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An Open Letter: The Clinical Fellowship and Early Intervention

1 Apr

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

Strategies for EI – Says WHO?

8 Apr

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review’s goal is to provide SLPs with evidence based strategies (rather than strategies that are anecdotal and maybe outdated and things that we just do because we see other therapists do it.)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?

  1. Provide AAC access
  2. Minimize the pressure to speak
  3. Imitate the child
  4. Utilize exaggerated intonation and decrease rate
  5. Augment auditory, visual, tactile, and proprioceptive feedback
  6. 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?

  1. 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.
  2. 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.
  3. 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.
  4. 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?)
  5. 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)
  6. 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 Toddlers

11 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).

RT image

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!

Works Cited

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

questions to ask a grad program

5 Jun

If you visit a graduate program I think it’s incredibly important to arrive with questions. It shows that you’re actively involved in the process and interested. Should you visit a graduate program? YES. It gives your name a face, it gives you contacts within a program, it gives you a chance to find out if you actually like the program as much as you think you do!

Do it.

So yes please bring questions. I think some of the most important questions you can ask are going to relate to clinical practicum. How long is practicum? How is it done? My program, for example, we had a year of on campus clinicals and one semester of externships. We have a longer medical externship than school based. Some schools however, you’re doing externships the whole time. You may have a semester or two of on campus placements and the rest of the time you’re off campus and taking night classes. I liked my program because I wasn’t taking courses while I did my externship. Also, I had the opportunity to go away. We had girls doing their clinicals all over the country. Other programs – if you’re taking classes you’ll have to do your externships in the same city. But with the extended off campus clinical time you really get the opportunity to try out many different settings and see a really wide variety of populations.

As I’ve said previously, ASHA mandates what sort of information you MUST be exposed to in a graduate program so that’s kind of predictable. Some programs offer EDHH focus or other extra classes for specific interests like AAC or craniofacial disorders. If you have a special interest ask if you’ll have an opportunity to take courses in that area. In my program we had no choice, we took all of the exact same classes. There were no electives.

It’s also important to know the set up of the program. How many people are in the program? My program was huge and I gotta say – I didn’t love it. I came from a small undergrad program and I just didn’t like so many people in my classes. Also if the program is large and you have a lot of on campus clinic you may see some panic for hours and available clients. It’s also good to know how many Ph.D.s will be teaching your courses and how available they are. Are they willing to supervise theses? Will they be gone for sabbatical? What are their research interests? These are the people who are guiding your education for the next two years so it’s good to know that they’ll be around.

I also like to just know little things about programs. Is their clinic set up on a sliding scale? How do patients get access to services in monetary terms? Do you spend time in the community doing screenings or volunteer work? Is the thesis required or an option? If it’s an option – how many students do it and is it supported/encouraged? Are students involved in NSSLHA nationally? Locally? State? Do students regularly attend conferences and is there funding for attendance? What sorts of clinic materials are available to clinicians? Is the clinic up to date in terms of technology support? Can you use iPad, Boardmaker, and AAC devices? Are there GAs and if so, how do you apply and get one? If you don’t get a GA, can you get a job? Where do students live most often?

This is a lot of information but you want to know the answers to these questions so you can make the best decision for yourself.

Aphasia therapy

26 May


If you’re working with adults you’re PROBABLY working on aphasia. There are maaany types of aphasia. If you use the WAB, which there is a good case you will, then you will give your patients any one of eight aphasia diagnoses (Broca’s, Wernicke’s, Transcortical Motor, Transcortical Sensory, Global, Isolation, Conduction, Anomic). Most aphasias  be classified as fluent (receptive) or non-fluent (expressive). And there are other aphasias out there like primary progressive, alexia, agraphia etc. AND the way you classify aphasia will depend on your “theory” of aphasia.

I say all of this, but really you won’t see “pure” aphasias often – I would say many are mixed. You’ll see patients with a variety of difficulties that manifest themselves in all sorts of exciting ways.

