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Using Picture Books to Teach Children That It’s OK to Make Mistakes and Take Risks

Image result for children making mistakesThose of you who follow my blog know that in my primary job as an SLP working for a psychiatric hospital, I assess and treat language and literacy impaired students with significant emotional and behavioral disturbances. I often do so via the aid of picture books (click HERE for my previous posts on this topic) dealing with a variety of social communication topics.

Two themes that consistently come up in my therapy sessions are taking risks and making mistakes. Many of my students are very afraid of taking risks and are terrified of trying new things whether educationally or socially. To address the issue of taking risks and changing one’s mindset I like using two books by Julia Cook Bubble Gum Brain’ as well as ‘Don’t Be Afraid to Drop’.

Image result for bubble gum brainBubble Gum Brain’ (video) is a book about two kids: Bubble Gum Brain and Brick Brain, with two drastically different frames of mind. Bubble Gum Brain is a fun fun-loving adventure-taker who makes loads of mistakes, whether falling off a unicycle, striking out at baseball, or playing the harmonica. Even though those things are very difficult, he is not concerned about making mistakes because he realizes that by persevering and not giving up he is learning new things and actually having fun in the process. In contrast, Brick Brain is convinced that “things are just fine the way they are” and trying new things is hard. Brick Brain is hugely reluctant to take any chances in sports, at play, and in life, and is frequently complaining that things are “way too hard”. Then Bubble Gum Brain shows Brick Brain that all he needs to do is to peel off his wrapper, in order to see that he also has a Bubble Gum Brain. After that Brick Brain starts to realize that school and life can be a lot more palatable and even fun even when one is making mistakes.

Book Buddy for Bubble Gum Brain by Julia CookMy favorite part about this book is teaching my students to understand the Power of Yet (“You can’t figure this out …yet”), and explaining to them that with hard work and perseverance they can accomplish just about anything they set their mind to, including the mastery of their language and literacy goals! I teach them to take chances by trying to go just a little bit farther each time and pushing themselves just a tiny bit more in each of their therapy sessions. In addition to asking my students critical thinking questions regarding this text, I at times use a FREE book companion from Technology Tidbits on TPT, to supplement my therapy sessions. It contains a lesson plan overview, a book quiz, a sorting activity, and a few other resources which can wonderfully supplement the session for this book.

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Similar to the above,’Don’t be Afraid to Drop’ (video) is a book about a raindrop who is incredibly comfortable living in his cloud with his friends. He is having a very difficult time letting go of the comforts of his cloud as he doesn’t like change or wants to take a risk. However, with his father’s encouragement, the raindrop is eventually persuaded to leave his comfort zone and jump to the ground to see what he is missing. I really like the positive message in this book regarding welcoming change as well as giving back. “You can have it silver you might end up – I promise, you’ll be just fine you will land where you are needed.” By the end of the book, the raindrop realizes that “dropping” had helped him to grow; that change is an ultimately positive thing; and that giving to others (e.g., watering a flower) helps us all grow!

To continue, a considerable number of my students not only both loath (unwilling, reluctant) and loathe (hate) to make mistakes and be perceived as wrong, but will react in some pretty significant ways when those mistakes occur (e.g., climb under the table and refuse to come out, throw a tantrum and refuse to attend therapy sessions, etc.). To teach my students that mistakes are actually beneficial for learning I like to use books such as ‘The Girl Who Never Made Mistakes!’ by Mark Pett and Gary Rubenstein and ‘Your Fantastic, Elastic Brain‘ by  JoAnn Deak. 

11526654Beatrice Bottomwell is ‘The Girl Who Never Made Mistakes!’ (video) This nine-year-old is perfect in every way, to the point that when she leaves the house she is greeted by her fans, who don’t even know her real name because she’s known to everyone in town as “The Girl Who Never Made Mistakes”.  Beatrice never forgets her math homework, never wears mismatched socks, and has won her school’s talent show by doing her juggling act for three years in a row.  Then one day during cooking class, Beatrice makes an ‘almost mistake’ as she slips on a piece of rhubarb while carrying eggs from the fridge. Even though she manages to catch all the eggs, Beatrice becomes highly preoccupied with her ‘almost mistake’. In fact, she is so perturbed by it that she doesn’t want to ice skate with her friends and can barely eat her food. Later that evening, during the school’s talent show Beatrice’s preoccupation with her ‘almost mistake’ causes her to make a spectacularly huge mistake, which results in her being soaked in water, covered in pepper, with a hamster on her head.  Luckily, rather than getting spectacularly upset, Beatrice comes to a realization that not only do mistakes happen but sometimes they can be pretty hilarious! So rather than crying or getting upset she begins to their end the audience joins in until soon, no can’t quite remember why they were everlasting. This serves as a catalyst for Beatrice not only to have peace of mind but also to mix-and-match her wardrobe choices, make unusual lunches, as well as do plenty of falling during ice-skating. This also precipitates townfolk to finally start calling Beatrice by her real name rather than “The Girl Who Never Made Mistakes”.

Prior to reading this book, I discuss with my students the concept of mistakes, how they feel about when they make mistakes, whether they know people who have never made mistakes, as well as when, do they think it is ok to make mistakes. I spend quite a bit of time on discussing text embedded vocabulary words as well as idiomatic expressions (e.g., ‘stunned’, ‘wobbled’, ‘didn’t miss a beat’, ‘auditorium was packed’, etc.). There is a wealth of amazing FREE materials available to complement this book.  They include but are not limited to: a book companionBloom taxonomy leveled questions for grades Pre-K-5th, as well as an educators guide from the book’s two authors.

Image result for YOUR FANTASTIC ELASTIC BRAIN: STRETCH IT, SHAPE ITIn contrast to all the above books, ‘Your Fantastic, Elastic Brain‘ (video) is a non-fiction book with a focus on describing brain structures and their functions in a very kid-friendly way. The author, who is a psychologist by trade, does a really great job at explaining to children that the brain controls everything we do. She describes the functions of such structures as the cerebrum, cerebellum, hippocampus, amygdala, prefrontal cortex, as well as neurons in very child-friendly terms.  She explains the importance of practicing to get better at doing something, as well as emphasizes that things “get easier when you keep trying”.   I love the stress on the fact that “making mistakes is one of the best ways your brain learns and grows,” and that “if you aren’t willing to risk being wrong, you want to take the chances that S-T-R-E-T-C-H your elastic brain“. In addition to already mentioned science-related words identifying select structures of the brain, the book offers other impressive vocabulary choices such as balance, movement, electrical, signal, cells, neurosculptor, courage, molds, etc.  Beyond understanding why it’s okay to make mistakes, my students feel “really grown-up” because they get the unique opportunity to discuss parts of the brain “even kids in high school don’t know,” as one of my students had put it.

The publishers of the book ‘Little Pickle Press’ have a wonderful 16-page, free lesson plan for educators, intended for children ranging in ages from pre-K through third grade (although it can be easily used with older students with language difficulties as well as intellectual impairment). It is chock-full of educational activities, additional resources, as well as questions which facilitate the growth of meta-cognitive and metalinguistic abilities in elementary aged children. I also use Ned the Neuron Videos to complement book reading as well as book activities. Finally, a handy poster associated with the book can be downloaded HERE.

Image result for Thanks for the Feedback, I thinkIn conjunction with teaching children that it is perfectly acceptable to make mistakes I also attempt to ensure that they react appropriately when provided with constructive feedback.  For the purpose, I like to utilize a book by Julia Cook, entitled: ‘Thanks for the Feedback, I think‘ (video).  While this book primarily deals with helping children  appropriately respond to compliments, there are still several instances in the book when RJ, the main character receives constructive feedback aimed at helping him to get better at certain things such as playing soccer, keeping a lower voice in class, staying in his seat, as well as dawdling less during assignments. One complimentary activity I like to do in conjunction with the book reading is to have my students watch a variety of YouTube videos, in which individuals are receiving some form of feedback from others. It could be anything from the ‘American Idol’ and ‘Voice’ auditions to ‘Chopped’ judges providing feedback to chefs. After watching the clips I ask the students their impressions on how feedback was received by the participants and how did they figure out whether the participants reacted well/poorly to the provided feedback.

Image result for the judgemental flowerTo cap off our discussion on taking risks, making mistakes, and accepting feedback, I also wanted to give an honorary mention to yet another book by the prolific Julia Cook entitled, ‘The Judgmental Flower‘. It teaches children the value of being non-judgemental and being accepting of others’ differences. Because I work with children with significant emotional and behavioral difficulties, this book comes especially handy, when my students are attempting to be quite judgmentally rude to each other. I use this book to teach them to embrace and learn from each other’s differences and emphasize the fact that the world would be very boring is all of us were exactly the same. I also spend some time exploring the notion of “growing in the right direction” as well as on explaining the concept of diversity. I occasionally supplement the book reading with select FREE Activities which can be found HERE and HERE.

Of course, it is important to note that while I use the above books to improve my students’ social communication and executive function abilities, I do so by creating a variety of goals which explicitly target my students’ verbal expression, as well as reading fluency, reading comprehension, spelling, and writing skills. These include answering concrete and abstract questions, defining context embedded vocabulary words, decoding words in books, answering reading comprehension questions given visual support, as well as formulating written sentences based on select words identified in the stories, utilizing appropriate punctuation and capitalization.

Image result for moreSo now that you know what type of books I use in my therapy sessions with a focus on taking risks, making mistakes, accepting feedback, as well as being nonjudgmental, I’d love to expand my list by learning about new titles I am not yet aware of from you. Feel free to comments below regarding what other books you are using to address these themes in therapy.

Helpful Smart Speech Therapy Resources:

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Speech, Language, and Literacy Fun with Helen Lester’s Picture Books

Picture books are absolutely wonderful for both assessment and treatment purposes! They are terrific as narrative elicitation aids for children of various ages, ranging from pre-K through fourth grade.  They are amazing treatment aids for addressing a variety of speech, language, and literacy goals that extend far beyond narrative production.

There are numerous children books authors whom I absolutely adore (e.g., Karma Wilson, Keiko Kasza, Jez Alborough, M. Christina Butler, etc.). Today I wanted to describe how I implement books by Helen Lester into my treatment sessions with elementary aged children. (For information on how I use her books: “Pookins Gets Her Way” and “A Porcupine Named Fluffy” for narrative elicitation purposes click HERE.)

It is important to note that while Ms. Lester’s books are intended for younger children (4-7 years; pre-K-3rd grade), older children (~10 years of age) with significant language and learning difficulties and/or intellectual disabilities have enjoyed working with them and have significantly benefited from reading/listening to them.

Two reasons why I love using Ms. Lester’s books are versatility and wealth of social themes. To illustrate, “Hooway for Wodney Wat” and “Wodney Wat’s Wobot” are two books about a shy rat who cannot pronounce his ‘r’ sounds. Wodney is hugely embarrassed by that fact, and since there are no speech-language pathologists in Rodentia-land, Wodney spends his recess, hiding inside his jacket, trying to be as inconspicuous as possible. The arrival of a bullying, Miss-know-it-all, Camilla Capybara, brings some unexpected changes into the school’s dynamic, as well as provides Wodney with a very welcome opportunity to shine socially.

