Monthly Archives: October 2013

10.29.13 — Supervisory Notes: Providing written feedback

Notes on clinical supervision, ,

I know many, many SLPs who are ‘blank sheet of paper’ data collectors — they can walk in a session with just a notebook, and write down notes or tallies as they go.  I am not that sort of SLP.  Whether it’s just my strong preference for structure, or my fears of forgetting something important, I have always liked setting up data collection sheets which provide both some space for specific targets (outlined according to the goals), and some space for writing down subjective impressions or notes for consideration.  When I started working as an instructor for clinical practicum experiences (aka, “supervisor”), I found it was no different:  I greatly benefit from having key points or skills designated.

McCrea & Brasseur, discuss Observing in the Supervisory Process in Chapter 6 of The Supervisory Process in Speech-Language Pathology and Audiology (2003), and specifically lend insight into different methods of data collection (p. 166 – 171).   My own “take-away” thoughts from their discussion included, “The understanding and appropriate use of systematic observation and data collection methods by supervisors is important for establishing supervision as a thoughtful, scientific, and validated process.  Supervisors need to be skilled observers, but more than that, they must also develop efficient, practical procedures for recording their observations for later use.” (p. 166).

This also meant that I had set up the opportunity to model:

— the value of data collection — I’m not a fan of “do as I say, not as I do.”  If I tell the students that it is critically important for them to take notes and keep track of learning trends, I think it is just as important that I am also doing so as a means of informing my own teaching,

— at least one example of how data collection can be structured.  We talk about how this is a very personalized endeavor and what works for one person may not work for another; that whatever the method of data collection/coding/tallies is, it should have low cognitive demands (if I have to think to much about my system of note-taking, it means I am distracted from my teaching and at risk for inaccuracy).

— a shared sense of expectations.  When we review my note-taking tools, I talk about what I will be looking for in their conduct, and the rationale.  We discuss how some learners may be curious about the notes they take, and that it can be an opportunity to engage them in self-monitoring.  Others may be distracted by the side activity or wonder about how they are performing, and so these are important considerations to take into account.  If, for whatever reason, it was not appropriate to directly share my  data, I always used to say, “I take notes to help me remember everything I’m learning about you.”

The SOAP format always basically made sense to me, and I designed the sheet that I use to include that structure  as well as the key points required in the grading rubric we use for either intervention or assessment.  I print two copies of the form and use carbon paper — the graduate student clinician gets the top copy (immediately following the session), and I keep the carbon version.   I do have a rating scale at the bottom and I need to track down where specifically I found these categories — they are not mine, but I am using them for now as a means of gauging my presence in the clinical process, how much influence or instruction was imparted for those areas.  I’m not convinced this is meaningful for me, but I’m giving it a try for a bit longer.

Although their particular tool didn’t quite work for me (see also, “data collection is very personal…”), I hope that it reflects the findings discussed in Wilson, D. & Emm, M. (April 2013).  Opportunity for Effective Feedback:  A Supervision Tool.  Perspectives on Administration and Supervision:  28-34.

Specifically, in brief:

(1) “Tracy, Van Dusen, and Robinson (1987) state that effective feedback needs to provide the recipient with knowledge and rationales for improvement.” (p. 28)
(2) balance with positive reinforcement and corrective feedback; “Supervisors are encouraged to be respectful, goal-based, non-judgmental, specific, and focused on behaviors, and to give the right amount of feedback and suggestions for improvement.” (p. 28)
(3) Be mindful of types of feedback:  vague-positive, specific-positive, vague-corrective, specific-corrective.  This is also consistent with McCrea & Brasseur, who cautioned about overuse of “…evaluative statements reflecting their perceptions of the appropriateness of the behaviors in the treatment or assessment session as they view it; for example, “Your directions were too difficult for the client” (p. 167).  They caution that although these kinds of statements may be needed at times, they should be associated with immediate plans for learning more effective strategies and self-evaluation.  That “it is these active, direct behaviors of the supervisor that do not encourage, in fact probably discourage, self-analysis and creative thinking on the part of supervises.” (p. 168).

(4) Finally, for Wilson, D. & Emm, M. (April 2013):  “The observation record was a single sheet form containing identifying information, a list of possible focus areas, and narrative space for both positive and corrective feedback comments.” (p. 29)

Over time, I have modified the forms I use based on feedback from the students, my experience with using it, and trying to apply principles of andragogy (how adults learn), as described in  Gordon-Pershey, M. & Walden, P. (April 2013).  Supervisor and Supervisee Perceptions of an Adult Learning Model of Graduate Student Supervision.  Perspectives on Administration and Supervision:  12-27.  Specifically, that my feedback is hopefully consistent with:  “The hallmarks of reflective practice are conscious thought about clinical situations, critical evaluation of possible solutions in clinical situations, and self-reflective assessment of the outcomes of one’s clinical actions (Jarvis, 1987; Schon, 1990; Walden, 2011).” (p. 13)

These are all under Resources (“m4ter14ls”), and should be findable with the search term “SOAP” but the one for intervention is not coming up for me unless I use the search term “observing”.  I don’t know why that is.  There is a series of supervision SOAP notes for assessments which follow the different phases of the model we use for AAC assessments at PSU.

