Toddler Talking Points

toddler blog

Toddlers are some of my favorite people—they explore with abandon, imitate pirates and fairies, refuse with gusto, stack, dump and search, communicate with persistence, and give enthusiastic hugs with sloppy kisses. So why would we get in their way? One of the most common mistakes I see parents make with their toddlers is to ask too many questions, which actually inhibits their language.

I arrived at a home this week, to evaluate an 18-month-old boy, whose mom was concerned he was delayed in talking. As our play session progressed, it was apparent that he wasn’t far behind, using many words meaningfully in his little world, like “milk,” “ball,” and “car.” When I watched his mother interact with him, she was questioning him with, “What’s that?” or “Can you say ‘book’?” I gently suggested that when we ask too many questions, especially for the child to perform, it is not natural and many times the child clams up. They are smarter than you think and can feel the pressure.

Rather than questioning, model a word, phrase or sentence related to what your toddler is doing at the time. When we talk about what she is focusing on, she can take in more language since it relates to her experience. When she chooses a book, simply say, “Book. Let’s read our book. This book is about the beach.”

Joining your child’s play, following their lead and talking about what they are playing with can boost their language development. Selecting appropriate toys for learning at this stage engages the child and builds cognitive and language skills. Pretend play begins to emerge at around 1 year of age and progresses as a child imitates the adults around him. At one year of age, a teddy bear, cup, spoon, and blanket can encourage a little story, while a two year-old will enjoy pushing a fire truck into the station.

Look for toys that have a few related props for open-ended play that your child can direct. Playmobil’s 1.2.3 sets are geared for toddlers, providing simpler chunky figures that only take a twist to sit them down, or ride on an animal. The Playmobil 1.2.3. Large Zoo comes with fence sections to enclose the animals, a tractor and detachable trailer to deliver the food, and plenty of people, including mom and baby to chat on a park bench.

Doll play encourages dialogue and imagination as children care for and take their friend out on activities. Corolle‘s premier dolls, geared for age appropriate play from infant and up, has just introduced a new doll that loves the water,

Bébé Bath & Accessories.” Pack up for a snorkeling adventure in the tub, complete with floaties, flippers and a snorkel mask!

Thinkfun’s “Hello Sunshine” joins their first toddler game, “Roll ‘n Play” which was popular with toddlers and their moms last year. I am more frequently asked for toy suggestions by parents of toddlers than any other age, which might explain why these simple starter games provide more structure for parents and caregivers who appreciate some guidance on where to start their play. Hide the plush Sunshine ball according to picture cards depicting positions such as in a box or on top of your head!

Flexible, multi-use toys are my favorites as HABA’s Arranging Game My Animal Friends can be a flat puzzle of 17 interlocking, brightly colored wooden pieces or a three-dimensional story making houses, bridges, or towers while stars, a fence, bridge and grass provide the backdrop for a cat, dog, mouse, frog, ladybug, and bee to carry on with the storytelling.

WOW Fire Rescue Rory is a parent’ s dream because it has only four pieces but so much potential for creative play. The helicopter is powered by kids, pulling the trigger, activating the friction motors to fly to the rescue. A casted figure slips into the stretcher to be scooped up by Rory thanks to a magnet system. Kids love to transport the injured person and release him to a doctor’s care. The story is totally up to the child as they add on doctors, hospitals and helpers.
Finally, an excellent resource for parents is “My Toddler Talks, Strategies and Activities to Promote Your Child’s Language Development” by Kimberly Scanlon, MA, CCC-SLP.

So come along side your toddlers and enter into her play, following her lead as she builds a town for her ladybug and bee, feeds the zoo animals, goes for a swim, searches for an injured friend, or delights in finding a little sunshine.
The opinions expressed are solely those of the author. The above products were provided by their companies for review.

Sherry Y. Artemenko MA, CCC-SLP, has worked with children for more than 35 years to improve their speech and language, serving as a speech language pathologist in both the public and private school systems and private practice.