Image result for wodney wobotSpeech Production: Not only is there a phenomenal opportunity to use this book with children struggling with /r/ sound production, but it’s also heavily laden with a plethora of /r/ words in a variety of word positions (e.g., rodeo, robot, contraption, barrel, terrific, fur, prickled, bigger, fear, classroom, smarter, sure, etc.).

Language: There are numerous language goals that could be formulated based on Helen Lester’s books including answering concrete and abstract listening comprehension questions, defining story-embedded vocabulary words, producing word associations, synonyms, antonyms, and multiple meaning words (semantic awareness), formulating compound and complex sentences (syntax), answering predicting and inferencing questions (critical thinking), gauging moods and identifying emotional reactions of characters (social communication), assuming characters’ perspectives and frame of reference (social cognition, theory of mind, etc.), identifying main ideas in text (Gestalt processing) and much, much more.

  • Select Highlights:
    • VocabularyFor the ages/grades that there’ve written for (4-7 years; pre-K-3rd grade), Ms. Lester’s books are laden with a wealth of sophisticated vocabulary words such a: curtsy, contraption, trembled, dreary, shudder, varmint, fashionable, rodent, rattled, shenanigans, chanting, surgical, plunked, occasion, exception, etc.
    • Word Play:  Ms. Lester infuses a great deal of humor and wit in her books. Just look at the names of her characters in “A Sheep in Wolf’s Clothing”, which are: Ewetopia, Ewecalyptus, Ewetensil, Heyewe, Rambunctious, Ramshackle, and Ramplestiltskin.  Her ovine characters live in Pastureland and attend Woolyones’ Costume Balls while her porcine characters eat in a trough-a-teria.  
    • Social Communication: Many of Ms. Lester’s book themes focus on the celebration of neurodiversity (e.g., “Tacky the Penguin”), learning valuable life lessons (e.g., “Me First”), addressing one’s fears (e.g., “Something Might Happen”) and feeling uncomfortable in own skin (e.g., “A Sheep in Wolf’s Clothing”), etc.

Literacy: Similar to the above, numerous literacy goals can be formulated based on these books. These include but are not limited to, goals targeting phonological (e.g., rhyming words, counting syllables in words, etc.) and phonemic awareness, phonics, reading fluency and comprehension, spelling, as well as the composition of written responses to story questions.

  • Image result for princess penelope's parrotSelect Highlights:
    • Phonics: Students can practice reading words containing a variety of syllable shapes as well as decode low-frequency words containing a variety of consonantal clusters (Examples from “Princess Penelope’s Parrot” are:  hissed, parrot, buzzard, horribly, flicked, plucked, field,  flapped, silence, Percival, velvet, cloak, caviar, clippy-clopped, poofiest, impressed, expensive, galloping, gulped, bouquet, squawked, etc.)
    • Morphology: There’s a terrific opportunity to introduce a discussion on roots and affixes when using Ms. Lester’s books to discuss how select prefixes and suffixes (e.g., ante-, -able, -ive, -ion, etc.) can significantly increase word sophistication of numerous root words (e.g., impressive, exception, etc.)
    • Spelling: There is a terrific opportunity for children to practice spelling numerous spelling patterns to solidify their spelling abilities, including -ee-, -ea-, -ou-,-oo-, -oa-, -ui-, -ck, -tt-, -rr-, -ss-, -cc-, etc.

When working with picture books, I typically spend numerous sessions working with the same book. That is because research indicates that language disordered children require 36 exposures  (as compared with 12 exposures for typically developing children) to learn new words via interactive book reading (Storkel et al, 2016). As such, I discuss vocabulary words before, during, and after the book reading, by asking the children to both repeatedly define and then use selected words in sentences so the students can solidify their knowledge of these words.

I also spent quite a bit of time on macrostructure, particularly on the identification and definitions of story grammar elements as well as having the student match the story grammar picture cards to various portions of the book.

When working with picture books, here are some verbal prompts that I provide to the students with a focus on story Characters and Setting

  • Who are the characters in this story?
  • Where is the setting in this story?
  • Are there multiple settings in this story?
  • What are some emotions the characters experience throughout this story?
  • When did they experience these emotions in the story?
  • How do you think this character is feeling when ____?
    • Why?
    • How do you know?
  • What do you think this character is thinking?
    • Why?
    • How do you know?
  • What are some actions the characters performed throughout the story?
  • What were the results of some of those actions?

Here is a sampling of verbal prompts I provide to the students with a focus on story Sequencing 

  • What happened at the beginning of the story?
    • What words can we use to start a story?
  • What happened next?
  • What happened after that?
  • What happened last?
  • How do we end a story?
  • What was the problem in the story?
  • Was there more than one problem?
    • What happened?
    • Who solved it?
    • How did s/he solve it?
  • Was there adventure in the story?
    • If yes, how did it start and end?

Here is a sampling of verbal prompts I provide to the students with a focus on Critical Thinking 

  • How are these two characters alike/different? (compare/contrast)
  • What do you think will happen next? (predicting)
  •  Why/How do you think ___ happened (inferencing)
  • Why shouldn’t you, couldn’t s/he ____ ? (answering negative questions)
  • What do you thing s/he must do to ______? (problem-solving)
  • How would you solve his problem? (determining solutions)
  • Why is your solution ______ a good solution? (providing justifications)

Image result for tacky penguinHere is a small sampling of verbal prompts I provide to the students with a focus on Social Communication and Social Cognition 

  • How would you feel if ____?
  • What is his/her mood at ____ point in the story?
    • How do you know?
  • What is his/her reaction to the ____?
    • How do you know?
  • How does it make you feel that s/he are _____?
  • Can you tell me two completely different results of this character’s actions?
  • What could you say to this character to make him/her feel better?
    • Why?
  • What would you think if?

At times, I also use Ms. Lester’s guide for the following books: ‘It Wasn’t My Fault’, ‘Listen, Buddy’, ‘Me First’, and ‘A Porcupine Named Fluffy‘ to supplement my therapy sessions goals. It provides additional helpful ideas and suggestions on how her books can be further used in both therapy room as well as the classroom.

Finally, one of the major reasons why I really like Ms. Lester’s books is because some of them are ‘art imitating life’ and do not necessarily end up in a ‘traditional’ happily ever after. To, illustrate, “Princess Penelope’s Parrot” is a book about a spoiled princess who cannot get her new parrot to talk, even after threatening it and calling it insulting names. When Prince Percival comes courting, the parrot takes his hilarious revenge on Princess Penelope, and the parrot and Prince Percival do end up living happily ever after. However, Princess Penelope quickly gets over her embarrassment and goes back to her unrepentantly spoiled way of acting.

There you have it! Just a few of my many reasons why I adore using Helen Lester’s books for language and literacy treatment purposes. How about you? Do you use any of her books for assessment and treatment purposes? If yes, comment below which ones you use and why do you use them?

References:

Helpful Related Smart Speech Therapy Resources: 

 

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On the Disadvantages of Parents Ceasing to Speak the Birth Language with Bilingual Language Impaired Children

ChildrenDespite significant advances in the fields of education and speech pathology, many harmful myths pertaining to multilingualism continue to persist. One particularly infuriating and patently incorrect recommendation to parents is the advice to stop speaking the birth language with their bilingual children with language disorders.

There is a plethora of evidence available regarding how bilingualism facilitates, increases, and improves language gains in children with developmental language disorders (DLD) as well as genetic conditions and syndromes (e.g., ASD, DS, FXS, etc.) Numerous researchers have released results of studies indicating the advantages of being bilingual for language impaired children (see this issue of Journal of Communication Disorders for starters for some studies on this subject).

But today in addition to briefly reiterating these advantages, I’d like to also explicitly discuss the disadvantages, which can result when parents are told to stop speaking the birth language with their language impaired children and switch to English-only interactions.

Cognitive advantages of maintaining the birth language for bilingual children with language impairments  (whose parents are able to provide them with that opportunity in the home) include increased attentional control and working memory, as well as perspective taking abilities. Linguistic advantages include increased awareness of vocabulary and grammar. Even social skills of these children have been reported to be more advanced as compared to monolingual only peers (See Pena, 2016, pp. 88-89 for a review of pertinent studies)

But what happens when parents decide to speak English only to their language impaired bilingual child? In the words of Helen Lester’s ‘Pookins’, lots! And I don’t mean it in a good way!

—Research indicates that children with language disorders will have language deficits in all the languages that they speak. As such, no matter which language is being used, the child will still present with some difficulty acquiring it and will do so at a much slower pace (Kohnert, 2010).

The problem is that NOT using the native language, can limit language and early literacy practices at home during sensitive periods of language acquisition. This will result in poorer language outcomes as compared to bilingual language impaired peers whose birth language continued to be supported at home. (Ijalba, 2010)

“There is also evidence to show that young minority L1 learners with impaired language systems are even more vulnerable than unaffected bilingual peers to loss or early plateaus in the home language if it is not supported ().” (Kohnert, 2010, p. 8)

“Minority-language families are especially affected since English is usually recommended as the target language.”  (Yu, 2016, p. 424) Some studies have reported that: “parents expressed personal loss and sadness (Fernandez y Garcia et al., 2012) if they chose to speak only English to their child with ASD.” Other studies have reported that “some [parents] also expressed discomfort and difficulty when speaking a non-native language with their child (Yu, 2013) or said they talked less frequently to their child when they used the majority language because it felt less natural.” (Bird, Genesee, Verhoeven, 2016. p. 5)

Perhaps the most disturbing findings are the studies that show that eliminating speaking birth language at home causes an emotional disconnect between immediate and extended family members and the child in question (Kouritzin, 1999; Tseng & Fuligni, 2000; Wharton et al 2000). Wharton and colleagues found that immigrant parents were more affective and engaging with their autistic children when they used their native language Wharton et al (2000).  Contrastingly, Kremer-Sadlik (2005) found that parents are less likely to engage their children in conversation when they cannot use their native language and that it further isolates a child who needs help with interactive skills.

“The advice to stick with a language that the family doesn’t speak well only intensifies the alienation experienced by these children.”  “You’re taking a child who is already socially isolated and you’re making them even more isolated”. Consequently, “development of heritage languages and bilingual competencies may be especially important for children with ASD given their core challenges in socialization, communication, and relational development.” (Yu, 2016, p. 434)

Given the combined results of the above studies, it is hugely important for professionals to appropriately support the parents of bilingual children with language and learning needs when it comes to offering them relevant recommendations on the topic of language use in the home. This can be accomplished by sharing with them the synthesis of currently available studies on the topic of bilingualism and language disorders, as well as encouraging them to speak the birth language in the home if they are willing and able to, rather than embracing English only practices, which may result in significant detrimental effects for both bilingual children and their families.

