Traveling SLP Magic: How to be in two places at once

Where are my itinerant clinician friends—those SLPs who pack up their therapy room in a weird rolling suitcase thing, make nice with administrative assistants all over town, eat in their cars, and find themselves constantly thwarted by conflicting building schedules? Yes, hello there! Let’s talk about how things could be different.

In a word… telepractice. As much as we value being physically present for our students and colleagues, we’re living in the age of Facetime, video conferencing, and working remotely. The whole realm of using technology to be a place that you’re not is now mainstream, and easier for people to accept and accommodate than even a few years ago. And after all, a 15-minute drive can easily mean 30 or 40 minutes of lost productivity, once you factor in packing/unpacking, parking, check-in, and everything else involved with a transition between buildings. This article takes the perspective that it’s not whether SLPs should be using telepractice, but how. There’s been plenty of research showing that telepractice can work (see our reviews on the topic), we just need to be smart about:

What job tasks we target for telepractice, and

How we go about it

The article lays out two case studies of SLP using telepractice for (1) direct service to high school students, (2) remote supervision of an SLPA, and (3) remote observations and consultations by a district AAC specialist. They include a lot of really helpful details about how they set these systems up, so definitely check out the article if you’re thinking about trying something similar. The authors studied the effectiveness of telepractice in these cases through a survey. The participants reported that:

  • Telepractice was effective and generally easy to implement for both direct and indirect services/supervision

  • The dreaded technical issues could be dealt with

  • It could be motivating to students, and

  • The SLPs had increased flexibility and decreased travel time

The downsides? Tech troubles did happen, and there were also some issues communicating and coordinating with sites. Choosing the right partners and laying down the groundwork is critical to making it work!

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The last part of the article lays out some very practical pro tips for other SLPs. For example, they recommend holding a team meeting upfront to demonstrate the systems you’ll use, answer questions, and secure buy-in from everyone involved. Also consider small but impactful steps like scheduling email reminders (with backup contact information and links to video sessions), or using two separate computers on the clinician end of thingsone for the audio/video, and one for all your other therapy “stuff.”  And if your admin needs any convincing? Remind them that you’ll be saving them time (from travel) and potentially money (from mileage reimbursements)!

Note: Not all states allow Medicaid billing of telesessions quite yet. So if you’re in the schools, that is an important thing to check first.

 

Boisvert, M. K., & Hall, N. (2019). Telepractice for School-Based Speech and Language Services: A Workload Management Strategy. Perspectives of the ASHA Special Interest Groups. doi:10.1044/2018_PERS-SIG18-2018-0004

Who needs extra time in fluency therapy?

A lot of what we know about evidence-based practice is how things work (or don’t) in general, for groups of similar clients, on average. But as we’ve all seen, even the best approaches don’t work for everyone, or don’t work to the same degree, at the same speed, or in exactly the same way in every case. Knowing how to factor individual differences into our assessment and intervention process is a huge research question (or ten thousand small ones), and it’ll take time for our field to get there. This new study is one link in that chain, addressing how self-regulation abilities relate to therapy outcomes and duration for young children who stutter.

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Children who stutter often struggle with self-regulation, in a similar way to kids with ADHD. (We mentioned a study last month that addressed the importance of “effortful control” in predicting stuttering severity.) Basically, self-regulation is the ability to control your reactions (emotions AND behaviors) to changes in your environment. Kids who have a hard time self-regulating will have really big emotions, both positive and negative, and struggle to calm down when they're upset or excited. They'll also have more trouble focusing and shifting attention than other kids. Here, Druker et al. looked at 185 children between 2 and 6 years old, all of whom had been discharged or discontinued from stuttering therapy within the last three months. About half of these kids displayed “elevated” ADHD symptoms (subclinical, so not actually receiving a diagnosis), as determined by a parent-report measure. Refer back to the article for more details on how this was measured.

