Treatment Suggestions | Smart Speech Therapy

Posted on July 27, 2015January 5, 2022 by Tatyana Elleseff — 6 Comments

Alternative Therapies, Herbs, Pills, and Snake Oils or “What’s the Harm in That?”

I’ve been meaning to write this post for some time and have finally decided to do it now due to an increased prevalence of “non-traditional” treatment options available to parents of language impaired children.

More and more unscrupulous or misguided individuals are offering fantastical cures to children diagnosed with the wide variety of disorders including but not limited to: Autism (ASD), Childhood Apraxia of Speech (CAS), language disorders, “Auditory Processing Deficits (APD)“, Dyslexia, and much much more.

What are some examples of controversial products and therapies you may ask?

Below I cite several links (which are in no way exhaustive) for your convenience.

Controversial Autism Treatments:

In 2013, Dr. Emily Willingham, guest writer for Forbes magazine wrote a post on the topic of “The 5 Scariest Autism ‘Treatments. In it she described some pretty horrifying methods (e.g., chelation, chemical castration, hyperbaric oxygen therapy) which purportedly promised to “cure” autism. For more information on other controversial treatments in autism click to read this keynote address entitled Evidence-Based Practices for Children with Autism Spectrum Disorders by Dr. Tristram Smith for The Society for Clinical Child and Adolescent Psychology (SCCAP).

Controversial Speech Sound Disorder Treatments

Dr. Caroline Bowen respected Speech Language Researcher from Australia has a delightfully edifying page on her website (http://speech-language-therapy.com/) entitled: “Controversial Practices in Children’s Speech Sound Disorders – Oral Motor Exercises, Dietary Supplements, Auditory Integration Training”. On it she thoroughly reviews non-research supported practices to improve children’s sound production including the use of oral motor/mouth exercises, dietary supplements (Apraxia Diet, Nourish Life Speak, Nutri Veda, etc.), as well as Auditory Integration Training (AIT).

Parent‐Friendly Information about Nonspeech Oral Motor Exercises (HERE)

Controversial Treatments for Children with Developmental and Learning Disabilities

Macquarie University Special Education Centre in Sydney Australia has even developed concise one-page briefings of a vast number of controversial treatments for children with developmental and learning disabilities (selected briefing links are below; the full list of briefings is available HERE):

How to Spot Controversial Practices?

In her 2012 post entitled: “10 Questions To Distinguish Real From Fake Science“, Dr. Emily Willingham wrote that “science consumers need a cheat sheet … when considering a product, book, therapy, or remedy”. She advised consumers to consider some of the following criteria:

Consider the source
Determine their agenda
Do they use highly emotionally charged language or meaningless jargon?
Are they relying on testimonials vs. evidence?
Are they claiming to be exclusive?
Do they mention words like ‘conspiracy’?
Is their treatment promising to cure multiple unrelated disorders?
What does the money trail reveal?

The truth is that there’s a lot of pseudoscience out there and as such it is very important for both parents and professionals not to fall into its trap. In 2012, Dr. Gregory Lof presented the following poster at the ASHA’s Atlanta Convention: “Science vs. Pseudoscience in CSD: A Checklist for Skeptical Thinking” to “help clinicians evaluate claims made by promoters of products or services to help determine if they are based on scientific principles or on pseudoscience”. An interactive version of the checklist is available HERE, and for the summary based on the checklist, written by Mary Huston, fellow SLP and author of the Speech Adventures, click HERE.

So what do pseudoscientific practices/claims look like?

People place heavy emphasis on beliefs and opinions vs. data, when it comes to therapeutic claims
- SLPs: “You are wrong! I’ve seen ________ work with my clients!”
- Parents: “Who cares about your research this _______worked for us so HOW DARE YOU question it?
The presented data is based on “expert opinions”, testimonials, and isolated case studies
- “These ridiculously expensive ‘speech sticks’ at $120 a pop worked for us, Yay!”
Data is disseminated via self-published books, popular press, proprietary websites lacking research sections, as well as non-peer reviewed conferences.
- You might want to review the list of predatory publishers HERE, review the guide of how to spot a bogus scientific publication HERE, and if you ever find yourself reading anything on this website, I suggest you close your laptop as fast as you can and possibly put it into another room for a while (Read Why – HERE).
Treatment sounds like a magic potion since it works on a wide range of disabilities, appeals to fears and wishful thinking, preys on the desperate and uses hyperboles (“miracle cure”)
- “Google, order, inject“
Use of disdainful comments against researchers because “only clinicians do real clinical work”coupled with over reliance on clinician’s experience and subjective judgment since it’s the “best way” to determine effectiveness
- “I’ve found ___________ to be highly effective with gazillion clients”.
Lack of change in practices despite a veritable mountain of evidence to the contrary
- “Your child NEEDS oral-motor exercises, NOW, for his speech to get better”
New terms are created to mask use of disproven pseudoscientific practices
- “oral placement therapy“
- “rapid prompting method“

Why do we keep believing when all the evidence points to the contrary?

Because our brains become emotionally attached to ideas. This is further supported by the construct of two biases.

Confirmation bias – our tendency to look for/interpret information in a way that confirms our beliefs by “cherry picking” the evidence that supports what we believe in and ignoring the evidence that argues against it.

Disconfirmation bias – when facing with evidence which directly contradicts our beliefs we will criticize and reject it because we do not want to be wrong.

So now let’s get back to talk about the title of this post: “What’s the harm in that?”

While I am accustomed to seeing the variation of this statement on parent forums, I was surprised when I learned that it’s popping up quite often in some unexpected places such as during IEP meetings or during doctor visits (as reported to me by some of my client’s parents).

So I wanted to take this opportunity to explicitly point out what the harm in these alternative practices could be, ranging from the obvious to the hidden.

For starters some of these ‘therapies’ could kill!

Over the years there has been a number of reports regarding deaths from controversial autism treatments including chelation and GcMAF injections.

Even if they don’t kill you they can cause some nasty side effects!

To illustrate, Nourish Life Speak Nutrients, which were prescribed to children to “increase their language output or to make them speak better”, were so loaded with vitamin E (way above the legal amount), that a number of children who were taking them experienced significant seizure activity.

It’s going to cost you!

