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Teaching “Insight” to students with language, social communication, and executive functions impairments

One common difficulty our “higher functioning” (refers to subjective notion of ‘perceived’ functioning in school setting only) language impaired students with social communication and executive function difficulties present with – is lack of insight into own strengths and weaknesses.

Yet insight is a very important skill, which most typically developing students exhibit without consciously thinking about it. Having insight allows students to review work for errors, compensate for any perceived weaknesses effectively, and succeed with efficient juggling of academic workload.

In contrast, lack of insight in students with language deficits further compounds their difficulties, as they lack realization into own weaknesses and as a result are unable to effectively compensate for them.

That is why I started to explicitly teach the students on my caseload in both psychiatric hospital and private practice the concept of insight.

Now some of you may have some legitimate concerns. You may ask: “How can one teach such an abstract concept to students who are already impaired in their comprehension of language?” The answer to that is – I teach this concept through a series of concrete steps as well as through the introduction of abstract definitions, simplified for the purpose of my sessions into concrete terms.

Furthermore, it is important to understand that the acquisition of “insight” cannot be accomplished in one or even several sessions. Rather after this concept is introduced and the related vocabulary has been ‘internalized’ by the student,  thematic therapy sessions can be used to continue the acquisition of “insight” for months and even years to come.

"The Beginning" Road Sign with dramatic blue sky and clouds.

How do we begin? 

When I first started teaching this concept I used to explain the terminology related to “insight” verbally to students. However, as my own ‘insight’ developed in response to the students’ performance, I created a product to assist them with the acquisition of insight (See HERE).

Intended Audiences:

  • Clients with Language Impairments
  • Clients with Social Pragmatic Language Difficulties
  • Clients with Executive Function Difficulties
  • Clients with Psychiatric Impairments
    • ODD, ADHD, MD, Anxiety, Depression, etc.
  • Clients with Autism Spectrum Disorders
  • Clients with Nonverbal Learning Disability
  • Clients with Fetal Alcohol Spectrum Disorders
  • Adult and pediatric post-Traumatic Brain Injury (TBI) clients
  • Clients with right-side CVA Damage


This thematic 10 page packet targets the development of “insight” in students with average IQ, 8+ years of age, presenting with social pragmatic and executive function difficulties.

The packet contains 1 page text explaining the concept of insight to students.

It also contains 11 Tier II vocabulary words relevant to the discussion of insight and their simplified definitions. The words were selected based on course curriculum standards for several grade levels (fourth through seventh) due to their wide usage in a variety of subjects (social studies, science, math, etc.)

Language activities in this packet include:

  • Explaining definitions
  • Answering open-ended comprehension questions
  • Sentence construction activity
  • Crossword puzzle
  • Two morphological awareness activities
    • Define prefixes and suffixes
    • Change word meanings by adding prefixes and suffixes to words
  • Self-reflection page in written format contains questions for students to assist them with judging their own strengths and weaknesses related to academic performance

And now a few words regarding the lesson structure

I introduce the concept of “insight” to clients by writing down the word and asking them to identify its parts: ‘in‘ and ‘sight‘. Depending on the student’s level of abilities I either get to the students to explain it to me or explain it myself that it is a compound word made up of two other words.

I then ask the students to interpret what the word could potentially mean. After I hear their responses I either confirm the correct one or end up explaining that this word refers to “looking into one’s brain” for answers related to how well someone understands information.

I have the students read the text located on the first page of my packet going over the concept of insight and some of its associated vocabulary words.  I ask the students to tell me the main idea of each paragraph as well as answer questions regarding supporting text details.

Once I am confident that the students have a fairly good grasp of the presented text I move on to the definitions page. There are actually two definition pages in the lesson: one at the beginning and one at the end of the packet. The first definitions page also contains word meaning and what parts of speech the definitions belong to.  The definition page at the end of the packet contains only the targeted words. It is now the students responsibility to write down the definition of all the vocabulary words and phrases in order for me to see how well they remember the meanings of pertinent words.

The packet also includes comprehension questions, a section on sentence construction several morphological awareness activities, a crossword puzzle and a self-reflection page.

The final activity in the packet requires the student to judge their own work performance during this activity.  I ask students questions such as:

  • How do you think you did on this task?
  • How do you know you did ________?
  • How can you prove to me you understood ________?

If a student responds “I know I did well because I understood everything”, I typically ask them to prove their comprehension to me, verbally. Here the goal is to have the student provide concrete verbal examples supporting their insight of their performance.