Helping Clients With Aphasia Retrieve Words—On Their Own

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Eric Broder Van Dyke / Shutterstock.com

“I can’t hear it!” This was said by Mrs. A, a 67-year-old woman with aphasia, who actually hears fine. What she meant to say is that she can’t recall the sequence of sounds to express a particular word or idea. When we have that tip-of-the-tongue loss of a name, how do we try to remember it? What strategies are we using to get to that word that we can’t remember?

Our success depends on our ability to hunt and gather—and on the number of neural connections we can tap into to access the information. These skills are cognitive, not simply learned operantly.

In my last blog post, I talked about establishing cueing hierarchies and functional activities for our adult clients. This post looks at using the cueing hierarchy to stimulate the rewiring process. Sometimes I think that I am a sort of electrician rather than an SLP. I work on finding the connections based on observed behavior from evaluations or activities (like writing, gesturing or drawing) that require least intervention.

How do we develop these skills? How can we teach strategies for short and long-term functional success?

Sometimes, we spend the therapy session working on the most disabled aspects of the communication disorder: comprehension, word retrieval, writing and reading. But if we don’t tap clients’ best abilities to foster some success, and if we don’t address whether they are continuing to practice these skills outside the therapy room, how will compensatory skills, adaptive skills and new connections work for them?

Let’s look at Mrs. A, who said, “I can’t hear it.” She was telling me about the very connection that she lacks due to her aphasia: re-auditorization. She can’t hear the words or the phonemes that make up the words in what I call “her mind’s ear.” If given the first phoneme, or a carrier phrase, she almost always names the word. She is able to write the word about 75 percent of the time but can only read it aloud about 30 percent of the time. She will often be able to speak complex multisyllabic words or a short phrase when discussing a topic. Auditory and reading comprehension is 75 percent for paragraphs. She is very intact cognitively, but her affect varies emotionally from congenially engaged to depressed and angry.

She is about two years post-stroke and has an all-in-one AAC that she doesn’t use. Our goals must address her frustration by establishing immediate successful compensatory strategies for communication. Then we need to build skills that will help in the rewiring, so that she begins to cue herself. The rewiring will be difficult here because she doesn’t link the phoneme to the letters she is able to write. But if she can write the word and then read it aloud more often, she can develop a clear strategy for verbalization that will reduce her frustration.

We will begin by simply reviewing phonetic placement in monosyllabic words. I like to use real words—which have semantic value—rather than nonsense syllables. Consonant-vowels alone don’t work as well as consonant-vowel-consonants that mean something. Mrs. A started relearning that a /b/ means that the lips come together when starting a whole word like “beer.” We chose beer for the visceral, emotional connection it has for many people. We talked about when she might drink beer, such as at a baseball game, which lends itself to picture assistance to boost cognitive links. We initially used a mirror to model the placement while sitting next to her. We highlighted the first letter and said it with her. She saw the picture, then wrote the word.

Mrs. A can now produce the whole word “beer” after seeing a picture of it. Looking at the Cueing Hierarchy, we have moved from most clinician involvement to independent self-cueing for this phoneme. She is moving on to more phonemes rapidly so that we may not need to review every letter after a period of time. Mrs. A. is beginning to generalize the link to other sounds. New neuro-behavioral links and relinks are helping her associate the orthographic letter with a physical movement and the sound that is produced. New cognitive links and self-cueing has begun!

Next, she will need to use the strategy in controlled conversation and small groups to increase her comfort level and functional use outside of treatment. This is a big hurdle. Families and caregivers are crucial players and need to be instructed how to encourage communication without frustration. When possible, teach the caregivers and families how the strategy works. They will use it more readily at home and will see how it can work in a variety of situations, such as in restaurants.

Another client, Mrs. C, had a similar functional ability to write but not verbalize. With time, she was able to trace the first letter in the air to cue herself to say a word.

In both cases, skills that had been present were improved, then used to create a compensatory strategy for functional communication. We must teach our clients strategies for improving the scope of their communication without our cues, using their own strategies, thereby making them more independently functional. While available strategies are unique to each client, they usually take the form of low tech gesturing, drawing, writing, even circumlocution.

We want our clients to be learning and improving communication dynamically. If we always fill in all of the sentences or speak for them, they cannot make their own connections. When allowed to use strategies independently, they then blossom, not only communicatively but socially.

