Foundations for TX PDF

Foundations for TX Road Map Definitions, considerations, & purpose of therapy Treatment strategies Aspects of a treatment plan Current research Purposes of treatment 1. Elimination a. Eliminating the root cause of language disorder i. For estab...

Foundations for TX Road Map Definitions, considerations, & purpose of therapy Treatment strategies Aspects of a treatment plan Current research Purposes of treatment 1. Elimination a. Eliminating the root cause of language disorder i. For established: 1. cleft palate - surgery 2. Hard of hearing - amplified sound ii. Language disorder is life long as it is a neurodivergent process 2. Change the disorder a. Change the way they experience language i. Introduce AAC, sign language, & other strategies 3. Teach compensatory strategies a. Supporting their current communication 4. Change the environment a. Child doesn't change what they're doing but the environment is adapted to them Role of therapy Neurodivergence You are a communication partner ○ Your goal: for child to be able to communicate independently ○ Your role: give power to client, be a coach & communication partner; help them find their mode of communication; we’re not there to fix!! Error-free learning Establish opportunities to communicate ○ Give them cues/model Use pattern of 1 strategy - wait - 2nd strategy - wait Response to child: ○ Avoid “good job” or “good talking” ○ Use a strategy: validate their mode of communication Reinforce the communicative behavior they just used  Evocative vs. Non-Evocative Strategies Non-evocative Evocative Self talk Communication temptation Think aloud Behavior chain interruption Build up/break down Up the ante Recast Wait time Modify the linguistic signal Preparatory sets Cloze procedure Choices Phonemic cue Visual cue Tactile cue Request for imitation Leading statement Question Cueing strategies Therapy strategies: non-evocative Strategies that do NOT require a response from the child Self talk ○ Talking through what you are doing to expose the child to language ○ I.e.: “I am walking..I am grabbing the shark…” Parallel talk ○ Talking through what the individual is doing ○ Ex: “I noticed that you are making eye contact with me, waiting for your turn…” Build up/break down ○ Start with what the child communicates AAC, ASL, gestures, vocalization ○ Ex: child says “cookie break”, then SLP builds it up, (complete idea) “your cookie broke into pieces.” then break it down (concept) “your cookie broke” Highlight the term you are trying to target Recasts: ○ Extension: elaborating on what the child is saying “The cookie break” -> “yes the cookie broke into smaller pieces”; only building up not breaking down ○ Expansion: taking what they say & repeating it back in a correct form “The cookie break” -> “yes the cookie broke”  ○ Think aloud: think aloud through the through process of what is occurring around you Ex: read and model how you go about adding whatever language form they are targeting Ex: targeting requesting -> model looking and object and how you’re going to go about it on asking for it Modify the linguistic signal: ○ Reducing rate of adult (i.e., clinician) speech ○ Repetition ○ Intonational Highlighting ○ Control complexity Therapy Strategies: Evocative Strategies to elicit targeted speech/language response: ○ Communication Temptation ○ Behavior Chain Interruption Interrupting behavior to trigger intentional communication ○ Up the ante Increase expectation for their communicative forms Wait time: ○ Use your body language to let client know that you are waiting for their response Preparatory sets: ○ Letting client know what you are working on & what the expectations are Cloze procedure: ○ Fill in the blank ○ Ex: “I need….” Phonemic cues: ○ Helps w/ word retrieval ○ Giving first sound of the word Only first sound or cluster Visual cues ○ Visual models ○ Pictorial representation Tactile cues ○ Physical ○ Ex: during articulation -> feeling for voiced vs unvoiced sounds Request for Imitation ○ Asking them to repeat what you said Leading Statements: ○ Tell me what you need ○ Use your words ○ Show me which one Questions:  Choices: 4 aspects of a treatment plan 1. Goals 2. Process (techniques & approaches used to achieve goals) 3. Context (what environment (where) will be used to address each goal) 4. How often? (frequency & duration) Considerations in developing TX plan Child’s culture (family of origin (who are they being raised by?), any recent traumas, pronouns, religious considerations - not all families celebrate the same holidays) Languages & dialects Strengths Most impacted areas of disability; environments important to child Priority on goals: convergence of concern (caregivers, educators, client) Setting goals: two primary approaches Developmental approach Communicative effectiveness Combination Setting goals: developmental approach Highest priority: language behaviors the clines uses 10-50% (emerging; can get it up to 80%) of the time accurately High priority: language behaviors the client uses 1-10% of the time & understands in all receptive tasks Lowest priority: language behaviors