Now that in itself is worth knowing, but even more useful is this: the children with more ADHD symptoms needed about 24% more time in therapy (here corresponding to about 3 sessions), to meet the criteria for discharge. If you know right off the bat that your new little client struggles with attention and self-regulation (consider adding a questionnaire to your evaluation protocol or intake process so you know this!), you can take that into account in your treatment plan and expectations for progress.

What other implications do we see for practice? The authors suggestjust like the authors from the piece last month—that SLPs directly address self-regulation skills within fluency therapy. We can’t say from the current research how to do that, or how it might affect outcomes, but it’s a logical step to consider.

 

Druker, K., Hennessey, N., Mazzucchelli, T., & Beilby, J. (2019). Elevated attention deficit hyperactivity disorder symptoms in children who stutter. Journal of Fluency Disorders, 59, 80–90.

An incredible inference intervention for children with DLD

So much of story comprehension depends on inferencing, or making assumptions and connections beyond what’s stated in a story. We know that children with developmental language disorder (DLD) struggle with inferencing, but we don’t have (much) good evidence for treatments to target it. Until now, that is—Dawes et al. are here to help with a fabulous, free, feasible treatment for inferential comprehension.

The researchers randomly assigned 5- to 6-year-olds with DLD to an inferential comprehension treatment condition or to a control phonological awareness treatment condition. Both groups attended 30-minute small-group treatment sessions twice a week for 8 weeks. The inferential comprehension treatment used strategies including narrative retell, dialogic reading, think-alouds, and graphic organizers (see Table 2 for full list). And, great news—the activities for all four books used in the intervention are available for free! 

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Children’s inferential comprehension ability was tested before, immediately after, and 8 weeks after the treatment using different stories. (The assessments are ALSO freely available, because these researchers are amazing.) Children in the treatment group improved significantly more than the control group on inferential comprehension measures and maintained their improvement after 8 weeks. This is about as good as it gets—a scripted, free program that you can deliver in groups with strong evidence for improvement after a short period of treatment.

For more info about profiles of children who struggle with inferential comprehension, see this article by the same researchers.

 

Dawes, E., Leitão, S., Claessen, M., & Kane, R. (2018). A randomized controlled trial of an oral inferential comprehension intervention for young children with developmental language disorder. Child Language Teaching and Therapy. Advance online publication. doi: 10.1177/0265659018815736

Iconicity of AAC symbols—Does it matter for learning?

If you work in AAC, you’ve encountered the AAC symbol hierarchy. You know—the idea that some symbols, like photographs, may be easier for kids to learn because they are more iconic. There’s a lot of chatter out there about this concept. Does a hierarchy exist? Is it just a myth? Guess what—the answer’s not so straightforward.

In this study, 13 school-aged students with both developmental and language delays participated in an observational symbol-learning task on the computer. They were shown 6 “iconic” Blissymbols and 6 “arbitrary” lexigrams. The Blissymbols looked like their referents (the one for clock looked like a clock), while the lexigrams had no relationship to their referents.

The task was simple: the students touched the symbols on the screen and a color photograph of the corresponding vocabulary popped up. The students did this repeatedly for 30 minutes, for a maximum of 12 sessions, and were then tested for their symbol-learning.

Turns out there was a very small advantage for the iconic symbols (they learned one more symbol), but only when the students knew the vocabulary beforehand. So if a student knew the concept DOG, they were a bit more likely to learn the iconic symbol for DOG, rather than the arbitrary symbol. 

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But, what if students didn’t know the vocabulary (an oh-so-common occurrence)?  There was no difference in the students’ ability to learn an iconic symbol versus an arbitrary symbol, when the vocabulary was previously unknown. So if a student didn’t know the concept GORILLA, they were just as likely to learn the iconic symbol as the arbitrary symbol.

This is not a black-and-white situation! Yes, iconic symbols may have a slight advantage in some situations. But—if you’re teaching new vocabulary, it’s probably not worth getting hung up on iconicity, since how closely a symbol looks like its referent doesn’t seem to make or break the learning process.

