Even though I find myself irked on the regular, I continue to follow a few SLP boards on Facebook. Recently a graduate student (presumably) asked about doing her clinical fellowship in an early intervention setting. And I was really bothered by so many negative responses – most people seemed to feel that a CF would not get the support they needed in an EI position. So I wanted a chance to express my point of view as a fairly recent EI CF (without having to unsubscribe myself after posting on her question because notifications for days.) Continue reading
I’ve sensed something. I can feel it coming. On the horizon it looms.
I was speaking with another SLP at the PALSS conference this week who said being “bagless” in early intervention has been “a thing” for “a long time.” You hear this sort of thing often – core vocabulary was identified in the 80s and 90s, NSOMEs were noted as an issue in the 80s, etc etc – but no one listened until 2008 or whenever. “Oh that’s nothing new! We’ve known about that forever!” What is with that? Is it that with social media we’re connected now and we can make sure everyone is on the same page? Or were we too bull-headed in 1986 to listen the first time?
I’ve seen talk about going into the home for early intervention and bringing nothing with you but the shirt on your back on Facebook for about a year now. But APPARENTLY it’s been best practice for awhile. WHY DIDN’T I KNOW HOW COME YOU DIDN’T TELL ME UNTIL NOW? We have really got to work on being accountable to ourselves and each other for best practice. Don’t hand me an article from 2003 about natural environments and routines and the negative effect of bringing toys into the home and say “tsk tsk” and slap my wrists in 2015. Tell me about it in 2003. I’ve only had my bag for 2 years! This whole thing could have been avoided if I didn’t have my damn bag in the first place.
OKAY. Now that I’ve got that out of my system. Going bag-free. Nothing has been written in stone for my clinic yet about getting rid of the toy bag, but I’ve been preparing. As I said, I’ve seen a lot of talk on social media, and I know in southern DE the therapists haven’t been bringing their toy bag for maybe 9 months now. So I know it is headed my way. I’ve been transitioning my bag out of the houses I usually go to by only bringing a few toys, or only bringing books or puzzles, and letting families now that we’ll be playing with their toys soon. Any new houses I’m going into I’m not bringing my bag in the first place. I’ve taken most of the toys out of my car (so now I look like a real freak with an apartment full of toys and no children.)
And honestly, it isn’t a big deal most of the time. A majority of the children I see are lucky and privileged enough to have toys and books in their homes. So it isn’t changing anything except for the clamoring to get into my bag. Really it is kind of nice – I feel a lot less like Santa.
But what about those homes that there isn’t much by way of toys? I’ve thought a lot about this too. And again I don’t see the problem – we’ll use routines, we’ll use the great outdoors, we can make toys, we can make fun. I can say to a family “What would you normally be doing right now – and how can I be a part of it?” As my CF supervisor always told me, “Be the toy” and as Lindsey Cargill at the PALSS conference said, “Be the fun.” I can do that. We can sing. We can listen to the radio. We can dance. We can meet at the library. I can give away my toys to less fortunate families. I can give away my books.
And the research makes sense. How crappy am I making families feel by bringing a bag of toys? Am I not saying, “Your stuff. that your child has access to the 167 hours a week that I’m not here, isn’t good enough?” Am I not saying, “Therapy only happens when I’m here with my bag-o-fun?”
HOWEVER, I do have one question for you SLPs who have gone bag-free (sounds a bit like going green, no?):
How are you addressing really specific goals that you’ve gleaned off the PLS that require pictures? Such as “identifies actions in images,” “identifies line drawings,” “identifies photos,” “identifies object function.”
Are you still bringing a book or puzzle now and then? Are you digging through the mail or the newspapers that families have to use their natural environment? Are you drawing pictures with crayons and markers? Using apps on Mom’s phone? Talking about what we see on TV? Talking about family photos on the walls? Drawing with chalk on the sidewalk? Yes to all of the above? Are you even writing these goals anymore, or are you writing goals based on the routines of the family?
I’m ready for a new challenge and I see this as a chance to improve my coaching skills and become more comfortable with getting involved with routines-based therapy. I’m interested to hear your point of view and get some fresh ideas!