used 50-90% (will get the rest higher w/o support) of the time OR behaviors not used at all & not understood in receptive tasks (non stimulable) Problems with developmental approach Implies “catch up” ○ They're not going to; we need to support their current skills Does not account for experience of disability ○ Compares to typical milestones Often based on existing “norms” - harmful to linguistically & culturally diverse students ○ milestones are centered into one demographic not all diverse groups Setting goals: communicative effectiveness Good to use in combination w/ developmental method Which goals will have the most impact on communication effectiveness experience of disability? (Reduce experience of disability?) May be critical factor in goal development for: ○ Clients not likely to achieve typical language (i.e., students w/ complex needs) ○ Children w/ restricted range of communicative functions ○ School-age children whose language skills don't align w/ language expectations of the classroom  Research informing TX plan decisions Active Ingredient: Active Engagement Engagement Definition Examples Active Verbally or nonverbally Answers questions participating in activity; on target; Follows directions may or may not be accurate Volunteers information on topic intermittent Child fluctuates between active & In one interval, child answers a question but passive engagement otherwise watches & waits Passive Focused & attentive, but not Looking in direction of activity speaking or responding Quietly waiting for turn Off Task Uninvolved in directed tasks Looking away from task/SLP Refusing to participate Physically disengaged Code N Intervals Minutes Off Task 135 1.58 (0 - 20.50) 0.39 (0-5) Passive 135 25.67 (2 - 63.50) 6.4 (.5 - 15.8) Intermittent 135 52.69 (13.5 - 103.50) 13.17 (2.5 - 25.87) Active 135 11.59 (0 - 64.00) 2.8 (0 - 16 min) How do we keep kids engaged during group therapy? Wrap up The role of the SLP in therapy & error free learning The purpose of therapy as well as the 4 main aspects of a treatment plan The 2 main strategies for setting goals: developmental approach & communicative effectiveness Research suggests tx intensity, engagement, inclusion, peer effects matter Treatment: prelinguistic stage Public policy Public law 99-457 ○ Birth to 2:11 IFSP ○ 3 to 21 IEP Focus of TX: Prevention Primary ○ Act of preventing a disease from ever happening Ex: childhood vaccines Secondary ○ Early Dx Babies born w/ genetical conditions ○ Early intervention services Reduces experience of disability Tertiary  ○ What happens w/ developmental language Communication disorder is not caught early on -> initiation of therapy happens later on Infant treatment in NICU Goals: ○ Achieve stabilization & homeostasis (turning in, coming out, reciprocity) of environment ○ Prevent &/or minimize secondary (in consequence of other conditions) disorders (i.e., language disorders, hearing loss) ○ Create supportive, developmentally appropriate environment Treatment: SLP role in NICU With NICU staff: ○ Help monitor noise levels ○ monitor/educate on overstimulation (noise, lights, tubes/monitors) ○ Advocate for oral motor development Keep stimulation going if stable enough for it With family: ○ Teach parents to read their infant’s state of arousal (state of organization/homeostasis) *lack of connection in NICU is a risk ○ When infant is ready for interactions, foster parent/child attachment & engagement ○ Teach stress signals How to read their child -> ready to rest/interact, likes & dislikes,... ○ Have them track infant behaviors Treatment: infants 1-8 months (discharged of NICU) 3 primary components ○ Educate caregivers on typical development ○ model/coach adult-infant communication (caregiver is who spends most of the time with them) ○ Teach caregivers to self-monitor Education matches universal/cultural guidelines - family knows what to expect Treatment: infants 9 - 18 months (transition to illocutionary) Primary goal: increase enjoyable, successful parent-infant interactions; teach parents to: ○ Scaffold  ○ Up the ante ○ Use communication temptations (setting up opportunities to communicate; carefully, playfully) ○ Provide supranormal levels of input ○ Encourage vocalization ○ Develop comprehension ○ Respond contingently to any initiation on child’s part (expand, extend) ○ Follow child’s lead What they have interest in Comprehension & communication can be taught through joint attention Want family to experience successful communication w/ child We are the supporters! Coach the family/any communication partner Caregiver role vs SLP role Role of caregiver: be primary communication partner ○ Goal: child & partner to have meaningful & successful communication Role of SLP: to coach & support, come in w/ knowledge of communication, provide the family w/ power ○ Don’t need conventional toys to engage ○ Empower the family w/ what's already accessible Treatment: emerging language 18 - 36 months Treatment plan Identify strengths & needs Determine goals for treatment Determine your plan for achieving these goals ○ Context (i.e., setting) ○ Intensity of TX ○ Continuum of