Improving Pragmatic and Social Cognitive Abilities of Children with Psychiatric Disturbances

“You have to come and observe him! I know the report we got from his previous school district said his language skills were average, but something is really off.” These were the words I heard from one of the classroom teachers, at my work, which just happens to be an out-of-district school program within a psychiatric day treatment facility. In our transitional program we work with children who, due to their complex diagnoses (e.g., personality, mood, anxiety, and attachment disorders), frequently cannot be accommodated within their local school district until their behaviors can be managed more effectively.

So, I set up a series of observation times for the child in question, a bright seven year-old boy named J.R. Before I did that, I carefully reviewed his records, particularly a speech and language report. A solid language test was administered, scores were explained appropriately, child did not qualify for speech-language services, end of story – but is it? After barely a 10 minute observation of JR in the recreation room, I certainly saw what the teacher meant. Despite possessing average language skills and intelligence, JR didn’t know the first thing about playing and interacting with his peers. He attempted to join games at the most inappropriate times, he tried to dominate every single conversation, and when his peers finally let him join in, he threw a tantrum when he lost a board game. Even when his peers initiated conversations with him, his responses were frequently tangential and his interests were too immature for his age, so other children quickly lost interest in further interacting with him.

To many of us in the field these are all clear signs of social pragmatic language deficits. Formal and informal testing in this area confirmed my initial impressions. The above behaviors interfere significantly with JR’s academic success in the classroom and with his social interactions in school setting, yet somehow in his language assessment report, the social pragmatic language component was not addressed.

JR’s case is not unique. Many of us routinely assess and treat social pragmatic deficits of children on the autistic spectrum. Yet, quite often, I receive speech and language evaluations on a child, diagnosed with emotional, behavioral, and psychiatric disturbances (classified as Emotionally Disturbed or Other Health Impaired in the IEP), which do not include pragmatic language assessments nor make any requests with respect to future assessment or remediation of difficulties in this area. Yet, it’s clearly evident that the child strongly needs these skills for both social and academic success.

It is very important to understand that children with psychiatric diagnoses need more than just medicine and behavior management to make them better. They need to gain the appropriate vocabulary and language abilities to talk about emotions (own and others), understand verbal and nonverbal social cues, as well as routinely engage in perspective taking, all of which, we speech-language pathologists can teach them. More awareness and advocacy is needed among speech-language professionals to understand that given appropriate goal design, we can effectively address social cognitive abilities and positively improve these children’s functioning in both school and social settings.

 

Tatyana Elleseff, MA CCC-SLP, is a bilingual speech-language pathologist. Presently she works for the University of Medicine and Dentistry of New Jersey and has a private practice in Somerset, NJ. She is a New York University Master’s Level graduate with Bilingual Certification from Columbia University. She is licensed by the state of New Jersey and holds a Certificate of Clinical Competence from ASHA. She specializes in working with bilingual, multicultural as well as internationally adopted children with complex medical, developmental, neurogenic, psychogenic, and acquired communication disorders.

Comments

  1. It is so nice to see that other SLP’s are seeing this as an area of need for these students. I also work with students in our district’s day treatment program, and our behavior and social development programs. I see many of these students that are underserved in the schools, and they make gains with just a little bit of service. We need to remember that just because they have significant behavior difficulties, doesn’t mean that they can’t benefit from service. It may take longer to develop rapport with them, but eventually the do begin to make gains.

  2. Many distict SLPs have a HUGE case load (60, 68, 75) students. These SLPs work many long hours after school (when everyone else leaves for the day) on paperwork etc. There are sooooo many demands on them (SLPs) in the school districts on top of serving a large number of students. In a perfect world, the SLPs would love to service every single child who needed help whether how mild the impairment was……..HOWEVER….there is not enough hours in the day and they must follow district guide lines.

    • Amanda,
      I do agree with you many school based SLP’s do have very demanding caseloads with a staggering number of students. Unfortunately there’s often not too much that can be done about that. However, I do respectfully disagree that we should just leave things as they are, without attempting to implement meaningful changes, to benefit the children we are working with. Just saying, I have too many kids, so I can’t possibly help them all, is not a constructive solution to this issue. However, greater education in this area on the part of SLP’s is the first step in finding a balance between workload demands and service delivery.
      There are a number of ways school based SLPs can implement social pragmatics assessment and training with these students – Especially in group therapy settings. Lesson plan design can easily contain one extra component focused on social language in conjunction with vocabulary, listening comprehension and whatever else you just happen to be working on. Certainly during the assessment, the SLPs can at least document the child’s social pragmatic difficulties observed in the classroom settings (all it takes is just a few minutes and good interviewing skills, or just sending a questionnaire to the teacher if you are that pressed for time). I think the issue is far more complex then just caseload size. I think that more professional education and greater advocacy and awareness is needed because frankly, despite tremendous strides that have been made by numerous SLP’s with respect to pragmatic/social cognitive assessment/remediation of school age students there are still a large number of professionals in our field who are unsure of how to appropriately assess and address these skills and integrate them with the state educational curriculum standards.

