Kid Confidential-Behavior Disorders and Language Impairment in School-Age Children

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In January, I read an article published in ASHA’s SIG 16 Perspectives December 2012 issue by Alexandra Hollo from the Department of Special Education, at Vanderbilt University in Nashville, Tenn., titled “Language and Behavior Disorders in School-Age Children: Comorbidity and Communication in the Classroom.”  She brought up some really good points that I think we, as SLPs, need to keep in mind when discussing, assessing and treating children who are labeled with behavior disorders.

Hollo discusses how often times children labeled with EBD (emotional and behavioral disorders) also have undiagnosed LI (language impairment).  According to this article, “Four out of five students with EBD are likely to have an unidentified language deficit,” which may result in children resorting to physical communication rather than effective use of expressive language to resolve issues.  In fact, it is estimated that 80.6 percent of students with EBD also have LI however, more than 50 percent of those LI diagnoses remain unidentified.  If staff members fail to recognize the child’s inability to functionally communicate, negative feelings and interactions between the student and staff members may result, which in turn negatively affects academic achievement. What is known about children with EBD is that they “have the most negative short- and long-term outcomes” (Hollo, 2012).

So what does EBD look like in children?  Well Hollo explains the two subcategories of EBD according to the DSM-IV, difficulties with internalizing and externalizing.  Deficits in internalizing include emotional withdrawal behaviors such as depression, anxiety or mood disorders.  Academic trends for these students with internalizing problems include high rates of absenteeism and low academic achievement.  Deficits in externalizing include disruptive behavior as in ADHD, ODD or conduct disorder.  Students with externalizing deficits tend to be more easily identified and receive services possibly due to the fact that their behavior is disruptive in the academic setting and can more easily be determined to interfere with learning.  Academic trends for students with externalizing issues:  disruptive behavior tends to interrupt and/or terminate instruction and therefore affect learning.  More importantly, it was stated that although students with EBD do perform similarly to those with other disorders on standardized tests, their academic performance tends to be BELOW that of other students with disabilities.

In addition to academic deficits, children with EBD also demonstrate deficits in language and social skills.  These children more often exhibit expressive language deficits rather than deficits in receptive language, and they tend to use simplified language within the classroom environment resulting in teachers grossly overestimating the student’s expressive language abilities.  It is important to note that based on Hollo’s research, the CELF and TOLD were the only two language tests that were able to consistently identify LI in children already diagnosed with EBD.

 

Socially, children with EBD tend to have negative teacher interactions, are often times rejected or victimized by peers, and struggle with use of effective conversational skills due to difficulties in initiating and maintaining friendships, problem solving deficits, and difficulties cooperating and collaborating with peers and adults.  In addition, students with EBD tend to be impulsive and struggle with the use of “inner dialogue” to effectively reason prior to responding to their emotions within various situations.  Their ability to control their emotions, follow directions, and transition between activities, classes and subjects is also affected.

Why is this information important for us as SLPs to know?  Well we must first be educated on the comorbidity between EBD and LI to effectively screen, assess, and treat these students.  We also have the responsibility to train staff members on the child’s communication and social skills deficits so as their behaviors may not be misconstrued.  We as SLPs can be instrumental in implementing linguistic supports for these children which include direct (i.e. teaching emotional language, using self-talk for regulation and problem solving skills, provide opportunities to practice negotiations with peers, etc.) and indirect instruction (i.e. collaborate with staff, train teachers on effective communication styles, teach use of slow rate of speech, etc.).  In addition, we can work with behavioral specialists to follow and enforce the behavioral supports that are deemed necessary to help students with EBD be successful in their daily environments.

So the next time you are in your weekly RTI meeting discussing a “problem child” or a “shy, quiet student,” pay attention, and keep in mind that EBD does not look the same in every child. Some behaviors may in fact be linked to language deficits.  Only we, as SLPs will be able to make that determination effectively in order to ensure students receive the services and support they require.

Note:  This entire article was not discussed in detail here.  I discussed the information I felt was important based on my personal clinical experiences.  I refer you to Hollo’s complete article in the December 2012 SIG 16 issue for further information and details.

Maria Del Duca, M.S. 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.