FOR A PDF HANDOUT FOR PARENTS AND PROFESSIONALS PLEASE CLICK HERE

Select Parent-Friendly Resources:

 References:

  1. Fernandez y Garcia, E., Brelau, J., Hansen, R., & Miller, E. (2012). Unintended consequences: An ethnographic narrative case series exploring language recommendations for bilingual families of children with autistic spectrum disorders. Journal of Medical Speech-Language Pathology, 20, 10–16.
  2. Hakansson G, Salameh E, Nettelbladt U. (2003) Measuring language development in bilingual children: Swedish-Arabic children with and without language impairmentLinguistics. 41:255–288.
  3. Ijalba, E (2010) Supporting early-literacy and language acquisition among bilingual children in HeadStart ASHA Convention Handout: Philadelphia, PA.
  4. Kay-Raining Bird, E, Genesee, F & Verhoeven, L (2016) Bilingualism in children with developmental disorders: A narrative review.  Journal of Communication Disorders, (63), pp. 1-14.
  5. Kohnert, K. (2010). Bilingual children with primary language impairment: Issues, evidence and implications for clinical actions. Journal of Communication Disorders43, 465–473.
  6. Kouritzin, S (1999) Face[t]s of First Language Loss. Routledge.
  7. Kremer-Sadlik, T. (2005). To be or not to be bilingual: Autistic children from multilingual families. Proceedings of the 4th International Symposium on Bilingualism, ed. James Cohen, Kara T. McAlister, Kellie Rolstad, and Jeff MacSwan, 1225-1234.
  8. Peña, E (2016) Supporting the home language of bilingual children with developmental disabilities: From knowing to doing. Journal of Communication Disorders, (63), pp. 85-92.
  9. Restrepo MA, Kruth K. (2001) Grammatical characteristics of a Spanish-English bilingual child with specific language impairment. Communication Disorders Quarterly. 21:66–76.
  10. Salameh E, Hakansson G, Nettelbladt U. (2004) Developmental perspectives on bilingual Swedish-Arabic children with and without language impairment: A longitudinal study. International Journal of Language & Communication Disorders. 39:65–91
  11. Tseng, Vivian. & Fuligni, Andrew J.(2000). Parent-adolescent language use and relationships among immigrant families with east Asian, Filipino and Latin American background. Journal of Marriage & Family, Vol. 62, No. 2,
  12. Wharton, R et al. (2000). Children with special need in bilingual families: A developmental approach to language recommendations. ICDL Clinical Practice Guidelines. The Unicorn Children’s Foundation: ICDL Press, Ch. 7. Pp 141-151.
  13. Yu, B. (2013). Issues in bilingualism and heritage language maintenance: Perspectives of minority-language mothers of children with Autism Spectrum Disorders. American Journal of Speech-Language Pathology, 22, 10–24.
  14. Yu, B. (2016). Bilingualism as conceptualized and bilingualism as lived: A critical examination of the monolingual socialization of a child with autism in a bilingual family. Journal of Autism and Developmental Disorders, 46, 424-435.

For more information on Evidence-Based Practices in Speech-Language Pathologists, SLPs can check out SLPs for Evidence-Based Practice 

For more Smart Speech LLC bilingual resources and topics click HERE

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Analyzing Discourse Abilities of Adolescents via Peer Conflict Resolution (PCR) Tasks

A substantial portion of my caseload is comprised of adolescent learners. Since standardized assessments possess significant limitations for that age group (as well as in general), I am frequently on the lookout for qualitative clinical measures that can accurately capture their abilities in the areas of discourse, critical thinking, and social communication.

One type of an assessment that I find particularly valuable for this age group is a set of two Peer Conflict Resolution Tasks. First described in a 2007 article by Dr. Marylin Nippold and her colleagues, they assess expository discourse of adolescent learners.

Expository discourse is the use of language to convey information (Bliss, 2002). As per Nippold and colleagues, “expository discourse occurs, when a speaker describes the steps and outcome of a biology experiment, explains how to operate the equipment at a medical lab, or gives directions on how to travel by train from one city to another.” (Nippold, Mansfield, & Billow, 2007, p. 180).  Not only does expository discourse require the “facility with complex syntax”, it also taps into the speaker’s social communication and critical thinking abilities, which is why I employ these tasks on a regular basis when assessing adolescent students.

Here is what these tasks entail. First, the tasks are introduced to the student: “People are always running into problems with others at school, at work, and at home. Everyone has to work out ways to solve these problems. I am going to read you two different stories that illustrate these types of problems. I would like you to listen carefully and be ready to tell each story back to me, in your own words. Then I will ask you some questions about the story. There are no penalties for incorrect answers. I just want to know what you think about the issues and how they should be handled.” (adapted from  Selman et al., 1986, p. 459)—

Below are the descriptions of actual tasks straight from the article.

Image result for model airplane clipartStory A: “The Science Fair” John’s (Debbie’s) teacher assigned him (her) to work with three other boys (girls) on a project for the science fair. The boys (girls) decided to build a model airplane that could actually fly. All of the boys (girls) except one, a boy (girl) named Bob (Melanie), worked hard on the project. Bob (Melanie) refused to do anything and just let the others do all the work. This bothered John (Debbie) very much. Now I’d like you to tell the story back to me, in your own words. Try to tell me everything you can remember about the story… Now I’d like to ask you some questions about the story:

  1. What is the main problem here?
  2. Why is that a problem?
  3. What is a good way for John (Debbie) to deal with Bob (Melanie)?
  4. Why is that a good way for John (Debbie) to deal with Bob (Melanie)?
  5. What do you think will happen if John (Debbie) does that?
  6. How do you think they both will feel if John (Debbie) does that?

Image result for fast food restaurant clipartStory B: “The Fast-Food Restaurant” Mike and Peter (Jane and Kathy) work at a fast-food restaurant together. It is Mike’s (Jane’s) turn to work on the grill, which he (she) really likes to do, and it is Peter’s (Kathy’s) turn to do the garbage. Peter (Kathy) says his (her) arm is sore and asks Mike (Jane) to switch jobs with him (her), but Mike (Jane) doesn’t want to lose his (her) chance on the grill. Now I’d like you to tell the story back to me, in your own words. Try to tell me everything you can remember about the story… Now I’d like to ask you some questions about the story:

  1. What is the main problem here?
  2. Why is that a problem?
  3. What is a good way for Mike (Jane) to deal with Peter (Kathy)?
  4. Why is that a good way for Mike (Jane) to deal with Peter (Kathy)?
  5. What do you think will happen if Mike (Jane) does that?
  6. How do you think they both will feel if Mike (Jane) does that?”(Nippold, Mansfield, & Billow, 2007, p. 187)

When presenting each task, the authors recommend that clinicians use male names with male students and female names with female students, as this may increase the chance that the students will better relate to the “characters’ actions, challenges, and emotions“. (187)

Let’s take a look at the analysis of one of the PCR tasks in action. Below are the responses of a 15-4-year-old student with suspected social communication impairment who was presented with the above mentioned Fast Food Restaurant prompt. He was asked to retell the situation in his own words and then answer a set of questions which incorporated aspects of peer interaction, as well as interpersonal conflict and resolution. 

Below is the student’s retelling of the “The Fast-Food Restaurant” story in his own words: “One guy wants works on grill the other guy wants takes out the trash. Guy breaks… has a sore arm and asks another guy to do do his job but other guy didn’t want other guy didn’t want to do lose the job”       

Here’s how this student answered the accompanying questions:

Image result for analysisAnalysis of ‘The Fast Food Restaurant’: The student’s discourse abilities were judged to be impaired for his age/grade level. His retelling was vague and nonspecific and was punctuated by frequent false starts characteristic of word retrieval difficulties.  To illustrate, he first began to state that one of the boys had a broken arm but then self-corrected and was able to explain that the arm was merely sore.  Rather than displaying appropriate anaphoric referencing and referring to both boys by names, he nonspecifically referred to both of them as “one guy” and “another guy”.

The student also did not adequately delve into the complexity of the social scenario. Rather than adequately explaining that one boy’s chance at a preferred activity at his job is jeopardized by his friend’s supposed injury, he imprecisely responded “One’s one’s ah Mike is not you know he’s (unintelligible) he is not being very generous. Also, also the other one is getting all wound up over a sore arm”, which is an inadequate explanation of the problem in the presented scenario.

The student’s answers were nonspecific as he did not appropriately identify the problem in the scenario nor offer an effective solution to it. His response in reference to the lack of cooperation between the two boys lacked concrete details, and his solution: “bargain” and “talk” was too vague to qualify as an adequate response to the scenario.

The student presented with difficulty assuming perspectives of both characters in the scenario (Mike and Peter) and had difficulty explaining what type of a mutually agreeable solution both boys could possibly reach.  The student’s sentence structure lacked adequate syntactic complexity and contained a number of awkwardly phrased sentences marked by significant word retrieval difficulties in the form of word phrase revisions, repetitions as well as pauses.

Impressions: Informal discourse analysis revealed deficits in the areas of semantics, syntax, word finding, problem-solving, perspective taking as well as social communication. Therapeutic intervention is strongly recommended to improve these abilities for social and academic purposes.

As you can see from the above sample, the PCR tasks possess terrific versatility and can reveal a great deal of information about adolescent students’ discourse, problem-solving, social communication abilities. Consequently, I highly recommend them as part of the adolescent language and literacy assessments.

References:

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Do Our Therapy Goals Make Sense or How to Create Functional Language Intervention Targets

In the past several years, I wrote a series of posts on the topic of improving clinical practices in speech-language pathology.  Some of these posts were based on my clinical experience as backed by research,  while others summarized key point from articles written by prominent colleagues in our field such as Dr. Alan KamhiDr.  David DeBonnisDr. Andrew Vermiglio, etc.

In the past, I have highlighted several articles from the 2014 LSHSS clinical forum entitled: Improving Clinical Practice. Today I would like to explicitly summarize another relevant article written by Dr. Wallach in 2014, entitled “Improving Clinical Practice: A School-Age and School-Based Perspective“, which discusses how to change the “persistence of traditional practices” in order to make our language interventions more functional and meaningful for students with language learning difficulties.

Image result for geraldine wallachDr. Wallach begins her article by describing 3  fairly typical to the schools’ scenarios.  In the first one,  a group of second graders with narrative retelling goals are working on a sequencing activity (“First the soup is on the counter, next it is opened, then it is cooked on the stove, last it is put in a bowl and ready to eat.”).

In the second scenario,  a group of fourth graders are working on following directions presented to them by the clinician (“Pick up the red triangle before you touch the large, green circle.”)

Image result for ambiguous newspaper headlinesIn  the third scenario,  a group of middle schoolers  are working on interpreting  newspaper headlines (“Jazz Helps Lakers Become Mellow in Victory.”)

Dr. Wallach then poses several overarching questions:

  • Do these goals make sense in the current context of research pertaining to language, learning, and literacy?
  • ‘Are the targets relevant to language and academic contexts beyond the “speech room” (i.e., are the choices, curriculum, and classroom relevant)?’
  • ‘Are they relevant to language learning in general?’
  • ‘Is the intervention’s focus encouraging performance (short-term learning that is context-bound) or long-term and context-independent learning?’ (p. 128)

She then delves deeper into where these goals come from as well as presents some suggestions regarding how these goals could be altered in order to make them more functional.

