specific judgments on the child may be pronounced: “There is nothing wrong with him/her, they’re just acting out to get what they want.” Some drastic recommendations could be made: “Maybe you should stop therapy until the child’s behaviors are stabilized”.

However, several crucial factors often get overlooked. First, a system to figure out why particular set of behaviors takes place and second, whether these behaviors may be manifestations of non-behaviorally based difficulties such as medical issues, or overt/subtle linguistically based deficits.

So what are some reasons kids may present with behavioral deficits? Obviously, there could be numerous reasons: some benign while others serious, ranging from lack of structure and understanding of expectations to manifestations of psychiatric illnesses and genetic syndromes. Oftentimes the underlying issues are incredibly difficult to recognize without a differential diagnosis. In other words, we cannot claim that the child’s difficulties are “just behavior” if we have not appropriately ruled out other causes which may be contributing to the “behavior”.

Here are some possible steps which can ensure appropriate identification of the source of the child’s behavioral difficulties in cases of hidden underlying language disorders (after of course relevant learning, genetic, medical, and psychiatric issues have been ruled out).

Let’s begin by answering a few simple questions. Was a thorough language evaluation with an emphasis on the child’s social pragmatic language abilities been completed? And by thorough, I am not referring to general language tests but to a variety of formal and informal social pragmatic language testing (read more HERE).

Please note that none of the general language tests such as the Preschool Language Scale-5 (PLS-5), Comprehensive Assessment of Spoken Language (CASL-2), the Test of Language Development-4 (TOLD-4) or even the Clinical Evaluation of Language Fundamentals Tests (CELF-P2)/ (CELF-5) tap into the child’s social language competence because they do NOT directly test the child’s social language skills (e.g., CELF-5 assesses them via a parental/teachers questionnaire).  Thus, many children can attain average scores on these tests yet still present with pervasive social language deficits. That is why it’s very important to thoroughly assess social pragmatic language abilities of all children  (no matter what their age is) presenting with behavioral deficits.

But let’s say that the social pragmatic language abilities have been assessed and the child was found/not found to be eligible for services, meanwhile, their behavioral deficits persist, what do we do now?

The first step in establishing a behavior management system is determining the function of challenging behaviors, since we need to understand why the behavior is occurring and what is triggering it (Chandler & Dahlquist, 2006)

We can begin by performing some basic data collection with a child of any age (even with toddlers) to determine behavior functions or reasons for specific behaviors. Here are just a few limited examples:

  • Seeking Attention/Reward
  • Seeking Sensory Stimulation
  • Seeking Control

Most behavior functions typically tend to be positively, negatively or automatically reinforced (Bobrow, 2002). For example, in cases of positive reinforcement, the child may exhibit challenging behaviors to obtain desirable items such as toys, games, attention, etc. If the parent/teacher inadvertently supplies the child with the desired item, they are reinforcing inappropriate behaviors positively and in a way strengthening the child’s desire to repeat the experience over and over again, since it had positively worked for them before.

In contrast, negative reinforcement takes place when the child exhibits challenging behaviors to escape a negative situation and gets his way. For example, the child is being disruptive in classroom/therapy because the tasks are too challenging and is ‘rewarded’ when therapy is discontinued early or when the classroom teacher asks an aide to take the child for a walk.

Finally, automatic reinforcements occur when certain behaviors such as repetitive movements or self-injury produce an enjoyable sensation for the child, which he then repeats again to recreate the sensation.

In order to determine what reinforces the child’s challenging behaviors, we must perform repeated observations and take data on the following:

  • Antecedent or what triggered the child’s behavior?
    • What was happening immediately before behavior occurred?
  • Behavior
    • What type of challenging behavior/s took place as a result?
  • Response/Consequence
    • How did you respond to behavior when it took place?

Here are just a few antecedent examples:

  • Therapist requested that child work on task
  • Child bored w/t task
  • Favorite task/activity taken away
  • Child could not obtain desired object/activity

In order to figure them out we need to collect data, prior to appropriately addressing them. After the data is collected the goals need to be prioritized based urgency/seriousness.  We can also use modification techniques aimed at managing interfering behaviors.  These techniques include modifications of: physical space, session structure, session materials as well as child’s behavior. As we are implementing these modifications we need to keep in mind the child’s maintaining factors or factors which contribute to the maintenance of the problem (Klein & Moses, 1999). These include: cognitive, sensorimotor, psychosocial and linguistic deficits. 