Betsy C. Schreiber, MMS, CCC-SLP, is a clinical supervisor at Ladge Speech and Hearing Clinic at LIU/Post on Long Island, and a partner at Hope 4 Speech Associates, P.C. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders, and 18, Telepractice.

Put ABA to Work: Tie Behavior to Language Goals for Kids on the Spectrum

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When I was in graduate school in the mid-90s, a family hired me to take care of their two-year old son, Jayden. He did not imitate or make any sounds. Jayden was an adorable toddler with autism who preferred to stare at the patterns on his kitchen floor or the spinning fan in his living room. His loving family flew halfway across the country several times a month to learn about the Lovaas method of applied behavioral analysis (ABA).

To get their son to speak, they flew in ABA-trained specialists, who wrote a binder of lesson plans and left them for graduate students like me to carry out. There were four fairly clueless graduate students who implemented the lessons in four-hour shifts. From our combined efforts, their little boy received eight hours of ABA services a day—every day—focused on communication and play.

Our lessons would go something like this: First, I would show Jayden a picture of an ordinary item, such as an apple. Then I would say, “Apple.” If the toddler made an approximated sound, I gave him a mini-marshmallow. We repeated this exercise in succession dozens of times. My novice grad-school self would wonder, “Does this kid understand the experience of an apple? Or does he now think an apple is a marshmallow?”

Twenty years later, I am a school-based practitioner. Eighty percent of my kids are children with autism, a majority with severe communication challenges. I work closely with several board-certified behavioral analysts, and many behaviorally trained paraprofessionals. I’ve developed an understanding of ABA principles, and the realization that reinforcement compels behaviors to continue or change. We all abide by these principles: You go to work, you get money and derive some job satisfaction. Because your duties are reinforcing (some days more than others), you continue to come into work. It is the same with language and ABA: I show you something is worth requesting, and you start to learn to ask for it by whatever means—pictures, signs, gestures—you need to.

Holistic learning

As practitioners, we must re-examine skill mastery. Mastery is beyond 4/5 opportunities in my speech session, or 8/10 trials with a paraprofessional in a cubicle. Skill mastery demands holistic consideration. We learn through schemas—that is, our experiences shape our understanding of the world. If we have no prior knowledge, then our ability to retain that information is reduced dramatically. If I talk about my vacation to the beach, we all produce a somewhat similar multi-sensory image in our head: There’s an ocean or a lake, sand and the various sounds and smells of a beach. Now imagine if you have never been to the beach (or heard of one) and someone shows you a picture. Then they hand you a marshmallow … do you think marshmallow is another word for beach? Have you really learned about a beach?

On occasion, I will inherit an individualized education program chock-full of language objectives written by someone other than an SLP. However, some of the most effective IEPs I have seen have been created through the coordinated efforts of SLPs collaborating with board-certified behavioral analysts.

Here are some good ways to keep meaningful language consideration alive and well when thinking about IEPs, communication, language and ABA principles:

Tease out language versus behavior.

Although language may provide a function, it does not always reduce behavior. This is why it is important for the team to use tools like preference assessments and functional behavior analyses. Little Susie may be pulling your hair because she wants your attention, or perhaps she is pulling your hair because she doesn’t want to wait. In the first example, the SLP could teach the language (e.g., “I want to talk to you.”). But in the second example, teaching the language “I don’t want to wait” may not be sufficient, because the child may act out anyway (picture a two-year-old being told to wait). In this case, a behavioral intervention with something other than words may be more appropriate.

Examine the language-behavior plan connection.

Behavioral support plans are a great way for the team to address behavior in a consistent way. Many behavior plans that come my way are language-laden. This is a great opportunity to work with board-certified behavioral analysts and other team members in refining what language to use with the child at his or her developmental level, while also refining functional communication.

Combine ABA with language and academic goals.