NP: Conor Maynard
PS: If you want to look at the routines based research it is Robin McWilliams starting circa 2003 and he has a ton of great stuff out there on the world wide web
PPS: Does anyone have a link to a good video of typical 2 year old language? One where Mom or therapist isn’t asking 60 bajillion questions? Just a 2 year old talking.
Okay so I’m having this trouble in my life and I need some SLP input. Actually it’s not just me with this particular trouble, it’s all the EI SLPs I know.
Imagine you get a referral for a late-talker. 18-24 months, little to no verbal output. And you and the family work and work and play and play and teach and teach and tada! – the child is almost three, and they’re jib jabbing up a storm. Oh man, they have a ton of great, functional one-three word utterances. Maybe they have 100, even 200 functional phrases. Wow! What great progress!
Now it’s time for a transition evaluation to see if they qualify for school services. Obviously you administer whatever assessment your state recommends for qualifying children for skilled SLP services. And they come out WNL right? Somewhere between 85-100 standard score. And their receptive language is strong – they can identify all sorts of good stuff, and they might even be a bit advanced with the colors, shapes, numbers, letters.
However, you feel something is just not right. Because you know that between 30-36 months a child should have between 450-1,000 words, and your kiddo is not quite there yet. ( Linguisystems Communication Milestones – page 18).
You would maybe even describe this child’s language as “rote.” Practiced. Routine. Reliant. Known. Structured. It’s functional, and they use the vocabulary they have very appropriately, because you are an excellent SLP and you’ve taught the child and the family all about modeling functional and useful words. But what does their spontaneous language look like? Can they answer basic Wh- questions? Are they asking basic questions? Are they using pronouns, possessives, present progressive -ing, plurals? Can they participate in “conversational” dialogue?
Chances are they are probably not doing these things unless these grammatical structures are part of a word or phrases that has been taught to them to use within a specific structure or routine. Their spontaneous output consists of those 100-200 words and phrases, over and over and over and over. Very limited novel output.
You guys know these kids right? You have a picture in your mind of a child or ten children on your caseload who fits this description?
I want to know, how are you expressing your concerns to the schools? Are you just hoping clinical judgment and qualitative explanation will help you make your point? Are you using an assessment? A language sample with type-token ratio? I was recently told about the Language Use Inventory, but I’m wondering if there are any other assessments you are using for this age group. My concern with the LUI is that it’s a parent questionnaire, so it may not really help our case despite the fact that it is standardized.
I hate to see my little guys who I know need the support lose services until they’re re-identified in Kindergarten at age 5. How can we prevent these kids from slipping through the early intervention cracks?
NP: Lana Del Rey – American
If you were an early intervention speech therapist, and you got a referral for a child who does not speak a language that you speak – what would you do?
@liselschwartz and I discussed the other day and I wanted to share some of our ideas. I see a lot of Spanish-speaking children, but I don’t get too many referrals for other languages. Even though I speak some Spanish, my sessions can be a little disjointed. Early intervention is about coaching and guiding parents so they can provide therapy services all week long when you aren’t there. If you can’t talk to them during your sessions how can you make this happen? Here are some ideas!
– Figure out how to get an interpreter in there. Our child-find program typically schedules an interpreter for at the least the first session, and then once a month following for non-English speaking families. If you don’t get an interpreter scheduled off the bat, ask your supervisor about what the protocol is for requesting one. When/if you get someone who can interpret for you, try to get some basic vocab words in THEIR language written down for your knowledge and use. For early intervention my top ten in no particular order are usually:
1. More (some therapists aren’t into this being a first word but it’s quick and easy so I’m sticking with it)
2. Give me/my turn
3. All done
8. Cookie – or cracker, or apple, or whatever the child eats a lot of
9. Milk – or water, or juice, or whatever the child drinks a lot of
– If you can’t get a list from someone who can interpret, trying Googling the words you want – if it’s the wrong word the family will likely know what you MEANT and will tell you the correct word (for example, I didn’t know the Spanish word for “marble” so I just called it “pelota” until a Mom told me “canica.”) If you put into Google “German for ball” it will give you several options, so I just pick the one that sounds closest and the families correct me if I picked the wrong concept. I also LOVE wordreference.com for colloquial definitions.