Out of sheer desperation, families will spend tens of thousands of dollars on ‘alternative’ treatments which are ineffective at best and harmful at worst. To illustrate via a fairly benign example. Here’s the typical question that can be seen on a variety of parent forums pertaining to therapies for “(C) APD”: Q: My nine-year-old was diagnosed with mild auditory processing problems and ADHD, inattentive type. It was recommended that she do Fast ForWord. This is very expensive — $3,500 in the office and $1,100 at home. Does this program work and is there a benefit to doing it in the office? I would hate to spend $3,500 for nothing. The problem is that “systematic reviews found no sign of a reliable effect of Fast ForWord® on reading or on expressive or receptive spoken language.” So where does that leave the parents who spend thousands of dollars on this program in hopes that it really will improve oral language and reading abilities of their children? This leads me to my next point.

They create false hope!

Whether it’s a placebo or the Hawthorne effect, or just a desperate desire to believe that something is working after you have sank so much hope, time, money, and energy into it, it may look like ineffective treatments are working at least for a short period of time. However, sooner or later parents start to notice that the issues whatever they may be continue to persist or even worsen despite the provided treatment. To illustrate, let’s take an example of a child with severe speech delay who is prescribed oral motor exercises to improve their speech production. At first, it appears that doing tongue curls, blowing kazoos, and chewing on bite blocks appears to be working and the child’s speech seems more intelligible. However, soon the parents may realize that while this expensive treatment is taking a significant period of time to complete the child’s speech production did not functionally improve since the therapist did not work directly on increasing the child’s repertoire of sounds and words.

They can create a sense of bitterness and hopelessness!

Ever spoken to parents who have tried every alternative treatment possible and have subsequently given up? If you haven’t, I assure you it’s not a pleasant or productive conversation. At best you will hear a lot of vitriol and accusations and at worst they may actually start a forum thread or a website bashing effective treatments such as speech language therapy because of their negative experiences. When you believe that you have tried everything and it’s still not helping, you feel defeated and lost and as a result tend to attack blindly anyone who attempts to assist you because you’ve stopped perceiving it as assistance but rather as just another scam.

They delay effective research-proven treatments!

Last week I wrote a blog post entitled: “Why (C) APD Diagnosis is NOT Valid!” citing the latest research literature to explain that the controversial diagnosis of APD tends to a) detract from understanding that the child presents with legitimate language based deficits in the areas of comprehension, expression, social communication and literacy development and b) may result in the above deficits not getting adequately addressed due to the provision of controversial APD treatments. In other words I was in NO way trying to disprove that the processing deficits exhibited by the children diagnosed with “APD” were not real. Rather I was trying to point out that these processing deficits are due to a different cause – namely a language disorder which has turned into a language disability and as such needed to be addressed by linguistic rather than ‘auditory’ therapies. In other words what research has found you can get auditory therapies indefinitely and with great frequency but they would still NOT generalize to improve the child’s language abilities (including reading) in the affected areas. The problem is that by delaying legitimate therapies (e.g., in the above case evidence-based reading intervention for the student) there is a significant risk of poorer social and academic outcomes as the child grows older.

They affect self-esteem and self-efficacy!

Now enough about parents and professionals. Let’s actually take a moment to talk about effect of these alternative practices on the most important people in question: the children who are on the receiving end of it! Let’s talk about all the negative effects that can be incurred by them by undergoing these useless treatments time after time. And no I am not actually talking about the hugely dangerous treatments, which can cause physical harm or awful side effects. I am talking about the relatively benign treatments of “vision therapy”, “memory training”, etc.
To illustrate, I work with are very bright 11-year-old boy with significant reading deficits and an extensive history of reading disabilities in the family. This boy’s deficit is in the area of reading, there is no doubt about it! He knows it and it’s very acutely aware of it. However, at the advice of well-meaning professionals he was taken to a behavioral optometrist, who told his mother that his issues with reading are due to visual processing deficits (despite the fact that his ophthalmologist ruled out any vision difficulties and declared his vision to be 20/20). It was then recommended that he undergo a costly vision therapy program in order to improve his “visual processing”. Guess, what his first words were, when I saw him in my office for reading intervention? ‘I went to the doctor who told me that I have problems in my eyes and that I need to stop reading! So I can’t do any more reading because of my eye problems.’ Imagine how he will feel when after several months of costly therapies there will be no functional improvement in his reading skills, since the only thing which can improve his reading abilities is the actual targeted reading instruction!
Our students are very acutely aware when something is not working. Just like us they get increasingly frustrated after being dragged from one professional to another, after ‘suffering’ through one controversial treatment after another with no respite in sight. Imagine what havoc it begins to wreak on their self-esteem and their self-efficacy (belief in own abilities to complete tasks and reach goals), when they keep undergoing these treatments without any improvement? All the negative self-talk they will use? Here are just a few statements I’ve heard over the years: “I am so stupid”; “There’s something wrong with my brain”, “I am not good at this, etc.) Instead of building them up these alternative therapies and treatments will not just tear them back down but may potentially cause behavioral and psychiatric effects to boot.

There you have it: that’s what the harm is! The toll of these quack practices can be very significant and can go far beyond the financial. So the next time someone utters the statement: “What’s the Harm in That?” consider the above information in order to make the informed decisions regarding the treatment for the most vulnerable parties involved: the children in your care!

Posted on June 7, 2015January 5, 2022 by Tatyana Elleseff — Leave a comment

Friend or Friendly: What Does Age Have To Do with It?

In my social pragmatic language groups I target a wide variety of social communication goals for children with varying levels and degrees of impairment with a focus on improving their social pragmatic language competence. In the past I have written blog posts on a variety of social pragmatic language therapy topics, including strategies for improving students’ emotional intelligence as well as on how to teach students to develop insight into own strengths and weaknesses. Today I wanted to discuss the importance of teaching students with social communication impairments, age recognition for friendship and safety purposes.

Now it is important to note that the focus of my sessions is a bit different from the focus of “teaching protective behaviors”, “circles of intimacy and relationships” or “teaching kids to deal with tricky people“. Rather the goal is to teach the students to recognize who it is okay “to hang out” or be friends with, and who is considered to be too old/too young to be a friend.

Why is it important to teach age recognition?

There are actually quite a few reasons.

Firstly, it is a fairly well-known fact that in the absence of age-level peers with similar weaknesses, students with social communication deficits will seek out either much younger or much older children as playmates/friends as these individuals are far less likely to judge them for their perceived social deficits. While this may be a short-term solution to the “friendship problem” it also comes with its own host of challenges. By maintaining relationships with peers outside of their age group, it is difficult for children with social communication impairments to understand and relate to peers of their age group in school setting. This creates a wider chasm in the classroom and increases the risk of peer isolation and bullying.