  3. I have a few of these students on caseload. I always do a pragmatic assessment. I think any student with ED dx will have deficits in this area.

    I worked on a dual diagnosis unit with adolescents at a Mental Health facility some years ago. Goals at that time focused more on language and vocabulary as opposed to social skills per se, but appropriate behavior was encouraged and reinforced.

    What I noticed over 2-3 years was that as their mental status improved, their social skills did as well. They were less likely to misinterpret comments and situations and were less irritable. They exhibited more instances of seeking out social interactions with others. Their comments were more lucid and less tangential. All were seen by a psychologist for individual and group counseling and a psychiatrist for brief counseling and medication management.

    When these clients experienced periods of decompensation, a marked reduction in social skills returned.

    I’d love to increase my skill and knowlege base so I better advocate with supervisors and administration for these students. Can you share any articles you have that support the efficacy of social skills training for ED students (excluding spectrum disorders).

    Thanks!

  4. Lila,
    Below is just a small sample of articles/ sources that supports the efficacy of social skills training for ED students (excluding spectrum disorders)

    1. Michelle Garcia Winner Thinking About You, Thinking About Me 2003 (just one of her many books supporting the teaching of social cognitive skills to students with average -high average IQ) while its focused largely on children with NVLD, HFA, and AS you can certainly use this resource to support teaching children with ED social skills

    2. Teaching the Language of Feelings to Students With Severe Emotional and Behavioral Handicaps 1995 (Jane J. Giddan, Karen M. Bade, Debra Rickenberg, Anderia Trail Ryley)

    3. School Children With Emotional Problems and Communication Deficits: Implications for
    Speech-Language Pathologists 1991 (Jane J. Giddan)

    4. Pragmatic Language Intervention for Children with Language and Emotional Brehavioral Disorders 2001 (Hyter, Simmons, Rogers -Adkinson, Self, Jantz)

    5. A CLINICAL APPRAISAL OF THE PRAGMATIC ASPECTS OF LANGUAGE 1987 (CAROL A. PRUTTING, DIANE M. KIRCHNER)

    6. Language and Social Skills in the School-Age Population Language, Social Skills, and Socioemotional Behavior 1993 (Bonnie Brinton, Martin Fujiki)

    if you need more information please feel free to email me privately

  5. I love this blog! I just found it and will be back. Keep up the good work.

  6. Brenda Arsenault says:

    Hi, would you mind telling me what formal test you used?
    Thanks

  7. Brenda,
    I typically don’t restrict myself to just one test. I try to select my testing materials based on a number of factors including: child’s presenting behaviors and reported weaknesses, full scale IQ, extent of medical/psychiatric involvement, etc. Below is just a small selection of formal and informal assessments which I use that deal with various aspects of pragmatic language and social cognitive functioning (there are a lot of others and I am not even mentioning the protocols which directly assess executive functions).

    1. Children’s Communication Checklist-2 (CCC–2)
    2. Test of Narrative Development (TNL) or a thorough informal assessment of narrative ability for both children and adolescents (Marilyn Nippold: Language Sampling with Adolescents)
    3. Test of Language Competence Expanded Edition (TLC-E)
    4. Test of Pragmatic Language-2 (TOPL-2)
    5. Social Emotional Evaluation (SEE)
    6. Dynamic Informal Social Thinking Assessment / ILAUGH Model (Michelle Garcia Winner)
    7. Social Language Development Test -Elementary (SLDT-E)
    8. Social Language Development Test -Adolescent (SLDT-A)
    9. Test of Problem Solving (Adolescent and Elementary versions)

    • Judy Roa says:

      Hi Tatyana,

      My child is 5 year old and diagnosed with Autism last year. He is High Functioning. He will be having a re-eval soon. We live in Jersey city, What test would be suggested in particular for a 5 year old going to Kindergarten.

      For Pragmatic speech, which tests would you suggest.