 This may include statements such as:

  • I know I did well because you said: “Nice Work!”
  • I know I did well because you didn’t correct me too much
  • I know I did well because you  kept smiling and showed me thumbs up as I was talking

As mentioned above this activity is only the beginning. After I ensure that the students have a decent grasp of this concept I continue working on it indirectly by having the students continuously judge their own performance on a variety of other therapy related activities and assignments.

You can find the complete packet on teaching “insight” in my online store (HERE).  Also, stay tuned for Part II of this series, which will describe how to continue solidifying the concept of “insight” in the context of therapy sessions for students with social pragmatic and executive function deficits.

Helpful Smart Speech Resources:


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What if Its More Than Just “Misbehaving”?

Frequently,  I see a variation of the following scenario on many speech and language forums.

The SLP is seeing a client with speech and/or language deficits through early intervention,  in the schools, or in private practice, who is having some kind of behavioral issues.

Some issues are described as mild such as calling out, hyperactivity, impulsivity, or inattention, while others are more severe and include refusal, noncompliance, or aggression such as kicking, biting,  or punching.

An array of advice from well-meaning professionals immediately follows.  Some behaviors may be labeled as “normal” due to the child’s age (toddler),  others may be “partially excused” due to a DSM-5  diagnosis (e.g., ASD).   Recommendations for reinforcement charts (not grounded in evidence) may be suggested. A call for other professionals to deal with the behaviors is frequently made (“in my setting the ______ (insert relevant professional here) deals with these behaviors and I don’t have to be involved”). Specific judgments on the child may be pronounced: “There is nothing wrong with him/her, they’re just acting out to get what they want.” Some drastic recommendations could be made: “Maybe you should stop therapy until the child’s behaviors are stabilized”.

However, several crucial factors often get overlooked. First, a system to figure out why particular set of behaviors takes place and second, whether these behaviors may be manifestations of non-behaviorally based difficulties such as medical issues, or overt/subtle linguistically based deficits.

So what are some reasons kids may present with behavioral deficits? Obviously, there could be numerous reasons: some benign while others serious, ranging from lack of structure and understanding of expectations to manifestations of psychiatric illnesses and genetic syndromes. Oftentimes the underlying issues are incredibly difficult to recognize without a differential diagnosis. In other words, we cannot claim that the child’s difficulties are “just behavior” if we have not appropriately ruled out other causes which may be contributing to the “behavior”.

Here are some possible steps which can ensure appropriate identification of the source of the child’s behavioral difficulties in cases of hidden underlying language disorders (after of course relevant learning, genetic, medical, and psychiatric issues have been ruled out).

Let’s begin by answering a few simple questions. Was a thorough language evaluation with an emphasis on the child’s social pragmatic language abilities been completed? And by thorough, I am not referring to general language tests but to a variety of formal and informal social pragmatic language testing (read more HERE).

Please note that none of the general language tests such as the Preschool Language Scale-5 (PLS-5), Comprehensive Assessment of Spoken Language (CASL-2), the Test of Language Development-4 (TOLD-4) or even the Clinical Evaluation of Language Fundamentals Tests (CELF-P2)/ (CELF-5) tap into the child’s social language competence because they do NOT directly test the child’s social language skills (e.g., CELF-5 assesses them via a parental/teachers questionnaire).  Thus, many children can attain average scores on these tests yet still present with pervasive social language deficits. That is why it’s very important to thoroughly assess social pragmatic language abilities of all children  (no matter what their age is) presenting with behavioral deficits.

But let’s say that the social pragmatic language abilities have been assessed and the child was found/not found to be eligible for services, meanwhile, their behavioral deficits persist, what do we do now?

The first step in establishing a behavior management system is determining the function of challenging behaviors, since we need to understand why the behavior is occurring and what is triggering it (Chandler & Dahlquist, 2006)

We can begin by performing some basic data collection with a child of any age (even with toddlers) to determine behavior functions or reasons for specific behaviors. Here are just a few limited examples:

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

Most behavior functions typically tend to be positively, negatively or automatically reinforced (Bobrow, 2002). For example, in cases of positive reinforcement, the child may exhibit challenging behaviors to obtain desirable items such as toys, games, attention, etc. If the parent/teacher inadvertently supplies the child with the desired item, they are reinforcing inappropriate behaviors positively and in a way strengthening the child’s desire to repeat the experience over and over again, since it had positively worked for them before.

In contrast, negative reinforcement takes place when the child exhibits challenging behaviors to escape a negative situation and gets his way. For example, the child is being disruptive in classroom/therapy because the tasks are too challenging and is ‘rewarded’ when therapy is discontinued early or when the classroom teacher asks an aide to take the child for a walk.