– Put those words to signs for the family. In our center we even make a little sign language book with a picture of the sign and the word below. I know each language has its own corresponding sign language – but this is hard enough without adding extra sign languages to the picture so I just stick with ASL.
And so on and so forth.
– Do what you can to provide services in their native language. This can hard for a number of reasons (the main being that YOU do not speak Twi or Cantonese or Hmong or whatever). But also sometimes families know that the child is going to be exposed to English in the school system, and so they just want you to speak English to the child. But the two year old should really keep being exposed to their native language so they can communicate with their family members when you aren’t there. This is why it’s vital to get the family playing and doing the therapy, while you coach.
– If caregiver knows someone who can read English, who isn’t there at the time of your sessions, see if you can write down ideas to have translated later. Sometimes Dad or cousin or sister reads English, and so I’ll write down my “ideas” for the week, and then they’ll have that person read later. If you can find something like “Handy Handouts” from SuperDuper (which is in both English and Spanish) that’s ever better – you want to provide resources as much in the native language as you can. As the languages get more “obscure,” the harder this becomes.
– Sometimes families will have a little English in the home, or siblings will speak English, so families will ask, “If the English word is easier to say, can I just model the English word?” (think “ball” instead of “pelota” or “shoe” instead of “zapato.”) I usually try to steer clear of this unless that really is their preferred word that they’d typically use (I see a lot of Spanglish so some families really do just say “apple” instead of “manzana.”) I typically recommend in this circumstance to model approximations of the native language word, rather than modeling the English.
– If there are older siblings in the home who speak English try getting them involved, they can be a huge help for you, and they always love teaching the “teacher” their language and words. :)
Any other ideas out there? What do you do with kiddos and parents who don’t share your language? What if you can’t get an interpreter, or the family resists an interpreter? Please share!
NP: Florence + the Machine – Blinding
I just had my 2 year workiversary! (At the end of July.) As such I thought I’d celebrate two months late by sharing some of my early intervention tips!
1. Put it on your head. I don’t know why, but kids think hats are hilarious. Whenever a kid is not looking at me, is about to cry, is crying, is about to bail on a toy, is distracted – whatever – I just put something on my head. 60% of the time this works every time.
2. Bubbles freeze in the winter and crayons melt in the summer. Plan accordingly.
3. Also on bubbles: blow UP not out. When you blow up, you have time to draw attention to the bubbles, talk about the bubbles, sing about the bubbles, and generally enjoy the bubbles. When you blow out they just fall down and suck.
4. Get yourself pants with a strong knee. I’ve gone through three pairs of pants in less than two years. Double duty knees. Support knees. Worker knees. Utility knees. Or maybe buy one of those gardening squishy rectangles.
5. In addition, get yourself a poker face. You can’t buy this but I highly recommend obtaining one. Poker face has been something I’ve been working on for years, but now that I’ve sort of got my face under control I find my life is a lot easier. When a kid does something that grosses me out, annoys me, makes me mad, makes me laugh (when I shouldn’t), makes me sad, or shocks me – you would never know. I’m like Mona Lisa MS, CCC-SLP over here. You don’t want parents or children feeding into your emotions during therapy sessions so lock it up!
6. Patience is a virtue. Learn to wait. I always tell the kids, “I know, waiting is so hard!” and I make them wait for everything…but it took me a long time to learn to wait for them. Waiting waiting waiting. I do it all day. Wait for them to reach, wait for them to vocalize, wait for them to calm down, wait for them to notice. Quit anticipating, quit assuming, quit rushing, quit pushing. COOL YOUR JETS.
7. Embrace the germs. I mean, Clorox wipe everything and wear gloves when needed. Embrace that you are going to get sick a lot when you first start. Like, a LOT. Way more than you can possibly anticipate. Start stocking up now on all your favorite cold and cough meds, you’re gonna need them. I’m here to tell you that there is a light at the end of the tunnel…after two years I have the immune system of a feral mutt. I can withstand anything (A kid sneezed into my open mouth the other day and I lived to tell the tale.) And you will too. But you have to live through the first six months.
