How to Evaluate Misbehavior

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Editor’s note: This is an excerpt of a blog post written by Tatyana Elleseff for her Smart Speech Therapy blog. Her full post can be read here.

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 in either school setting or 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.

Well-meaning professionals immediately offer an array of advice. Some behaviors get labeled as “normal” due to the child’s age (toddler), others are “partially excused” due to a psychiatric diagnosis (ASD). Some might recommend reinforcement charts, although not grounded in evidence. Letting other professionals deal with the behaviors is common: “in my setting the ______ (insert relevant professional here) deals with these behaviors and I don’t have to be involved.”

These well-intentioned advisors are overlooking several factors. First, a system to figure out why particular set of behaviors takes place, and second, if these behaviors may be manifestations of non-behaviorally based difficulties such as sensory deficits, medical issues or overt/subtle linguistically-based deficits.

What are the reasons kids present with behavioral deficits? Obviously, there could be numerous answers to that question. The underlying issues are often difficult to recognize without a differential diagnosis. In other words, we can’t claim that the child’s difficulties are “just behavior” if we don’t appropriately rule out other contributing causes. Here are some steps to identify the source of a child’s behavioral difficulties in cases of hidden underlying language disorders (after, of course, ruling out relevant genetic, medical, psychiatric and sensory issues).

Start by answering a few questions: Was a thorough language evaluation—with an emphasis on the child’s social pragmatic language abilities—completed? And by thorough, I am not referring to general language tests, but a variety of formal and informal social pragmatic language testing. Let’s say the social pragmatic language abilities were assessed and the child found/not found to be eligible for services. Meanwhile her behavioral deficits persist. What do we do now?

Determine why the behavior is occurring and what is triggering it (Chandler & Dahlquist, 2015). Here are just a few examples of basic behavior functions or reasons for specific behaviors:

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

Most behavior functions tend to be positively, negatively or automatically reinforced (Bobrow, 2002). Determine what reinforces the child’s challenging behaviors by performing repeated observations and collecting 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?

Once you determine behaviors and reinforcements, then set goals on which behaviors to manage first. Some techniques include modifying the physical space, session structure or session materials as well as the child’s behavior. Keep in mind the child’s maintaining factors or factors that contribute to the maintenance of the problem (Klein & Moses, 1999). These include: cognitive, sensorimotor, psychosocial and linguistic deficits.

Choose your reward system wisely. The most effective systems facilitate positive change through intrinsic rewards like pride of own accomplishments (Kohn, 2001). We need to teach the child positive behaviors to replace negative, with an emphasis on self-talk, critical thinking and talking about the problem instead of acting out.

Of course, it’s also important to use a team-based approach and involve all related professionals in the child’s care along with the parents. This ensures smooth and consistent care across all settings. Consistency is definitely a huge part of all behavior plans as it optimizes intervention results and achieves the desired outcomes.

So the next time the client on your caseload is acting out, troubleshoot using these appropriate steps in order to figure out what is REALLY going on and then attempt to change the situation in a team-based, systematic way.

 

Tatyana Elleseff, MA, SLP, is a bilingual speech-language pathologist with Rutgers University Behavioral Healthcare and runs a private practice, Smart Speech Therapy LLC, in Central New Jersey. She specializes in working with multicultural, internationally and domestically adopted children and at-risk children with complex communication disorders. Visit her website for more information or contact her at tatyana.elleseff@smartspeechtherapy.com.

A Tool to Help Children Ask for Help

questioning child
Richie is an engaging 9-year-old boy who is in treatment to improve his language skills. He is compliant and cooperative in sessions and is eager to learn new information. There’s only one problem: Richie is unable to spontaneously ask questions and request clarification when he doesn’t understand what he is told.

He’ll just sit quietly, making nice eye contact with the clinician. His entire body posture says, “I am listening to you!” But when it comes to answering questions about what he’s learned, Richie clearly doesn’t get. He might attempt to answer the questions and stumble halfway through before giving up. He might also provide an answer completely unrelated to the question. But most of the time, much to our frustration, Richie will simply shrug his shoulders and reply, “I don’t know.” This is typically when some might ask him with barely disguised frustration: “Why didn’t you tell me before that you didn’t understand?” Richie will shrug his shoulders again.

But here’s what’s important: He is not trying to be oppositional. He really doesn’t know.

Richie has impaired executive function, and this causes difficulties with initiation—asking questions, getting help, beginning to work on tasks and so forth—and pursuing clarification when he needs it.