Secondly, the difficulty presented by friendships significantly outside of one’s peer group, is the risk of, for lack of better words, ‘getting into trouble’. This may include but is not limited to exploring own sexuality (which is perfectly normal) with a significantly younger child (which can be problematic) or be instigated by an older child/adolescent in doing something inappropriate (e.g, shoplifting, drinking, smoking, exposing self to peers, etc.).

Thirdly, this difficulty (gauging people’s age) further exacerbates the students’ social communication deficits as it prevents them from effectively understanding such pragmatic parameters such as audience (e.g., with whom its appropriate to use certain language in a certain tone and with whom it is not) and topic (with whom it is appropriate to discuss certain subjects and with whom it is not).

So due to the above reasons I began working on age recognition with the students (6+ years of age) on my caseload diagnosed with social communication and language impairments. I mention language impairments because it is very important to understand that more and more research is coming out connecting language impairments with social communication deficits. Therefore it’s not just students on the autism spectrum or students with social pragmatic deficits (an official DSM-5 diagnosis) who have difficulties in the area of social communication. Students with language impairments could also benefit from services focused on improving their social communication skills.

I begin my therapy sessions on age recognition by presenting the students with photos of people of different ages and asking them to attempt to explain how old do they think the people in the pictures are and what visual clues and/or prior knowledge assisted them in the formulation of their responses. I typically select the pictures from some of the social pragmatic therapy materials packets that I had created over the years (e.g., Gauging Moods, Are You Being Social?, Multiple Interpretations, etc.).

I make sure to carefully choose my pictures based on the student’s age and experience to ensure that the student has at least some degree of success making guesses. So for a six-year-old I would select pictures of either toddlers or children his/her age to begin teaching them recognition of concepts: “same” and “younger” (e.g., Social Pragmatic Photo Bundle for Early Elementary Aged Children).

For older children, I vary the photos of different aged individuals significantly. I also introduce relevant vocabulary words as related to a particular age demographic, such as:

Infant (0-1 years of age)
Toddler (2-3 years of age)
Preschooler (3-5 years of age)
Teenager (individual between 13-19 years of age)
Early, mid and late 20s, 30s, 40s
Middle-aged (individuals around 50 years of age)
Senior/senior citizen (individuals ~65+ years of age)

I explain to the students that people of different ages look differently and teach them how to identify relevant visual clues to assist them with making educated guesses about people’s ages. I also use photos of my own family or ask the students to bring in their own family photos to use for age determination of people in the presented pictures. When students learn the ages of their own family members, they have an easier time determining the age ranges of strangers.

My next step is to explain to students the importance of understanding people’s ages. I present to the students a picture of an individual significantly younger or older than them and ask them whether it’s appropriate to be that person’s friend. Here students with better developed insight will state that it is not appropriate to be that person’s friend because they have nothing in common with them and do not share their interests. In contrast, students with limited insight will state that it’s perfectly okay to be that person’s friend.

This is the perfect teachable moment for explaining the difference between “friend” and “friendly”. Here I again reiterate that people of different ages have significantly different interests as well as have significant differences in what they are allowed to do (e.g., a 16-year-old is allowed to have a driver’s permit in many US states as well as has a later curfew while an 11-year-old clearly doesn’t). I also explain that it’s perfectly okay to be friendly and polite with older or younger people in social situations (e.g., say hello all, talk, answer questions, etc.) but that does not constitute true friendship.

I also ask students to compile a list of qualities of what they look for in a “friend” as well as have them engage in some perspective taking (e.g, have them imagine that they showed up at a toddler’s house and asked to play with him/her, or that a teenager came into their house, and what their parents reaction would be?).

Finally, I discuss with students the importance of paying attention to who wants to hang out/be friends with them as well as vice versa (individuals they want to hang out with) in order to better develop their insight into the appropriateness of relationships. I instruct them to think critically when an older individual (e.g, young adult) wants to get particularly close to them. I use examples from an excellent post written by a colleague and good friend, Maria Del Duca of Communication Station Blog re: dealing with tricky people, in order to teach them to recognize signs of individuals crossing the boundary of being friendly, and what to do about it.

So there you have it. These are some of the reasons why I teach age recognition to clients with social communication weaknesses. Do you teach age recognition to your clients? If so, comment under this post, how do you do it and what materials do you use?

Helpful Smart Speech Resources Related to Assessment and Treatment of Social Pragmatic Disorders

Posted on May 28, 2015January 5, 2022 by Tatyana Elleseff — 3 Comments

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.

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:

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

Helpful Smart Speech Resources:

References:

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.
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.
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.
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.
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
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.
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.
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.
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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Posted on May 23, 2015January 5, 2022 by Tatyana Elleseff — 3 Comments

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.

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

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:

Posted on May 18, 2015January 5, 2022 by Tatyana Elleseff — 2 Comments

Designing RTI-Based Vocabulary Interventions

Smart Speech Therapy LLC is celebrating #BHSM2015 ASHA Better Hearing and Speech Month. So without further ado, below you will find my recommendations for designing effective vocabulary interventions for struggling students.

This past academic year I have been delivering vocabulary intervention once a week for an hour in my setting to 5 different classrooms of low achieving students. This allowed me to research quite a bit regarding the principles of vocabulary teaching as well as gave me an opportunity to adapt and design my own vocabulary intervention materials.

Vocabulary is of course one of the integral components of reading comprehension along with phonological awareness, phonics, and reading fluency. Knowledge of vocabulary is especially important for navigation of informational texts.

Who can benefit from explicit vocabulary instruction?

The answer is simple: any child with decreased vocabulary skills! This may include but not be limited to:

Children from low socioeconomic backgrounds
Children with Limited English Proficiency
Children with language impairments and learning disabilities

How can we design effective vocabulary interventions?

According to Judy Montgomery “You can never select the wrong words to teach.” Beck et al (2002) recommends teaching Tier II words, as they would make the most significant impact on a child’s spoken and written expressive capabilities, and are useful across a variety of settings.

Tips on creating intervention materials:

Make vocabulary words thematic and center them around current events
Select a topic students are learning about in the classroom or center it around a seasonal event/holiday
Select no more than 10 words per packet and work on the packet for a period of several weeks to engage in a frequent mass practice
Attempt to select vocabulary words used across several domains, which are still applicable to the student’s academic experience

Packet Layout :

1. Embed the selected vocabulary words in a short thematic text

2. Create a definitions page with usage tips to assist students with comprehension of vocabulary definitions

3. Have the students practice using these vocabulary words in various activities such as fill-in the blank, matching, sentence creation, etc.