8. Get a mentor (or three). I have a lot of mentors. I have my mentor for picture exchange, I have my mentor for feeding, I have my mentor for behavior, I have my mentor for apraxia…the list goes on. I don’t harangue these people endlessly for lunch dates so we can discuss me and my progress in becoming a grown SLP like them. But I do say, “Hey can I pick your brain about this little guy?” when I need back up. Know when you need backup, and find strong resources. It’s okay to ask for help, and it’s okay to have lots of mentors. (I recommend reading Lean In’s chapter “Are You My Mentor?” if you’re looking to develop mentor-mentee relationships…it’s really very enlightening.)
9. Learn about the other disciplines as much as you can. In early intervention it is SO important to look at the whole child. And until you work with OT/PT/ECE regularly you’re going to have a harder time looking at the whole child (because what are you looking for!?) You’ll see so much improvement when you make adjustments based on those other disciplines. You’ll know when to make referrals, and when to just make a suggestion. It’s hard to help the whole child make major improvements when you’re just looking at his mouth. Cotreat. Observe. Ask.
10. Be flexible. No two kids are alike. Seriously. None. What worked with one, will work again with none. It’s insane. You will see new things every single day. I always say, “Never a dull moment” with EI. It will keep you on your toes and keep you moving and thinking constantly. As an early interventionist you’ve got to be open to new ideas – whatever you’ve got planned probably isn’t going to go as you imagined :)
If you’re just starting out in EI I hope some of these help you on your path. If you’re a seasoned EI Vet – share some of your tips and tricks, I’m always looking for new ideas!
NP: Ingrid Michaelson – Home
I wrote a blog post for PrAACtical AAC on motivating adult clients to utilize AAC systems. You may read it here if you so desire:
Enjoy! Let me know if you have questions or comments or ideas or suggestions or if you just want to see more pictures of Simon (he is ultra-cute.)
At my facility we are currently using the PLS-5 for early intervention language evaluations for both initial intake as well as transition to the school district. We’re finding that it is somewhat soft, and we’re having a hard time qualifying children based on the standard scores and age equivalencies (it would appear from FB that other SLPs nation-wide are experiencing the same.)
I’m wondering what other tests are out there? I’ve got a list going that includes:
I have not been doing the “AAC” thing long, and I don’t deal with tech-AA
C frequently. I make a lot of communication books, gesture dictionaries, and just general working with families on implementing strategies to increase communicative attempts in the natural environment. I have recommended an actual communication device only 3 times so the funding piece of things tends to be a bit over my head. Most companies have someone that will work with you on getting devices to trial, completing the appropriate paperwork, and procuring the device and I worship the ground said person walks on.
I recently recommended a device for a client, contacted the company to find out about funding and was told that they don’t do it. AACK. WHAT? Mind blown. I just assumed that every speech generating device for every client would be funded in some capacity, one way or another (I also live in magical fairy AAC land, did I not mention that?) But the device doesn’t qualify as “durable medical equipment” so the company doesn’t bill insurance.
So now what? The company told me to contact a durable medical equipment company in my area and have them “give them a call.” ABOUT WHAT? GIVE YOU A CALL? I swear some days I feel like I’m losing my mind with these hoops.
Luckily I have my very own AT guru (you may all express your jealousy) who explained that the client’s primary insurance company likely has a DME company they work with for AAC. So the trick is to contact that specific DME company, and work with THEM on funding the device. It’s just more red tape than usual but seriously who knew? In case you didn’t know – now you do!
Learn something new every day I suppose.
(On the AAC-upside, I’m working with a client right now who is actually having success and demonstrating progress with the Tobii I-15 eye-gaze system and I couldn’t be more thrilled. I’ve only ever seen typical adults use eye-gaze systems so it’s a beautiful thing to watch it happen before your very eyes with someone who has disabilities.)
NP: Dime Porque (One of my client’s parents was listening to this during a home visit today and I was like, “This is quite catchy even though I do not understand.)
Research Tuesday Numero Tres!
When “Simon Says” Doesn’t Work: Alternatives to Imitation for Facilitating Early Speech Development
Citation: Laura S. DeThorne, Cynthia J. Johnson, Louise Walder, Jamie Mahurin-Smith; When “Simon Says” Doesn’t Work: Alternatives to Imitation for Facilitating Early Speech Development. Am J Speech Lang Pathol 2009;18(2):133-145. doi: 10.1044/1058-0360(2008/07-0090).
