Finding the Right Fit: Social Pragmatics Groups in Middle School

1kidgroupThe recent explosion of social pragmatics curricula and materials for students with social challenges like autism spectrum disorder is both a blessing and a curse to those of us SLPs who work in private practice or outpatient settings. On the one hand, I am grateful for the selection of topics and target goals. On the other hand, how can we best weed through it all and offer a group curriculum that is the most functional and change-inspiring for this tricky but very deserving population of pre-adolescents?

There are many benefits of conducting groups outside the school environment in an outpatient setting, including more time spent on concepts, practice in a “safe” and diverse environment (participants may not have to see each other again), making new friends (participants may like to see each other again), parent/caregiver education and training, and parent/caregiver networking opportunities.

Along with the benefits, there are challenges that are unique for private practice and outpatient SLPs as we try to help these children and their families. These challenges can be grouped into two categories: logistical and content-related.

Logistics are tricky, but are definitely the easiest barriers to overcome. A typical group series for outpatient settings lasts 8 weeks. Group sessions range from 1-2 hours, depending on the number of participants. Costs to families for each session can be substantial, despite the Health Care Affordability Act, whether it be insurance co-pays or out-of-pocket. And there are also transportation costs and challenges for families who live in rural areas. These barriers mostly belong to the families of our group participants, but SLPs can help reduce their impact by strategies such as offering the group at “family-friendly” times (evenings or Saturdays), as well as choosing a central location for the meetings.

Once logistics are met, the real work begins. This brings me to the content of this post: content-related challenges. As a former instructional designer and journalist, my foremost consideration is “know my audience.” It may be a funny way to initially think about a therapy group, but it’s a basic tenant that I find critical.

Unlike the school setting where therapists can get to know the child in their “natural environment,” outpatient SLPs must somehow determine which kids can best go together in groups. Finding the right fit may sound like a logistical challenge, but is actually content-based.

From experience, placing the right kids together can make or break the success of the group, particularly at the tween/middle school age. Knowing this however, is only the beginning of the solution. My colleagues and I have whittled out three main areas of need for this age group:

  • Basic Social Rules—skills associated with being with another or group, such as eye contact, body language, expected behaviors, thinking about others.
  • Conversation Rules—skills associated with communication with another or group, such as establishing a topic, asking and answering questions, staying on or switching topics, social wondering.
  • Higher-level Social Skills—skills associated with making others comfortable and making/keeping friends, such as social problem-solving and perspective-taking.

Regardless of diagnosis or age, these three areas seem to be a good way to group kids so that behaviors can be managed equally and everyone learns. I have tried pragmatic assessments such as the CELF-5 Pragmatics subtest. I have given self-made parent/caregiver surveys of functional skills that coincide with the teaching concepts of the group. I have given their referring SLPs surveys of functional skills. Sometimes I have used all three methods. So far, I have not found a combination that can qualify everyone accurately. In every group, there always seems to be at least one kid whose skills are significantly more advanced or significantly more impaired than the rest.

The question is this: How can we most effectively figure out where each child fits? How do we qualify a child for the right group when the reality is that most of our candidates demonstrate a constellation of challenges across two or all of these areas?

That is the question I am posing to this ASHAsphere community. Thank you in advance for your responses as we problem-solve together.

Lisa Lucas, MA, CCC-SLP, is a speech-language pathologist in Cincinnati, Ohio. She practices as an outpatient SLP for Cincinnati Children’s Hospital and as a telepractice SLP for Presence Learning. She is an affiliate of ASHA Special Interest Group 18, Telepractice.

Pragmatic Language Intervention for Adults with Autism

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A man enters the room, apparently comfortable with his surroundings and with those around him. Despite his large physique, he exudes a gentle demeanor and a genuine kindness as he approaches the other adults in the room. He curtly nods to a few people in the room, and then takes a seat in his usual spot. As he scans the papers in front of him, his face lights up and he points to a picture representing the day’s refreshments. He smiles at the woman sitting next to him and carefully produces the words, “Want…snack.” He nods again and smiles with noticeable satisfaction.

