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.

Tricks to Take the Pain Out of Writing Treatment Goals

questioningwoman

Supervising has taught me a great deal about what trips up SLPs. And one of the most challenging things for new SLPs seems to writing treatment goals. One reason is, of course, that we know these goals will drive the treatment and that they are important; but it is more than that. We want goals to organize our treatment and make it more linear, more hierarchical. We want our goals to be read as a path to development, or recovery: first do this, then move to this and then go on to that. This is, after all, the essence of task analysis.

Speech and language development, or recovery, is not however, linear or even, in many instances, hierarchal. It is so much more, but that is for another post.  We also want our goals to address the clients’ most important needs and in some cases we are hard pressed to figure out just what is most important. We also need to have our goals fit in with the guidelines that our employer sets and that just keeps changing on us. So goals become a challenge.

When writing goals keep in mind that goals are supposed to be SMART: specific, measureable, attainable, relevant and timely. A pet peeve of mine are goals that say “the client will improve his receptive/expressive skills.” These are not SMART: First of all they are not specific, but more, importantly, there is no measurable component in them.  In a report you can head the respective goals with, “In order to improve his receptive/expressive skills the client will…..” But those sentences are not goals and are certainly not SMART goals.

There are numerous data banks of goals on the Web, but I have never found the goals in any database to be just quite right; they all need to be tweaked for the client. You can certainly look up goals in those databanks, but you have the skills to write goals on your own. They are not that difficult when you think them through. You can use a template such as ___ will ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­___ by ___ to ___ percent above baseline or ___ percent of the time as measured by ___ or some such formula but you still have to fill in everything from your own mental data bank. You can do this easily by using the answers to some simple questions you must ask yourself.

Let’s look more closely at SMART.

Specific
Part of the problem is thinking about goals as a separate entity. Goals are just a way to put what you want to do in therapy in writing. Most SLPs are not uncomfortable about doing therapy so why should goals be a problem? Ask the following questions for a start for your specific goals.

  • What are the client’s communicative strengths?
  • What are the client’s communicative weaknesses?
  • What are the skills contributing to the strengths?
  • What skills are deficient and therefore contributing to the weaknesses?
  • Which of client’s skills can be used to compensate for deficiencies?
  • Which skills that are lacking can I actually help the client attain?
  • What do I want to work on first? And now answer: Why do you want to work on that first?  That answer will help you determine if you have made a viable choice.
  • What are the tasks you will have the client complete or engage in to work on the skill?
  • What supports will you provide for the client?

When you have the answers to those questions you have the “specific” for the goals.

Measureable
Can you define the skill that will determine if the client is doing what you want him to do and can you measure progress in that skill?  How will you measure progress? When will you consider the goal accomplished? If you can answer all these questions move on; if not, go back and adjust the goal to something you know you can see or hear and therefore measure.

Attainable
Do you think the client can actually accomplish this in a year? If the answer is yes, move on. If the answer is no, go back and choose something you think the client can accomplish within a reasonable timeframe.

Relevant
Will the attainment of this goal serve a communicative function for the client or will it just be something you can do with the client?  Will it serve a purpose in the client’s life considering the limits and ramifications of the diagnosis and his cultural and social needs?  In the case of an IEP does this goal serve to move the child along to fulfill the common core standards?  If the answer is yes, move on if not… yes, you get the picture go back and start again.

Timely
Does the goal contain a time frame or a date for accomplishing the goal? And can the goal be attained in that time frame? If yes….

Short-term objectives need to follow the same criteria but they should not just be separate pieces of the overall task but rather steps to getting to the long-term goal. The timeframe for accomplishing each part of the short term objective is, obviously a portion of the long term goal and the objective should actually contain that time frame.

As I stated in my last post, what best facilitates treatment is knowing what you want the client to do and knowing that your treatment is actually addressing this. Well, such knowledge also facilitates goal-writing. Use it to write your goals. You have the skills. You need to convince yourself that you can use them. When you keep that in mind, goal writing can be simple.