Executive function is a set of mental processes regulated by the frontal lobe of the brain that help with optimal life functioning. Intact executive function allows us to manage, plan, organize, strategize, attend to, and remember things appropriately. However, if EF is underdeveloped or impaired (damaged) as a result of an injury or disorder, such as attention-deficit hyperactivity disorder or fetal alcohol spectrum disorder, then the child will present with significant difficulties in various areas of functioning. This will make it difficult to appropriately meet school requirements or engage in successful social interactions.

While it is important that children with EF impairment receive remediation in all affected areas, I typically start by targeting initiation, specifically improving the child’s ability to ask for help when needed. Why is that skill more important than the rest? For starters, it lets you know when something is wrong, or in some extreme cases, very wrong.

Imagine working with a 10-year-old verbal child who all of the sudden shuts down and cries while clutching her stomach. You spend valuable time questioning, prodding and cajoling until, about 10 minutes later, you find out that the child had an acute stomach ache. She was simply unable to initiate and tell you, “I need help. My stomach hurts.”

This is why it is important to use charts and other such strategies to help these children navigate treatment. To illustrate, I’ve created a “Strategies of Asking for Help” chart for my clients who are verbal but have mild cognitive impairment (IQ 70+) or have average cognition. I keep this chart in the child’s line of vision and remind him or her to choose a relevant strategy from the chart to alert me when in need of help. For example, under the category, “if confused,” the chart advises saying, “I don’t know where to find the answer.”

Of course, prior to using the chart, I pre-teach the child the strategies on the chart. I also explain when to use each strategy (during what type of tasks/questions/situations), as well as why it is so important to ask for help. Depending on the severity of the child’s impairment, I may need to spend several sessions pre-teaching these concepts to optimize the child’s success.

I also don’t limit use of the chart to language treatment sessions. What would be the point if the child only learns to ask for help during treatment, but is unable to do so when working on assignments in class or homework at home? Consequently, I provide a copy to both teachers and parents to attach to the child’s desk in class and at home.

Thus, the chart serves as a continuing visual reminder to ask help, along with strategies for how to do it. For your own free copy of the chart, download a copy here from my blog, Smart Therapy LLC.


Tatyana Elleseff, MA, CCC-SLP,
is a bilingual speech-language pathologist with Rutgers University Behavioral Healthcare and runs a private practice, Smart Speech Therapy LLC, in Central New Jersey. This post is adapted from a post that originally appeared on her blog, Smart Speech Therapy LLC. She specializes in working with multicultural, internationally and domestically adopted children and at-risk children with complex communication disorders. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education, 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, and 16, School-Based Issues.

Why Suspected Childhood Apraxia of Speech Requires Careful Assessment

toddlerpointing
Recently I got one of those phone calls that speech-language pathologists often dread. It went something like this:

Parent: Hi. I am looking for a speech therapist who uses PROMPT [Prompts for Restructuring Oral Muscular Phonetic Targets] to treat my son’s childhood apraxia of speech. Are you PROMPT-certified?

Me: I am PROMPT-trained and I do treat motor speech disorders but perhaps you can first tell me a little bit about your child? What is his age? What type of speech difficulties does he have? Who diagnosed him and recommended the treatment?

Parent: He is turning 3. He was diagnosed by a neurodevelopmental pediatrician a few weeks ago. She recommended speech therapy four times a week for 30 minutes, using PROMPT.

Me: And what did the speech therapy evaluation reveal?

Parent: We did not do a speech therapy evaluation yet.

Sadly, I get these types of phone calls at least once a month. Frantic parents of toddlers ages 18 months to 3+ years call to inquire about PROMPT therapy based on a neurodevelopmental pediatrician’s diagnosis. The speech-language diagnosis, method of treatment and treatment were typically specified by the physician in the absence of a comprehensive speech language evaluation and/or past speech-language therapy treatments.

The conversation that follows is often uncomfortable. I listen to the parent’s description of the symptoms and explain that the child needs a comprehensive speech language assessment by a certified SLP before being treated. I explain to the parent that, depending on the child’s age and the findings, the assessment may or may not substantiate CAS because symptoms are similar in a number of other speech and communication disorders.

Parents react in a number of ways. Some hurriedly thank me for my time and resoundingly hang up. Some stay on the line and ask me detailed questions. Some request an evaluation and become clients. A number of them find that their child never had CAS! Past misdiagnoses have ranged from autism spectrum disorder (CAS was suspected because of imprecise speech and excessive jargon) to severe phonological disorder to dysarthria secondary to cerebral palsy.

CAS is a disorder that disrupts speech motor control and creates difficulty with volitional, intelligible speech production. Research indicates that while children with CAS have difficulty forming words and sentences at the speech level, they also struggle with areas of receptive and expressive language. In other words, “pure” apraxia of speech is rare.