As you know, I work with children 0-3 (I’d say the average age I get referrals is probably 26 months) in group center-based, individual center-based, and home-based therapy. I often make suggestions to parents on the very first day I see a child, maybe even in the evaluation – but I’ve often wondered …where do I get this stuff? Says who?
I saw this article while I was trying to find an article that supports the notion of putting an object near the face when you label it to gain attention and encourage imitation. I found a variety of sources that make the same suggestion but I have not seen any studies (if you know of one throw it my way). I seriously make this suggestion like three times a week but WHY? Who says it actually does anything? Somebody out there has to know.
ANYWAY, this literature review focused on six strategies that SLPs recommend and utilize for early speech imitation and language development. The review’s goal is to provide SLPs with evidence based strategies (rather than strategies that are anecdotal and maybe outdated and things that we just do because we see other therapists do it.) I have this dream that one day I’ll have a citation for every strategy I suggest to families. Which sounds alarming but really, I wouldn’t want a medication that hasn’t been proven to work.
What are these six strategies that SLPs frequently utilize to elicit speech imitation?
- Provide AAC access
- Minimize the pressure to speak
- Imitate the child
- Utilize exaggerated intonation and decrease rate
- Augment auditory, visual, tactile, and proprioceptive feedback
- Avoid emphasis on nonspeech-like articulator movements: focus on function
How did researchers pick these strategies?
First, they created a list of strategies that already had some theoretical framework which were supported by the big wigs of speech pathology. Then they used a variety of search methods to track down associated intervention studies. Then they narrowed down the list to these strategies with Level Two empirical evidence (supported by at least one experimental or quasi-experimental study on a relevant population).
You guys remember about empirical evidence right? Let’s review friends:
What is something cool that this literature review told me about each of these strategies?
- Provide AAC: The authors identified SIX studies which support providing AAC to children who do not easily imitate. Within those six studies, 89% of the children showed an increase in verbal output, and 11% showed no change. AAC had no detrimental impact on speech production in any of the children.
- Minimize pressure: In a study with 29 late-talking preschoolers, using mands and prompted imitation increased imitation within a speech session, however showed no carryover to the natural environment. The study indicated that directly prompting an imitation does not increase word-learning any more than low-pressure imitation.
- Imitate the child: Recent studies have shown that when you see someone perform a familiar action, neurons fire in YOUR brain too as though you’re doing the action. So when a child sees a clinician perform an action it may incite neurons in their brain which acts as an involuntary rehearsal. How neat is that? Super neat.
- Exaggerated intonation and slowed rate: This one is kind of weird because they call it exaggerated intonation and slow rate but they talk about singing – which I think are two separate things but nobody asked me. The research for singing and speech is extensive for adults. However, one study showed that melodic intonation therapy for children was more effective at increasing phoneme imitation versus oral motor therapy (which makes sense because we all know non-speech oral motor therapy does nothing for speech right? WE ALL KNOW THIS RIGHT?)
- Enhance sensory feedback: There’s a pretty small amount of literature on use of auditory and visual feedback for small children. However, tactile and proprioceptive information has shown promise for eliciting imitation in children via the PROMPT program. The idea of using enhanced sensory feedback is that we’re helping the child develop internal models for speech sound production (i.e. motor planning has a sensory result)
- Focus on function: Oral motor therapy is not effective based on a number of unpublished studies. If you feel the need to recommended non-speech oral motor exercises, do it only when a child is genuinely not imitating speech at all, and the activity should match as closely as possible in the areas of position, movement, and function of the target sounds.
So now when you recommend a speech imitation strategy to a family or caregiver you can at least rest easy knowing these six strategies do have an evidence base. There are numerous other suggestions we make as clinicians that don’t have a Level 2 evidence rating – we should strive to increase our EBP for early language imitation and development. Don’t you think?
Classification Accuracy of Brief Parent Report Measures of Language Development in Spanish-Speaking Toddlers11 Mar
Mark Guiberson, Barbara L. Rodríguez, Philip S. Dale; Classification Accuracy of Brief Parent Report Measures of Language Development in Spanish-Speaking Toddlers. Lang Speech Hear Serv Sch 2011;42(4):536-549. doi: 10.1044/0161-1461(2011/10-0076).