This thematic packet, which can be used all year round, was created to target listening and reading comprehension of older students diagnosed with language impairments and learning disabilities.

The packet contains the following items:

4 Paragraph Reading Comprehension Passage about the Hyrologic (Water) Cycle
7 Open ended comprehension questions
12 Response to Intervention (RTI) Tier 2 vocabulary words in story context
10 Synonyms and antonyms matching words
15 Fill-in the blank words to complete sentences
Open ended sentence formulation utilizing 10 story vocabulary words

You can grab it HERE in my online store.

Helpful Smart Speech Resources:

Posted on April 9, 2015January 12, 2022 by Tatyana Elleseff — 3 Comments

Thematic Language Intervention with Language Impaired Children Using Nonfiction Texts

In the past a number of my SLP colleague bloggers (Communication Station, Twin Sisters SLPs, Practical AAC, etc.) wrote posts regarding the use of thematic texts for language intervention purposes. They discussed implementation of fictional texts such as the use of children’s books and fairy tales to target linguistic goals such as vocabulary knowledge in use, sentence formulation, answering WH questions, as well as story recall and production.

Today I would like to supplement those posts with information regarding the implementation of intervention based on thematic nonfiction texts to further improve language abilities of children with language difficulties.

First, here’s why the use of nonfiction texts in language intervention is important. While narrative texts have high familiarity for children due to preexisting, background knowledge, familiar vocabulary, repetitive themes, etc. nonfiction texts are far more difficult to comprehend. It typically contains unknown concepts and vocabulary, which is then used in the text multiple times. Therefore lack of knowledge of these concepts and related vocabulary will result in lack of text comprehension. According to Duke (2013) half of all the primary read-alouds should be informational text. It will allow students to build up knowledge and the necessary academic vocabulary to effectively participate and partake from the curriculum.

So what type of nonfiction materials can be used for language intervention purposes. While there is a rich variety of sources available, I have had great success using Let’s Read and Find Out Stage 1 and 2 Science Series with clients with varying degrees of language impairment.

Here’s are just a few reasons why I like to use this series.

They can be implemented by parents and professionals alike for different purposes with equal effectiveness.
They can be implemented with children fairly early beginning with preschool on-wards
The can be used with the following pediatric populations:
- Language Disordered Children
- Children with learning disabilities and low IQ
- Children with developmental disorders and genetic syndromes (Fragile X, Down Syndrome, Autism, etc.)
- Children with Fetal Alcohol Spectrum Disorders
- Internationally adopted children with language impairment
- Bilingual children with language impairment
- Children with dyslexia and reading disabilities
- Children with psychiatric Impairments
The books are readily available online (Barnes & Noble, Amazon, etc.) and in stores.
They are relatively inexpensive (individual books cost about $5-6).
Parents or professionals who want to continuously use them seasonally can purchase them in bulk at a significantly cheaper price from select distributors (Source: rainbowresource.com)
They are highly thematic, contain terrific visual support, and are surprisingly versatile, with information on topics ranging from animal habitats and life cycles to natural disasters and space.
They contain subject-relevant vocabulary words that the students are likely to use in the future over and over again (Stahl & Fairbanks, 1986).
The words are already pre-grouped in semantic clusters which create schemes (mental representations) for the students (Marzano & Marzano, 1988).

For example, the above books on weather and seasons contain information on:

1. Front Formations
2. Water Cycle
3. High & Low Pressure Systems

Let’s look at the vocabulary words from Flash, Crash, Rumble, and Roll (see detailed lesson plan HERE). (Source: ReadWorks):

Word: water vapor
Context: Steam from a hot soup is water vapor.

Word: expands
Context: The hot air expands and pops the balloon.

Word: atmosphere
Context: The atmosphere is the air that covers the Earth.

Word: forecast
Context: The forecast had a lot to tell us about the storm.

Word: condense
Context: steam in the air condenses to form water drops.

These books are not just great for increasing academic vocabulary knowledge and use. They are great for teaching sequencing skills (e.g., life cycles), critical thinking skills (e.g., What do animals need to do in the winter to survive?), compare and contrast skills (e.g., what is the difference between hatching and molting?) and much, much, more!

So why is use of nonfiction texts important for strengthening vocabulary knowledge and words in language impaired children?

As I noted in my previous post on effective vocabulary instruction (HERE): “teachers with many struggling children often significantly reduce the quality of their own vocabulary unconsciously to ensure understanding” (Excerpts from Anita Archer’s Interview with Advance for SLPs).

The same goes for SLPs and parents. Many of them are under misperception that if they teach complex subject-related words like “metamorphosis” or “vaporization” to children with significant language impairments or developmental disabilities that these students will not understand them and will not benefit from learning them.

However, that is not the case! These students will still significantly benefit from learning these words, it will simply take them longer periods of practice to retain them!

By simplifying our explanations, minimizing verbiage and emphasizing the visuals, the books can be successfully adapted for use with children with severe language impairments. I have had parents observe my intervention sessions using these books and then successfully use them in the home with their children by reviewing the information and reinforcing newly learned vocabulary knowledge.

Here are just a few examples of prompts I use in treatment with more severely affected language-impaired children:

What do you see in this picture?
This is a _____ Can you say _____
What do you know about _____?
What do you think is happening? Why?
What do you think they are doing? Why?
Let’s make up a sentence with __________ (this word)
You can say ____ or you can say ______ (teaching synonyms)
What would be the opposite of _______? (teaching antonyms)
Do you know that _____(this word) has 2 meanings
- 1st meaning
- 2nd meaning
How do ____ and _____ go together?

Here are the questions related to Sequencing of Processes (Life Cycle, Water Cycle, etc.)

What happened first?
What happened second?
What happened next?
What happened after that?
What happened last?

As the child advances his/her skills I attempt to engage them in more complex book interactions

Compare and contrast items
(e.g. objects/people/animals)
Make predictions and inferences about will happen next?
Why is this book important?

“Picture walks” (flipping through the pages) of these books are also surprisingly effective for activation of the student’s background knowledge (what a student already knows about a subject). This is an important prerequisite skill needed for continued acquisition of new knowledge. It is important because “students who lack sufficient background knowledge or are unable to activate it may struggle to access, participate, and progress through the general curriculum” (Stangman, Hall & Meyer, 2004).