Finally, automatic reinforcements occur when certain behaviors such as repetitive movements or self-injury produce an enjoyable sensation for the child, which he then repeats again to recreate the sensation.

In order to determine what reinforces the child’s challenging behaviors, we must perform repeated observations and take data on the following:

  • Antecedent or what triggered the child’s behavior?
    • What was happening immediately before behavior occurred?
  • Behavior
    • What type of challenging behavior/s took place as a result?
  • Response/Consequence
    • How did you respond to behavior when it took place?

Here are just a few antecedent examples:

  • Therapist requested that child work on task
  • Child bored w/t task
  • Favorite task/activity taken away
  • Child could not obtain desired object/activity

In order to figure them out we need to collect data, prior to appropriately addressing them. After the data is collected the goals need to be prioritized based urgency/seriousness.  We can also use modification techniques aimed at managing interfering behaviors.  These techniques include modifications of: physical space, session structure, session materials as well as child’s behavior. As we are implementing these modifications we need to keep in mind the child’s maintaining factors or factors which contribute to the maintenance of the problem (Klein & Moses, 1999). These include: cognitive, sensorimotor, psychosocial and linguistic deficits. 

We also need to choose our reward system wisely, since the most effective systems which facilitate positive change actually utilize intrinsic rewards (pride in self for own accomplishments) (Kohn, 2001).  We need to teach the child positive replacement behaviors  to replace the use of negative ones, with an emphasis on self-talk, critical thinking, as well as talking about the problem vs. acting out behaviorally.

Of course it is very important that we utilize a team based approach and involve all the professionals involved in the child’s care including the child’s parents in order to ensure smooth and consistent carryover across all settings. Consistency is definitely a huge part of all behavior plans as it optimizes intervention results and achieves the desired therapy outcomes.

So the next time the client on your caseload is acting out don’t be so hasty in judging their behavior, when you have no idea regarding the reasons for it. Troubleshoot using appropriate and relevant steps in order to figure out what is REALLY going on and then attempt to change the situation in a team-based, systematic way.

For more detailed information on the topic of social pragmatic language assessment and behavior management in speech pathology see if the following Smart Speech Therapy LLC products could be of use:



  1. Bobrow, A. (2002). Problem behaviors in the classroom: What they mean and how to help. Functional Behavioral Assessment, 7 (2), 1–6.
  2. Chandler, L.K., & Dahlquist, C.M. Functional assessment: strategies to prevent and remediate challenging behavior in school settings (2nd ed.). Upper Saddle River, New Jersey: Pearson Education, Inc.
  3. —Klein, H., & Moses, N. (1999). Intervention planning for children with communication disorders: A guide to the clinical practicum and professional practice. (2nd Ed.). Boston, MA.: Allyn & Bacon.
  4. —Kohn, A. (2001, Sept). Five reasons to stop saying “good job!’. Young Children. Retrieved from
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Simplifying Testing Results to Understand the Student’s Difficulties


Oftentimes explaining testing results in the form of standard scores, percentiles, and charts is labor-intensive for the SLP and confusing for parents and ancillary  professionals. Furthermore, just because you show testing results does not always ensure that the ramifications of testing are fully understood, especially when it comes to performance of high functioning students with deficits in isolated areas, which may significantly impact the student’s functioning in social and academic settings.

So finding an effective method of sharing testing results was fraught with difficulties until recently. In early January, I attended a Sarah Ward executive function conference, where Sarah shared one of her tricks of sharing testing results.  She used a picture of a bell curve and inserted testing results into it. So it looked a little similar to the picture I have below:


As you can see the student’s listening comprehension and expressive language performance fell in the average range as denoted on the bottom of the picture. In contrast, the student’s problem solving and social pragmatic testing abilities fell in the below average range as is denoted by both a red bar as well as the caption underneath the picture.

It is a visually simple way to see what areas need to be worked on in one snapshot.

Charts in Action: Students with Social Skills Deficits 

This system is even more effective for displaying testing results of higher functioning students with select deficit areas. To illustrate, I recently performed a comprehensive language assessment on a 12-year-old adolescent with suspected ASD. The student had a superior IQ, excellent vocabulary, and phenomenal memory.

When tested in school setting she did not qualify to receive language intervention. However, her comprehensive language testing with me showed a number of disparities. While the majority of her testing fell in the above average and superior range, in a number of testing areas she performed within average and below average range (combined SLP, ED, and Psych. testing results below).