As a follow up to last month’s Research Tuesday article, I chose this research article as my second topic. Also in my workplace, we use the SPLS as our qualifying assessment for Spanish-speaking children, so I was curious to see what these researchers had to say.
The goal in this project was to evaluate the classification accuracy of three different parent report measures as they assess they language development of Spanish-speaking toddlers. The three parent report measures chosen were the Ages and Stages Questionnaire (Spanish ASQ; Squires, Potter, & Bricker, 1999), he short-form of the Inventarios del Desarrollo de Habilidades Comunicativas Palabras y Enunciados (INV–II; Jackson-Maldonado, Bates, & Thal, 1992; Jackson-Maldonado et al., 2003), and reported children’s 3 longest utterances (M3L–W). The children were also administered the Spanish Preschool Language Scale-4 (SPLS–4; Zimmerman, Steiner, & Pond, 2002) to assess concurrent validity of the parent report measures in comparison to the Expressive Language Subtest.
Who took part in this study? 45 Spanish-speaking families and their 2 year olds. 22 of the children had expressive language delays (ELD), and 23 of the children were typically developing in their language development (TD.)
What’s going on with these parent measures? Well, the Communication Subscale of the ASQ is six questions long. The short-form INV-II is a 100 word checklist with a question regarding combining words. The M3L-W is assessed by asking parents to write down the three longest utterances their child has produced (To calculate a score you add the number of words and then divide by three.)
And what did we learn? Tell me about the results!
- All three parent measures were significantly correlated with the SPLS-4. They showed concurrent validity (a type of evidence that is demonstrated when a test elicits similar results to a test which has already been validated).
- When researchers compared the test scores of the children with expressive language delays and those test scores of the children considered typically developing, children with ELD received significantly lower scores than the children considered TD. (…which makes perfect sense? I guess that’s good to know – probably wouldn’t be great if both groups scored similarly.) The biggest difference was noted on the M3L-W measure.
- The classification accuracy aspect of the project looked at sensitivity, specificity, negative predictive value, and positive predictive value. Sensitivity of the measures reveals how many of the children who had a dx of ELD, also tested as ELD. Specificity of the measures reveals the portion of children considered TD, who tested as TD. Negative predictive value (NPV) is the percentage of children with negative screening results who were accurately classified, and the positive predictive value (PPV) with positive screening results that were accurately classified. (This is all very confusing for me, I’m hoping as I read it becomes clearer.)
- The ASQ showed low sensitivity and NPV, but strong specificity and PPV – the ASQ was determined to be inadequate at detecting children with ELD (Possibly due to the fact that the questions are direct translations from English, and the ASQ was developed specifically for parental styles typical for Europe and America.)
- The INV-II had high sensitivity, specificity, NPV, and PPV – it “shows promise” for use as an expressive language screener
- The M3L-W had high sensitivity, specificity, NPV, and PPV – promising in terms of “pass/fail” screenings to determine need for in-depth assessment
- Since the INV-II and the M3L-W had similar results, the researchers performed another test called a “receiver operating characteristics” which revealed the M3L-W was “non-significantly” better and demonstrated stronger classification accuracy.
To sum it up, when screening toddler-age, Spanish-speaking children it is appropriate to use a vocabulary checklist as well as a parent report on MLU to gain clinical information prior to an in-depth evaluation. But don’t bother with the translated ASQ.
Stay tuned kids, for Research Tuesday in April!
Jackson-Maldonado, D., Bates, E., Thal, D. (1992). Fundación MacArthur: Inventario del desarrollo de habilidades comunicativas. San Diego, CA San Diego State University
Jackson-Maldonado, D., Thal, D. J., Fenson, L., Marchman, V. A., Newton, T., Conboy, B. (2003). MacArthur Inventarios del Desarrollo de Habilidades Comunicativas user’s guide and technical manual. Baltimore, MD Brooke
Squires, J., Potter, L., Bricker, D. (1999). Ages and Stages Questionnaire user’s guide. Baltimore, MD Brookes
Zimmerman, I. L., Steiner, V. G., Pond, R. E. (2002). Preschool Language Scale, Fourth Edition, Spanish Edition. San Antonio, TX Harcourt Assessment