These book allow for :

1.Learning vocabulary words in context embedded texts with high interest visuals

2.Teaching specific content related vocabulary words directly to comprehend classroom-specific work

3.Providing multiple and repetitive exposures of vocabulary words in texts

4. Maximizing multisensory intervention when learning vocabulary to maximize gains (visual, auditory, tactile via related projects, etc.)

To summarize, children with significant language impairment often suffer from the Matthew Effect (“rich get richer, poor get poorer”), or interactions with the environment exaggerate individual differences over time

Children with good vocabulary knowledge learn more words and gain further knowledge by building of these words

Children with poor vocabulary knowledge learn less words and widen the gap between self and peers over time due to their inability to effectively meet the ever increasing academic effects of the classroom. The vocabulary problems of students who enter school with poorer limited vocabularies only worsen over time (White, Graves & Slater, 1990). We need to provide these children with all the feasible opportunities to narrow this gap and partake from the curriculum in a more similar fashion as typically developing peers.

Helpful Smart Speech Therapy Resources:

References:

Duke, N. K. (2013). Starting out: Practices to Use in K-3. Educational Leadership, 71, 40-44.

Marzano, R. J., & Marzano, J. (1988). Toward a cognitive theory of commitment and its implications for therapy. Psychotherapy in Private Practice 6(4), 69–81.

Stahl, S. A. & Fairbanks, M. M. “The Effects of Vocabulary Instruction: A Model-based Metaanalysis.” Review of Educational Research 56 (1986): 72-110.

Strangman, N., Hall, T., & Meyer, A. (2004). Background knowledge with UDL. Wakefield, MA: National Center on Accessing the General Curriculum.

White, T. G., Graves, M. F., & Slater W. H. (1990). Growth of reading vocabulary in diverse elementary schools: Decoding and word meaning. Journal of Educational Psychology, 82, 281–290.

Posted on March 22, 2015January 5, 2022 by Tatyana Elleseff — 15 Comments

Is it Language Disorder or Learning Disability? A Tutorial for Parents and Professionals

Recently I read a terrific article written in 2014 by Sun and Wallach entitled: “Language Disorders Are Learning Disabilities: Challenges on the Divergent and Diverse Paths to Language Learning Disability“. I found it to be so valuable that I wanted to summarize some of its key points to my readers because it bears tremendous impact on our understanding of what happens to children with language disorders when they reach school years.

The authors begin the article by introducing a scenario familiar to numerous SLPs. A young child is diagnosed with receptive, expressive and social pragmatic language deficits as a toddler (2.5 years of age) begins to receive speech language services, which continue through preschool and elementary school until 2nd grade. The child is receiving therapy under the diagnosis of specific language impairment (SLI), which is characterized by difficulties with acquiring language in the absence of any other known disorders. By 2nd grade the child has seemingly “caught up” in the areas of listening comprehension and complex sentence production but is now struggling academically in the areas of reading and writing. Now his teachers are concerned that he has a learning disability, and his bewildered parent asks “Is it true that my child now has another problem on top of his language problem?”

From that scenario the authors skillfully navigate the complex relationship between language disorders and school disability labels to explain that the child does NOT have a new disorder but rather continues to face new challenges presented by his old disorder due to which he is now struggling to meet the growing language demands of the academic curriculum.

Here’s the approximate hierarchy of language development in young children:

Exploration of the environment
Play
Receptive Language
- Comprehension of words, phrases, sentences, stories
Expressive Language
- Speaking single words, phrases, sentences, engaging in conversations, producing stories
- Reading
  - Words, sentences, short stories, chapter books, etc.
  - General topics
  - Domain specific topics (science, social studies, etc)
- Spelling
- Writing
  - Words, sentences, short stories, essays

The problem is that if the child experiences any deficits in the foundational language areas such as listening and speaking, he will most certainly experience difficulties in the more complex areas of language which is reading and writing.

The authors continue by explaining the complexity of various labels given to children with language and learning difficulties under the IDEA 2004, DSM-5, as well as “research literature and nonschool clinical settings”. They conclude that: “the use of different labels by different professionals in different contexts should not obscure the commonalities among children with language disorders, no matter what they are called”.

Then they go on to explain that longitudinal (over a period of time) research has revealed numerous difficulties experienced by children with “early language disorders” during school years and in adulthood “in all domains of academic achievement (spelling, reading comprehension, word identification, word attack, calculation)…”. They also point out that many of these children with language disorders were later classified with a learning disability because their “later learning difficulties [took on] the form of problems acquiring higher levels of spoken language comprehension and expression as well as reading and writing”.

The authors also explain the complex process of literacy acquisition as well as discuss the important concept of “illusory recovery“. They note that there may be “a time period when the students with early language disorders seem to catch up with their typically developing peers” by undergoing a “spurt” in language learning, which is followed by a “postspurt plateau” because due to their ongoing deficits and an increase in academic demands “many children with early language disorders fail to “outgrow” these difficulties or catch up with their typically developing peers”.

They pointed out that because many of these children “may not show academic or language-related learning difficulties until linguistic and cognitive demands of the task increase and exceed their limited abilities”, SLPs must consider the “underlying deficits that may be masked by early oral language development” and “evaluate a child’s language abilities in all modalities, including preliteracy, literacy, and metalinguistic skills”.

Finally, the authors reiterate that since language is embedded in all parts of the curriculum “intervention choices should be based on students’ ongoing language learning and literacy problems within curricular contexts, regardless of their diagnostic labels”. In other words, SLPs should actively use the students’ curriculum in the intervention process.

In their conclusion the authors summarize the key article points:

The diagnostic labels may change but the students linguistic needs stay the same. Thus clinicians need to a) “identify existing language/literacy needs that may have been unidentified previously” and b) provide “relevant and functional interventions that are curriculum-based and literacy-focused”
“Early language disorders are chronic and tend to follow children through time, manifesting themselves differently based upon an individual’s inherent abilities”. Thus SLPs need to be keenly aware regarding the nature and timing of “illusory recoveries” NOT to be fooled by them.
“Definitions of literacy have broadened” so “intervention goals and targeted language learning strategies should change accordingly to guide effective and relevant intervention“
“Majority of learning disabilities are language disorders that have changed over time”.

I hope that you’ve found this article helpful in furthering your understanding of these highly relevant yet often misunderstood labels and that this knowledge will assist you to make better decisions when serving the clients on your caseload.