For my students whose IEPs include ABA, one great way to work on generalization through immersion is having the paraprofessional run programs that address “speech and language” goals. For many of my students who have a board-certified behavioral analyst, each goal area on the IEP has an ABA program that corresponds to each objective. I collaborate with the board-certified behavioral analyst on presentation and prompt hierarchies so that we can all agree on the student’s current performance and level of independence. Paraprofessionals take data for each program. Come progress report time, I consult the data collected from staff and combine it with my own. This allows the team to identify discrepancies in how content is delivered, and provides a great opportunity for the team to troubleshoot any issues in terms of skill mastery or curriculum modifications.

Final thoughts.

The overlap between language, communication and behavior is undeniable. Keeping language separate from behavior can ultimately compromise your teaching process’s efficiency. Schools and special education teams need to carve out opportunities for behavioral specialists and speech-language pathologists to collaborate, and think beyond the “reward” of the mini-marshmallow.

Dr. Kerry Davis is a city-wide speech-language pathologist in the Boston area. Her areas of interest include working with children with multiple disabilities, inclusion in education and professional development. The views on this blog are my own and do not represent those of my employer. Dr. Davis can be followed on Twitter at @DrKDavisslp.

Writing an Article for Special Interest Group Perspectives

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You’ve never contemplated writing a research article since you left college, right? Perhaps writing in your field was something someone else did? No time, interest, or motivation to pursue such a professional endeavor? If you have a passion for your work, you can write that article if you simply approach it in steps. Start with your topic and what would you like to share with colleagues. It could be a therapy approach, new information about a specific population, or facilitating your documentation. Start compiling information through your search engines such as Google Scholar and ASHA’s research databases. Start bookmarking abstracts and articles on your topic. You’ll discover there are many facets that you never considered–bookmark those too. As you gather information, you’ll learn more about your subject.

The next step is to paste your facts or paraphrase them from your abstracts and articles including your article’s bibliography into a Word document. You’ll notice there are sometimes two, three, or more authors on a specific facet to your topic. This document will be your working template and will give you a basic framework for your article. Your next step is to review and revise your template into a readable paper. As you edit your paper, you’ll find yourself moving portions of your research from beginning to end, omitting data, and going back to your search engine to pursue that one piece of information you’d like to add.

Once your paper is assembled, ask a colleague to read it to see how the paper flows in form and style. Read it again and revise it again. Now it’s ready to be sent to your Perspectives Editor (find the editor for any Perspectives publication under the heading, “Information for Authors.” Example: SIG 15’s Information for Authors.).

My first article I sent off came back with so many revisions and corrections that I felt like I was back in English 101. I felt deflated and intimidated. My issues included simple grammatical errors, citation omissions, spelling and sentence fragments. The only way I was going to get this information out was to fix my mistakes and improve my first draft. You will feel like giving up. I would recommend that you avoid working on it when you encounter a difficult section, but keep chipping away at it. You will ultimately be rewarded for your efforts, learn a great deal about your topic and professional writing, and have the satisfaction to know you’ve written your first article.

My editor taught me a lot about professional writing and surviving the process of editing and revision. I kept my first draft with revisions to document my growth as a writer and researcher.

Once your revisions are completed, read it again, and ask your colleague to read it again. You’re almost done. You now need to write your article’s abstract and submit five questions about your article’s content for continuing education credits for other SLPs. You can do this!

I want to take this opportunity to acknowledge my colleagues who encouraged me to attempt my first article: Ann Kulichik, owner at AK Speech, past SIG 15 Associate Coordinator who inspired me to write; Joanne Wisely, Vice President, Regulatory Administration & Compliance for Genesis Rehab Services, who reviewed my articles and encouraged me to keep writing; Grace Burke, Senior Director of Adult Day Services at Life Senior Services, who was the previous editor of Perspectives and guided me through my first article with patience and professionalism and Anna Feezor, Senior Clinical Specialist at Genesis Rehab Services and present Associate Editor for SIG 15 Perspectives. Thank you!

George A. Voyzey, M. Ed., CCC-SLP, is a speech pathologist for Genesis Rehab Services at Maine General Rehab and Nursing Care at Glenridge in Augusta, Maine, a 125 bed skilled long-term care facility specializing in Alzheimer’s and other dementia care. Mr. Voyzey also serves as a Master Clinician in the area of dementia, a clinical instructor and mentor. He recently had his fourth article published for ASHA’s Special Interest Division 15 (Gerontology) on-line publication, Perspectives, and serves as a coordinating committee member for SIG 15. Mr. Voyzey received his Master’s degree in Communication Disorders from Pennsylvania State University in 1983. 