She begins by explaining that labeling SLP  provided school-based services as “speech” “creates artificial barriers, inaccurate perceptions, and inappropriate intervention recommendations that exacerbate an already complex situation, that is, meeting the language learning and literacy needs of students across a changing landscape of required knowledge and skills needed to succeed academically.” (128)

From there,  she explains why targets in the first two scenarios are inaccurate and not functional.  She explains that while working on improving narrative abilities is functional,  working on isolated sequencing abilities is not functional since in the context of her present scenario the child was not retelling an actual story. Furthermore, ‘the clinician’s focus on sequencing as an underlying skill comes from sources that are unknown’ and ‘the “transfer” to producing and comprehending temporal and causal narratives from the soup scenario is an assumption that research fails to support” (128) She adds, that  “Duke and Pearson (2008/2009) mirror these notions when they state that the “transfer [of taught skills and strategies] decreases as a function of distance from the original information domain” (p. 113).”    Then, of course, there is the usage of “expository text (i.e., a sequential text) rather than narrative text,”  further indicating that the goal is not functionally transferable.  The second graders are receiving a message that we are working on storytelling skills,  when in reality that is not what is taking place in the session.

To balance the above criticism, Dr. Wallach does describe a number of positive elements involved in what her fictional clinician in her scenario is doing: (e.g, using expository text knowledge, talking about language, etc.), but she also asks: (1) Is the activity developmentally appropriate? and (2) Are the metalinguistic task aspects too complex for children that age? (129).

Now, let’s move on to multiple step commands, a persistent intervention meme, created because our students have difficulty understanding instructions, paying attention in class, as well as processing and completing classroom assignments.

The problem is that the processing of multistep directions is influenced by a number of contextual, semantic, and linguistic factors.  By far, not all multistep directions are created equal. Some are far more contextually related and semantically constrained than others (e.g., “After you open the book, turn to page 120” vs. “Pick up the red triangle before you touch the large, green circle.”) (p. 129). Consequently, “following directions” is not a simple task of “memorizing the steps”, rather it is a complex process which involves activation of available semantic and syntactic knowledge, comprehension of sentences with a variety of clauses, as well as numerous other linguistic factors.

Unfortunately, the provision of decontextualized directions will not meaningfully assist the students with comprehension of school work and navigation of the classroom environment. As such, rather than teaching the students multiple step directions which will not meaningfully transfer to other settings it may be far more appropriate to teach the students how to request clarification from their speakers in order to break up complex instructions into manageable chunks of information.

In contrast, the goals and procedures in the 3rd scenario (see pgs. 127-128 for full details ) are actually supported by research in developmental disorders.  The SLP is helping students to be actively involved in language by activating their background knowledge, use new strategies, reduce competing resources, heighten the students’ metalinguistic abilities, as well as incorporating aspects of both language and literacy into sessions, making her intervention highly relevant to the curriculum.

Dr. Wallach then moves on to provide constructive suggestions regarding how intervention services can be improved in the school setting. This includes: “(a) creating intervention goals that are knowledge-based and help students connect known and new information; (b) balancing content knowledge and awareness of text structure in functional, authentic tasks that optimize long-term retention and transfer across grades and content-area subjects; and (c) matching students’ language goals and objectives to the “outside world” of curricular and classroom contexts.” (p. 130)

First, “research suggests that engaging students in prior knowledge activities increases the comprehension and retention of information” (p. 130). In other words, “when too much is new, comprehension and retention suffer; something has to “give” or be modified to facilitate learning” (p. 130).  She suggests using a familiar high-interest topic to teach a discrete amount of new information.  Here, the role of background knowledge is hugely important when it comes to learning. “Engaging students in prior knowledge activities that include questioning and other meaning-based strategies encourage them to use and express what they do know, talk about what they need to know and become more actively involved in interacting with spoken and written text (Wallach et al., 2014)” (p. 131).

To illustrate, Dr. Wallach provides an example from a ninth-grade science textbook, laden with complex information. She then explains how to “use of evidence-based strategies including self-questioning and clinician-led discussions to guide students” in better understanding the material via use of various frameworks (e.g., K-W-L) (p. 131). She also emphasizes how within a collaborative framework SLPs can focus on aspects of text structure to ask relevant questions about content.

From there she segues into a fifth-grade history text and explains that  “No kit or program from the hundreds that appear in ASHA Convention exhibit halls year after year will come to our rescue” (131), As such, SLPs need to teach their clients both macro (text organization) and micro (syntax, morphology, etc.) components of language so they could successfully navigate complex texts. A number of researchers (e.g., A. Kamhi, C. Scott, M. Nippold, B. Ehren, etc.) have highlighted the fact that our middle school and high school students lack the comprehension of complex morphosyntax. Hence, explicitly teaching it to out students will significantly improve both our clinical practice and their academic outcomes. Here, Dr. Wallach also recommends the work of “McKeown and her colleagues (e.g., Beck, McKeown, & Worthy, 1995McKeown et al., 2009McKeown, Beck, Sinatra, & Loxterman, 1992) when trying to understand the complex interaction between content and structure knowledge.” (p. 132)

After that Dr. Wallach segues into a discussion on how our clients’ language goals can be better aligned with the academic curricular demands. She states that SLPs need to delve deeper (or at all) into disciplinary literacy (teaching our students subject-specific comprehension and vocabulary). Here, collaboration with content-area teachers is very important. “For example, science involves many technical terms and definitions and requires clear and concise cause and effect thinking (Fang, 2004Halliday, 1993). “The noun phrases [in science texts] contain a large quantity of information that in more commonsense language of everyday life would require several sentences to express” (Fang, 2012, p. 24). ” (132). “Alternatively, social studies involves being able to put events into a context, comparing sources, and understanding the biases of the writer. Unlike science, authorship is important in history.” (132)

Dr. Wallach suggests a number of questions clinicians can ask selves about our students when determining therapy targets:

  1. Can they handle complex syntactic forms that are more common in written language than spoken language?
  2. Do they have an understanding of word derivations?
  3. Do our students know how to write a compare and contrast expository piece?
  4. Are they able to evaluate sources information?
  5. Do they use prior knowledge and experience to help them comprehend new information?

She then offers SLPs valuable ideas on how to create a thoughtful balance between general and subject-specific language targets (see pg 133 for complete details).

Dr. Wallach concludes her article with the following points.

  • Students with language learning disabilities are at a disadvantage in school due to having reduced/limited background knowledge and language proficiency as compared to typically developing peers. Hence “school-based SLPs must consider ways that students’ language abilities influence and interact with their academic success (Wallach et al., 2014). Our intervention should be seen as developing a set of language initiatives focused toward content-area learning (A. S. Bashir, personal communication, 2012; Wallach et al., 2009). ” 
  • Staying focused on the continuum of change across the grades is an important aspect of clinical practice in the school years. Likewise, as suggested by many authors, connecting our preschool endeavors to the horizon of school-age demands underpins our work over time
  • As we look to changes in service delivery models in schools including research that supports response-to-intervention (RtI) models (e.g., Wixson, Lipson, & Valencia, 2014), we can be optimistic that less relevant and nonfunctional practices will die natural deaths.” (pgs. 133-134)

There you have it! Numerous practical suggestions as well as functional clarifications from Dr. Wallach so SLPs can improve their treatment practices with school-aged children.  And for more information, I highly recommend reading the other articles in the same clinical forum, all of which possess highly practical and relevant ideas for therapeutic implementation.

They include:

References:

  • Beck, I. L., McKeown, M. G., & Worthy, J. (1995). Giving text a voice can improve students’ understanding. Reading Research Quarterly30, 220–238.
  • Duke, N. K., & Pearson, P. D. (2008/2009). Effective practices for developing reading comprehension. Journal of Education189, 107–122.
  • Fang, Z. (2004). Scientific literacy: A systematic functional linguistics perspective. Science Education89, 335–347. 
  • Fang, Z. (2012). Language correlates of disciplinary literacy. Topics in Language Disorders32, 19–34. 
  • Halliday, M. A. K. (1993). Some grammatical problems in scientific English. In Halliday, M. A. K., & Martin, J. R. (Eds.), Writing science: Literacy and discursive power (pp. 69–85). London, England: Falmer.
  • McKeown, M. G., Beck, I. L., & Blake, R. G. K. (2009). Rethinking reading comprehension instruction: A comparison of instruction for strategies and content approaches. Reading Research Quarterly44, 218–253. 
  • McKeown, M. G., Beck, I. L., Sinatra, G. M., & Loxterman, J. A. (1992). The contribution of prior knowledge and coherent text to comprehension. Reading Research Quarterly27, 79–93.
  • Wallach, G. P., Charlton, S. J., & Christie, J. (2009). Making a broader case for the narrow view? Where to begin? Language, Speech, and Hearing Services in Schools40, 201–211. 
  • Wallach, G.P. (2014). Improving clinical practice: A school-age and school-based perspective. Language, Speech, and Hearing Services in Schools, 45, 127-136
  • Wallach, G.P., Charlton, S., & Christie Bartholomew, J. (2014). The spoken-written comprehension connection: Constructive intervention strategies. In C.A. Stone, E.R. Silliman, B.J. Ehren, & G.P. Wallach (Eds). Handbook of language and literacy: Development and disorders (pp. 485-501). NY: Guilford Press.
  • Wixson, K. K., Lipson, M. Y., & Valencia, S. W. (2014). Response to intervention for teaching and learning in language and literacy. InStone, C. A., Silliman, E. R., Ehren, B. J., & Wallach, G. P. (Eds.), Handbook of language and literacy: Development and disorders (2nd ed., pp. 637–653). New York, NY: Guilford Press.

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Help, My Student has a Huge Score Discrepancy Between Tests and I Don’t Know Why?

Here’s a  familiar scenario to many SLPs. You’ve administered several standardized language tests to your student (e.g., CELF-5 & TILLS). You expected to see roughly similar scores across tests. Much to your surprise, you find that while your student attained somewhat average scores on one assessment, s/he had completely bombed the second assessment, and you have no idea why that happened.

So you go on social media and start crowdsourcing for information from a variety of SLPs located in a variety of states and countries in order to figure out what has happened and what you should do about this. Of course, the problem in such situations is that while some responses will be spot on, many will be utterly inappropriate. Luckily, the answer lies much closer than you think, in the actual technical manual of the administered tests.

So what is responsible for such as drastic discrepancy?  A few things actually. For starters, unless both tests were co-normed (used the same sample of test takers) be prepared to see disparate scores due to the ability levels of children in the normative groups of each test.  Another important factor involved in the score discrepancy is how accurately does the test differentiate disordered children from typical functioning ones.