 

Sevcik, R. A., Barton-Hulsey, A., Romski, M., & Hyatt Fonseca, A. (2018). Visual-graphic symbol acquisition in school age children with developmental and language delays. Augmentative and Alternative Communication, 34(4), 265–275.

Diagnosing DLD when you don’t speak a child’s first language

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We know that it’s best to assess children in their first languages. But, we simply don’t have access to measures or interpreters for all of the world’s languages. What’s a monolingual SLP to do?

New research supports what we’ve discussed previously: that by using parent questionnaires and measures of language processing, we can accurately diagnose language disorders in English language learners using only English measures. Li’el et al. recruited a sample of bilingual and monolingual Australian English-speaking 5- to 6-year-old children with and without developmental language disorder (DLD). “Bilingual” was defined as hearing English less than half the time at home. Parents completed a questionnaire and children completed the CTOPP nonword repetition and CELF-P2 recalling sentences subtests.

The researchers found that the parent questionnaire alone had the highest sensitivity and specificity (accuracy at ruling in and ruling out DLD). However, all of the assessments in combination still had good diagnostic accuracy, and it’s not a good idea to diagnose a child with only one test, so the authors recommend using more than one measure.

Overall, this study adds to evidence that by interviewing parents and using language processing tasks, we can do a pretty good job teasing apart a lack of English exposure from an underlying language disorder even if we can’t assess in a child’s first language.

 

Li’el, N., Williams, C. & Kane, R. (2018). Identifying developmental language disorder in bilingual children from diverse linguistic backgrounds. International Journal of Speech-Language Pathology. Advance online publication. doi: 10.1080/17549507.2018.1513073

Perspectives and Tutorials

On Evidence-Based Practice:

So with the start of this new year, ASHA’s Perspectives has revamped and relaunched as a “fully indexed scholarly review journal” focused on the research-to-practice gap. Sounds excellent, eh? That’s what we’re all about here! They launched this new concept with a special issue of tutorials from members of CRISP, ASHA’s Committee on Clinical Research, Implementation Science, and Evidence-Based Practice*. This whole special issue is open-access, so you don’t have to be an ASHA or SIG member to read. We’ll be excited to see what comes from this new Perspectives over the coming months, and we’ll be sure to highlight the really good stuff for you.

Bridging Knowledge Between Research and Practice (Introduction to the issue)

Implementation Science: Tackling the Research to Practice Gap in Communication Sciences and Disorders

Patient-Reported Outcomes Measures: An Introduction for Clinicians 

This tutorial speaks to that third side of the EBP triangle we don’t talk about as much—the values and perspectives of the clients/patients themselves. The piece gets a little technical re: how patient-reported outcome measures are created and validated, but it does a job explaining why we should consider using these tools and a couple examples of existing measures you could use with your (adult) patients.

Research–Practice Partnership: Application to Implementation of Multitiered System of Supports in Early Childhood Education

Advancing the Delivery of Communication Sciences and Disorders Services Through Research: The Promise of Health Services Research

Clinical Quality Improvement and Quality Improvement Research

*Disclosure: Dr. Harold, owner of The Informed SLP, is a member of this committee.

More Perspectives and Tutorials:

Congruence in Research Question, Design, and Analysis: A Tutorial on the Measurement of Change in Clinical Speech and Language Research

Fostering Preschoolers' Emergent Literacy: Recommendations for Enhanced Literacy Experiences and Collaborative Instruction

This tutorial gives a good basic overview of emergent literacy and ways we can support that for our preschool friends. The gold here are the tables of basic strategies to use during specific literacy activities (shared book reading and making experience books) and sample collaborative lesson plans.

Planning for and Working With Children With an Auditory Brainstem Implant: What Therapists Need to Know

Positive Behavioral Interventions and Supports in Schools: A Tutorial

Figuring out how you fit into your school’s PBIS program? Or are you still puzzling out that particular edu-speak acronym? Come here for an in-depth look at what PBIS programs are (should be?) all about.