References:

Sun, L & Wallach G (2014) Language Disorders Are Learning Disabilities: Challenges on the Divergent and Diverse Paths to Language Learning Disability. Topics in Language Disorders, Vol. 34; (1), pp 25–38.

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Posted on March 20, 2015January 5, 2022 by Tatyana Elleseff — 4 Comments

Effective Vocabulary Instruction: What SLPs Need to Know

Having a solid vocabulary knowledge is key to academic success. Vocabulary is the building block of language. It allows us to create complex sentences, tell elaborate stories as well as write great essays. Having limited vocabulary is primary indicator of language learning disability, which in turn blocks students from obtaining critical literacy skills necessary for reading, writing, and spelling. “Indeed, one of the , most enduring findings in reading research is the extent to which students’ vocabulary knowledge relates to their reading comprehension” (Osborn & Hiebert, 2004)

Teachers and SLPs frequently inquire regarding effective vocabulary instruction methods for children with learning disabilities. However, what some researchers have found when they set out to “examine how oral vocabulary instruction was enacted in kindergarten” was truly alarming.

In September 2014, Wright and Neuman, analyzed about 660 hours of observations over a course of 4 days (12 hours) in 55 classrooms in a range of socio-economic status schools.

They found that teachers explained word meanings during “teachable moments” in the context of other instruction.

They also found that teachers:

Gave one-time, brief word explanations
Engaged in unsystematic word selection
And spent minimal time on vocabulary devoted to subject areas (e.g., science and social studies in which word explanations were most dense)

They also found an economic status discrepancy, namely:

Teachers serving in economically advantaged schools explained words more often and were more likely to address sophisticated words than teachers serving in economically disadvantaged schools.

They concluded that “these results suggest that the current state of instruction may be CONTRIBUTING to rather than ameliorating vocabulary gaps by socioeconomic status.”

Similar findings were reported by other scholars in the field who noted that “teachers with many struggling children often significantly reduce the quality of their own vocabulary unconsciously to ensure understanding.” So they “reduce the complexity of their vocabulary drastically.” “For many children the teacher is the highest vocabulary example in their life. It’s sort of like having a buffet table but removing everything except a bowl of peanuts-that’s all you get“. (Excerpts from Anita Archer’s Interview with Advance for SLPs)

It is important to note that vocabulary gains are affected by socioeconomic status as well as maternal education level. Thus, children whose family incomes are at or below the poverty level fare much more poorly in the area of vocabulary acquisition than middle class children. Furthermore, Becker (2011) found that children of higher educated parents can improve their vocabulary more strongly than children whose parents have a lower educational level.

Limitations of Poor Readers:

Poor readers often lack adequate vocabulary to get meaning from what they read. To them, reading is difficult and tedious, and they are unable (and often unwilling) to do the large amount of reading they must do if they are to encounter unknown words often enough to learn them.

Matthew Effect, “rich get richer, poor get poorer”, or interactions with the environment exaggerate individual differences over time. Good readers read more, become even better readers, and learn more words. Poor readers read less, become poorer readers, and learn fewer words. The vocabulary problems of students who enter school with poorer limited vocabularies only exacerbate over time.

However, even further exacerbating the issue is that students from low SES households have limited access to books. 61% of low-income families have NO BOOKS at all in their homes for their children (Reading Literacy in the United States: Findings from the IEA Reading Literacy Study, 1996.) In some under-resourced communities, there is ONLY 1 book for every 300 children. Neuman, S., & Dickinson, D. (Eds.). (2006) Handbook of Early Literacy Research (Vol. 2). In contrast, the average middle class child has 13+ books in the home.

The above discrepancy can be effectively addressed by holding book drives to raise books for under privileged students and their siblings. Instructions for successful book drives HERE.

So what are effective methods of vocabulary instruction for children with language impairments?

According to (NRP, 2000) a good way for students to learn vocabulary directly is to explicitly teach them individual words and word-learning strategies .

For children with low initial vocabularies, approaches that teach word meanings as part of a semantic field are found to be especially effective (Marmolejo, 1991).

Many vocabulary scholars (Archer, 2011; Biemiller, 2004; Gunning 2004, etc.) agree on a number of select instructional strategies which include:

Rich experiences/high classroom language related to the student experience/interests
Explicit vs. incidental instruction with frequent exposure to words
Instructional routine for vocabulary
- Establishing word relationships
- Word-learning strategies to impart depth of meaning
- Morphological awareness instruction

Response to Intervention: Improving Vocabulary Outcomes

For students with low vocabularies, to attain the same level of academic achievement as their peers on academic coursework of language arts, reading, and written composition, targeted Tier II intervention may be needed.

Tier II words are those for which children have an understanding of the underlying concepts, are useful across a variety of settings and can be used instructionally in a variety of ways

According to Beck et al 2002, Tier II words should be the primary focus of vocabulary instruction, as they would make the most significant impact on a child’s spoken and written expressive capabilities.

Tier II vocabulary words

High frequency words which occur across a variety of domains conversations, text, etc.
Contain multiple meanings
Descriptive in nature
Most important words for direct instruction as they facilitate academic success
- Hostile, illegible, tolerate, immigrate, tremble, despicable, elapse, etc.

According to Judy Montgomery “You can never select the wrong words to teach.”

Vocabulary Selection Tips:

Make it thematic
Embed it in current events (e.g., holidays, elections, seasonal activities, etc)
Classroom topic related (e.g., French Revolution, the Water Cycle, Penguin Survival in the Polar Regions, etc)
Do not select more than 4-5 words to teach per unit to not overload the working memory (Robb, 2003)
Select difficult/unknown words that are critical to the passage meaning, which the students are likely to use in the future (Archer, 2015)
Select words used across many domains

Examples of Spring Related Vocabulary

Adjectives:

Flourishing
Lush
Verdant
Refreshing

Nouns:

Allergies
Regeneration
Outdoors
Seedling
Sapling

Verbs

Awaken
Teem
Romp
Rejuvenate

Idiomatic Expressions:

April Showers Bring May Flowers
Green Thumb
Spring Chicken
Spring Into Action

Creating an Effective Vocabulary Intervention Packets and Materials

Sample Activity Suggestions:

Text Page (story introducing the topic containing context embedded words)
Vocabulary Page (list of story embedded words their definitions, and what parts of speech the words are)
Multiple Choice Questions or Open Ended Questions Page
Crossword Puzzle Page
Fill in the Blank Page
True (one word meaning) Synonym/Antonym Matching Page
Explain the Multiple Meaning of Words Page
Create Complex Sentences Using Story Vocabulary Page

Intervention Technique Suggestions:

1.Read vocabulary words in context embedded in relevant short texts

2.Teach individual vocabulary words directly to comprehend classroom-specific texts (definitions)

3.Provide multiple exposures of vocabulary words in multiple contexts, (synonyms, antonyms, multiple meaning words, etc.)