We also need to choose our reward system wisely, since the most effective systems which facilitate positive change actually utilize intrinsic rewards (pride in self for own accomplishments) (Kohn, 2001).  We need to teach the child positive replacement behaviors  to replace the use of negative ones, with an emphasis on self-talk, critical thinking, as well as talking about the problem vs. acting out behaviorally.

Of course it is very important that we utilize a team based approach and involve all the professionals involved in the child’s care including the child’s parents in order to ensure smooth and consistent carryover across all settings. Consistency is definitely a huge part of all behavior plans as it optimizes intervention results and achieves the desired therapy outcomes.

So the next time the client on your caseload is acting out don’t be so hasty in judging their behavior, when you have no idea regarding the reasons for it. Troubleshoot using appropriate and relevant steps in order to figure out what is REALLY going on and then attempt to change the situation in a team-based, systematic way.

For more detailed information on the topic of social pragmatic language assessment and behavior management in speech pathology see if the following Smart Speech Therapy LLC products could be of use:

 

References: 

  1. Bobrow, A. (2002). Problem behaviors in the classroom: What they mean and how to help. Functional Behavioral Assessment, 7 (2), 1–6.
  2. Chandler, L.K., & Dahlquist, C.M. Functional assessment: strategies to prevent and remediate challenging behavior in school settings (2nd ed.). Upper Saddle River, New Jersey: Pearson Education, Inc.
  3. —Klein, H., & Moses, N. (1999). Intervention planning for children with communication disorders: A guide to the clinical practicum and professional practice. (2nd Ed.). Boston, MA.: Allyn & Bacon.
  4. —Kohn, A. (2001, Sept). Five reasons to stop saying “good job!’. Young Children. Retrieved from http://www.alfiekohn.org/parenting/gj.htm
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Why is FASD diagnosis so important?

Recently, I’ve participated in various on-line and in-person discussions with both school-based speech language pathologists (SLPs) as well as medical health professionals (e.g., neurologists, pediatricians, etc.) regarding their views on the need of formal diagnosis for school aged children with suspected alcohol related deficits. While their responses differed considerably from: “we do not base intervention on diagnosis, but rather on demonstrated student need” to “with a diagnosis of ASD ‘these children’ would get the same level of services“, the message I was receiving loud and clear was: “Why? What would be the point?”  So today I decided to share my views on this matter and explain why I think the diagnosis matters.
Continue reading Why is FASD diagnosis so important?

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Why Do I Have to Tell You What’s Wrong with My Child? Or On the Importance of Targeted Assessments

A few days ago I received a phone call from a parent who was seeking a language evaluation for her child. As it is my policy with all assessments, I asked her to fill out an intake and a checklist to identify her child’s specific areas of difficulty in order to compile a comprehensive and targeted testing battery.  Her response to me was: “I’ve never heard of this before? Why do I have to tell you what’s wrong with my child? Why can’t you figure it out?” Similarly, last week, another parent has questioned: “So you can’t do the assessment without this form?” Given the above questions, and especially because May is a Better Hearing and Speech Month #BHSM, during which it is important to raise awareness about communication disorders, I want to take this time to explain to parents why performing targeted speech language assessments is SO CRUCIAL.

To begin with it is very important to understand that speech and language can be analyzed in many different ways beyond looking at pronunciation, vocabulary or listening and speaking skills.