Let’s compare two actual language tests to learn more. For the purpose of this exercise let us select The Clinical Evaluation of Language Fundamentals-5 (CELF-5) and the Test of Integrated Language and Literacy (TILLS).   The former is a very familiar entity to numerous SLPs, while the latter is just coming into its own, having been released in the market only several years ago.

Both tests share a number of similarities. Both were created to assess the language abilities of children and adolescents with suspected language disorders. Both assess aspects of language and literacy (albeit not to the same degree nor with the same level of thoroughness).  Both can be used for language disorder classification purposes, or can they?

Actually, my last statement is rather debatable.  A careful perusal of the CELF – 5 reveals that its normative sample of 3000 children included a whopping 23% of children with language-related disabilities. In fact, the folks from the Leaders Project did such an excellent and thorough job reviewing its psychometric properties rather than repeating that information, the readers can simply click here to review the limitations of the CELF – 5 straight on the Leaders Project website.  Furthermore, even the CELF – 5 developers themselves have stated that: “Based on CELF-5 sensitivity and specificity values, the optimal cut score to achieve the best balance is -1.33 (standard score of 80). Using a standard score of 80 as a cut score yields sensitivity and specificity values of .97.

In other words, obtaining a standard score of 80 on the CELF – 5 indicates that a child presents with a language disorder. Of course, as many SLPs already know, the eligibility criteria in the schools requires language scores far below that in order for the student to qualify to receive language therapy services.

In fact, the test’s authors are fully aware of that and acknowledge that in the same document. “Keep in mind that students who have language deficits may not obtain scores that qualify him or her for placement based on the program’s criteria for eligibility. You’ll need to plan how to address the student’s needs within the framework established by your program.”

But here is another issue – the CELF-5 sensitivity group included only a very small number of: “67 children ranging from 5;0 to 15;11”, whose only requirement was to score 1.5SDs < mean “on any standardized language test”.  As the Leaders Project reviewers point out: “This means that the 67 children in the sensitivity group could all have had severe disabilities. They might have multiple disabilities in addition to severe language disorders including severe intellectual disabilities or Autism Spectrum Disorder making it easy for a language disorder test to identify this group as having language disorders with extremely high accuracy. ” (pgs. 7-8)

Of course, this begs the question,  why would anyone continue to administer any test to students, if its administration A. Does not guarantee disorder identification B. Will not make the student eligible for language therapy despite demonstrated need?

The problem is that even though SLPs are mandated to use a variety of quantitative clinical observations and procedures in order to reliably qualify students for services, standardized tests still carry more value then they should.  Consequently,  it is important for SLPs to select the right test to make their job easier.

The TILLS is a far less known assessment than the CELF-5 yet in the few years it has been out on the market it really made its presence felt by being a solid assessment tool due to its valid and reliable psychometric properties. Again, the venerable Dr. Carol Westby had already done such an excellent job reviewing its psychometric properties that I will refer the readers to her review here, rather than repeating this information as it will not add anything new on this topic. The upshot of her review as follows: “The TILLS does not include children and adolescents with language/literacy impairments (LLIs) in the norming sample. Since the 1990s, nearly all language assessments have included children with LLIs in the norming sample. Doing so lowers overall scores, making it more difficult to use the assessment to identify students with LLIs. (pg. 11)”

Now, here many proponents of inclusion of children with language disorders in the normative sample will make a variation of the following claim: “You CANNOT diagnose a language impairment if children with language impairment were not included in the normative sample of that assessment!Here’s a major problem with such assertion. When a child is referred for a language assessment, we really have no way of knowing if this child has a language impairment until we actually finish testing them. We are in fact attempting to confirm or refute this fact, hopefully via the use of reliable and valid testing. However, if the normative sample includes many children with language and learning difficulties, this significantly affects the accuracy of our identification, since we are interested in comparing this child’s results to typically developing children and not the disordered ones, in order to learn if the child has a disorder in the first place.  As per Peña, Spaulding and Plante (2006), “the inclusion of children with disabilities may be at odds with the goal of classification, typically the primary function of the speech pathologist’s assessment. In fact, by including such children in the normative sample, we may be “shooting ourselves in the foot” in terms of testing for the purpose of identifying disorders.”(p. 248)

Then there’s a variation of this assertion, which I have seen in several Facebook groups: “Children with language disorders score at the low end of normal distribution“.  Once again such assertion is incorrect since Spaulding, Plante & Farinella (2006) have actually shown that on average, these kids will score at least 1.28 SDs below the mean, which is not the low average range of normal distribution by any means.  As per authors: “Specific data supporting the application of “low score” criteria for the identification of language impairment is not supported by the majority of current commercially available tests. However, alternate sources of data (sensitivity and specificity rates) that support accurate identification are available for a subset of the available tests.” (p. 61)

Now, let us get back to your child in question, who performed so differently on both of the administered tests. Given his clinically observed difficulties, you fully expected your testing to confirm it. But you are now more confused than before. Don’t be! Search the technical manual for information on the particular test’s sensitivity and specificity to look up the numbers.   Vance and Plante (1994) put forth the following criteria for accurate identification of a disorder (discriminant accuracy): “90% should be considered good discriminant accuracy; 80% to 89% should be considered fair. Below 80%, misidentifications occur at unacceptably high rates” and leading to “serious social consequences” of misidentified children. (p. 21)

Review the sensitivity and specificity of your test/s, take a look at the normative samples, see if anything unusual jumps out at you, which leads you to believe that the administered test may have some issues with assessing what it purports to assess. Then, after supplementing your standardized testing results with good quality clinical data (e.g., narrative samples, dynamic assessment tasks, etc.), consider creating a solidly referenced purchasing pitch to your administration to invest in more valid and reliable standardized tests.

Hope you find this information helpful in your quest to better serve the clients on your caseload. If you are interested in learning more regarding evidence-based assessment practices as well as psychometric properties of various standardized speech-language tests visit the SLPs for Evidence-Based Practice  group on Facebook learn more.

References:

 

 

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It’s All Due to …Language: How Subtle Symptoms Can Cause Serious Academic Deficits

Scenario: Len is a 7-2-year-old, 2nd-grade student who struggles with reading and writing in the classroom. He is very bright and has a high average IQ, yet when he is speaking he frequently can’t get his point across to others due to excessive linguistic reformulations and word-finding difficulties. The problem is that Len passed all the typical educational and language testing with flying colors, receiving average scores across the board on various tests including the Woodcock-Johnson Fourth Edition (WJ-IV) and the Clinical Evaluation of Language Fundamentals-5 (CELF-5). Stranger still is the fact that he aced Comprehensive Test of Phonological Processing, Second Edition (CTOPP-2), with flying colors, so he is not even eligible for a “dyslexia” diagnosis. Len is clearly struggling in the classroom with coherently expressing self, telling stories, understanding what he is reading, as well as putting his thoughts on paper. His parents have compiled impressively huge folders containing examples of his struggles. Yet because of his performance on the basic standardized assessment batteries, Len does not qualify for any functional assistance in the school setting, despite being virtually functionally illiterate in second grade.

The truth is that Len is quite a familiar figure to many SLPs, who at one time or another have encountered such a student and asked for guidance regarding the appropriate accommodations and services for him on various SLP-geared social media forums. But what makes Len such an enigma, one may inquire? Surely if the child had tangible deficits, wouldn’t standardized testing at least partially reveal them?

Well, it all depends really, on what type of testing was administered to Len in the first place. A few years ago I wrote a post entitled: “What Research Shows About the Functional Relevance of Standardized Language Tests“.  What researchers found is that there is a “lack of a correlation between frequency of test use and test accuracy, measured both in terms of sensitivity/specificity and mean difference scores” (Betz et al, 2012, 141). Furthermore, they also found that the most frequently used tests were the comprehensive assessments including the Clinical Evaluation of Language Fundamentals and the Preschool Language Scale as well as one-word vocabulary tests such as the Peabody Picture Vocabulary Test”. Most damaging finding was the fact that: “frequently SLPs did not follow up the comprehensive standardized testing with domain-specific assessments (critical thinking, social communication, etc.) but instead used the vocabulary testing as a second measure”.(Betz et al, 2012, 140)

In other words, many SLPs only use the tests at hand rather than the RIGHT tests aimed at identifying the student’s specific deficits. But the problem doesn’t actually stop there. Due to the variation in psychometric properties of various tests, many children with language impairment are overlooked by standardized tests by receiving scores within the average range or not receiving low enough scores to qualify for services.

Thus, “the clinical consequence is that a child who truly has a language impairment has a roughly equal chance of being correctly or incorrectly identified, depending on the test that he or she is given.” Furthermore, “even if a child is diagnosed accurately as language impaired at one point in time, future diagnoses may lead to the false perception that the child has recovered, depending on the test(s) that he or she has been given (Spaulding, Plante & Farinella, 2006, 69).”

There’s of course yet another factor affecting our hypothetical client and that is his relatively young age. This is especially evident with many educational and language testing for children in the 5-7 age group. Because the bar is set so low, concept-wise for these age-groups, many children with moderate language and literacy deficits can pass these tests with flying colors, only to be flagged by them literally two years later and be identified with deficits, far too late in the game.  Coupled with the fact that many SLPs do not utilize non-standardized measures to supplement their assessments, Len is in a pretty serious predicament.

But what if there was a do-over? What could we do differently for Len to rectify this situation? For starters, we need to pay careful attention to his deficits profile in order to choose appropriate tests to evaluate his areas of needs. The above can be accomplished via a number of ways. The SLP can interview Len’s teacher and his caregiver/s in order to obtain a summary of his pressing deficits. Depending on the extent of the reported deficits the SLP can also provide them with a referral checklist to mark off the most significant areas of need.

In Len’s case, we already have a pretty good idea regarding what’s going on. We know that he passed basic language and educational testing, so in the words of Dr. Geraldine Wallach, we need to keep “peeling the onion” via the administration of more sensitive tests to tap into Len’s reported areas of deficits which include: word-retrieval, narrative production, as well as reading and writing.

For that purpose, Len is a good candidate for the administration of the Test of Integrated Language and Literacy (TILLS), which was developed to identify language and literacy disorders, has good psychometric properties, and contains subtests for assessment of relevant skills such as reading fluency, reading comprehension, phonological awareness,  spelling, as well as writing  in school-age children.

Given Len’s reported history of narrative production deficits, Len is also a good candidate for the administration of the Social Language Development Test Elementary (SLDTE). Here’s why. Research indicates that narrative weaknesses significantly correlate with social communication deficits (Norbury, Gemmell & Paul, 2014). As such, it’s not just children with Autism Spectrum Disorders who present with impaired narrative abilities. Many children with developmental language impairment (DLD) (#devlangdis) can present with significant narrative deficits affecting their social and academic functioning, which means that their social communication abilities need to be tested to confirm/rule out presence of these difficulties.

However, standardized tests are not enough, since even the best-standardized tests have significant limitations. As such, several non-standardized assessments in the areas of narrative production, reading, and writing, may be recommended for Len to meaningfully supplement his testing.