4.Maximize multisensory intervention when learning vocabulary to maximize gains (visual, auditory, tactile, etc.)

5.Use multiple instructional methods for a range of vocabulary learning tasks and outcomes (read it, spell it, write it in a sentence, practice with a friend, etc.)

6.Use morphological awareness instruction (post to follow)

An ability to recognize, understand, and use word parts (prefixes, suffixes that “carry significance” when speaking and in reading tasks

Conclusion:

Having the right tools for the job is just a small first step in the right direction of creating a vocabulary-rich environment even for the most disadvantaged learners. So Happy Speeching!

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Posted on March 3, 2015January 5, 2022 by Tatyana Elleseff — Leave a comment

Assessing and Treating Bilinguals Who Stutter: Facts for Bilingual and Monolingual SLPs

Introduction: When it comes to bilingual children who stutter there is still considerable amount of misinformation regarding the best recommendations on assessment and treatment. The aim of this article is to review best practices in assessment and treatment of bilingual children who stutter, to shed some light on this important yet highly misunderstood area in speech-language pathology.

Types of Bilingualism: Young bilingual children can be broadly divided into two categories: those who are learning several languages simultaneously from birth (simultaneous bilingual), and those who begin to learn a second language after two years of age (sequential bilingual) (De Houwer, 2009b). The language milestones for simultaneous bilinguals may be somewhat uneven but they are not that much different from those of monolingual children (De Houwer, 2009a). Namely, first words emerge between 8 and 15 months and early phrase production occurs around +/-20 months of age, with sentence production following thereafter (De Houwer, 2009b). In contrast, sequential bilinguals undergo a number of stages during which they acquire abilities in the second language, which include preproduction, early production, as well as intermediate and advanced proficiency in the second language.

Stuttering and Monolingual Children: With respect to stuttering in the monolingual children we know that there are certain risk factors associated with stuttering. These include family history (family members who stutter), age of onset (children who begin stuttering before the age of three have a greater likelihood of outgrowing stuttering), time since onset (depending on how long the child have been stuttering certain children may outgrow it), gender (research has shown that girls are more likely to outgrow stuttering than boys), presence of other speech/language factors (poor speech intelligibility, advance language skills etc.) (Stuttering Foundation: Risk Factors). We also know that the symptoms of stuttering manifest via sound, syllable and word repetitions, sound prolongations as well as sound and word blocks. In addition to overt stuttering characteristics there could also be secondary characteristics including gaze avoidance, word substitutions, anxiety about speaking, muscle tension in the face, jaw and neck, as well as fist clenching, just to name a few.

Stuttering and Bilingual Children: So what do we currently know regarding the manifestations of stuttering in bilingual children? Here is some information based on existing research. While some researchers believe that stuttering is more common in bilingual versus monolingual individuals, currently there is no data which supports such a hypothesis. The distribution and severity of stuttering tend to differ from language to language and one language is typically affected more than the other (Van Borsel, Maes & Foulon, 2001). Lim and colleagues (2008) found that language dominance influences the severity but not the types of stuttering behaviors. They also found that bilingual stutterers exhibit different stuttering characteristics in both languages such as displaying stuttering on content words in L1 and function words in L2 (less-developed language system). According to Watson & Kayser (1994) key features of ‘true’ stuttering include the presence of stuttering in both languages with accompanying self-awareness as well as secondary behaviors. This is important to understand giving the fact that bilingual children in the process of learning another language may present with pseudo-stuttering characteristics related to word retrieval rather than true stuttering.

Assessment of Bilingual Stutterers: Now let’s talk about aspects of the assessment. Typically assessment should begin with the taking of detailed background history regarding stuttering risk factors, the extent of the child’s exposure and proficiency in each language, age of stuttering onset, the extent of stuttering in each language, as well as presence of any other concomitant concerns regarding the child’s speech and language (e.g., suspicion of language/articulation deficits etc.) Shenker (2013) also recommends the parental use of perceptual rating scales to assess child’s proficiency in each language.

Assessment procedures, especially those for newly referred children (vs. children whose speech and language abilities were previously assessed), should include comprehensive assessments of speech and language in addition to assessment of stuttering in order to rule out any hidden concomitant deficits. It is also important to obtain conversational and narrative samples in each language as well as reading samples when applicable. When analyzing the samples it is very important to understand and make allowance for typical disfluencies (especially when it comes to preschool children) as well as understand the difference between true stuttering and word retrieval deficits (which pertain to linguistic difficulties), which can manifest as fillers, word phrase repetitions, as well as conversational pauses (German, 2005).

When analyzing the child’s conversational speech for dysfluencies it may be helpful to gradually increase linguistic complexity in order to determine at which level (e.g., word, phrase, etc.) dysfluencies take place (Schenker, 2013). To calculate frequency and duration of disfluencies, word-based (vs. syllable-based) counts of stuttering frequency will be more accurate across languages (Bernstein Ratner, 2004).

Finally during the assessment it is also very important to determine the family’s cultural beliefs toward stuttering since stuttering perceptions vary greatly amongst different cultures (Tellis & Tellis, 2003) and may not always be positive. For example, Waheed-Kahn (1998) found that Middle Eastern parents attempted to deal with their children’s stuttering in the following ways: prayed for change, asked them to “speak properly”, completed their sentences, changed their setting by sending them to live with a relative as well as asked them not to talk in public. Gauging familial beliefs toward stuttering will allow clinicians to: understand parental involvement and acceptance of therapy services, select best treatment models for particular clients as well as gain knowledge of how cultural attitudes may impact treatment outcomes (Schenker, 2013).

Image courtesy of mnsu.edu

Treatment of Bilingual Stutterers: With respect to stuttering treatment delivery for bilingual children, research has found that treatment in one language results in spontaneous improvement in fluency in the untreated language (Rousseau, Packman, & Onslow, 2005). This is helpful for monolingual SLPs who often do not have the option of treating clients in their birth language.

For young preschool children both direct and indirect therapy approaches may be utilized.

