Throwback (2012): One way to support your older students with DLD

If you serve students with developmental language disorders (DLD) in middle or high school, you’ve probably grappled with most of these problems: large caseloads, the impossible Tetris-game of scheduling pull-out sessions, a disconnect between therapy and classroom activities, time diverted to supporting missed or misunderstood class assignments, and difficulty connecting with general education teachers to co-plan or co-teach… to name just a few. So how do we navigate these hurdles to make meaningful changes for our students?

Back in 2012, Starling et al. took a novel approach to improving the language skills of a group of middle-grade students* (Australian Year 8, corresponding to the same grade in the U.S.) with language disorders: teaching the students’ teachers to modify their instructional language. This is taking a systemic approach to supporting students by targeting their environment and some of their most impactful communication partners—the ones delivering core academic instruction.

Teacher training addressed a few different areas, focusing on “practical and useable techniques”

  1. Modifying teacher’s written language in worksheets by breaking up large chunks of information, adding visuals, giving descriptions of vocab terms, and putting questions on the same page as the text they refer to.

  2. Modifying oral language by making directions explicit, giving extra processing time, rephrasing/repeating important points, and looking at the class when speaking.

  3. Visual strategies like lesson outlines, mind maps, and anchor charts/posters that the whole class participated in making.

  4. Vocabulary instruction techniques using the 3-tier system, adding extra opportunities to work with new words, and breaking down new words into roots and affixes.

Teachers met weekly individually or in small groups with the SLP for 10 weeks, and the SLP sat in on a few of each teachers’ lessons during that time to monitor how they put the strategies into practice. Click through to the article for specific examples of how lessons were modified based on the coaching process.

(An aside: We hear you, secondary-school SLP friends. This is WAY more access to gen-ed teachers than any of us are likely to have. Despite that, there are probably creative ways to implement something similar in your setting, even if you can’t follow the same schedule. If your school uses Professional Learning Communities, invests in peer coaching, or has other, regularly-occurring chances for professional development, you might be able to squirrel your way right in there! Administrators in charge of professional development stuff love coaching models—that’s how adults often learn best, after all—especially when they aren’t paying for an expensive outside consultant to deliver them.)

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Compared to another school, randomly chosen to wait until the next term for the intervention, trained teachers successfully adopted the new strategies and kept up with them, even after the coaching was ended. Even better, their students with identified language disorders improved in a standardized measure of listening comprehension and written expression compared to the students at the other school, and maintained those gains after three months. Similar improvements didn’t show up in oral expression or reading comprehension, though. The authors acknowledge that this teacher-focused intervention isn’t enough for students with significant language needs—of course it’s not. Many (most… all…) of them will still benefit from individualized instruction in some areas. But this can be one layer in a “comprehensive model of service delivery in supporting secondary students with [language disorders].” And bonus? These kinds of teaching practices have benefits for ALL students, not just the ones with disabilities. If your school or district follows RTI/MTSS or Universal Design for Learning, SLP-delivered teacher coaching fits perfectly with those values.

 

*An important note: English learners were not included in the target student group.

Starling, J., Munro, N., Togher, L., & Arciuli, J. (2012). Training Secondary School Teachers in Instructional Language Modification Techniques to Support Adolescents With Language Impairment: A Randomized Controlled Trial. Language, Speech, and Hearing Services in Schools. doi:10.1044/0161-1461(2012/11-0066)

Training natural communication partners how to model AAC

Model, model, model! We all know how important and effective AAC modeling can be (see here and here, for example)—however, modeling is only as good as the partners who are implementing it. If you’re working with kids who use AAC, chances are there are communication partners who need guidance in how to model, and that’s no simple task. If you’re thinking “I agree, but HOW do I teach the partners?”, this review is for you!

The authors of this study gathered 29 studies in which more than 250 communication partners (including peers, teachers, paraprofessionals, parents, and other adults) implemented modeling strategies across various settings. Although they looked at a handful of research questions, the most clinically relevant questions were: How were the communication partners trained and what did they have to say about the training they received?