Kid Confidential: Hearing Loss, Classroom Difficulties, and Accommodations

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(photo credit: sound waves via Bigstock)

Ah, the familiar sounds of rustling papers, fast paced walks from meeting to meeting room, and that all too common groan, a mixture of frustration and exhaustion in equal parts, remind me that it is that time of year in the schools.  It is “IEP season”.

In honor of the countless hours of reassessment, data collection, and paperwork completion you will be doing over the next few months, I thought I’d write a post to help out those of you who are once again, hitting the keyboards and staring at that blank section on your IEP.  You know the one I’m talking about.  You spend a lot of time thinking about it only after all the data and classroom observations are compiled.  You know it needs to be completed but after writing your student’s present level of performance, his goals and objects and of course his service time, who has the energy left to even think about classroom accommodations and modifications.  Well that is where I step in, at least for those of you who have students with hearing loss on your caseloads.

Last year at this time I had a few students with hearing loss managed with both hearing aids and cochlear implant (CI) on my caseload.  As a multidisciplinary team, we had to do some research to find appropriate accommodations and modifications for those students.  However, I recently read the book Children with Hearing Loss: Developing Listening and Talking Birth to Six, by Elizabeth Cole and Carol Flexer which provided some clinically useful information on the specific deficits a child with hearing loss might have in the classroom setting.  I wish I had read this last year while I was struggling with the multidisciplinary team to write an appropriate IEP.  But now that I found this information, I thought I would adapt parts of it and compile that information into a table for quick reference in the future.

The accommodations and modifications in the graphic below are suggestions of possibilities you may attempt to provide for your students.  This is by no means an exhaustive list nor would every student benefit from each suggestion.  Therefore, I recommend you use this list as a guide only while working collaboratively with your multidisciplinary team to determine appropriate accommodations and modifications for each student on an individual basis.

You will notice that the first accommodation for any hearing loss is the use of an FM system alone or in conjunction with auditory management (e.g. hearing aids, cochlear implant, other technology).  Research has shown the use of individual FM systems positively impact students with hearing loss of any severity level AND that classroom or sound field FM systems benefit ALL students.  One can’t help but wonder how different a student’s behavior would be in a classroom where the speech to noise ratio was in fact the recommended +15-20 dB rather than the typical +4 dB (Cole, Flexer 2007).  That is why the recommendation of an FM system is first as it is not only practical but very beneficial even for a child with very mild hearing loss.

Here are the levels of severity, classroom difficulties and possible accommodations and modifications for children with hearing loss.

You can download your copy of the above materials here.

I hope these materials help guide you and your multidisciplinary team when writing IEPs for your students with hearing loss.  Do you have additional modifications or accommodations you would add to this list?  Let us know by commenting below.

Thanks for stopping by and reading our second installment of Kid Confidential.  If you have any topics you would like us to discuss here, feel free to share.  You just might see your topic suggestion in one of the upcoming columns.  I’ll meet you back here on the second Thursday of next month.

Until then, remember, knowledge is power, so let’s keep learning!

References:

  • Cole, Elizabeth, and Carol Flexer. Classroom Accommodations for Students with Hearing Impairment. San Diego, CA: Plural Publishing, Inc., 2007. Print

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Maria Del Duca, MS, CCC-SLP, is a pediatric speech-language pathologist in southern, Arizona.  She owns a private practice, Communication Station: Speech Therapy, PLLC, and has a speech and language blog under the same name.  Maria received her master’s degree from Bloomsburg University of Pennsylvania.  She has been practicing as an ASHA certified member since 2003 and is an affiliate of Special Interest Group 16, School-Based Issues.  She has experience in various settings such as private practice, hospital and school environments and has practiced speech pathology in NJ, MD, KS and now AZ.  Maria has a passion for early childhood, autism spectrum disorders, rare syndromes, and childhood Apraxia of speech.  For more information, visit her blog or find her on Facebook.