Let’s begin with an informal narrative assessment which provides detailed information regarding microstructural and macrostructural aspects of storytelling as well as child’s thought processes and socio-emotional functioning. My nonstandardized narrative assessments are based on the book elicitation recommendations from the SALT website. For 2nd graders, I use the book by Helen Lester entitled Pookins Gets Her Way. I first read the story to the child, then cover up the words and ask the child to retell the story based on pictures. I read the story first because: “the model narrative presents the events, plot structure, and words that the narrator is to retell, which allows more reliable scoring than a generated story that can go in many directions” (Allen et al, 2012, p. 207).

As the child is retelling his story I digitally record him using the Voice Memos application on my iPhone, for a later transcription and thorough analysis.  During storytelling, I only use the prompts: ‘What else can you tell me?’ and ‘Can you tell me more?’ to elicit additional information. I try not to prompt the child excessively since I am interested in cataloging all of his narrative-based deficits. After I transcribe the sample, I analyze it and make sure that I include the transcription and a detailed write-up in the body of my report, so parents and professionals can see and understand the nature of the child’s errors/weaknesses.

Now we are ready to move on to a brief nonstandardized reading assessment. For this purpose, I often use the books from the Continental Press series entitled: Reading for Comprehension, which contains books for grades 1-8.  After I confirm with either the parent or the child’s teacher that the selected passage is reflective of the complexity of work presented in the classroom for his grade level, I ask the child to read the text.  As the child is reading, I calculate the correct number of words he reads per minute as well as what type of errors the child is exhibiting during reading.  Then I ask the child to state the main idea of the text, summarize its key points as well as define select text embedded vocabulary words and answer a few, verbally presented reading comprehension questions. After that, I provide the child with accompanying 5 multiple choice question worksheet and ask the child to complete it. I analyze my results in order to determine whether I have accurately captured the child’s reading profile.

Finally, if any additional information is needed, I administer a nonstandardized writing assessment, which I base on the Common Core State Standards for 2nd grade. For this task, I provide a student with a writing prompt common for second grade and give him a period of 15-20 minutes to generate a writing sample. I then analyze the writing sample with respect to contextual conventions (punctuation, capitalization, grammar, and syntax) as well as story composition (overall coherence and cohesion of the written sample).

The above relatively short assessment battery (2 standardized tests and 3 informal assessment tasks) which takes approximately 2-2.5 hours to administer, allows me to create a comprehensive profile of the child’s language and literacy strengths and needs. It also allows me to generate targeted goals in order to begin effective and meaningful remediation of the child’s deficits.

Children like Len will, unfortunately, remain unidentified unless they are administered more sensitive tasks to better understand their subtle pattern of deficits. Consequently, to ensure that they do not fall through the cracks of our educational system due to misguided overreliance on a limited number of standardized assessments, it is very important that professionals select the right assessments, rather than the assessments at hand, in order to accurately determine the child’s areas of needs.

References:

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Improving Executive Function Skills of Language Impaired Students with Hedbanz

Image result for hedbanzThose of you who have previously read my blog know that I rarely use children’s games to address language goals.  However, over the summer I have been working on improving executive function abilities (EFs) of some of the language impaired students on my caseload. As such, I found select children’s games to be highly beneficial for improving language-based executive function abilities.

For those of you who are only vaguely familiar with this concept, executive functions are higher level cognitive processes involved in the inhibition of thought, action, and emotion, which located in the prefrontal cortex of the frontal lobe of the brain. The development of executive functions begins in early infancy; but it can be easily disrupted by a number of adverse environmental and organic experiences (e.g., psychosocial deprivation, trauma).  Furthermore, research in this area indicates that the children with language impairments present with executive function weaknesses which require remediation.

Image result for executive functions brain

EF components include working memory, inhibitory control, planning, and set-shifting.

  • Working memory
    • Ability to store and manipulate information in mind over brief periods of time
  • Inhibitory control
    • Suppressing responses that are not relevant to the task
  • Set-shifting
    • Ability to shift behavior in response to changes in tasks or environment

Simply put, EFs contribute to the child’s ability to sustain attention, ignore distractions, and succeed in academic settings. By now some of you must be wondering: “So what does Hedbanz have to do with any of it?”

Well, Hedbanz is a quick-paced multiplayer  (2-6 people) game of “What Am I?” for children ages 7 and up.  Players get 3 chips and wear a “picture card” in their headband. They need to ask questions in rapid succession to figure out what they are. “Am I fruit?” “Am I a dessert?” “Am I sports equipment?” When they figure it out, they get rid of a chip. The first player to get rid of all three chips wins.

The game sounds deceptively simple. Yet if any SLPs or parents have ever played that game with their language impaired students/children as they would be quick to note how extraordinarily difficult it is for the children to figure out what their card is. Interestingly, in my clinical experience, I’ve noticed that it’s not just moderately language impaired children who present with difficulty playing this game. Even my bright, average intelligence teens, who have passed vocabulary and semantic flexibility testing (such as the WORD Test 2-Adolescent or the  Vocabulary Awareness subtest of the Test of Integrated Language and Literacy ) significantly struggle with their language organization when playing this game.

So what makes Hedbanz so challenging for language impaired students? Primarily, it’s the involvement and coordination of the multiple executive functions during the game. In order to play Hedbanz effectively and effortlessly, the following EF involvement is needed:

  • Task Initiation
    • Students with executive function impairments will often “freeze up” and as a result may have difficulty initiating the asking of questions in the game because many will not know what kind of questions to ask, even after extensive explanations and elaborations by the therapist.
  • Organization
    • Students with executive function impairments will present with difficulty organizing their questions by meaningful categories and as a result will frequently lose their track of thought in the game.
  • Working Memory
    • This executive function requires the student to keep key information in mind as well as keep track of whatever questions they have already asked.
  • Flexible Thinking
    • This executive function requires the student to consider a situation from multiple angles in order to figure out the quickest and most effective way of arriving at a solution. During the game, students may present with difficulty flexibly generating enough organizational categories in order to be effective participants.
  • Impulse Control
    • Many students with difficulties in this area may blurt out an inappropriate category or in an appropriate question without thinking it through first.
      • They may also present with difficulty set-shifting. To illustrate, one of my 13-year-old students with ASD, kept repeating the same question when it was his turn, despite the fact that he was informed by myself as well as other players of the answer previously.
  • Emotional Control
    • This executive function will help students with keeping their emotions in check when the game becomes too frustrating. Many students of difficulties in this area will begin reacting behaviorally when things don’t go their way and they are unable to figure out what their card is quickly enough. As a result, they may have difficulty mentally regrouping and reorganizing their questions when something goes wrong in the game.
  • Self-Monitoring
    • This executive function allows the students to figure out how well or how poorly they are doing in the game. Students with poor insight into own abilities may present with difficulty understanding that they are doing poorly and may require explicit instruction in order to change their question types.
  • Planning and Prioritizing
    • Students with poor abilities in this area will present with difficulty prioritizing their questions during the game.

Image result for executive functionsConsequently, all of the above executive functions can be addressed via language-based goals.  However, before I cover that, I’d like to review some of my session procedures first.

Typically, long before game initiation, I use the cards from the game to prep the students by teaching them how to categorize and classify presented information so they effectively and efficiently play the game.

Rather than using the “tip cards”, I explain to the students how to categorize information effectively.

This, in turn, becomes a great opportunity for teaching students relevant vocabulary words, which can be extended far beyond playing the game.

I begin the session by explaining to the students that pretty much everything can be roughly divided into two categories animate (living) or inanimate (nonliving) things. I explain that humans, animals, as well as plants belong to the category of living things, while everything else belongs to the category of inanimate objects. I further divide the category of inanimate things into naturally existing and man-made items. I explain to the students that the naturally existing category includes bodies of water, landmarks, as well as things in space (moon, stars, sky, sun, etc.). In contrast, things constructed in factories or made by people would be example of man-made objects (e.g., building, aircraft, etc.)

When I’m confident that the students understand my general explanations, we move on to discuss further refinement of these broad categories. If a student determines that their card belongs to the category of living things, we discuss how from there the student can further determine whether they are an animal, a plant, or a human. If a student determined that their card belongs to the animal category, we discuss how we can narrow down the options of figuring out what animal is depicted on their card by asking questions regarding their habitat (“Am I a jungle animal?”), and classification (“Am I a reptile?”). From there, discussion of attributes prominently comes into play. We discuss shapes, sizes, colors, accessories, etc., until the student is able to confidently figure out which animal is depicted on their card.

In contrast, if the student’s card belongs to the inanimate category of man-made objects, we further subcategorize the information by the object’s location (“Am I found outside or inside?”; “Am I found in ___ room of the house?”, etc.), utility (“Can I be used for ___?”), as well as attributes (e.g., size, shape, color, etc.)

Thus, in addition to improving the students’ semantic flexibility skills (production of definitions, synonyms, attributes, etc.) the game teaches the students to organize and compartmentalize information in order to effectively and efficiently arrive at a conclusion in the most time expedient fashion.

Now, we are ready to discuss what type of EF language-based goals, SLPs can target by simply playing this game.

1. Initiation: Student will initiate questioning during an activity in __ number of instances per 30-minute session given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

2. Planning: Given a specific routine, student will verbally state the order of steps needed to complete it with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

3. Working Memory: Student will repeat clinician provided verbal instructions pertaining to the presented activity, prior to its initiation, with 80% accuracy  given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

4. Flexible Thinking: Following a training by the clinician, student will generate at least __ questions needed for task completion (e.g., winning the game) with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

5. Organization: Student will use predetermined written/visual cues during an activity to assist self with organization of information (e.g., questions to ask) with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

6. Impulse Control: During the presented activity the student will curb blurting out inappropriate responses (by silently counting to 3 prior to providing his response) in __ number of instances per 30 minute session given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

7. Emotional Control: When upset, student will verbalize his/her frustration (vs. behavioral activing out) in __ number of instances per 30 minute session given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

8. Self-Monitoring:  Following the completion of an activity (e.g., game) student will provide insight into own strengths and weaknesses during the activity (recap) by verbally naming the instances in which s/he did well, and instances in which s/he struggled with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

There you have it. This one simple game doesn’t just target a plethora of typical expressive language goals. It can effectively target and improve language-based executive function goals as well. Considering the fact that it sells for approximately $12 on Amazon.com, that’s a pretty useful therapy material to have in one’s clinical tool repertoire. For fancier versions, clinicians can use “Jeepers Peepers” photo card sets sold by Super Duper Inc. Strapped for cash, due to highly limited budget? You can find plenty of free materials online if you simply input “Hedbanz cards” in your search query on Google. So have a little fun in therapy, while your students learn something valuable in the process and play Hedbanz today!

Related Smart Speech Therapy Resources:

 

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The End of See it, Zap it! Ankyloglossia (Tongue-Tie) Controversies in Research and Clinical Practice

Today it is my pleasure and privilege to interview 3 Australian lactation consultations: Lois Wattis, Renee Kam, and Pamela Douglas, the authors of a March 2017 article in the Breastfeeding Review: “Three experienced lactation consultants reflect upon the oral tie phenomenon” (which can be found HERE).