This man’s name is Jim, and he is an adult with autism. Jim attends one of the two Adult Language and Pragmatics Skills (ALPS) programs offered at Towson University’s Hussman Center for Adults with Autism. Like many other individuals on the autism spectrum, Jim struggles to communicate verbally and to engage in meaningful social relationships. These difficulties represent unique challenges for Jim and other adults on the spectrum. To address these challenges, Jim attends the ALPS group each week and participates in meaningful activities designed to explicitly address areas of need. The activities target communication in a variety of social contexts, and participants show subsequent improvements areas of need.

In addition to the positive changes observed with group participants, the ALPS programs also are gaining positive attention from families in the greater Baltimore community. Jim’s mother recently expressed her appreciation for the ALPS group and for the noticeable improvements she sees in her son’s communication. She wrote, “There are not enough words to express my gratitude to you and your team. Jim’s communication did significantly increase with the Fall session. I know that your program is critical to Jim’s continued progress.”

So what makes the ALPS programs at Towson University effective and attractive? Some would say the impressive amenities available at Towson University’s Institute for Well Being facilitate the programs’ success. Admittedly, the rooms equipped with multi-media technology and the fully furnished apartment in which adults can practice skills are indeed helpful. But the ALPS groups also offer experiences purposefully designed to incorporate evidence-based practice techniques for optimal success:

  1. Mentor/Peer Role Models – The use of peer role models is well-supported in the literature as an evidence-based practice intervention (Llaneza, DeLuke, Batista, Crawley & Frye, 2010; McGee, Almeida, Sulzer-Azaroff & Feldman, 1992; Orsmond, Krauss & Seltzer, 2004). Mentors from the ALPS groups include graduate student clinicians earning clinical hours in the speech-language pathology program, as well as undergraduate mentors earning service learning hours. Mentors plan the group sessions as well as individualized activities to target specific goals agreed upon by mentors and participants. The mentor-participant relationship emerges as a mutually-beneficial partnership in which each party experiences growth and personal satisfaction. Participants learn from the mentors through direct modeling experiences, and the mentors gain invaluable experience with adults on the spectrum. Often, the student mentors indicate that their perceptions of autism significantly change as a result.
  1. Relevant Topics – To foster meaningful learning experiences relevant to the unique challenges that adults with autism face, topics are selected that directly relate to participants’ everyday lives. Topics vary from semester to semester, but generally include practical themes such as nonverbal communication, managing emotions in moments of conflict, dating and relationships, self-advocacy, communication in the workplace, and increasing independence. Many participants suggest ideas for topics, and sessions are planned with the participants’ specific needs in mind.
  1. Universal Design for Learning Standards – To target specific strengths and needs of participants in the group and to incorporate learning style preferences, sessions are planned utilizing Universal Design for Learning (UDL) guidelines. The UDL approach asserts that to best meet the individual needs of diverse groups of learners, clinicians should offer (a) multiple means of presentation, (b) multiple means of response and (c) multiple means of engagement (Rose & Gravel, 2010). The ALPS groups at Towson University incorporate UDL standards in several specific ways:
    • Technology Tools – to increase engagement and to provide additional visual representation, ALPS groups routinely incorporate multi-media videos, interactive whiteboard activities, iPads, smartphones, and personal communication devices into learning experiences.
    • Response systems – to facilitate and maintain engagement of the group and to include nonverbal responders, discussions are often supplemented with systems that allow all participants to answer questions and express opinions simultaneously. Pinch cards, signs, color-coded paddles and gestures are all used to facilitate each participant’s communication of ideas and opinions.
    • Kinesthetic and tactile experiences – to include kinesthetic/tactile learning styles and to address participants’ need for movement for regulating sensory input, all sessions include activities requiring the participants to move. Sometimes the movement also serves as a mode of response (e.g., moving to a designated location in the room to indicate a choice), further integrating UDL guidelines.
    • Differentiated supports – to meet the needs of individual learners in a diverse group, activities are adapted specifically for each participant. Student mentors often create and implement visual supports, and provide hierarchical prompts to promote the highest levels of success and independence.
  1. Experiential Learning Opportunities – to address multiple learning styles and to provide hands-on practice, sessions often include functional activities that utilize social communication skills. Group members participate in role play activities, everything from acting out scripted dyadic communication to real-world experiences like ordering food in a restaurant. Participants do not simply listen to an instructor talking about strategies for successful communication; rather, participants engage in direct and relevant experiences that target effective communication and self-advocacy.
  1. Social Connection Opportunities – ALPS sessions are comprised of a variety of social experiences, encouraging participants to connect with others through structured practice. Whole group, small group and individual experiences are offered weekly as group members discuss ideas and opinions relevant to the session topic. Activities that foster partnership and cooperation are also utilized, encouraging participants to step out of their comfort zone as they practice social skills.
  1. Reflection and Review Experiences – All participants are encouraged to reflect on their experiences and to review important strategies. Each week, participants and mentors discuss progress and identify goals for the participant to consider in the week ahead.
  1. FUN – As one participant freely offered, “I don’t learn much when I’m bored. But I always remember the fun parts!” A preference for fun is certainly not unique to the autism population. Don’t we all remember the fun parts? To maintain an enjoyable and social atmosphere, sessions are planned using central themes. Activities, snacks, and even attire may revolve around the designated theme. Past selections include favorite movie, sport, travel and holiday themes. To further the fun, ALPS groups end each semester with a celebration party in which each group member is recognized for personal achievements.