The most common training strategies were:

  • orally sharing information

  • modeling the strategies, and

  • allowing the partners to practice in controlled settings (role plays), or with a child, while providing feedback

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Overall, partners rated instruction as worth the time, easy to understand, practical, and transferable to other children. Some additionally offered the suggestion to provide more direction on how to model during a child’s regularly occurring activities (something to consider when you are providing training).

Seems pretty straightforward, right? We train the partners using those strategies and then off they go? Not so fast. The authors found that most communication partners also benefited from simultaneous support while learning to model. So after you train the partners, it’s important that you stick around to offer coaching and consultation as necessary.

If this seems daunting (how can I possibly fit this into my already jam-packed day!?), it’s important to remember that teaching communication partners can drastically improve the reach of our interventions—the amount of time we spend with our students is so limited compared to their interactions with natural communication partners.

If partner instruction is something you’d like to improve, be sure to check out the full article (specifically Table 2) for a list of the included studies and the training strategies used in each.

 

Biggs, E. E., Carter, E. W., & Gilson, C. B. (2019). A scoping review of the involvement of children's communication partners in aided augmentative and alternative communication modeling interventions. American Journal of Speech–Language Pathology. doi: 10.1044/2018_AJSLP-18-0024

AAC carryover: Buy-in is only the beginning

One of the biggest frustrations for clinicians who support AAC are the devices that don’t get used. You know, the ones that sit in the cabinet unless you’re in the room, or the ones that parents ask you not to send home. There are a lot of factors that contribute to this kind of device abandonment (can’t you just picture a lonely device feeling sorry for itself?). We need to understand these factors, so we can focus our work on the key ingredients that will promote AAC device use and help students—and their support teams—be successful.  

You won’t be surprised by two of the most common caregiver-related barriers to device success: 

1)    The adults don’t know how to use the device (or, they lack operational competency).

This includes finding words, programming, troubleshooting, and navigating the device settings. Parents and teachers often report that they don’t get enough training in this stuff.

2)    The adults don’t have positive attitudes about the device (or, they lack buy-in).  

Specific aspects of buy-in can include considering the device the child’s voice and believing that it should be available at all times.

These two barriers are important, for sure, but how important? And what else are we missing? This study delved into this issue, focusing on the operational competency and buy-in of parents and teachers of school-aged (3–16 years) children with autism, and whether they related to how frequently the children’s AAC devices were used. The 33 children in the study all used a personally-owned PRC device or the related LAMP Words for Life app as their main method of communication at both home and school. To measure how much devices were used, the researchers analyzed data from PRC’s Realize Language feature across three school days and one weekend. Parent and teacher surveys were used to measure operational competency and buy-in.

The good news? Overall, buy-in and operational competency was high for everyone. The bad news? No one was using devices that much. In this group, teachers reported greater buy-in (or at least answered their surveys that way, but that’s a whole different topic...), but parents and teachers were equally comfortable operating the devices. The devices were used more frequently at school vs. home (over half of the kids didn’t use the devices at home at all). 

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A big grain of salt here: the study looked at really a pretty small window in time (Is one weekend at your house representative of how your family works?), and only one device company—that uses a relatively complex language system—was in the mix. We also don’t know if looking at students with diagnoses other than autism would make a difference. Even so, it’s clear that something’s going on here. We can see that good intentions, valuing the device, and being trained in its use just isn’t enough. It looks like we need a broader conversation about barriers, including the practicalities of incorporating a device into daily activities and routines, especially at home. We definitely need to address operational competency and buy-in, but our families and other stakeholders are likely to need more support than that. The authors remind us to keep communication at the center of the conversation, rather than the technology. After all, the device is only the tool—communication is the point.