Kid Confidential: Teaching Our Kids About “Tricky People”

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We’ve all heard of “stranger danger” and have probably taught our own children about the concept.  Don’t go anywhere or get into a car with anyone you don’t know.  As speech-language pathologists we may have even discussed this as part of our safety topics along with fire safety, learning about law enforcement and teaching our students how to dial 911.  We may even talk about “stranger danger” when we are targeting problem solving and reasoning skills for those students with social communication or cognitive delays.   But is “stranger danger” the best way to teach our children to be aware of adults, teenagers, or even same age peers that may hurt them?  According to the American Psychological Association’s web article, titled “Child Sexual Abuse: What Parents Should Know,” 30% of predators of sexual abuse are family members, while it is estimated that an additional 60% of predators are non-family members but are known to the child (i.e. family friends, caregivers, neighbors, etc.).  Considering 90% of all child sexual abuse cases occur by someone the child knows, is “stranger danger” really accurate?  I’m not so sure anymore.

I recently became aware of Safely Every After, Inc, a company devoted to child safety that focuses on teaching children and adults ways to identify the “tricky people” in our lives because many times “tricky people” are not strangers at all.  Pattie Fitzgerald, owner of Safely Every After, Inc., has been advocating for child safety for more than 10 years and has a number of wonderful free resources on her website including prevention tips, red flags for parents/adults, safety rules for children, internet safety rules and cyberbullying guidelines.  Pattie educates children of all ages as young as 3 years of age.  For preschool age children (3-5 years), she has written a book titled, No Trespassing-This is MY Body!, which discusses what “thumbs up” and “thumbs down” touch is and that children are the “boss of their own bodies.”  She also presents her information to schools and offers workshops for children grades K-4 (Kidz-Power) and grades 5-8 (Play it Safe!).  Additional workshops for kids and adults such as Internet Safety and Social Media and Protect the Children You Teach geared toward educators and school staff are also available.  If you think your school could benefit from a presentation by Pattie, feel free to refer your administrator to her website for more information.

So who are “tricky people”?  According to Pattie, here are just a few red flags that you are with a “tricky person”:

  1. This person continually tries to arrange for “alone time” with children;
  2. He/she befriends one particular child and lavishes gifts upon him/her;
  3. He/she frequently offers to babysit or “help out” for free;
  4. He/she insists on being physical with a child especially when the child seems uneasy or has asked the person to stop; and
  5. He/she blurs boundaries of physical touch or uses inappropriate words to comment on a child’s looks or body.

Tricky people can be a stranger or someone the child knows.  A tricky person can be a friend of the child’s parent or a family member.  Tricky people are everywhere and we need to listen to our instincts when we get that “uh-oh” feeling.  These are the things Pattie and her crew at Safely Every After, Inc., advocate teaching children and adults.

Granted, as SLPs in schools, clinics, and private practice, we may not be permitted to discuss the topics of touch with our students depending on parental preference.  However, we can discuss and teach general safety rules.  For example, the second rule on Pattie’s “Super-Ten Safe-Smart Rules for Kids and Grownups” is that a child must know his/her name, address, phone number, and parents’ cell phone numbers in case of an emergency.  We as SLPs do work on having our students answer biographical information questions so this rule works perfectly within our therapy goals.  A few more examples of rules that would go nicely with targeting problem solving and reasoning skills are rules three, four, and five that state “Safe grownups don’t ask kids for help.  They go to other adults for assistance,” or “I never go anywhere or take anything from someone I don’t know no matter what they say,” and “I always check first and get permission before I go anywhere, change my plans, or take something even if it’s from someone I know.”  There are several other safety rules that can be discussed when targeting reasoning and problem-solving skills in a safe way and I encourage you to read all about them on Pattie’s website.

So why, during ASHA’s Better Speech and Hearing Month, am I discussing the topic of child safety?  Well, who better to modify and explain child safety rules to our communication-delayed children, than SLPs?  Who better to determine if our children have the capacity to communicate when and how they have been hurt? Who better than the programmers of our non-verbal students’ AAC devices, to make sure there is language available for our students to express when they are hurting?   Who better, than us, to prepare our students for safety over the summer months?  In fact, we, as SLPs, may be the first adults to successfully broach the topic of safety with our students as we can modify and adapt information to the child’s level of comprehension.  So my question is, who better than us?