All of these techniques are integrated into meaningful ALPS sessions for the advancement of pragmatic language and social skills. Future projects at the center include studies to objectively evaluate treatment efficacy and functional outcomes of the participants and mentors. While the ALPS groups continue to adapt and improve, the current success of the programs remains readily apparent. As we work to document improvements and successes, we are continually inspired by the adults who come to our center. Adults like Jim, entering our rooms with nods and smiles, looking for fun and friendly faces. Our hope is that these special adults feel equally inspired, and that they leave our rooms feeling successfully connected.

 

Lisa Geary, M.S., CCC-SLP, serves as Clinical Assistant Professor in the Department of Audiology, Speech-Language Pathology and Deaf Studies at Towson University. In addition to teaching and supervising graduate students in the on-campus Speech-Language Center, Lisa serves as program facilitator for the Adult Language and Pragmatic Skills Groups at Towson’s Hussman Center for Adults with Autism. Her teaching and research interests include Universal Design for Learning, Autism through the Lifespan, Augmentative and Alternative Communication (AAC), and Instructional Technology. Lisa can be reached at lgeary@towson.edu

 

References

Orsmond GI, Krauss MW, Seltzer MM. Peer relationships and social and recreational activities among adolescents and adults with autism. Journal of Autism Dev elopmental Disorders, 2004; 34:245–256.

LLaneza DC, DeLuke SV, Batista M, Crawley JN, Christodulu KV, Frye CA. Communications, interventions and scientific advances in autism: a commentary. Physiol Behav. 2010;100:268–276.

McGee, G. G., Almeida, M. C., Sulzer-Azaroff, B., Feldman, R. S. (1992). Promoting reciprocal interactions via peer incidental teaching. Journal of Applied Behavioral Analysis. 25 117–126.

Rose, D.H. & Gravel, J.W. (2010). Universal design for learning. In E. Baker, P. Peterson, & B. McGaw (Eds.). International Encyclopedia of Education, 3rd Ed. Oxford: Elsevier.

 

 

 

Skyrocketing Autism Numbers a Call to Action for SLPs

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Last week the child-development community got a jolt from news of a jump in numbers of children diagnosed with autism spectrum disorder: an increase of 30 percent in just two years. One in 68 children had ASD in 2010, up from one in 88 children in 2008, according to data from the U.S. Centers for Disease Control and Prevention.