Tatyana Elleseff: Colleagues, as you very well know, the subject of ankyloglossia or tongue tie affecting breastfeeding and speech production has risen into significant prominence in the past several years. Numerous journal articles, blog posts, as well as social media forums have been discussing this phenomenon with rather conflicting recommendations.  Many health professionals and parents are convinced that “releasing the tie” or performing either a frenotomy or frenectomy will lead to significant improvements in speech and feeding.

Image result for evidence based practicePresently, systematic reviews1-3 demonstrate there is insufficient evidence for the above. However, when many professionals including myself, cite reputable research explaining the lack of support of surgical intervention for tongue tie, there has been a pushback on the part of a number of other health professionals including lactation consultants, nurses, dentists, as well as speech-language pathologists stating that in their clinical experience surgical intervention does resolve issues with tongue tie as related to speech and feeding.

So today, given your 33 combined years of practice as lactation consultants I would love to ask your some questions regarding the tongue tie phenomena.

I would like to begin our discussion with a description of normal breastfeeding and what can interfere with it from an anatomical and physiological standpoint for mothers and babies.

Now, many of this blog’s readers already know that a tongue tie occurs when the connective tissue under the tongue known as a lingual frenulum restricts tongue movement to some degree and adversely affects its function.  But many may not realize that children can present with a normal anatomical variant of “ties” which can be completely asymptomatic. Can you please address that?

Lois Wattis:  “Normal” breastfeeding takes time and skill to achieve. The breastfeeding dyad is multifactorial, influenced by maternal breast and nipple anatomy combined with the infant’s facial and oral structures, all of which are highly variable. Mothers who have successfully breastfed the first baby may encounter problems with subsequent babies due to size (e.g., smaller, larger, etc.), be compromised by birth interventions or drugs during labor, or incur birth injuries – all of which can affect the initiation of breastfeeding and progression to a happy and comfortable feeding relationship. Unfortunately, the overview of each dyad’s story can be lost when tunnel vision of either health provider or parents regarding the baby’s oral anatomy is believed to be the chief influencer of breastfeeding success or failure.

Tatyana Elleseff: Colleagues, what do we know regarding the true prevalence of various ‘tongue ties’? Are there any studies of good quality?

Image result for prevalencePamela Douglas:  In a literature review in 2005, Hall and Renfrew acknowledged that the true prevalence of ankyloglossia remained unknown, though they estimated 3-4% of newborns.4

After 2005, once the diagnosis of posterior tongue-tie (PTT) had been introduced,5, 6 attempts to quantify incidence of tongue-tie have remained of very poor quality, but estimates currently rest at between 4-10%.7

The problem is that there is a lack of definitional clarity concerning the diagnosis of PTT. Consequently, anterior or classic tongue tie CTT is now often conflated with PTT simply as ‘tongue-tie’ (TT).    

Tatyana Elleseff: Thank you for clarifying it.  In addition to the anterior and posterior tongue tie labels, many parents and professionals also frequently hear the terms lip tie and buccal ties. Is there’s reputable research behind these terms indicating that these ties can truly impact speech and feeding?

Pamela Douglas:  Current definitions of ankyloglossia tend to confuse oral and tongue function (which is affected by multiple variables, and in particular by a fit and hold in breastfeeding) with structure (which is highly anatomically variable for both the tongue length and appearance and lingual and maxillary frenula).

For my own purposes, I define CTT as Type 1 and 2 on the Coryllos-Genna-Watson scale.8 In clinical practice, I also find it useful to rate the anterior membrane by the percentage of the undersurface of the tongue into which the membrane connects, applying the first two categories of the Griffiths Classification System.9 

There is a wide spectrum of lingual frenula morphologies and elasticities, and deciding where to draw a line between a normal variant and CTT will depend on the clinical judgment concerning the infant’s capacity for pain-free efficient milk transfer. However, that means we need to have an approach to fit and hold that we are confident does optimize pain-free efficient milk transfer and at the moment, research shows that not only do the old ‘hands on’ approach to fit and hold not work, but that baby-led attachment is also not enough for many women. This is why at the Possums Clinic we’ve been working on developing an approach to fit and hold (gestalt breastfeeding) that builds on baby-led attachment but also integrates the findings of the latest ultrasound studies.

I personally don’t find the diagnoses of posterior tongue tie PTT and upper lip tie ULT helpful, and don’t use them. Lois, Renee and myself find that a wide spectrum of normal anatomic lingual and maxillary frenula variants are currently being misdiagnosed as a PTT and ULT, which has worried us and led Lois to initiate the article with Renee.

Tatyana Elleseff: Segueing from the above question: is there an established criterion based upon which a decision is made by relevant professionals to “release” the tie and if so can you explain how it’s determined?

Image result for release tongue tieLois Wattis: When an anterior frenulum is attached at the tongue tip or nearby and is short enough to cause restriction of lift towards the palate, usually associated with extreme discomfort for the breastfeeding mother, I have no reservations about snipping it to release the tongue to enable optimal function for breastfeeding. If a simple frenotomy is going to assist the baby to breastfeed well it is worth doing, and as soon as possible. What I do encounter in my clinical practice are distressed and disempowered mothers whose baby has been labeled as having a posterior tongue tie and/or upper lip tie which is the cause of current and even future problems. Upon examination, the baby has completely normal oral anatomy and breastfeeding upskilling and confidence building of both mother and baby enables the dyad to go forward with strategies which address all elements of their unique story.

Although the Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF) is a pioneering contribution, bringing us our first systematized approach to examination of the infant’s tongue and oral connective tissues, it is unreliable as a tool for decision-making concerning frenotomy.10-12 In practice many of the item criteria are highly subjective. Although one study found moderate inter-rater reliability on the ATLFF’s structural items, the authors did not find inter-rater reliability on most of the functional items.13 In my clinical experience, there is no reliable correlation between what the tongue is observed to do during oral examinations and what occurs during breastfeeding, other than in the case of classic tongue-tie (excluding congenital craniofacial abnormalities from this discussion.

In my practice as a Lactation Consultant in an acute hospital setting I use a combination of the available assessment tools mainly for documentation purposes, however, the most important tools I use are my eyes and my ears. Observing the mother and baby physical combination and interactions, and suggesting adjustments where indicated to the positioning and attachment technique used (which  Pam calls fit and hold) can very often resolve difficulties immediately – even if the baby also has an obvious frenulum under his/her tongue. Listening to the mother’s feedback, and observing the baby’s responses are primary indicators of whether further intervention is needed, or not. Watching how the baby achieves and retains the latch is key, then the examination of baby’s mouth to assess tongue mobility and appearance provide final information about whether baby’s ability to breastfeed comfortably is or is not being hindered by a restrictive lingual frenulum.

Tatyana Elleseff: So frenotomy is an incision (cut) of lingual frenum while frenectomy (complete removal) is an excision of lingual frenum.  Both can be performed via various methods of “release”. What effects on breastfeeding have you seen with respect to healing?

Lois Wattis:  The significant difference between both procedures involves the degree of invasiveness and level of pain experienced during and after the procedures, and the differing time it takes for the resumption and/or improvement in breastfeeding comfort and efficacy.

It is commonplace for a baby who has had a simple incision to breastfeed immediately after the procedure and exhibit no further signs of discomfort or oral aversion. Conversely, the baby who has had laser division(s) may breastfeed soon after the procedure while topical anesthetics are still working. However, many infants demonstrate discomfort, extreme pain responses and reluctance to feed for days or weeks following a  laser treatment.  Parents are warned to expect delays resuming feeding and the baby is usually also subjected to wound “stretches” for weeks following the laser treatments. Unfortunately, in my clinical practice I see many parents and babies who are very traumatized by this whole process, and in many cases, breastfeeding can be derailed either temporarily or permanently.

Image result for research studiesTatyana Elleseff: Thank you! This is highly relevant information for both health professionals and parents alike. I truly appreciate your clinical expertise on this topic. While we are on the topic of restrictive lingual frenulums can we discuss several recent articles published on surgical interventions for the above? For example (Ghaheri, Cole, Fausel, Chuop & Mace, 2016), recently published the result of their study which concluded that: “Surgical release of tongue-tie/lip-tie results in significant improvement in breastfeeding outcomes”.  Can you elucidate upon the study design and its findings?

Pamela Douglas:  Pre-post surveys, such as Ghaheri et al’s 2016 study, are notoriously methodologically weak and prone to interpretive bias.14 

Renee Kam:  Research about the efficacy of releasing ULTs to improve breastfeeding outcomes is seriously lacking. There is no reliable assessment tool for upper lip-tie and a lack of evidence to support the efficacy of a frenotomy of labial frenula in breastfed babies. The few studies which have included ULT release have either included very small numbers of babies having upper lip-tie releases or have included babies having a release upper lip ties and tongue ties at the same time, making it impossible to know if any improvements were due to the tongue-tie release, upper lip-tie release or both. Here, to answer your previous question, to date, no research has looked into the treatment of buccal ties for breastfeeding outcomes.

There are various classification scales for labial frenulums such as the Kotlow scale. The title of this scale is misleading as it contains the word ‘tie’. Hence it can give some people the incorrect assumption that a class III or IV labial frenulum is somehow a problem. What this scale actually shows is the normal range of insertion sites for a labial frenulum. And, in normal cases, the vast majority of babies’ labial frenulums insert low down on the upper gum (class III) or even wrap around it (class IV). It’s important to note that, for effective breastfeeding, the upper lip does not have to flange out in order to create a seal. It just has to rest in a neutral position — not flanged out, not tucked in.

Lois Wattis: I entirely agree with Renee’s view about the neutrality of the upper lip, including the labial frenulum, in relation to latch for breastfeeding. Even babies with asymmetrical facial features, cleft lips and other permanent and temporary anomalies only need to achieve a seal with the upper lip to breastfeed successfully.

Image resultTatyana Elleseff: Thank you for that. In addition to studies on tongue tie revisions and breastfeeding outcomes, there has been an increase in studies, specifically Kotlow (2016) and Siegel (2016), which claimed that surgical intervention improves outcomes for acid reflux and aerophagia in babies”.  Can you discuss these studies design and findings?

Renee Kam: The AIR hypothesis has led to reflux being used as another reason to diagnose the oral anatomic abnormalities in infants in the presence of breastfeeding problems. More research with objective indicators and less vested interest is needed in this area. A thorough understanding of normal infant behavior and feeding problems which aren’t tie related are also imperative before any conclusions about AIR can be reached.

Tatyana Elleseff: One final question, colleagues are you aware of any studies which describe long-term outcomes of surgical interventions for tongue ties?

Pamela Douglas:  The systematic reviews note that there is a lack of evidence demonstrating long-term outcomes of surgical interventions. 

Tatyana Elleseff: Thank you for such informative discussion, colleagues.