 

DeCarlo, J., Bean, A., Lyle, S., & Cargill, L. P. M. (2019). The Relationship Between Operational Competency, Buy-In, and Augmentative and Alternative Communication Use in School-Age Children With Autism. American Journal of Speech-Language Pathology. doi:10.1044/2018_AJSLP-17-0175

Throwback (2015): What and how to teach AAC communication partners

We all know that communication is a two-way street—in order to be effective, there must be give-and-take, back-and-forth. Unfortunately, in the case of AAC users, the importance of the communication partner is often minimized. It makes some sense: using AAC is not intuitive, and there is a lot to teach, so we focus on the communicator. So, what’s the problem here? 

We’re neglecting the other half of the communication process!

Interacting with someone who is learning AAC is also not intuitive and often requires explicit instruction. So—what exactly should we teach partners?  And equally important, how should we do it?

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This meta-analysis aimed to answer these questions by investigating the effectiveness of communication partner instruction on the communication of individuals using AAC. The authors analyzed 17 studies and 53 participants, including a variety of communicators (i.e., different diagnoses and age groups), partners (caregivers, educational assistants, parents, peers, and teachers), intervention approaches (teaching one skill at a time versus a set of skills), and outcome measures (pragmatic, semantic, or syntactic skills). They found that, in general, partner instruction led to improvements in the communication of individuals using AAC.

These are promising results, but what can we take away? What should we be teaching our students’ communication partners? Across the studies, the most frequently targeted skills included:

  • Aided AAC modeling
  • Expectant delay
  • Open-ended questions

And then, how should we teach those skills? Frequently-used instructional activities included:

  • Providing a descriptive overview
  • Instructor modeling
  • Guided practice
  • Role plays

When these skills were taught using these instructional strategies, a range of communication partners were able to modify their interaction patterns to better support individuals using AAC.  Evidence like this can help us advocate for dedicated staff training time in our workplaces, like after-school sessions with paraprofessionals and teachers. Make it your mantra: partner training is a communication intervention!

If you’re interested in the specific variables analyzed across the studies, check out the coding manual here. For more on this topic, check out our 2016 review of three more studies of communication partner training.

 

Kent-Walsh, J., Murza, K.A., Malani, M.D., & Binger, C. (2015) Effects of communication partner instruction on the communication of individuals using AAC: A meta-analysis. Augmentative and Alternative Communication, 31  271-284. doi: 10.3109/07434618.2015.1052153.

Predicting resolution of speech sound errors

Producing speech sound errors early in development is normal. Many children make errors in the preschool years that they simply grow out of in early elementary school. However, some kids don’t grow out of their errors. These are the kids that need speech–language pathologists’ attention, but how do we know which kids these are?

This study aimed to answer exactly that question—which kids just need time, and which kids need speech therapy? They examined 93 children at age four (all “identified as speech impaired” with the GFTA-2 or DEAP), categorized the children’s error types, then looked again at age seven, and found the following:

  • Total number of errors didn’t predict spontaneous resolution of SSD.
  • Type of errors, however did! Kids with speech sound errors best described as “phonologically delayed” (that is, those who use error patterns consistent with younger children, e.g. stopping or cluster reduction) were nearly twice as likely to spontaneously resolve as kids with speech sound errors best described as “atypical” (e.g. backing or initial consonant deletion). The kids who made the fewest atypical errors were most likely to improve over time.

What does this mean for SLPs? First, looking at the types of errors kids make may make more sense than counting the number of consonants errors. This may aid us in predicting who is more or less likely to grow out of their speech errors!

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But, then what to do? Should we prioritize services for children with atypical errors, and wait it out for kids with more typical error patterns? Ehhh…. not so fast. First, we have to be cautious making decisions that apply to entire caseloads or entire school districts (as many of our supervisors want so badly to do!) To think on this, we also need to look more closely at the actual percentages, here: The authors state, “67% of phonologically delayed children had resolved by seven years (of age) compared to 35% of children making atypical speech errors.” So… if 67% of phonologically delayed children resolve, that’s great—but what about the 33% who don’t? Even though the authors have some nice data, here, categorizing kids this way clearly isn’t a perfect predictor of the future. There may be slightly better methods that are even more predictive than what was done in the current study (yay for more science!). Also—resolution of speech sound errors isn’t all that matters, here, when kids with phonological delay may be experiencing other difficulties as well (e.g. literacy). Clearly more data and more discussions are needed, before we attempt to make widespread procedural decisions. But this is a really good start!