When one looked at the student’s overall testing results, they clearly indicated cumulative performance in the average range of functioning. However, after I plotted all of her results on the bell curve her deficit areas became very clearly apparent and her testing discrepancy clearly indicated that intervention in select areas of functioning was needed.

So even though select scores were clearly in the average range of functioning on the bell curve, they were actually BELOW AVERAGE for this student as compared to significant strengths in all other areas.

Many would argue with me pointing out that scores in the average range mean average range. The student doesn’t qualify – end of story!  So let me explain the above scores in REAL-LIFE terms.

Why Students with Average Scores May Still Require Services 

This particular student was referred for a social pragmatic evaluation due to behavioral difficulties in the classroom which included verbal outbursts, difficulty engaging in cooperative group work and verbal confrontations with classmates.

Interactions with the student revealed an engaging adolescent who preferred the company of adults and was very likable. However, throughout testing she made comments indicating cognizance that she was not accepted by typically developing peers. She frustratedly stated that she “doesn’t get” peers, is not interested in the “typical” experiences and has “nothing in common” with peers her age because she “misses the point” of their verbal interchanges.

Due to her exceptional performance on standardized testing, many school-based professionals  believed that because she did so well well she did not have any “true” social learning deficits. In contrast the student’s peer group was able to see her social differences with very little effort.  In school, the student did not qualify for social pragmatic language therapy, on the basis of her challenges being perceived as too “mild” to merit services, however her social deficits were NOT mild as judged by her peers. They were only mild as compared to individuals with severe social learning challenges. Without appropriate intervention, these difficulties would  continue to pervasively impact her academic and social performance, as well as affect future employment and relationship status.

So this is why I now love plotting scores on the bell curve for parents and professionals. A simple picture clearly shows the significance of score distribution, the deficits areas in need of intervention, and is literally worth a 1000 words!

Helpful Resources Related to Social Pragmatic Language Overview, Assessment  and Remediation:

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Dear School Professionals Please Be Aware of This

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I frequently get  emails,  phone calls,  and questions from parents and professionals  regarding academic functioning of internationally adopted post institutionalized children.  Unfortunately despite the fact that  there is  a  fairly large body of research  on this topic  there still continue to be numerous misconceptions regarding how these children’s needs should be addressed  in academic settings.

Perhaps  one of the most serious and damaging misconceptions is that internationally adopted children are bilingual/multicultural children with Limited English Proficiency who need to be treated as ESL speakers. This erroneous belief often leads to denial or mismanagement of appropriate level of services for these children not only with respect to their  language processing and verbal expression but also their social pragmatic language abilities.

Even after researchers published a number of articles on this topic, many psychologists, teachers and speech language pathologists still don’t know that internationally adopted children rapidly lose their little birth language literally months post their adoption by English-speaking parents/families. Gindis (2005) found that children adopted between 4-7 years of age lose expressive birth language abilities within 2-3 months and receptive abilities within 3-6 months post- adoption. This process is further expedited in children under 4, whose language is delayed or impaired at the time of adoption (Gindis, 2008).    Even school-aged children of 10-12 years of age who were able to read and write in their birth language,  rapidly lose  their comprehension and expression of birth language  within their first year post adoption,  if adopted by English-speaking parents who are unable to support their birth language.

 So how does this translate into appropriate provision of speech language services you may ask?   To begin with,  I often see posts on the ASHA forums  or in Facebook speech pathology and special education groups seeking assistance with finding interpreters fluent in various exotic languages.  However, unless the child is “fresh off the boat” (several months post arrival to US)  schools shouldn’t be feverishly trying to locate interpreters to assist with testing in the child’s birth language.  They will not be able to obtain any viable results especially if the child had been residing in the United States for several years.

So if the post-institutionalized, internationally  adopted child is still struggling with academics  several years post adoption,  one should not immediately jump to the conclusion that this is an “ESL” issue,  but get relevant professionals (e.g., speech pathologists, psychologists) to perform thorough testing in order to determine whether it’s the lack of foundational abilities due to institutionalization which is adversely impacting the child’s academic abilities.

Furthermore, ESL itself is often not applicable as an educational method to internationally adopted children.  Here’s why:

Let’s literally take the first definition of ESL which pops-up on Google when you put in a query: “What is ESL?”  “English as a Second Language (ESL) is an instructional program for students whose dominant language is not English. The purpose of the program is to increase the English language proficiency of eligible students so they can attain academic standards and achieve success in the classroom.”