Treating Children With Cleft Palate: Case Examples

True story: Last night I had a vivid dream that I was at a tropical resort, and some random person found out I was an SLP and somehow convinced me to do an on-the-fly evaluation of someone with a cleft lip and palate. This is something I have never actually needed to do in real life, and I’m now feeling anxious about it. Needless to say, I am printing out these case studies for future reference. The cases are clearly presented and summarized, with very readable back-and-forth commentary between experts discussing them and how they were handled.

What Clinicians Need to Know About Early Literacy Development in Children With Hearing Loss

This is an excellent read and resource if you are serving young DHH children. The article breaks down early literacy into its four components (print concept knowledge, alphabet knowledge, phonological awareness, and oral language skills) and summarizes research on hearing-related differences and interventions for each.

And more...

Chester et al. enrolled school-aged children with ASD in group social skills training that included play (unstructured or semi-structured) for 8 weeks. They found that participants gained social skills (as rated by parents, teachers, and the children themselves) compared to waiting controls.  

Conlon et al. looked at narratives (via the ERNNI) produced by 8-year-old boys and girls with ASD and average nonverbal intelligence. While we know that children with ASD often struggle with narratives in general, there may be important gender-related differences. This study found that girls’ stories were more complete, included more information about characters’ intentions, and were easier to follow (i.e. they had better referencing).

Joseph used word boxes (a low-tech method using drawn rectangles and letter tiles) to teach sound segmentation, word identification, and spelling skills to three third graders with autism, and found that all children improved on sound segmentation and word ID and two children improved on spelling. 

Montallana et al. studied inter-rater reliability of the VB-MAPP Milestones and Barriers assessments. The VB-MAPP is commonly used to assess and plan intervention for children with ASD, but we haven’t known much about its psychometrics. While the milestones section had largely moderate to good reliability, agreement between raters on barriers was poor to moderate.  

Thirumanickam et al. found that a video-based modeling intervention was effective in increasing conversational turn-taking in a small number of adolescents with ASD who used AAC—BUT, only when provided with additional instruction (least-to-most prompting). They stated that for students with ASD, some level of prompting is likely required to engage in video-based interventions.

 

Chester, M., Richdale, A. L., & McGillivray, J. (2019). Group-Based Social Skills Training with Play for Children on the Autism Spectrum. Journal of Autism and Developmental Disorders. Advance online publication. doi:10.1007/s10803-019-03892-7

Conlon, O., Volden, J., Smith, I. M., Duku, E., Zwaigenbaum, L., Waddell, C., … Pathways in ASD Study Team. (2019). Gender Differences in Pragmatic Communication in School-Aged Children with Autism Spectrum Disorder (ASD). Journal of Autism and Developmental Disorders. Advance online publication. doi:10.1007/s10803-018-03873-2

Joseph, L. M. (2018). Effects of word boxes on phoneme segmentation, word identification, and spelling for a sample of children with autism. Child Language Teaching and Therapy34(3), 303–317.

Montallana, K. L., Gard, B. M., Lotfizadeh, A. D., & Poling, A. (2019). Inter-Rater Agreement for the Milestones and Barriers Assessments of the Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP). Journal of Autism and Developmental Disorders. Advance online publication. doi:10.1007/s10803-019-03879-4

Thirumanickam, A., Raghavendra, P., McMillan, J. M., & van Steenbrugge, W. (2018). Effectiveness of video-based modelling to facilitate conversational turn taking of adolescents with autism spectrum disorder who use AAC. Augmentative and Alternative Communication, 34(4), 311–322.

Measuring the earliest forms of communication

As you may have realized (with frustration!) by now, we have limited options for evaluating the expressive communication skills of children who are minimally verbal. Enter: the Communication Complexity Scale (CCS), designed to measure just that. Prior papers have described the development of the CCS and determined its validity and reliability, but in this study, we get to see it in action with a peer-mediated intervention.