Oh, and BTW—are you looking for research to justify working on speech sound errors at a young age, or single speech sound errors, because you have administrators who think the “speech kids” don’t need your attention? In the background of this paper, they review research on why we shouldn’t be framing this as just an articulation problem—“Children’s school achievement is often adversely affected (Hayiou-Thomas et al., 2016) as are their peer relationships, due to social, emotional and behavioral difficulties (Murphy et al., 2014). Persistent impairment in adolescence affects literacy, mental health and employment (Law et al., 2017).” You can get some real gems from this background of this paper!

 

Dodd, B., Ttofari-Eecen, K., Brommeyer, K., Ng, K., Reilly, S., Morgan, A. (2017). Delayed and disordered development of articulation and phonology between four and seven years. Child Language Teaching and Therapy. Advance online publication. doi: 10.1177/0265659017735958.

Throwback Pub (2015): Intervention on the playground—engaging children with autism with their peers

Searching for time in the day to work on engaging children with ASD with their peers? Look no further than recess! Kretzman, Shih, and Kasari developed Remaking Recess, an intervention designed to teach adults how to engage children with ASD during lunch and recess.

The researchers taught 35 school playground staff at four schools (one-on-one aides, classroom aides, playground aides) strategies to promote engagement among 24 children with ASD and their peers. The intervention included teaching the paraprofessionals about:

  1. the relationship between peer engagement and social development,
  2. strategies to use to improve peer engagement, and
  3. how to identify activities that could be added to recess to maximize peer engagement.

NOTE: The sequence and content of the Remaking Recess training protocol is outlined in Table 2 of the paper.

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What were the findings? After receiving the Remaking Recess training, the paraprofessionals demonstrated a significant increase in their use of the strategies AND the children with ASD (in grades 1–5) were rated as more engaged with their peers on the playground.

This school-wide intervention shows promise for facilitating meaningful and generalizable engagement in children with ASD in elementary school, but not without a few caveats. First, the children in the study were fully included in the general education curriculum. Adaptations may need to be made for children with ASD who are not included in the general education curriculum because they may have different needs. Second, the paraprofessionals’ responsiveness and strategy use did not carry over at the 10-week follow up point. The authors stress the importance of assessing paraprofessionals’ buy-in and motivation. As SLPs, we have knowledge and skills needed to support peer engagement, and to teach others about how to facilitate engagement inside and outside the classroom. However, we need to draw upon best practices for collaboration to make adult-mediated interventions like this one as successful as possible.

 

Kretzmann, M., Shih, W., & Kasari, C. (2015). Improving peer engagement of children with Autism on the school playground: A randomized controlled trial. Behavior Therapy, 46(1), 20–28.

Perspective Pieces

Recall that TISLP doesn’t review Perspective Pieces. However, we do love them (sometimes our FAVORITE publications each month are Perspective Pieces), and think you should be reading these gems, too. There were a TON published this month. Browse the titles for topics you’re interested in, and enjoy!

·      Understanding Word Reading Difficulties in Children With SLI

·      Practitioner Reflection That Enhances Interprofessional Collaborative Practices for Serving Children Who Are Deaf/ Hard-of-Hearing

·      Using Multilinguistic Strategies to Improve Decoding in Older School-Age Students in a Contextualized and Motivational Approach

·      A Review of Psychosocial Risks and Management for Children with Cleft Lip and/or Palate

·      The Role of Semantic Knowledge in Learning to Read Exception Words

·      Technology Training in Speech-Language Pathology: A Focus on Tablets and Apps

·      Reading Longer Words: Insights Into Multisyllabic Word Reading

·      Small Group Reading Instruction: Activities for Teaching Phonemic Awareness, the Alphabetic Principle, and Phonics in a Tier 2 Setting

·      Speech Assessment in Children With Childhood Apraxia of Speech

·      Does Access to Visual Input Inhibit Auditory Development for Children With Cochlear Implants? A Review ofthe Evidence