Targeted areas within the scope of practice of pediatric school based speech language pathologists include the assessment of:

  • SPEECH
    • The child may have difficulties with pronunciation of sounds in words, stutter, clutter, have a lisp or have difficulties in the areas of voice, prosody, or resonance. For the majority of  the above difficulties completely different tests and testing procedures may be needed in order to appropriately assess the child.
  • LANGUAGE
    • Receptive Language
      • Ability to follow directions, answer questions, recall sentences, understand verbal messages, as well as comprehend orally presented text
    • Memory and Attention 
      • Also see executive function skills
    • Expressive Language
      • Vocabulary knowledge and use, formulation of words and sentences as well as production of narratives or stories
    • Problem Solving
      • Verbal reasoning and critical thinking skills are very important for successful independent decision making as well as for interpretation of academically based texts and complete assignments
    • Pragmatic Language 
      • Successful use of language for a variety of communicative purposes
        • Initiate and maintain topics, maintain conversational exchanges, request help, etc
    • Social Emotional Competence
      • Effective interpersonal negotiation skills, compromise and negotiation abilities, as well as perspective taking are integral to academic and social success. These abilities are often compromised in children with language disorders and require a thorough assessment
    • Executive Functions (EFs) 
      • These are higher level cognitive processes involved in inhibition of thought, action and emotion, which are located in the prefrontal cortex of the frontal lobe of the brain.  
      • Major EF components include working memory, inhibitory control, planning, and set-shifting. EFs contribute to child’s ability to sustain attention, ignore distractions, and succeed in academic settings. 
  • READING DISABILITIES AND DYSLEXIA
    • Phonological Awareness
    • Reading Ability
    • Writing
    • Spelling 

One General Language Test Does Not Fit All! 

Children with speech and language disorders do not necessarily display weaknesses in all affected areas but may only display difficulties in selected few.

To illustrate, high functioning students on the autistic spectrum may have very strong academic skills related to comprehension and expression of language but may display significant social pragmatic language weaknesses, which will not be apparent on general language testing (e.g., administration of Clinical Evaluation of Language Fundamentals -5). Thus, the administration of a general language test will be contraindicated for these students as it will only show typical performance on these tests and will not qualify them for targeted language based services that they need.  However, by administering to them a testing battery composed of tests sensitive to social pragmatic language competence will highlight their areas of difficulty and result in a creation of a targeted intervention plan to improve their abilities in the affected areas. 

Similarly, children at risk for reading disabilities will not benefit from the administration of general language testing either, since their deficits may lie in the areas of sound discrimination, isolation, or blending as well as as impaired decoding ability.  So the administration of tests sensitive to phonological awareness and emergent reading ability would be much more relevant. 

This is exactly why taking an extra step and filling out a simple form will result in a much more targeted and beneficial speech language assessment for the child.  The goal of any competent professional assessment is to eliminate the administration of unnecessary and irrelevant tests and focus only on the administration of instruments directly targeting the areas of difficulty that the child presents with.  Given the fact that assessment of language covers so many broad areas, it makes perfect sense to ask parents to fill out relevant checklists/intakes as a routine part of a pre-assessment procedure.  Otherwise, even after observations in school setting, I would still just be blindly ‘fishing’ for deficits without really knowing whether I will  ‘accidentally stumble upon them’ using a general test at hand.

Of course, even checklists need to be targeted by age and areas of functioning. Here’s how I use mine. When performing comprehensive fist time assessments I ask the parent to fill out the comprehensive checklists based on the child’s age.    These are broken down as follows:

However, oftentimes when I perform reassessments or second opinion evaluations, I may ask the parent to fill out checklists pertaining to specific, known, areas of difficulty. These currently include:

After the parent fills the checklist out, the child’s areas of difficulty literally jump out from the pages. Now, all I need to do is to choose the appropriate testing instruments, which will BEST help me determine the exact nature and cause of the child’s deficits and I am all set. I administer the testing, interpret the results and write a comprehensive report detailing which therapy goals will be targeted. And this is why pre-assessment checklist administration is so important.

Helpful Resources: 

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The Executive Functions Test-Elementary (EFT-E): What SLPs and Parents Need to Know

Image result for Executive Functions Test: ElementaryRecently I’ve purchased the Executive Functions Test-Elementary (EFT-E) by Linguisystems  and used it with a few clients  in my private practice and outpatient hospital-based school program.  The EFT-E is a test of language skills that affect executive functions of working memory, problem solving, inferring, predicting outcomes, and shifting tasks. For those of you not familiar with executive functions (EFs), they are higher level cognitive processes involved in inhibition of thought, action and emotion, which are located in the prefrontal cortex of the frontal lobe of the brain.  Continue reading The Executive Functions Test-Elementary (EFT-E): What SLPs and Parents Need to Know