This condition needs to be diagnosed by an SLP. In fact, due to the disorder’s complexity, it is strongly recommended that parents seek an assessment by an SLP specializing in assessment and treatment of motor speech disorders. Here’s why.

  • CAS has a number of overlapping symptoms with other speech sound disorders, such as severe phonological disorder and dysarthria.
  • Symptoms that may initially appear as CAS may change during the course of intervention, which is why diagnosing toddlers under 3 years of age is problematic. Instead, a “suspected” or “working” diagnosis is recommended in order to avoid misdiagnosis.
  • Diagnosis of CAS is nuanced, complex and challenging, though a new instrument—Dynamic Evaluation of Motor Speech Skill (DEMSS)—shows promise with respect to differential diagnosis of severe speech impairments in children.

When children with less severe impairments, SLPs need to determine where the breakdown is taking place by designing tasks assessing:

  • Automatic versus volitional control.
  • Simple versus complex speech productions.
  • Consistency of productions on repetitions of same word.
  • Vowel productions.
  • Imitation abilities.
  • Prosody.
  • Phonetic inventory before and after intervention.
  • Types and levels of cuing required for response.

Given the complexity of CAS assessment and treatment described here, you can see that the PROMPT approach may not even be applicable to some children. Thus, I strongly urge developmental clinicians to first refer a child for a speech language assessment—and refrain from making recommendations for specific types and frequencies of treatment—when difficulty with speech production is observed.

For more information on childhood apraxia of speech, please visit the Childhood Apraxia of Speech Association of North America website or visit the ASHA website to find a professional specializing in the diagnosis and treatment of CAS near you.

 

Tatyana Elleseff, MA, CCC-SLP, is a bilingual speech-language pathologist with Rutgers University Behavioral Healthcare and runs a private practice, Smart Speech Therapy LLC, in Central New Jersey. This post is adapted from a post that originally appeared on her blog, Smart Speech Therapy LLC. She specializes in working with multicultural, internationally and domestically adopted children and at-risk children with complex communication disorders. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education, 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, and 16, School-Based Issues.

“Appdapting” Flashcard Apps to Address Social Skills

boy throwing ball

I have to admit, I don’t really like flashcards. I especially don’t like it when parents or SLPs use flashcards to drill vocabulary in toddlers and preschoolers, much less school aged children. I feel that it produces very limited learnability and generalization. I am personally a proponent of thematic language learning, since it allows me to take a handful of words/concepts and reinforce them in a number of different ways. The clients still get the benefit of information repetition, much like one would get during a typical flashcard drill.  However, they are also getting much more.  Thematic language learning allows the client to increase word comprehension, make connections to real life scenarios,  develop abstract thinking skills, as well as to transfer and generalize knowledge (Morrow, Pressley, Smith, &  Smith, 1997; Ramey, 1995).

However, even though I dislike flashcards, I still don’t necessarily want to give up using them completely, especially because nowadays many different type of image based language flashcards can be found for free as both printables as well as Iphone/Ipad apps.  Consequently, I decided to pick a free flashcard app and adapt it or rather  ”appdapt” it (coined by “The Speech Guy”, Jeremy Legaspi, the “Appdapt Guru”) in a meaningful and functional way for my students.

After looking over and rejecting a number of contenders, without a clear plan of action in mind,  I stumbled upon a free app, ABA Flash Cards – Actions by kindergarten.com, which is designed to target verb labeling in ASD children.   When I saw this app, I immediately knew how I wanted to appdapt it.  I especially liked the fact that the app is made for both Ipad and Iphone. Here’s why.

My primary setting is an out of district day school inside a partial psychiatric hospital.  So in my line of work I  frequently do therapy with students just coming out from  ”chill out rooms” and “calm down areas”.  This is definitely not the time when I want to bring or use a lot of materials in the session, since in a moment’s notice the session’s atmosphere can change from calm and productive into volatile and complicated.  I also didn’t  want to use a bulky Ipad in sessions with relatively new children on the caseload, since it usually takes a few sessions of careful observations and interaction to learn what makes them “tick”. Consequently, I was looking for an app which could ideally be downloaded onto not just the Ipad but also the Iphone. I reasoned that in unexpected  situations I could simply put the phone into my pocket, unlike the Ipad, which in crisis situations can easily become a target or a missile.

Given the fact that many children with psychiatric disorders present with significant social pragmatic language deficits (Hyter, 2003; Hyter et al 2001; Cohen et al., 1998; Bryan, 1991; Goldman, 1987 ), which is certainly the case for the children on my caseload, I planned on adapting this app to target my students’ pragmatic language development, social problem solving skills as well as perspective taking abilities.