AND QUITE FRANKLY – sometimes the diagnosis is SORTA irrelevant. To me – I’m not treating a diagnosis. I’m treating the issue. Just because someone has Broca’s aphasia doesn’t necessarily mean that the treatments typically used for Broca’s aphasia will work for this patient.

So what do you do with these patients – who may have difficulty speaking, understanding, reading, writing, spelling and a plethora of other troublesome word related tasks?

I’ll try to narrow it down a bit.

The patients I saw MOST OFTEN were having difficulty with word finding. I’ve had one patient with global aphasia and one patient with Wernicke’s. My externship had a very cool “Evidence Based Aphasia Clinic” which analyzed the aphasic characteristics of patients enrolled in the clinic, and then looked at EVIDENCE BASED protocols for treating aphasias. WHICH IS SO SMART. Everyone should do this. Not just with aphasia. With all things. One day I’d like to have at least one legit journal article printed off that explains why I do what I do with each kind of disorder that I focus on.

Back to what I was saying – What do we do with these patients? With a global aphasia you’ll likely be trying to find some kind of multi-modality communication system that will be consistently and appropriately utilized in the patient’s life. These are tough patients but you’ll find a way to communicate. One of my most favorite patients had global aphasia. She was the sassiest.

Wernicke’s? Wernicke’s aphasia is really cool. There is a Treatment for Wernicke’s Aphasia which works, but is extremely tedious and exhausting for EVERYBODY. Be sure to break up your sessions if you attempt it. The idea is you put out six photos (of 12 photos total) of everyday photos and first – hand the patient a card with a word on it. The patient matches the word to the picture. The patient then reads the word or verbally identifies the picture. The patient then repeats the word after you. Then you ask the patient to identify the picture with just a verbal cue. There is no scaffolding or cueing, but obviously for training purposes and for success purposes you’ll want to cue and prompt as necessary at the beginning. When I find the source for this I’ll share it – I’m not sure where I hid it. You can also do Response Elaboration Training, Cloze Procedures, Melodic Intonation Therapy, and I’m sure a number of other procedures.

And the biggie – word finding. This is going to change with each patient. I really enjoy category naming and teaching HOW to do this efficiently. I think often we say to a patient “Name all of the animals you can!” and then they have a hard time and we write down how many they got and then we tell them to name some other things. THIS IS NOT GOOD THERAPY.

Teach, don’t test, people.

So some ways we can deal with naming and word finding is to do semantic mapping tasks and semantic feature analysis. You can TEACH patients how to categorize by really thinking about how our brain works. How is our brain organized? Do we just have a jumble of animals in our brain all willy nilly? If someone asked YOU to name as many animals as you could what would you do? I often tell patients to subcategorize. Tell me animals, but first tell me farm animals, then zoo, pets, woodland, ocean, flying, etc. Tell me vegetables but envision yourself at the grocery store. And also consider – are you asking the patient to name CONCRETE items or ABSTRACT? Example time. Concrete: Animals. Abstract: Red things. Our brain is not organized by color.

Other tasks for word finding: synonym and antonym generation. And not just ONE word. Tell the patient to think of THREE antonyms. This gives you a good idea of where they are as far as what is difficult and what sorts of scaffolding is required. Can you give a patient a FIM score without really pushing them and figuring out what is hard? (No.)

Unscrambling tasks. Idiom defining.  Homonym explanation. Word defining. Seriously – ask a patient with a word finding disorder to define the word “tree”. Try that one. I really recommend the WALC books and Cognitive Reorganization if you work with aphasia often.

Now, I’m going to do the last edit of my thesis because I’ve been…not doing it.

NP: Anna Begins – Counting Crows

PS – if you Google just the word “WALC” you get this website. Lolz.

this is a long one. sorry boutcha.

21 Oct

I’ve had a request to post a lil’ about getting into graduate school. I’m giving a presentation next week to NSSLHA about this topic so I’m all ready to go! (ADDENDUM: I don’t know anything about using CSDCAS so don’t ask me!)

I’ll try to do this in steps so you can check things off as you go.

1. Make a list of schools you’re interested in and a pros and cons list if you have more than…six. I went to a presentation by Donald Asher my senior year and he said six was a good number. 2 reach, 2 safe, 2 middle of the road.