First, a little bit about the tool. It’s a coding scale—not a standardized assessment—that can be used during observations. Because prelinguistic communication skills often take time to develop with this population, this tool helps us think about all the incremental steps along the way and accounts for the variety of communicative modes the children might use. It’s a 12-point scale following this pattern:

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The researchers found that the CCS could measure improvement in overall communication complexity and behavior regulation for preschoolers with autism after a peer-mediated intervention (the same one we reviewed here!).

So far in the research, the CCS has only been used during structured tasks meant to elicit communicative responses (see the supplemental material), such as holding a clear bag with toys where the child can see it, but can’t access it independently. We know it's crucial to observe our students in natural communication opportunities, though, so we'd have to be a little flexible in using the CCS during unstructured observations. The scale could definitely be useful when describing communication behaviors during evaluations or when monitoring progress. Wouldn’t it be much more helpful to say “The child consistently stopped moving (i.e. changed her behavior) in response to the wind-up toy stopping” instead of “The child was not observed to demonstrate joint attention”? Using the CCS, we have new ways of describing those “small” behaviors that really aren’t small at all!

NOTE: This study crosses over our Early Intervention vs. Preschool cut-offs, with kids from 2 to 5 years old. So for those of you who also read the Early Intervention section, we’ll publish this there next month! Just giving you the heads-up so you don’t feel like it’s Groundhog Day :)


Thiemann-Bourque, K. S., Brady, N., & Hoffman, L. (2018). Application of the communication complexity scale in peer and adult assessment contexts for preschoolers with autism spectrum disorders. American Journal of Speech-Language Pathology. doi:10.1044/2018_AJSLP-18-0054

A one–two punch for assessing young Spanish–English learners

Do you serve pre-K or kindergarten-aged kids? Are some/lots/all of them from Hispanic backgrounds and learning Spanish AND English? Mandatory reading right here, friends!

So—a major issue for young, dual-language learners? Appropriate language assessments. We talk about it a lot (plus here, here, here, and here, to name a few). In this new study, the authors compared a handful of assessments to see which could most accurately classify 4- and 5-year-olds (all Mexican–American and dual-language learners) as having typical vs. disordered language.

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The single measure with the best diagnostic accuracy was two subtests of the Bilingual English-Spanish Assessment (BESA)—Morphosyntax and Semantics (the third subtest is phonology, which they didn’t use here). But to get even more accurate? Like, sensitivity of 100% and specificity of about 93%? Add in a story retell task (they used Frog, Where Are You?). Sample both Spanish and English, and take the better MLUw of the two. This BESA + MLU assessment battery outperformed other options in the mix (English and Spanish CELF-P2, plus a composite of the two, a parent interview, and a dynamic vocab assessment).

Not familiar with the BESA? It’s a newer test, designed—as the name implies—specifically for children who are bilingual, with different versions (not translated) of subtests in each language. If you give a subtest in both languages, you use the one with the highest score. And before you ask—yes, the test authors believe that monolingual SLPs can administer the BESA, given preparation and a trained assistant.

Now, the researchers here don’t include specific cut scores to work with on these assessments, but you can look at Table 2 in the paper and see the score ranges for the typical vs. disordered language groups. They also note that an MLUw of 4 or less can be a red flag for this group.

The major issue with this study, affecting our ability to generalize what it tells us, is that the sample size was really small—just 30 kids total. So, take these new results on board, but don’t override all that other smart stuff you know about assessing dual-language learners (see our links above for some refreshers if needed). And keep an eye out for more diagnostic studies down the road—you know we’ll point them out when they come!

 

Lazewnik, R., Creaghead, N. A., Smith, A. B., Prendeville, J.-A., Raisor-Becker, L., & Silbert, N. (2018). Identifiers of Language Impairment for Spanish-English Dual Language Learners. Language, Speech, and Hearing Services in Schools. Advance online publication.  https://doi.org/10.1044/2018_LSHSS-17-0046