For example, the Palin (PCI) approach for children 2-7 years of age uses play-based sessions, video feedback, and facilitated discussions to help parents support and increase their child’s fluency. Its primary focus is to modify parent–child interactions via a facilitative rather than an instructive approach by developing and reinforcing parents’ expertise via use of video feedback to set own targets and reinforce progress. In contrast, the Lidcombe Program for children 2-7 years of age is a behavioral treatment with a focus on stuttering elimination. It is administered by the parents under the supervision of an SLP, who teaches the parents how to control the child’s stuttering with verbal response contingent stimulation (Onslow & Millard, 2012). While the Palin PCI approach still requires further research to determine its use with bilingual children, the Lidcombe Program has been trialed in a number of studies with bilingual children and was found to be effective in both languages (Schenker, 2013).

For bilingual school-age children with persistent stuttering, it is important to focus on stuttering management vs. stuttering elimination (Reardon-Reeves & Yaruss, 2013). Here we are looking to reduce frequency and severity of disfluencies, teach the children to successfully manage stuttering moments, as well as work on the student’s emotional attitude toward stuttering. Use of support groups for children who stutter (e.g., “FRIENDS”: http://www.friendswhostutter.org/), may also be recommended.

Depending on the student’s preferences, desires, and needs, the approaches may involve a combination of fluency shaping and stuttering modification techniques. Fluency shaping intervention focuses on increasing fluent speech through teaching methods that reduce speaking rate such as easy onsets, loose contacts, changing breathing, prolonging sounds or words, pausing, etc. The goal of fluency shaping is to “encourage spontaneous fluency where possible and controlled fluency when it is not” (Ramig & Dodge, 2004). In contrast stuttering modification therapy focuses on modifying the severity of stuttering moments as well as on reduction of fear, anxiety and avoidance behaviors associated with stuttering. Stuttering modification techniques are aimed at assisting the client “to confront the stuttering moment through implementation of pre-block, in-block, and/or post-block corrections, as well as through a change in how they perceive the stuttering experience” (Ramig & Dodge, 2004). While studies on these treatment methods are still very limited it is important to note that each technique as well as a combination of both techniques have been trialed and found successful with bilingual and even trilingual speakers (Conture & Curlee, 2007; Howell & Van Borsel, 2011).

Finally, it is very important for clinicians to account for cultural differences during treatment. This can be accomplished by carefully selecting culturally appropriate stimuli, preparing instructions which account for the parents’ language and culture, attempting to provide audio/video examples in the child’s birth language, as well as finding/creating opportunities for practicing fluency in culturally-relevant contexts and activities (Schenker, 2013).

Conclusion: Presently, no evidence has been found that bilingualism causes stuttering. Furthermore, treatment outcomes for bilingual children appear to be comparable to those of monolingual children. Bilingual SLPs encountering bilingual children who stutter are encouraged to provide stuttering treatment in the language the child is most proficient in. Monolingual SLPs encountering bilingual children are encouraged to provide stuttering treatment in English with the expectation that the treatment will carry over into the child’s birth language. All clinicians are encouraged to involve the children’s families in the stuttering treatment as well as utilize methods and interventions that are in agreement with the family’s cultural beliefs and values, in order to create optimum treatment outcomes for bilingual children who stutter.

References:

Bernstein Ratner, N. (2004). Fluency and stuttering in bilingual children. In B. Goldstein (ed.). Language Development: a focus on the Spanish-English speaker. Baltimore, MD: Brookes. (287-310).
Conture, E. G., & Curlee, R. F. (2007). Stuttering and related disorders of fl uency. New York, NY: Thieme Medical Publishers.
De Houwer, A. (2009a). Bilingual first language acquisition. Bristol: Multilingual Matters.
De Houwer, A. (2009b). Assessing lexical development in bilingual first language acquisition: What can we learn from monolingual norms? In M. Cruz-Ferreira (Ed.), Multilingual norms (pp. 279-322). Frankfurt: Peter Lang.
German, D.J. (2005) Word-Finding Intervention Program, Second Edition (WFIP-2)Austin Texas: Pro.Ed
Howell, P & Van Borsel, , (2011). Multicultural Aspects of Fluency Disorders, Multilingual Matters, Bristol, UK.
Lim, V. P. C., Rickard Liow, S. J., Lincoln, M., Chan, Y. H., & Onslow, M. (2008). Determining language dominance in English–Mandarin bilinguals: Development of a selfreport classification tool for clinical use. Applied Psycholinguistics, 29, 389–412.
Onslow M, Millard S. (2012). Palin Parent Child Interaction and the Lidcombe Program: Clarifying some issues. Journal of Fluency Disorders37(1 ):1-8.
Tellis, G. & Tellis, C. (2003). Multicultural issues in school settings. Seminars in Speech and Language, 24, 21-26.
Ramig, P. R., & Dodge, D. (2004, September 08). Fluency shaping intervention: Helpful, but why it is important to know more. Retrieved from http://www.mnsu.edu/comdis/isad7/papers/ramig7.html
Reardon-Reeves, N., & Yaruss, J.S. (2013). School-age Stuttering Therapy: A Practical Guide. McKinney, TX: Stuttering Therapy Resources, Inc.
Rousseau, I., Packman, A., & Onslow, M. (2005, June). A trial of the Lidcombe Program with school age stuttering children. Paper presented at the Speech Pathology National Conference, Canberra, Australia.
Shenker, R. C. (2013). Bilingual myth-busters series. When young children who stutter are also bilingual: Some thoughts about assessment and treatment. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse (CLD) Populations, 20(1), 15-23.
Stuttering Foundation website: Stuttering Risk Factors http://www.stutteringhelp.org/risk-factors
Van Borsel, J. Maes, E., & Foulon, S. (2001). Stuttering and bilingualism: A review. Journal of Fluency Disorders, 26, 179-205.
Waheed-Kahn, N. (1998). Fluency therapy with multilingual clients. In Healey, E. C. & Peters, H. F. M. (Eds.),Proceedings of the Second World Congress on Fluency Disorders, San Francisco, August 18. 22(pp. 195–199). Nijmegen, The Netherlands: Nijmegen University Press.
Watson, J., & Kayser, H. (1994). Assessment of bilingual/bicultural adults who stutter. Seminars in Speech and Language, 15, 149-163.

Posted on February 10, 2015January 5, 2022 by Tatyana Elleseff — 4 Comments

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:

Bobrow, A. (2002). Problem behaviors in the classroom: What they mean and how to help. Functional Behavioral Assessment, 7 (2), 1–6.
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.
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.
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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