naturalness ○ Strategies to use Choose activities to address goals Consider common problems Play Communicative ○ Functions ○ Forms ○ Frequency Comprehension Semantics  Syntax (only if MLU > 1.0) Developing play skills Assumes joint attention is present. Then, determine the stage of play within child’s ZPD No one right way to play! Follow child’s preferences & extend skills within Be explicit in teaching play sequences: ○ Social stories ○ Step-by-step instructions ○ Use people games/sensory to “pretend” Developing intentional communication: initiation frequency; communication temptations Hybrid form of intervention ○ Structure environment; wait; any form; reinforce ○ Embedded within routines (best if routine is already established) ○ Involve parents as role models Behavior chain interruption Developing intentional communication: functions (i.e., range of intentions) Behavior regulation (or proto-imperatives) ○ Generally targeted first ○ Suggestions for eliciting requests ○ Suggestions for eliciting protests Joint attention (or proto-declaratives) ○ Introduce novel toy or stimulus ○ Within routine, make a silly mistake ○ WAIT for child to notice ○ Exaggerate YOUR reaction Developing intentional communication: modality Myth busters: ○ AAC modalities DO NOT interfere in the development of spoken language ○ No prerequisites for introducing AAC ○ Spoken language is not better than AAC Rationale for AAC: ○ Not all will develop spoken language ○ AAC can be easier entry into communication Developing intentional communication: form Best to work on with an existing function Use similar process as eliciting initiations ○ Then up the ante ○ Interpret communication attempt - then wait for higher form ○ Use a preparatory set Considerations for eliciting 2-word utterances ○ Create situations where shorter utterances are insufficient ○ Give more options Developing receptive language Consider comprehension strategies ○ If @ 8 -12 mo stage: ○ If @ 12 -18 mo stage: ○ If @ 18 - 24 mo stage: ○ If @ 24 - 36 mo stage: Increasing lexicon Choose developmentally appropriate words Choose words that help serve a range of communicative functions Choose words that extend range of semantic notions Choose words that match child’s phonological inventory (sounds & syllables) Preliteracy exposure/enjoyment Beginnings of print awareness (how to turn pages, pictures vs. print) Great for parents: how to choose books, focus on interaction NOT reading ○ Not teaching how to read but enjoying the book Treatment: developing language Consider common problems Phonology Semantics Syntax Pragmatics Comprehension Play Therapy NOT teaching What thought processes are required to complete that language skill ○ Create little language users For child to effectively communicate ○ Ex: answering wh questions How do you know what to answer? Breaking up the answer/what is it looking for ○ Who Person ○ What Object ○ Where Place ○ When Time How to communicate your ideas Create: ○ Opportunity to learn the “rule” or “language skill” ○ Opportunity to use the new skill ○ Strategies to enable client to think on their own Phonology Speech & language disorders often co-occur ○ Don't wait for intelligibility You can work on both simultaneously Each individual opportunity is separate Don’t require child to say it right & use it right Metaphonology (aka phonological awareness) Semantics May need to hear new word twice as many times as typically developing peers (at least) Rich vocabulary instruction ○ Choose appropriate words Mental words Think, wonder, decide,... Transitive verbs Direct object Intransitive Don't require direct object Semantic features of words  Synonyms, categories ○ Explicit instruction Directly explaining ○ Child-friendly definition ○ Many examples ○ Use it! Give them a situation where they have to use it Consider continuum of naturalness Increasing quantity/richness: ○ Choose books with targeted vocabulary Character is doing the word Works w/ verbs & mental terms ○ Ex: she is running/she is deciding ○ Be explicit about finding “new word” ○ Define it (visually, child friendly words) ○ Act it out/put it to use ○ Create word book/word video Unclear referents ○ Barrier tasks There is a barrier btn you & client You have to guess what it is “Put that”/”it’s this” ○ Need more clarification Syntax & morphology Comprehension vs production (receptive vs expressive) ○ Priority: targets understood but not used Already in their receptive inventory ○ Not critical that they understand first If it's their target word, you can start to work on it Missing morphemes? Reduced MLU/simple syntax? ○ What kinds of words are missing? ○ Create situations where those words are needed Make it natural Listening comprehension Following directions ○ Vary in length & complexity Start small to ensure they understand basic words ○ Number of critical components ○ Ensure knowledge of the actual words  Do they understand what you’re asking for Play 2 ways of addressing play ○ As a goal = continuing to improve symbolic play ○ As a context for language goals, such as new vocabulary, negotiating, protesting, turn taking Semantics & pragmatics Pragmatics 2 ways of addressing pragmatics 1. As specific goals: a. Turn taking b. Topic maintenance c. Communication repair d. Full range of communicative functions 2. As the context of therapy a. Use pragmatics context (turn taking game or conversation) as activity to use other syntactic or semantic language form i. To target other language components b. Most effective for generalization i. Reflective of their natural setting Activities that lend themselves to TX Thematic units (high interest, breadth & depth of vocab) Barrier tasks ○ Prepositions ○ Use of clear referents ○ WH question/answer Arts and crafts Cooking Books & stories Physical games Activities vs strategies Almost ANYTHING can be used as an activity or therapy context. The trick is what you do w/ that activity to make it therapeutic ○ Activity vs. goal - how is activity manipulated for them? Examples:  ○ Reading “napping house” to work on use of -ing. The activity = book reading; the goal = use of -ing ○ HOW you use Napping House will depend on the continuum of naturalness Some activities may lend themselves to certain goals/targets ○ Can choose 1 activity for all & modify per Pt. Modify the activity After you have selected your activity, you need to modify it to meet your child’s goals Planning therapy Be intentional w/ everything you do More than just determining activity Plan each second: ○ How will room be arranged at the beginning of therapy ○ What will you say/do to get started? ○ What do you hope the child will say/do? ○ What does child need to know what to say/do? ○ Do you expect they will be successful on the first attempt? If not, how will you scaffold that? Goal: reshape their thinking -> get them to be effective communicators Language & the connection to literacy How does literacy fit in? Literacy is not separate from language. It is a modality ○ Reading = form of receptive language Decoding - looking at print & comprehending someone else's work ○ Writing = form of expressive language ○ BUT - must be explicitly taught ○ Prevalent form of language in academic settings  Stages of literacy development Early elementary Later elementary - High school - college middle school Emergent literacy Early literacy Conventional literacy Construction & reconstruction PreK 5 - 7 yo 7 - 8 yo 9 - 14 yo 15 - young adult Prereading Stage 1 Stage 2 Stage 3 Stages 4 & 5 Learning about Letter-Sound Increasing “Reading to learn” Navigate increasingly print & sound corresponde fluency; reading to gain new complex texts; can nce; decoding knowledge consider multiple decoding more viewpoints; selective automatic reading for purpose Print awareness (aka print knowledge) Print interest ○ Orientation of book ○ Turning pages left to right Recognizing print functions ○ Pictures vs print ○ Convey meaning  ○ Written Words = spoken or signed words Code based skills Prints as opposed to pictures Print awareness Understanding writing & print conventions How we use print ○ Exclamation marks, quotation marks, question marks ○ Thought bubbles vs speech bubbles ○ Use of print size to denote emotion, loudness Understand print part-to-whole relationships ○ Letters vs words vs sentences ○ Long vs short words C-A-T vs. E-L-E-P-H-A-N-T ○ Visually what it is but not decoding Role of the SLP Literacy = written modality Children w/ DLD at increased risk for deficits in literacy (decoding & reading comprehension) It is not our job to TEACH reading & writing. Our job is to support the use of literacy for communication in the schools. No right way to do this ○ Be part of a team to support child! ○ Be a part of the conversation! Process: treatment approaches Contexts Promote carry over ○ Are therapy strategies present outside of therapy room Least natural: Hybrid Most natural: clinician-directed (CD) Child-centered (CC) You come up with a In the middle Play based plan Mix between both ○ Using toys/games The expectations are Take benefit of booths that child is focused on what Take naturalized interested in clinician plan is activities Prior: set up the room “Here’s a prompt you Choose a game or toy to be intentional need to respond” but clinician leads it communication Drilling practices ○ Expectations are temptation No room for child to set During session: follow do what they want Preparatory sets the child's lead Benefits: Flexible Able to connect  ○ lots of repetition ○ You have a target therapeutic strategies ○ Very targeted but there is to their interests ○ Structured flexibility in how Benefit: joint attention Good for introducing child responds Challenge: requires new terms ○ There is still room high ○ Ex: past tense for the child to flexibility/modification Pretend play: choose but not fully Positive: naturalistic ○ Ex: here is a child led activities banana pretend to Pretend play: eat it ○ Ex: child goes to pretend kitchen themselves and “eats” an apple Active ingredient: treatment intensity Pt. needs a little bit at a time and not large doses of therapy ○ Prevent burnt out ○ Evidence: high dose has negative effect on language ○ Brain doesn’t have capacity to store a big amount of information at a time