And that’s raised many questions among speech-language pathologists and other developmental experts. For one thing, what’s driving the increase? And what does it mean for ASD diagnosis and treatment? There are no clear answers or absolutes. But developmental expert Stephen Camarata is willing to speculate. We talked with the Vanderbilt University hearing and speech sciences professor about his take.

What is behind this increase? Is it really just an increase in identification?

There are three main factors. One is a real increase in incidence. Our technological ability to take preemies weighing less than a pound and have them survive has changed, and it’s not surprising that more of these kids might have challenges.
Second, there’s increased awareness, so more people are looking for ASD in kids. And third there’s the expansion of the definition of spectrum. The numbers of kids identified as high functioning and as having Asperger syndrome has skyrocketed.

What do the higher numbers mean for SLPs?

We’re the speaking profession, so we have a central role in assessing and treating these kids. Based on this, we’re obviously seeing a big increase in caseload, which as a field we need to develop ways to handle. But more basically than that, we need to figure out how to differentially diagnose these young kids, these 2-year-olds, distinguishing between ASD and the new DSM-5 [Diagnostic and Statistical Manual of Mental Disorders] category of social communication disorder.

We are the main profession driving identification and treatment of SCD, and we need to develop assessments and interventions in this area. It’s a huge opportunity and a huge challenge—and we need to be prepared to handle this demand.

The study suggests that there is a lag in identification, with most kids diagnosed at 4 and older when they could be diagnosed as early as age 2. What can SLPs do to help get these kids diagnosed earlier?

First I should point out that when the kids in this study were toddlers, in 2004 and 2005, we weren’t yet able to accurately diagnose autism at those young ages. Now, with the toddler module of the Autism Diagnostic Observation Schedule, we can. And given that with ASD comes late onset of speaking, SLPs are often doing the earliest assessments. Right now, we may be less inclined to put a late-speaker in the SCD category because we want to get these kids services but don’t yet have appropriate assessments, treatments or reimbursement for SCD. Our charge is to develop these. And it’s also to it’s also to continue to develop continuing education for our practitioners to diagnose autism, which we can do, typically as part of a team.

The study suggests that kids who are African American and Hispanic are being underdiagnosed relative to white kids—again, what can SLPs be doing to help close this gap?

It should be noted that, if you look at the report, there actually has been a dramatic increase in diagnosis in both those communities. But yes, the rates still lag behind those in white children a great deal, so there’s a need to close this gap. Part of this is an issue of cultural difference, but it’s also the well-known health-disparities story of lack of access to services. So we need to do more outreach and education in the African American and Hispanic communities about early intervention and their entitlement to public services.

What are the implications of these findings for the services SLPs provide to children on the spectrum?

This is my sense: Some SLPs feel like they’re not necessarily the primary interventionists in cases of autism but if a kid’s primary weakness is in the speech and language domain—which is the case in ASD, along with behavior—then they really have the role. Improved speech improves behavior. And parents want their kids to talk, so we are and should be primary clinicians involved in diagnosing and treating ASD.

As we go forward, we need to work on distinguishing SCD from autism. We need to own this, but to do that we need to provide data that make a difference and train others on what we know.

 Learn more about social communication disorders  and autism spectrum disorder on ASHA’s website. More information on both categories is available from ASHA—e-mail Diane Paul, ASHA director of clinical issues in speech-language pathology, at dpaul@asha.org.

Stephen Camarata, PhD, CCC-SLP, is a professor of hearing and speech sciences at the Bill Wilkerson Center at the Vanderbilt University School of Medicine. He is an affiliate of Special Interest Group 1, Language Learning and Education. Contact him at stephen.m.camarata@vanderbilt.edu.