So here are just a few examples of how I appdapted the cards.  First, I turned off the sound, since the visual images were what I was going after.  Then I separated the cards into several categories and formulated some sample questions and scenarios that I was going to ask/pose to the students:

Making Inferences (re: People, Locations and Actions)

iPhone Screenshot 2

What do you think the girl is thinking about?

How do you know what she is thinking?

How do you think she is feeling?

How can you tell?

Where do you think she is?

How do you know?

 

Multiple Interpretations of Actions and Settings: 

iPhone Screenshot 3

What do you think the girl is doing?

What else could she be doing?

 

 

 

 

 

 

 

 

 

How does the boy feel about the flower?

Give me a different explanation of how else can he possibly feel?

 

 

 

 

 

 

 

 

Who are the boys in the picture? (relationship)

Who else could they be?

What do you think the boy in a blue shirt is whispering to the boy in a red shirt?

What else could he be saying?

How do you know?

 

 

Supporting Empathy/Sympathy and Developing Peer Relatedness:

 

 

 

 

 

 

 

 

 

How does this child feel?

Why do you think he is crying?

What can you ask him/tell him to make things better?

 

 

 

 

 

 

 

 

The girl is laughing because someone did something nice for her?

What do you think they did?

 

Interpreting Ambiguous Situations:

 

 

 

 

 

 

 

 

 

What is the boy doing?

Who do you think is the woman in the picture?

How do you know?

How does she feel about what the boy is doing?

How do you know?

 

My goal was to help the students how to correctly interpret facial features, body language, and context clues in order to teach them how to appropriately justify their responses. I also wanted to demonstrate to them that many times the situations in which we find ourselves in or the scenes that we are confronted with on daily basis  could be interpreted in multiple ways. Moreover, I wanted to teach how appropriately speak to, console, praise, or compliment others in order to improve their ability to relate to peers. Finally, I wanted to provide them with an opportunity to improve their perspective taking abilities so they could comprehend and verbally demonstrate  that other people could have feelings, beliefs and desires different from theirs.

Since I knew that many of my students had significant difficulties with even such simple tasks as labeling and identifying feelings, I also wanted to make sure that the students got multiple opportunities to describe a variety of emotions that they saw in the images, beyond offering the rudimentary labels of “happy”, “mad”, “sad”, so I took pictures of Emotions Word Bank as well as Emotion Color Wheel courtesy of the Do2Learn website, to store in my phone, in order to provide them with extra support.

                

The above allowed me not only to provide them with visual and written illustrations but also to teach them synonyms and antonyms of relevant words.  Finally, per my psychotherapist colleagues request,  I also compiled a list of vocabulary terms reflecting additional internal states besides emotions (happy, mad) and emotional behaviors (laughing, crying, frowning). These included words related to:  Cognition (know, think, remember, guess), Perception (see, hear, watch, feel), and Desire (want, need, wish), (Dodd, 2012) so my students could optimally benefit not just from language related therapy services but also their individual psychotherapy sessions as well.

I’ve only just began trialing the usage of this app with the students but I have to admit, even though its still the early days, so far things have been working pretty well. Looks like there’s hope for flashcards after all!

References:

———Bryan, T. (1991). Social problems and learning disabilities. In B. Y. L. Wong (Ed.), Learning about learning disabilities (pp. 195-229). San Diego, CA: Academic Press.

—Cohen, N. & Barwick, M. (1996) Comorbidity of Language and Social-Emotional Disorders: Comparison of Psychiatric Outpatients and Their Siblings. Journal of Clinical Child Psychology, 25(2), 192-200.

Goldman, L. G. (1987). Social implications of learning disorders. Reading, Writing and Learning Disabilities, 3, 119-130.

—Hyter, Y. D., et al (2001). Pragmatic language intervention for children with language and emotional/behavioral disorders. Communication Disorders Quarterly, 23(1), 4–16.

Hyter, Y. D. (2003). Language intervention  for children with emotional or behavioral disorders. Behavioral  Disorders, 29, 65–76.

Morrow, L. M., Pressley, M., Smith, J.K., & Smith, M. (1997). The effect of a literature-based program integrated into literacy and science instruction with children from diverse background. Reading Research Quarterly, 32(1), 54-76.

Petersen, D. B., Dodd, J & Finestack, L. H (2012, Oct 9) Narrative Assessment and Intervention: Live Chat. Sponsored by SIG 1: Language Learning and Education. http://www.asha.org/events/live/10-09-2012-narrative-assessment-and-intervention/

Ramey, E. K. (1995). An integrated approach to language arts instruction. The Reading Teacher, 48(5), 418-419.