Here is our first problem.  These students don’t have a dominant language.   They are typically adopted by parents who do not speak their birth language and that are unable to support them in their birth language. So upon arrival to US, IA children will typically acquire English via the subtractive model of language acquisition (birth language is replaced and eliminated by English), which is a direct contrast to bilingual children, many of whom learn via the additive model (adding English to the birth language (Gindis, 2005). As a result, of subtractive language acquisition IA children experience very rapid birth language attrition (loss) post-adoption (Gindis, 2003; Glennen, 2009).   Thus they will literally undergo what some researchers have called: “second-first language acquisition” (Scott et al., 2011)  and their first language will “become completely obsolete as English is learned” (Nelson, 2012, p. 2). 

This brings us to our second problem: the question of “eligibility”.  Historically, ESL programs have been designed to assist children of immigrant families  acquire academic readiness skills.  This methodology is based on the fact that skills from first language was ultimately transfer to the  second language.  However, since post-institutionalized children don’t technically have a “first language”  and  their home language is English,  how could they technically be eligible for ESL services? Furthermore,  because of frequent lack of basic foundational skills in the birth language  internationally adopted post-institutionalized children will not benefit the same way from ESL instruction the same way bilingual children of immigrant families do.  So instead of focusing on these children’s questionable eligibility for ESL services  it is important to perform detailed review of their pre-adoption records in order to determine birth language deficits and consider eligibility for  speech language services with the emphasis on improving  these children’s  foundational skills.

If the child’s pre-adoption records specifically state that s/he has birth language delay then it should be taken seriously (Gindis, 1999) since language delays in the birth language transfer and affect the new language (McLaughlin, Gesi, & Osani, 1995). These delays will not “go away” without appropriate interventions.  “Any child with a known history of speech and language delays in the sending country should be considered to have true delays or disorders and should receive speech and language services after adoption.” (Glennen, 2009, p.52)

Now that we have discussed the issue of ESL services, lets touch upon social pragmatic language abilities of internationally adopted children.  Here’s how erroneous beliefs can contribute to mismanagement of appropriate services in this area.

Different cultures have different pragmatic conventions,  therefore we are taught to be very careful when labeling  certain behaviors  of children from other cultures as atypical, just because they are not consistent with the conventions and behaviors of children from the mainstream culture. Here’s a recent example. A mainstream American parent consulted an SLP regarding the inappropriate social pragmatic skills of her teenaged daughter adopted almost a decade ago from Southeast Asia. The SLP was under the  impression that  some of the child’s deficits  were due to multicultural differences and had to do with the customs and traditions of the child’s country of origin. She was considering  advising the parent regarding requesting  an evaluation by a SLP who spoke the child’s birth language.

Here are two problems with the above scenario.  Firstly,  any internationally adopted post-institutionalized child who was adopted by American parents who were not part of the culture from which the child was adopted, the child will quickly become acculturated  and  immersed in the American culture.  These children “need functional English for survival”, and thus have a powerful incentive to acquire English (Gindis, 2005; p. 299).   consequently, any unusual or atypical behaviors they exhibit in social interactions and in academic setting with other individuals cannot be  attributed to customs and traditions of another culture.

Secondly,  It is very important to understand that  institutionalization and orphanage care have been closely linked to increase in mental health disorders  and psychiatric impairments.   As a result, internationally adopted children have a high incidence of social pragmatic deficits as compared to non-adopted peers as well as post-institutionalized children adopted at younger ages, (under 3).    Given this, if parents present with concerns regarding their internationally adopted post-institutionalized children’s social pragmatic and behavioral functioning it is very important not to  jump to erroneous conclusion pertaining to these children’s birth countries but rather preform comprehensive evaluations in order to determine whether these children can be assisted further in the realm of social pragmatic functioning in a variety of settings.

In order to develop a clear picture regarding appropriate service delivery for IA children, school based professionals need to educate themselves regarding the fundamental differences between development and learning trajectories of internationally adopted children and multicultural/bilingual children. Children, who struggle academically, after years of adequate schooling exposure, do not deserve a “wait and see” approach. They should start receiving appropriate intervention as soon as possible (Hough & Kaczmarek, 2011; Scott & Roberts, 2007).

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The risk of social-emotional deficits in language-impaired young children

In recent years there has been an increase in infants, toddlers and preschoolers diagnosed with significant social-emotional and/or behavioral problems.  An estimated 10% to 15% of birth-5 year-old population experience serious social-emotional problems which significantly impact their functioning and development in the areas of language, behavior, cognition and school-readiness (Brauner & Stephens, 2006). Continue reading The risk of social-emotional deficits in language-impaired young children