Disclaimer:  I am not, nor have I ever received payment or any form of compensation from Pattie Fitzgerald or Safely Ever After,Inc. for writing this blog article.  My purpose for writing this article is purely for educational purposes to share the knowledge I have recently learned and found on this website.  Use this information at your discretion.

 

Maria Del Duca, M.S. 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.

Kid Confidential: “Join In on the Stim!”

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Autism Spectrum Disorders (ASD) is one of the great loves in my professional career. Persons with ASD are fascinating and wonderful and many times their behavior actually makes sense to me. I know what you are thinking, “This woman has got to be on the spectrum herself.” Well although I do believe that we all exhibit hyper- and/or hypo-sensitivities to various stimuli and that we all have what I like to call “a little autism in us,” it just may not be on the scale of persons who are diagnosed with ASD formally. It may not consume our entire interactions as it does for some students with ASD. So the question is, what do we do about it?

When I was in graduate school, the prevailing acceptable intervention was based on behavioral modification techniques. I was expected to spend time determining why that stimulatory behavior occurred (i.e. avoidance, stress, seeking sensory input, coping mechanism, sensory overload, etc.) and replace it with a more appropriate behavior. I still agree that this treatment strategy is appropriate in certain situations. For instance, if the student is seeking sensory input, let’s provide him/her with an appropriate sensory diet (under the supervision of an OT with the appropriate experience). If the student is exhibiting behaviors that are harmful to him or herself or others, they MUST be replaced by more appropriate safe behaviors. If the student is overloaded and attempting to escape/avoid a situation, let’s give him/her a break and/or modify the activity and expectations.

But are there times when we should actually encourage the stimulatory behavior? Are there times when we should not only support it, but “join in on the stim”? My answer to this is ABSOLUTELY! I know I just lost a few of you, but hear me out. The first time I read this idea, I was skeptical as well.

Jonathan Levy, author of “What You Can Do Right Now to Help Your Child with Autism,” challenges parents and therapists alike to do just this, join the child in his/her world by simultaneously imitating the stimulatory behavior. The idea is that for children who are profoundly affected by ASD and who spend all or most of their time exhibiting stimulatory behaviors actually need us to invade their world and physically pull them out of it by imitating them.

According to Levy, by joining your child/student in their stimulatory behavior you are telling them several things:

  • You understand their need to use this behavior.
  • You have something in common with them.
  • You want to interact with them and you are willing to enter their world.
  • They are safe to “be themselves” around you and you will not interrupt their need to stimulate themselves using these behaviors.

Does this actually work? According to Jonathan Levy, this is a technique Barry and Samahria Kaufmann, authors of the Son-Rise Program and founders of the Autism Treatment Center of America (ATCA), not only believe in, but have used successfully on their own child as well as numerous children nationally and internationally for more than 25 years. Anecdotally, I can tell you from my personal experience, I have done this and I have noted several positive changes with consistency:

  • Almost immediate increase in eye contact or facial referencing.
  • Students with ASD began to approach and/or gravitate to me whenever I entered their classrooms.
  • Students began to tolerate my touch or would take my hands and place them on their own bodies. For example, I had a female student once start pulling on my arms. I figured out very quickly she wanted me to do this to her. Although nonverbal, she made a request for the first time in her life! After I provided that sensory feedback, she was able to sit on the floor with her class during a large group lesson for the very first time.
  • And after a few weeks of joining in the stimulatory behaviors, I began to hear vocalizations. And for some of these children, it was the first time they ever vocalized!

Yes I was that therapist, jumping around in circles, flapping my hands, vocalizing various moans and groans along with my students. I was that therapist sitting at the lunch table filtering light through my fingers and screeching with my student as he attempted to eat. I was also the first person they made eye contact with; the first person, to which they handed a picture (i.e. PEC); the first person, with whom they exhibited joint attention; and the first person to whom they intentionally vocalized when making a request.

So does this technique work? I believe that it does if used properly for the appropriate students. This is not a technique that I believe every student with ASD requires or can benefit from, but it certainly appears to make significant changes in those who are so profoundly affected that they cannot find a way out of their own worlds without us stepping in and meeting them where they are.