 

(This post originally appeared on the Smart Speech Therapy LLC blog)

 

Tatyana Elleseff MA CCC-SLP, is a bilingual speech language pathologist with a full-time hospital affiliation (UMDNJ) and a private practice (Smart Speech Therapy LLC) in Central, NJ. She received her MA from NYU and her Bilingual Extension Certification from Columbia University. She specializes in working with bilingual, multicultural, internationally and domestically adopted at risk children with complex medical, developmental, neurogenic, psychogenic, and acquired communication disorders.

Therapy Fun with Ready Made Fall and Halloween Bingo

 

There are many fun therapy activities you can do with your preschool and school aged clients in the fall. One of my personal favorites is bingo. Boggles World, an online ESL teacher resource actually has a number of ready made materials, flashcards, and worksheets which can be adapted for speech language therapy purposes. For example, their Fall and Halloween Bingo comes with both call out cards and a 3×3 and a 4×4 (as well as 3×3) card generator/boards. Clicking the refresh button will generate as many cards as you need, so the supply is endless! You can copy and paste the entire bingo board into a word document resize it and then print it out on reinforced paper or just laminate it.

Fall vocabulary words include: corn, crops, farmer, scarecrow, apples, acorns, oak leaf, maple leaves, ginkgo leaves, grapes, mushrooms, salmon, geese, squirrel, jacket, turkey, Jack-O’-Lantern, rake, pumpkins, harvest moon, hay, chestnuts, crow, and sparrow

Halloween vocabulary words include: witch, ghost, skeleton, skull, spider, owl, Jack-O’-Lantern, devil, cobweb, graveyard, clown, pirate, robot, superhero, mummy, vampire, bat, black cat, trick or treaters, alien, werewolf

Now the fun begins!

Some suggested activities:

Phonological Awareness:

  • Practice Rhyming words (you can do discrimination and production activities): cat/bat/ trick/leaf/ rake/moon
  • Practice Syllable and Phoneme Segmentation  (I am going to say a word (e.g., ghost, spider, alien, etc) and I want you to clap one time for each syllable or sound I say)
  • Practice Isolation of initial, medial, and final phonemes in words ( e.g., What is the beginning/final  sound in mummy, vampire, robot, etc?) What is the middle sound in bat/cat/geese/rake etc?
  • Practice Initial and Final Syllable and Phoneme Deletion in Words  (Say spider! Now say it without the der, what do you have left? Say trick, now say it without the /t/ what is left; say corn, now say it without the /n/, what is left?)

Articulation/Fluency:

  • Practice production of select sounds/consonant clusters that you are working on or just production at word or sentence levels with those clients who just need a little bit more work in therapy increasing their intelligibility or sentence fluency.

Language:

  • Practice Categorization skills via convergent and divergent naming activities: Name Fall words, Name Halloween Words, How many trees  whose leaves change color can you name?, how many vegetables and fruits do we harvest in the fall? etc.
  • Practice naming Associations: what goes with a witch (broom), what goes with a squirrel (acorn), etc.
  • Practice providing Attributes via naming category, function, location, parts, size, shape, color, composition, as well as accessory/necessity.  For example, (I see a pumpkin. It’s a fruit/vegetable that you can plant, grow and eat. You find it on a farm. It’s round and orange and is the size of a ball. Inside the pumpkin are seeds. You can carve it and make a jack o lantern out of it).
  • Practice providing Definitions: Tell me what a skeleton is. Tell me what a scarecrow is.
  • Practice naming Similarities and Differences among semantically related items: How are pumpkin and apple alike? How are they different?
  • Practice explaining Multiple Meaning words:   What are some meanings of the word bat, witch, clown, etc?
  • Practice Complex Sentence Formulation: make up a sentence with the words crops and unless, make up a sentence with the words skeleton and however, etc.
  • Or you can just make up your own receptive, expressive and social  pragmatic language activities to go along with these games.

So join in the fun and start playing!

(This post originally appeared on the Smart Speech Therapy LLC blog)

 

Tatyana Elleseff MA CCC-SLP, is a bilingual speech language pathologist with a full-time hospital affiliation (UMDNJ) and a private practice (Smart Speech Therapy LLC) in Central, NJ. She received her MA from NYU and her Bilingual Extension Certification from Columbia University. She specializes in working with bilingual, multicultural, internationally and domestically adopted at risk children with complex medical, developmental, neurogenic, psychogenic, and acquired communication disorders.