Related imageThere you have it, readers. Both research and clinical practice align to indicate that:

  • There’s significant normal variation when it comes to most anatomical structures including the frenulum
  • Just because a child presents with restricted frenulum does not automatically imply adverse feeding as well as speech outcomes and immediately necessitates a tongue tie release
  • When breastfeeding difficulties arise, in the presence of restricted frenulum, it is very important to involve an experienced lactation specialist who will perform a differential diagnosis in order to determine the source of the baby’s true breastfeeding difficulties

Now, I’d like to take a moment and address the myth of tongue ties affecting speech production,  which continues to persist among speech-language pathologists despite overwhelming evidence to the contrary.

For that purpose, I will use excerpts from an excellent ASHA Leader December 2005 article written by an esteemed Dr. Kummer who is certainly well qualified to discuss this issue. According to Dr. Kummer, “there is no empirical evidence in the literature that ankyloglossia typically causes speech defects. On the contrary, several authors, even from decades ago, have disputed the belief that there is a strong causal relationship (Wallace, 1963; Block, 1968; Catlin & De Haan, 1971; Wright, 1995; Agarwal & Raina, 2003).”

Related imageSince many children with restricted frenulum do not have any speech production difficulties, Dr Kummer explains why that is the case by discussing the effect of tongue tip positioning for speech production.

Lingual-alveolar sounds (t, d, n) are produced with the top of the tongue tip and therefore, they can be produced with very little tongue elevation or mobility.

The /s/ and /z/ sounds require the tongue tip to be elevated only slightly but can be produced with little distortion if the tip is down.

The most the tongue tip needs to elevate is to the alveolar ridge for the production of an /l/. However, this sound can actually be produced with the tongue tip down and the dorsum of the tongue up against the alveolar ridge. Even an /r/ sound can be produced with the tongue tip down as long as the back of the tongue is elevated on both sides.

The most the tongue needs to protrude is to the back of the maxillary incisors for the production of /th/. All of these sounds can usually be produced, even with significant tongue tip restriction. This can be tested by producing these sounds with the tongue tip pressed down or against the mandibular gingiva. This results in little, if any, distortion.” (Kummer, 2005, ASHA Leader)

In 2009, Dr. Sharynne McLeod, did research on electropalatography of speech sounds with adults. Her findings (below) which are coronal images of tongue positioning including bracing, lateral contact and groove formation for consonants support the above information provided by Dr. Kummer.

Once again research and clinical practice align to indicate that there’s insufficient evidence to indicate the effect of restricted frenulum on the production of speech sounds.

Finally, I would like to conclude this post with a list of links from recent systematic reviews summarizing the latest research on this topic.

Ankyloglossia/Tongue Tie Systematic Review Summaries to Date (2017):

  1. A small body of evidence suggests that frenotomy may be associated with mother reported improvements in breastfeeding, and potentially in nipple pain, but with small, short-term studies with inconsistent methodology, the strength of the evidence is low to insufficient.
  2. In an infant with tongue-tie and feeding difficulties, surgical release of the tongue-tie does not consistently improve infant feeding but is likely to improve maternal nipple pain. Further research is needed to clarify and confirm this effect.
  3. Data are currently insufficient for assessing the effects of frenotomy on nonbreastfeeding outcomes that may be associated with ankyloglossia
  4. Given the lack of good-quality studies and limitations in the measurement of outcomes, we considered the strength of the evidence for the effect of surgical interventions to improve speech and articulation to be insufficient.
  5. Large temporal increases and substantial spatial variations in ankyloglossia and frenotomy rates were observed that may indicate a diagnostic suspicion bias and increasing use of a potentially unnecessary surgical procedure among infants.

References

  1. Power R, Murphy J. Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance. Archives of Disease in Childhood 2015;100:489-494.
  2. Francis DO, Krishnaswami S, McPheeters M. Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics. 2015;135(6):e1467-e1474.
  3. O’Shea JE, Foster JP, O’Donnell CPF, Breathnach D, Jacobs SE, Todd DA, et al. Frenotomy for tongue-tie in newborn infants (Review). Cochrane Database of Systematic Reviews. 2017 (3):Art. No.:CD011065.
  4. Hall D, Renfrew M. Tongue tie. Archives of Disease in Childhood. 2005;90:1211-1215.
  5. Coryllos E, Watson Genna C, Salloum A. Congenital tongue-tie and its impact on breastfeeding. Breastfeeding: Best for Mother and Baby, American Academy of Pediatrics. 2004 Summer:1-6.
  6. Coryllos EV, Watson Genna C, LeVan Fram J. Minimally Invasive Treatment for Posterior Tongue-Tie (The Hidden Tongue-Tie). In: Watson Genna C, editor. Supporting Sucking Skills. Burlington, MA: Jones and Bartlett Learning; 2013. p. 243-251.
  7. National Health and Medical Research Council. Infant feeding guidelines: information for health workers. In: Government A, editor. 2012. p. https://www.nhmrc.gov.au/guidelines-publications/n56.
  8. Watson Genna C, editor. Supporting sucking skills in breastfeeding infants. Burlington, MA: Jones and Bartlett Learning; 2016.
  9. Griffiths DM. Do tongue ties affect breastfeeding? . Journal of Human Lactation. 2004;20:411.
  10. Ricke L, Baker N, Madlon-Kay D. Newborn tongue-tie: prevalence and effect on breastfeeding. Journal of American Board of Family Practice. 2005;8:1-8.
  11. Madlon-Kay D, Ricke L, Baker N, DeFor TA. Case series of 148 tongue-tied newborn babies evaluated with the assessment tool for lingual function. Midwifery. 2008;24:353-357.
  12. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110:e63.
  13. Amir L, James JP, Donath SM. Reliability of the Hazelbaker Assessment Tool for Lingual Frenulum Function. International Breastfeeding Journal. 2006;1:3.
  14. Douglas PS. Conclusions of Ghaheri’s study that laser surgery for posterior tongue and lip ties improve breastfeeding are not substantiated. Breastfeeding Medicine. 2017;12(3):DOI: 10.1089/bfm.2017.0008.

Author Bios (in alphabetical order):

Dr. Pamela Douglas  is the founder of a charitable organization, the Possums Clinic, a general practitioner since 1987, an IBCLC (1994-2004; 2012-Present) and researcher. She is an Associate Professor (Adjunct) with the Centre for Health Practice Innovation, Griffith University, and a Senior Lecturer with the Discipline of General Practice, The University of Queensland. Pam enjoys working clinically with families across the spectrum of challenges in early life, many complex (including breastfeeding difficulty) unsettled infant behaviors, reflux, allergies, tongue-tie/oral connective tissue problems, and gut problems. She is author of The discontented little baby book: all you need to know about feeds, sleep and crying (UQP) www.possumsonline.com; www.pameladouglas.com.au

Renee Kam qualified with a Bachelor of Physiotherapy from the University of Melbourne in 2000. She then worked as a physiotherapist for 6 years, predominantly in the areas of women’s health, pediatric and musculoskeletal physiotherapy. She became an Australian Breastfeeding Association Breastfeeding (ABA) counselor in 2010 and obtained the credential of International Board Certified Lactation Consultant (IBCLC) in 2012. In 2013, Renee’s book, The Newborn Baby Manual, was published which covers the topics that Renee is passionate about; breastfeeding, baby sleep and baby behavior. These days, Renee spends most of her time being a mother to her two young daughters, writing breastfeeding content for BellyBelly.com.au, fulfilling her role as national breastfeeding information manager with ABA and working as an IBCLC in private practice and at a private hospital in Melbourne, Australia.

Lois Wattis is a Registered Nurse/Midwife, International Board Certified Lactation Consultant and Fellow of the Australian College of Midwives. Working in both hospital and community settings, Lois has enhanced her midwifery skills and expertise by providing women-centred care to thousands of mothers and babies, including more than 50 women who chose to give birth at home. Lois’ qualifications include Bachelor of Nursing Degree (Edith Cowan University, Perth WA), Post Graduate Diploma in Clinical Nursing, Midwifery (Curtin University, Perth WA), accreditation as Independent Practising Midwife by the Australian College of Midwives in 2002 and International Board Certified Lactation Consultant in 2004. Lois was inducted as a Fellow of the Australian College of Midwives (FACM) in 2005 in recognition of her services to women and midwifery in Australia. Lois has authored numerous articles which have been published internationally in parenting and midwifery journals, and shares her broad experience via her creations “New Baby 101” book, smartphone App, on-line videos and Facebook page. www.newbaby101.com.au Lois has worked for the past 10 years in Qld, Australia in a dedicated Lactation Consultant role as well as in private practice www.birthjourney.com

 

 

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A Focus on Literacy

Image result for literacyIn recent months, I have been focusing more and more on speaking engagements as well as the development of products with an explicit focus on assessment and intervention of literacy in speech-language pathology. Today I’d like to introduce 4 of my recently developed products pertinent to assessment and treatment of literacy in speech-language pathology.

First up is the Comprehensive Assessment and Treatment of Literacy Disorders in Speech-Language Pathology

which describes how speech-language pathologists can effectively assess and treat children with literacy disorders, (reading, spelling, and writing deficits including dyslexia) from preschool through adolescence.  It explains the impact of language disorders on literacy development, lists formal and informal assessment instruments and procedures, as well as describes the importance of assessing higher order language skills for literacy purposes. It reviews components of effective reading instruction including phonological awareness, orthographic knowledge, vocabulary awareness,  morphological awareness, as well as reading fluency and comprehension. Finally, it provides recommendations on how components of effective reading instruction can be cohesively integrated into speech-language therapy sessions in order to improve literacy abilities of children with language disorders and learning disabilities.

from wordless books to readingNext up is a product entitled From Wordless Picture Books to Reading Instruction: Effective Strategies for SLPs Working with Intellectually Impaired StudentsThis product discusses how to address the development of critical thinking skills through a variety of picture books utilizing the framework outlined in Bloom’s Taxonomy: Cognitive Domain which encompasses the categories of knowledge, comprehension, application, analysis, synthesis, and evaluation in children with intellectual impairments. It shares a number of similarities with the above product as it also reviews components of effective reading instruction for children with language and intellectual disabilities as well as provides recommendations on how to integrate reading instruction effectively into speech-language therapy sessions.

Improving critical thinking via picture booksThe product Improving Critical Thinking Skills via Picture Books in Children with Language Disorders is also available for sale on its own with a focus on only teaching critical thinking skills via the use of picture books.

Best Practices in Bilingual LiteracyFinally,   my last product Best Practices in Bilingual Literacy Assessments and Interventions focuses on how bilingual speech-language pathologists (SLPs) can effectively assess and intervene with simultaneously bilingual and multicultural children (with stronger academic English language skills) diagnosed with linguistically-based literacy impairments. Topics include components of effective literacy assessments for simultaneously bilingual children (with stronger English abilities), best instructional literacy practices, translanguaging support strategies, critical questions relevant to the provision of effective interventions, as well as use of accommodations, modifications and compensatory strategies for improvement of bilingual students’ performance in social and academic settings.

You can find these and other products in my online store (HERE).

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