Mr. Levy does leave us with a word of caution. Some children do not respond immediately to this technique as they are so far within their own worlds it could take them weeks to even notice your attempts to join the stimulatory behavior. But he ensures us, that this is not a reason to give up and believes that by giving the child adequate time, he will take note of your attempts to enter his world and you will break through the child’s barriers of stimulatory protection (Levy, 2007).

This has not been the case for me as I saw changes fairly immediately. However, I do believe that can be attributed to the fact that if the child is in a school setting, they are aware at some level that there are other people within the room, whether they seem to show it or not. I believe the school setting is unique in that just the setting itself forces the child with ASD to, even on a subconscious level, acknowledge there is a world bigger and different than what is found within themselves.

So the next time you have a student with ASD on your caseload that is profoundly affected and appears to spend all or most of his/her time exhibiting stimulatory behaviors, no longer ask yourself “What do I do with this child?”. Rather, make an attempt to enter their world and “join in the stim”. By doing this, you may just be the first person who has ever been able to connect with them.

Maria Del Duca, M.S. 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 New Jersey, Maryland, Kansas and now Arizona. 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.

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.

Welcome to Kid Confidential: Let’s Play!

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(photo credit)

Welcome to the first installment of Kid Confidential, a monthly column where Maria Del Duca, M.S. CCC-SLP will be discussing all topics related to speech, language and child development. 

First off, let me say that I am not a researcher, I’m an observer.  I’m just a clinician like you using Evidence Based Practice (EBP) and trial and error to make my way in the world of language development.  I do not claim to be an expert, but I have had a hodge-podge of experiences and have worked with amazing clinicians and educators who have taught me along the way.

Through my years of experience and my constant need for information I have exhausted the minds of those with whom I have worked.  I have badgered them with a barrage of questions about why and how they were doing what they were doing.  Most of the time, I have found teachers and therapists willing to share their knowledge with me.  So today, I’m paying it forward.  Let’s talk play skills!

I don’t know about you, but upon completing graduate school I knew a whole lot about normal language acquisition, how to read, understand and review a research article, and how to administer and interpret numerous standardized tests, but I knew nothing about play skills.  Of course looking back at it now, this seems a bit ridiculous when we think of the number of children on our caseloads that are younger than five years of age.  But at the time, I didn’t know what I didn’t know.

Research shows us that play really is the work of a child.  We understand that play skills affect cognition, pragmatics and language development.  According to Pretend Play: The Magical Benefits of Role Play, by One Step Ahead:

Pretend play facilitates growth in more than just the areas mentioned above.  Encouraging a child to participate in pretend play positively affects:

  • Imaginative thinking and exploration
  • Abstract thinking
  • Problem Solving
  • Life skills
  • Leadership skills
  • Communication development
  • Social Skills development
  • Use of “Theory of Mind” (understanding/taking another’s perspective)
  • Understanding of safety
  • Self-confidence and a high self-esteem

We know we should assess play skills in young children.  But do we know what developmental play skills look like when we see them?  According to the Developmentally Appropriate Curriculum: Best Practices in Early Childhood Education, otherwise known as “the EC bible” in the world of early childhood educators, there are three distinct types and five social stages of play children typically exhibit between birth and age five (Kostelnik, Soderman, and Phipps Whiren).  Do you know what they are?  Read all about them in the tables below.

Slide1 Slide2You can download your copy of the above tables here.

I would be remiss if I did not share a word of caution when assessing play skills.  There are many cultures that do not value the child-centered, independent play of our western culture.  In order to differentially diagnose deficit versus difference we must keep in mind any cultural differences of the child’s family.  For more information on this topic, read Multicultural Considerations in Assessment of Play by Tatyana Elleseff MA CCC-SLP.

So now we know what typical play skills look like.  How do you assess play skills?  What are your favorite materials to use?  What topics do you want to see discussed here on Kid Confidential?

Don’t be afraid to share your ideas by commenting below.  And remember…“Knowledge is power” (Sir Francis Bacon)!

Reference

Kostelnik, Marjorie, Anne Soderman, and Alice Phipps Whiren. Developmentally Appropriate Curriculum: Best Practices in Early Childhood Education. 5. Upper Saddle River, NJ: Pearson, 2011. Print

 

Maria Del Duca, M.S. 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