Irene Gilbert Torres, MS, CCC-SLP
, chair of ASHA’s Multicultural Issues Board, is a clinician in New York City who contributes this ASHAsphere series for beginning SLPs and welcomes treatment questions to address in future posts. She concentrates primarily on infant and preschool evaluations and supervision of graduate students. She is an affiliate of ASHA Special Interest Groups 11, Administration and Supervision; 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations; 16, School-Based Issues; and 17, Global Issues in Communication Sciences and Related Disorders.

Distinguishing Cluttering from Stuttering

boyphone

Developmental stuttering affects 1 percent of the population and over 3 million people in the United States. However, there are other, lesser known fluency disorders that include neurogenic stuttering and cluttering. Telling the difference between stuttering and cluttering is often a point of confusion, so we take a closer look here at what, exactly, cluttering is—and the process of identifying and treating it.

The International Cluttering Association defines cluttering as “…a fluency disorder characterized by a rate that is perceived to be abnormally rapid, irregular or both for the speaker. These rate abnormalities further are manifest in one or more of the following symptoms: an excessive number of disfluencies, the majority of which are not typical of people who stutter; the frequent placement of pauses and use of prosodic patterns that do not conform to syntactic and semantic constraints; and inappropriate (usually excessive) degrees of coarticulation among sounds, especially in multisyllabic words. ”

So what does cluttering look and sound like?

1. Often people who clutter have what I (and many other speech-language pathologists) refer to as “machine-gun” speech. Their speech comes out in rapid bursts, which is described above as “irregular rate,” and may include pauses where it doesn’t feel appropriate.

2. A person who clutters may also demonstrate disfluencies that are unlike what we see in people who stutter. Some examples of disfluencies that are more typical of a person who clutters is excessive whole word repetitions, unfinished words and interjections (such as um and well). I have also noticed more atypical disfluencies, such as final part word repetitions (chair-air, bike-ike).

3. Coarticulation refers to when a person collapses or omits a syllable of a word (for example, “wuffel” for “wonderful”).

There is quite a bit of symptom variability, as well as co-existing conditions, that make this an even more confusing diagnosis. Below is a list of characteristics and co-morbid conditions that have been seen in people who clutter. (Note: Some people who clutter may have several of the below symptoms/co-existing conditions; some may have only one; and some may have none at all.)

  • Limited or no awareness of their irregular speech pattern unless someone draws their attention to it (very different from what we see in stuttering).
  • Sloppy handwriting.
  • Difficulty organizing thoughts; listeners easily get “lost.”
  • Learning disability.
  • Attention difficulties (i.e., ADHD).
  • Auditory Processing Disorders.
  • Asperger’s Syndrome/Autism Spectrum Disorder.
  • Stuttering (a person can clutter and stutter).

If you feel this diagnosis is hard to grasp, you’re not alone.  As a result, this condition goes largely misdiagnosed (as developmental stuttering) or undiagnosed (“I just speak too fast! I don’t have a “real” speech problem!”). For a helpful chart that breaks down the similarities and differences between stuttering and cluttering, see this brochure created by Kathleen Scaler Scott for the National Stuttering Association.

So what do you do if you think your child is cluttering?

Since this a relatively lesser known diagnosis, your best bet would be to find a speech- language pathologist who has experience working with fluency disorders. As you have learned, cluttering is a highly variable disorder. We cannot prescribe a “one size fits all” plan of treatment. There must be careful and continuous observation in order to create a treatment plan that is specific to the symptoms your child is displaying. Here are some common treatment objectives:

    • Self-Monitoring. One common characteristic among people who clutter is limited awareness of their own speech. It is important to heighten the client’s ability to monitor his or her disfluencies, rate, and/or mis-articulations. For a person who stutters, calling their attention to stuttering, although sometimes necessary, may initially cause an increase in disfluencies. However, for people who clutter, calling attention to their speech often helps them improve their rate and overall clarity (at least for a short bit).
    • Over-articulation. Another common characteristic among people who clutter is the collapsing or omitting of syllables. By practicing the over-articulation of sounds, it calls a person’s attention to all the syllables in a word, both stressed and unstressed. The speech of people who clutter may be monotone or “robotic.” Practicing over-articulation can be worked on in conjunction with exaggerating stressed syllables and inflection. Here is a useful video of an SLP discussing the speech of a child who clutters. This particular language sample highlights what it sounds like when a child collapses and omits syllables:http://youtu.be/2AFygz-bxwQ
    • Pausing and Phrasing. Using this technique,  a person practices inserting more pauses into their speech, with attention to the proper placement of these pauses. For younger children, I will have them place pauses every one to three words, but as they get older, more attention will be paid to inserting pauses based on proper phrasing. I often will transcribe a client’s language sample, to include both the words they say and the placement of their pauses. I will then have them mark up the paper with where the pauses should have gone. Having a visual representation of speech is a helpful way to identify when there are way too many words being said between pauses (machine gun speech). Pausing is another too used in teaching a people to slow their rate, which is much more effective and constructive when compared with saying “slow down.
    • Provide strategies for “typical” disfluencies. As noted above, some people will demonstrate stutter-like disfluencies in addition to their cluttering characteristics. In this case, standard stuttering techniques should be addressed. These include cancellations, pull-outs and the like. SLP discussing the speech of a child who clutters. This particular language sample highlights what it sounds like when a child collapses and omits syllables.

Brooke Leiman, MA, CCC-SLP, is the fluency clinic supervisor at the National Speech Language Therapy Center in Bethesda, Md. She is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. This blog post is adapted from a post on her blog, www.stutteringsource.com, which focuses on fluency disorders and their treatment.

 

The Top 10 Take-aways for CSD Work With Families

familyportraitAccording to my dusty hardcover Webster’s dictionary, a family is defined as: All the people living in the same house; household, 2) a social unit consisting of parents and the children they rear…” (Neufeldt, V, 1988). Since this was dated, I thought I should go to The Free Encyclopedia – Wikipedia. They define family as: “In human context, a family is a group of people affiliated by consanguinity, affinity, or co-residence. In most societies it is the principal institution of the socialization of children…”

In our profession, we have had to make a mind shift from client-based services to the child to family-centered services focused on collaborating with and supporting the family. In this partnership, all people involved acknowledge that each possesses unique skills and knowledge, and they demonstrate trust and respect for one another. Professionals recognize the decision making power of the parent.

Why is family-centered care important? Outcomes! For a child to reach his or her fullest potential, it is essential to have appropriate resources, qualified professionals and family involvement. In family partnerships, families receive support not only from professionals, but from other families with similar circumstances and from the community at large.

Here are the top 10 take-aways for the next time you work with a family:

10) Time. As a professional everything is fast paced. After all time is money — and you serve a lot of people. For a parent, however, time is very slow; they are constantly waiting.

9) Don’t make assumptions or generalizations. Every family is unique with very specific needs. Present all options…don’t be biased in what you say.

8) Don’t label families—or each other.

7) Don’t make inappropriate comments about your profession. Talking negatively about your workplace or another professional reflects poorly on you. The average “wronged” customer will tell 25 others about the bad experience. Don’t reinforce negative experiences.

6) Be confident but not arrogant.

5) Communicate! Communicate! And communicate some more! You cannot overstate anything. Monitor your tone of voice, body language, rate of speech, and be mindful of professional jargon.

4) Listen! Listen! And listen some more! Show the family you are listening (body language). Provide feedback, defer judgment, and don’t try to rescue—empathize.

3) Acknowledge the parent’s efforts and strengths. No matter how small it is — acknowledge something positive.

2) Keep in mind the lack of consistency in our field. Families will see a variety of specialists, and each will provide an opinion about what the parents should do. “This method is better because”…or “You should try this.” The various opinions can be confusing and overwhelming for the family. Be respectful of one another.

1) Respect and patience. Remember parents are people too!

To learn more about family support and family-centered practices, check out the transcript of an “Ask the Expert” online chat about these services, held April 30 by ASHA Special Interest Group  9, Hearing and Hearing Disorders in Childhood.

Tamala Selke Bradham, PhD, CCC-A, is coordinator of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood. She is also associate director of quality, protocols, and risk management in the Department of Hearing and Speech Sciences at Vanderbilt University. She and Joni Alberg, PhD, executive director of BEGINNINGS for Parents of Children Who Are Deaf or Hard of Hearing, Inc., in Raleigh, N.C., answered questions during the SIG 9 online chat.