Coaching Parents to Foster Their Child’s Expressive Language Skills

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I recently had the opportunity to provide tele-speech-language services to a toddler with autism spectrum disorder. I knew it would be difficult to have him sit in front of a computer for long periods, so I decided that I would employ a “parent coaching” approach, empowering his parents to more effectively help their son.

I started by having the parents videotape their daily interactions with him, which revealed that they were aware of their son’s difficulties and in-tune with his communication needs. However, even though this little boy appeared quite bright, it was difficult to distinguish when he was answering a question from what he had learned, or if it was a rote response. The parents had specific goals they wanted their son to achieve, so how was I going to help them?

I provided the boy’s parents with information about expressive language development and explained that their expectations appeared to be beyond this child’s current capabilities (determined by the boy’s age, as well as his disability). Next I took the language and vocabulary skills the parents wanted their son to learn—such as labeling an apple—and broke them out into smaller steps. These are the types of activities I suggest parents use to help a child grasp a language concept:

  • Present the child with several apples, preferably of different colors.
  • Talk about the outside of the apples: color, shape, size, smell, taste and texture.
  • Cut open the apples (“What do you see?”) , and eat some of each, talking about how it sounds and tastes as you bite into each piece.
  • Cut an apple in half horizontally and use washable tempera paints to make apple prints on paper using the different colors apples can be.
  • Find a simple recipe to make applesauce or another food from apples.
  • Eat apple slices with peanut butter and talk about how it tastes, and about the messiness and stickiness.
  • Make a pretend apple out of PlayDoh.
  • Compare the “fake” apple with the real one, explaining that you can eat a “real” apple but not the “pretend.” This models analytical thinking.
  • Bring in another fruit, such as an orange, and do the same steps.
  • Try making and drinking homemade orange juice.
  • Compare an apple to an orange.
  • Show video clips of people picking apples and oranges, showing how both grow on a tree.
  • Add bananas, doing the first seven steps (tastes great with peanut butter).
  • Roll the items across the floor and talk about how they roll. Compare.
  • Use this method to teach about common fruits you either purchase or see in the market.

Of course, just relating these steps to parents isn’t enough, because they have a tendency to take over for their child if they see the child struggling. For example, it’s tempting for them to place the child’s hands on the paper to make the apple prints, which removes the child from the process and leads to a loss of interest. To help parents avoid this, I explain that learning involves making mistakes. Other suggestions I provide include:

  • When speaking to your child, keep your sentences simple and to the point (approximately three to four words per utterance: “Are you hungry?” versus “Are you ready to go have some sandwiches for lunch?” Expanding utterances will come along a bit later!
  • Speak slowly because it may take the child additional time to process the information.
  • Do not require the child to look you in the eye when you are speaking to him. A glance at your face, especially at this age, should suffice. Toddlers are busy-bodies and need to keep moving and exploring.
  • If you ask a child a comprehension question, he or she may provide a quick or rote answer to be able to do what he wants to do.
  • Allow time to just play with your child. Let the child direct the play. Have a few toys out to choose from and follow his or her lead.
  • Make simple remarks about what is going on, but avoid asking questions to probe for an answer: “What color is your truck? How about that car? What is this part of the car called?” This is play time, not teaching time.
  • Model out loud how to think about items: “You have a big, blue truck! Wow! Mine is small. I have a small, yellow truck. “
  • Model out loud how to problem-solve (over-and-over-and-over again): “Oops! The wheel came off my truck. Hmmm. How can I fix it? {looking over the whole truck while thinking….} If I get something to help the wheel stay on, I should be able to fix it. If I use glue, the wheel may not spin.”
  • Allow some “quiet” play time as well and let your child do the talking (or not if he so chooses). This is a great opportunity to just sit and listen to what your child is saying (to you and/or the toys).

I have parents send me some YouTube video of them performing some of these activities with their child. In subsequent sessions, we discuss what works well (and not so well) with the child, and I share more activity ideas and literature with them.