      Thanks,
      Judy

  8. Tatyana-
    I work at a school district and I, like many others, have an incredible caseload. I do a lot of social or pragmatic therapy with several different types of kids. I have the most success with students who are on the Autism Spectrum or who are unaware of their social differences. I use a lot of Michelle Garcia Winner’s social thinking concepts as well as picking and choosing from others. I have some student’s on my caseload whom I serve for social or pragmatic communication, however, they are mostly aware of the social rules, vocabulary, and how their behaviors affect others. How do you work on social or pragmatic skills with student’s who appear to be knowledgeable about the skills, but choose to not use them? I have all sorts of ideas, but I want to know how you approach these kinds of students.
    Thank you!

  9. Emily,
    Great question. There could be several answers to it.
    1. Knowing the social rules and applying them to a specific situation are actually two different skills. If it’s an issue of application then the student needs to be explicitly taught (how to apply what he knows to different situations and practice it in various settings).
    2. However, if this is an issue of deliberately not doing something then the question is “What is the student gaining (positive reinforcement) from this behavior?” I currently have several children on my caseload with diagnoses of Oppositional Defiant Disorder, who definitely do gain something by defying and provoking others. Typically, behaviorists try two options in this situation either provide negative reinforcement/consequences to extinguish this behavior, or find some social reinforcer that may motivate the children to change. I myself am on the “motivator” side. If the child is socially invested in something than they are far more likely to change their behavior. If #2 is the case with your students then try to do a modified FBA to see what triggers lack of follow through and what do they gain from it.
    Hope this Helps
    Tatyana

  10. Barbara Froman says:

    I certianly agree with pragmatic language skills need to be taught to children with complex mental health issues. However, from my own personal experience, I firmly believe a team approach is the only way to effectively help these children. And to say “well, it’s pragmatic language” gives administration an easy way to go for the cheapest treatment option. This can put clinicians at risk, esp. in a small community. Any clincian, not just the SLP.
    When I worked as a school SLP, I also had an insanely heavy caseload. The proverbial straw that broke this camel’s back was 5 charts for 5 young men at one of the schools I covered. Each young man had very serious psychiatric disorders, including a “psycho-sexual disorder”, what ever that was. Administration at the schools assigned me to see these young men, one on one, with no back up in case of emergency. 3 of the young men had a history of violence. When I protested, I was told “They have to see someone and you’re it”
    I was repeatedly threatened by one of these young men, and he knew where I lived and he knew I lived alone. This young man had already commited one violent offence again a female, so I knew there was a good chance he would carry out his threat against me. No help from administration or local law enforcement was forthcoming.

    I broke contract and moved out of the state. I just couldn’t work at that school division any more. My disenchantment with the job had been growing, but the flagrant disregard for my safety was where I had to draw the line.

    So while yes, these kids desperately need pragmatic language services, we need to be very careful in how the programme is structured. No one should be placed in the position I was placed in.

  11. Barbara Harden says:

    I also left the schools for similar reasons. I now work in healthcare which has its own issues but paperwork is minimal and you only see as many kids as the hours you have available. I have often shared with my colleagues, during shortages of SLP’s it is crucial that we work the contract we are given. If your contract says you work 38.5 hours DO NOT WORK LONGER. It is the only way to put pressure on the district. Working beyond your contracted hours sends a clear message: I care more about the immediate needs of my current caseload than I do providing ethical and appropriate intervention. In addition, pressure needs to be put on state legislatures and the Federal Legislatures. ASHA acknowledges the problem but the solution has been to identify ‘workload’ versus caseload, which VERY few special education and school administrators buy into. The other issue is that ASHA put a lot of federal pressure when it looked like there would be caps put on the number of sessions in the arena of healthcare. It was effective in preventing some of the caps. School SLP’s are the bulk of ASHA membership and yet ASHA does less to advocate politically for major changes in the schools. Contact your state speech-language association and SCREAM for political advocacy. Then as a state group contact your federal legislators as well as your state representatives. Emphasize impact on kids due to watered down services. Typically legislators are relatively unconcerned about working conditions for SLPs but are more likely to listen to the ultimate impact on kids when educational policies are unrealistic in implementation.
    When we expand our services and scope of practice without addressing the impact of practical application, any help we do provide tends to be minimized. I’m nearing the end of a 33 year career in Speech-language path. I’ve worked in the schools for 20 of those 33 years with stints in clinics, statewide needs grants and universities. As a group, I find the SLPs are more ‘go along to get along’ than they are boat rockers. We need to rock the boat!!!