2. Once you have that list, make a check list for each school‘s requirements. Schools are weird, they can’t all just have a uniform manner in which they accept applications. Different deadlines, different costs, different expectations, different requirements. BE VERY CAREFUL HERE. If you eff it up, you’re OUT.

3. Compile. Get it together. Make a resume/Curriculum Vitae. Write a personal statement (I’ll blog a different time about writing a personal statement). Get your references in line. Start requesting transcripts yesterday.

4. Send in your actual application and fee as soon as possible. That way you’ll be on file and they’ll have a safe place to keep your stuff. The actual application shouldn’t be hard to do – it’s just the general things they need to know about you.

5. Ask people for recommendations as early as humanly possible. Schools vary on how many recommendations you need, but expect about three. I’d try to get them from people in your major who can write you STRONG letters of recommendation. Ask in person – “Would you be willing to write me a strong letter of recommendation for graduate school?”

6. Make the life of your recommender EASY. Give them a folder with everything they need in it. Supply your CV, your transcripts, your personal statement. Some schools may have a specific form they want your recommender to fill out, some may have an online survey, some just want a letter. Provide an addressed and stamped envelope and tell them the specifics about that letter. Some schools want YOU to mail it with all of your other stuff, but many want your recommender to seal it and sign it on the seal and mail it themselves. Once again, be very careful here, get it right the first time.

7. Also on that note, your school may require that you fill out a “waiver of rights” so recommenders may talk freely about your grades. Provide each person with a waiver about each school.

8. Transcripts suck. They take forever, they cost money, they never go to the right place. It’s a disaster so get started early. And remember to get transcripts from every school you attended – even if you did dual credit your junior year of high school through the community college.

9. Get your resume/CV together and edited by EVERYONE. You don’t want to look like a dummy with typos. And if your GPA isn’t AWESOME feel free to just mention the last 60 hours. (I mean, if they specifically ask your GPA, tell them, but on your resume you can put “3.45/4.00 last 60 hours”).

10. FOLLOW UP ON YOUR LETTERS OF REC. Ugh. Okay. This is the worst but it has to happen. Sometimes it is Christmas break, you gave all of your stuff to your recommender in October, and you get an email from your schools saying “We have two of three letters of recommendation” – sometimes they tell you who they’ve gotten them from. So it’s easy to narrow it down. You must hunt that person down and kindly, gently, nudge them to write that letter. They’ve likely just forgotten because they’re crazy busy just like you – they appreciate the reminder even if you feel awkward doing it. ON THAT NOTE – when you hand them the folders with all of the stuff they need – label that folder “YOUR NAME, The date you provided them with the folder, and the school it is for” – some people just do one folder for all their schools but I made an individual folder for each school and each professor.

11. Oh, and you can ask the same professor to write you multiple letters. And tell them which school you REALLY want. Professors want to help you, I promise.

12. Right, right, right before the deadline CALL the school and MAKE SURE they have received EVERYTHING. You might feel like you’re bugging them, but you’ll feel better once you do it. Especially if you applied to several schools. I’ve seen it happen where it is two days before the deadline and someone finds out a school never got their transcript. (Usually a school will accept an unofficial transcript until a real one gets to them – just FYI)

13. Once it is all said and done, you’ll start receiving notice in the mail (may go to your parents’ home) after spring break. And rejections come first. So if you haven’t heard from your number one school and it is early April don’t stress yet.

14. After that, write your thanks-you’s to the people who wrote your recommendations. Literally write them. On thank you cards. In pen. I waited until I got my decisions from schools because I didn’t want them to think I was sucking up to them (even though I sucked up to them all of the time any way because I am a suck up.)

15. If you get into multiple schools you’ll need to pick a school and write an acceptance letter by the date they give you. You’ll also have to write refusal letters. You can Google how to do that.

The end. If you want to know more about the types of graduate schools to apply to I wrote this last spring: for the chitlins

NP: Conor Maynard – Marvin’s Room (gorgeous. gorgeous. gorgeous cover.)