Tracy Sippl, MS, CCC-SLP, is a Seymour, Wisc.-based speech-language pathologist and tele-therapist with Cumberland Therapy Services. She is an affiliate of ASHA Special Interest Group 18, Telepractice. This post was adapted from a post on the Cumberland Therapy blog,  Right Therapy–Right Results–Right Now.

Yes, DSM-5 Changes SLP-Relevant Disorder Categories: What You Need to Know

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The speech-language pathology community has been abuzz for months about the pending release of the new Diagnostic and Statistical Manual of Mental Disorders because of expected changes to autism spectrum disorder and other communication disorders involving SLPs.

And indeed, the fifth edition, issued by the American Psychiatric Association last month, significantly changes ASD and several other SLP-relevant categories—and also unveils the new social (pragmatic) communication disorder.

As most SLPs well know, DSM is the standard classification of mental disorders used in clinical and community settings in the United States and other countries. The new edition is available first in print, with an electronic version to be offered later this year. See highlights of the changes to DSM-5 on the American Psychiatric Association’s website.

Here are some of the major changes in the category of Neurodevelopmental Disorders that are relevant to the work of speech-language pathologists:

 Intellectual disability (Intellectual developmental disorder)

  • Replaces the term “mental retardation” with “Intellectual disability (Intellectual developmental disorder).”
  • Relies more on adaptive functioning rather than on specific IQ scores.

Communication Disorders

Changed from expressive and mixed receptive-expressive language disorders to include:

  • language disorder
  • speech sound disorder
  • childhood-onset fluency disorder
  • social(pragmatic) communication disorder

Autism spectrum disorder (ASD)

  • Eliminates pervasive developmental disorder and its subcategories (autistic disorder, Rett’s disorder, childhood disintegrative disorder, Asperger’s disorder, pervasive developmental disorder-not otherwise specified). Instead, children meeting the criteria will be given a diagnosis of “autism spectrum disorder” with varying degrees of severity.
  • Omits criterion related to the development of spoken language.

 Specific Learning Disorder

  • Combines diagnoses of reading disorder, disorder of written expression, mathematics disorders, and learning disorder not otherwise specified.
  • Recognizes the need to use a variety of culturally and linguistically appropriate assessment tools and strategies and does not require use of a standardized measure.
  • Does not include oral language.
  • No reference to modalities of language.


Changes in the section on Neurocognitive Disorders pertinent to the speech-language pathology field include the following:

  • Dementia is considered a major neurocognitive disorder.
  • A less severe cognitive impairment is considered a mild neurocognitive disorder.

We were fortunate to have SLPs involved in developing some of the diagnostic criteria in DSM-5. Amy Wetherby was a member of the DSM-5 neurodevelopmental workgroup and chaired a subgroup on communication disorders. Mabel Rice, Nickola Nelson and I worked on this group. ASHA responded during the three public comment periods.

Now that the new edition is out, ASHA has assembled a DSM-5 response team coordinated by me and composed of Janet McCarty, Andrea (Dee Dee) Moxley, Froma Roth and Monica Sampson. We are developing resources to guide members and consumers on the changes, including at least three articles in upcoming issues of The ASHA Leader. The articles will include:

  • A comparative analysis of what ASHA recommended and what DSM-5 includes, with clinical implications for SLPs.
  • Coding implications for reimbursement.
  • Case studies to demonstrate how the changes will affect people with speech, language, communication and cognitive disorders.

ASHA also will communicate with consumers about what the DSM-5 might mean to them through podcasts, media interviews and other dissemination vehicles. A critical message we want to convey is that SLPs will continue to provide needed services, which are based on assessment of communication strengths and needs, and not on specific DSM-5 diagnostic labels.

ASHA would like to know how you think the changes in DSM-5 will affect your clinical practice. We also are seeking case studies that demonstrate impacts of the changes for a future Leader article. Please contact Diane Paul at dpaul@asha.org.

Diane Paul, PhD, CCC-SLP, is ASHA’s director of clinical issues in speech-language pathology.