·      Efficacious Treatment of Children With Childhood Apraxia of Speech According to the International Classification of Functioning, Disability and Health

·      Beyond Eyes and Ears: The Need for Movement Analysis of Speech and Nonspeech Behaviors in ChildrenWith Cerebral Palsy

·      Leading the Way With Supervision Training: Embracing Change and Transforming Clinical Practice

·      Perceptions of Mentoring SLPs and Clinical Fellows During the Clinical Fellowship

·      How Stuttering Develops: The Multifactorial Dynamic Pathways Theory

·      Examination of Coaching Behaviors Used by Providers When Delivering Early Intervention via Telehealth to Families of Children Who Are Deaf or Hard of Hearing

·      We’ve Got Some Growing Up to Do: An Evidence-Based Service Delivery Model for the Transition of Care for the Young Adult with Cleft Lip and Palate

·      Are We Slipping Them Through the Cracks? The Insufficiency of Norm-Referenced Assessments for Identifying Language Weaknesses in Children With Hearing Loss

Better Together: Interprofessional Collaborative Practice

This month, AJSLP published six articles on Interprofessional Collaborative Practice (IPCP). This is a very trending topic right now across health professions. Recent grads may recognize the terminology, because many of them have received Interprofessional Education (IPE) while completing their coursework, where students from different professional programs (e.g. SLP, PT, OT, Nursing, Education) learn together and work together early on.

For the school-based SLP, taking the lead to develop a more interprofessional environment requires consideration of many moving pieces. It’s not just what you’re doing. It’s what the teachers, PTs, OTs, social workers, school psychologists, principals, administrators, and parents are doing or willing to do, as well (yay for trying to move a mountain, lol!) Just because it’s tough to implement in some settings, and tough to try something new, doesn’t mean it’s not doable, though. A single PT–SLP pair, for example, can make a substantial difference if they simply start identifying and modeling better collaboration. Or one SLP–Reading Specialist duo. Or one SLP plus SPED teacher working together to improve AAC implementation…

On to the articles—so, I won’t review each of these articles in-depth, because they don’t fit the TISLP “empirical research” requirement. This set is more like a series of tutorials or perspective pieces. Nonetheless, I’ll give you a little guidance on what’s contained within each, so you know what you may want to prioritize:

Addressing the Communication and Other Needs of Persons With Severe Disabilities Through Engaged Interprofessional Teams: Introduction to a Clinical Forum

  • This one’s the “Intro”. Helpful for definitions and explanation of IPCP.

The Trifocus Framework and Interprofessional Collaborative Practice in Severe Disabilities

  • This one reviews the literature on IPCP and students with severe disabilities. It’s the most dense of the series, because it considers a theoretical model behind IPE and provides snippets of information from tons of studies. It may be the most overwhelming of the set, unless you’re ready to think about IPCP more deeply.

Effective Team Practices: Interprofessional Contributions to Communication Issues With a Parent's Perspective

  • This one presents a literature summary and guidance on what good teams look like.

Comprehensive Literacy Instruction, Interprofessional Collaborative Practice, and Students With Severe Disabilities

  • This one’s all about how to collaborate among professionals for literacy instruction. It provides a really rich set of evidence-based treatment options, in addition to discussing how they can be implemented across professions. So if you aren’t an SLP who currently feels as involved as you could/should be in supporting your students in literacy growth, this is a great article.

Cotreatment as a Vehicle for Interprofessional Collaborative Practice: Physical Therapists and Speech-Language Pathologists Collaborating in the Care of Children With Severe Disabilities

  • This one’s authored by PTs and an SLP, and is a set of stories/examples in which the two professions may work together to treat clients.

Mary's Case: An Illustration of Interprofessional Collaborative Practice for a Child With Severe Disabilities

  • This one reads like a story—an individual case of IPCP for a child with a severe disability. It walks you through “Mary’s Case” from birth to adulthood—so no matter what your current setting, there should be a portion of the story you identify with.