End blip.

10.17.13 — Supervisory Notes, Talking about 2nd phase of assessment w/examples

Notes on clinical supervision, , ,

In the clinical practicum instruction I provide for assessments of individuals with complex communication disorders, we apply a multiple-phase process: (1) information gathering through record review, interview, surveys/checklists, and observation with familiar partners in familiar surroundings (by video if distance prohibits on-site visits), (2) direct observation at the campus clinic via structured “naturalistic” opportunities to review current communication (receptive, expressive, and pragmatic language; means of communication; purposes of communication; sensory and/or motor, seating and positioning considerations; literacy; partner-interactions, etc.), (3) direct observation at the campus clinic via structured “naturalistic” opportunities for what strategies and supports may effect meaningful change in the individual’s communication opportunities and effectiveness, and according to what features (e.g., size, symbol representation, organization, etc.);  and (4) a review of findings.  There is considerable overlap among the phases and it requires multiple sessions to complete.   I find that students have a sense of the principles involved and frequently have practiced these ideologies through case study example projects for courses.  But having a real person to think about and face, a team to work within, a family or school to report to, and, most importantly, the genuine hope to truly help an individual, all add a profound stress on how to think all of this through.  After talking with students, the following is an email I send to review the principles we discussed.  This example is for a preteen young woman with complex sensory and motor needs in addition to no verbal communication and mixed reports about minimal language (e.g., both making choices to convey wants and answering yes/no questions are in question).

“We’ve talked about how the assessment plan for our first session here on campus needs to reflect what unanswered questions you feel you need to directly observe, and what strategies/supports you would like to consider for review (no tech, low tech, high tech).  Much like plans for intervention, this should include your objective (what you want to learn), rationale (why/how what you learn will inform next steps), the activity or structured event, whatever materials are needed to complete activity, means of communication, and data collection.  Different from intervention at the clinic, I also need to know who is doing what.

When we met at the very beginning, we said that we needed to start from what we know now and hypotheses based on our observations and what the literature/research base would inform as relevant for her age/experience.  We want to consider our objectives for how we are going to learn what we need to know, and then develop activities that will allow us opportunities to gather information.  When we talked earlier, I wanted to expand on that piece with some examples but I know it can be difficult to remember everything.  My apologies for the long email but I hope this can be a reference of my thought process and how it leads to specific questions/objectives.

For example:
Rationale:  Based on interview and parent completion of surveys/checklists, determine CLIENT’s receptive and expressive vocabulary.  Observations and parental report indicate that CLIENT has an extremely limited vocabulary.  No tech:  Siegel and Cress’ (2002) Communication Signal Inventory from Exemplary Practices for Beginning Communicators (p. 36-38) to determine what behaviors/patterns/signals familiar partners successfully cue into.  Multimodal (no tech, low tech, high tech): The PSU research on early intervention with beginning communicators (with young children) and early research with older individuals who are at beginning levels of communication suggest in-context support of vocabulary and benefits of social sequences (aka, joint action routines).  The UW AugComm Continuum of Communication Independence discusses a need for a clear and reliable signal for acceptance and rejection as foundational for building yes/no.

Accordingly, assessment questions/objectives may include (but are not limited to):
(1).  Provide structured opportunities for observation of CLIENT’s receptive vocabulary, expressive behaviors/signals/signs.
(2).  Provide structured opportunities for observation and assessment of supports/interventions to expand her vocabulary with symbolic means.
(a).  Given instruction and coaching on partner assisted scanning consistent with Linda Burkhardt’s research; please particularly note information re: Rett Syndrome since that has been suggested as the closest comparable profile):  what is parental reaction; based on observations, what is sense of vision/motor obstacles; observable behaviors of reaction from CLIENT?; observable indicators of potential?; if yes, journals/data collection to be sent home for specific targets?
(b).  Given instruction and coaching on principles of intervention outlined by Light & Drager research, adapted for older individuals who are beginning communicators:  what is parental reaction; observable behaviors of reaction from CLIENT?; observable indicators of potential?; if yes, journals/data collection to be sent home for specific targets?  Will require provision of some materials (e.g., printed symbols/photographs; recommendations for apps).

At present, CLIENT has extremely limited means of communication and it is not clear what types of references will be most beneficial/effective for her.
(3).  Provide structured opportunities for observation and assessment of symbolic representation:  signs/gestures, actual objects, photographs of discrete items, photographs of scenes/contexts; picture symbols; text; photographs, picture symbols, or text which have been modified for high contrast, etc.  What would we need to know about vocabulary/concepts that she currently understands in order to be able to set this up; or, in the absence of that information, what kinds of teaching/structure would we need to put in place for a valid assessment?  What are observable behaviors of reaction from CLIENT?  Are there distinctions in engagement (interacting at all, without specifying whether or not was ‘correct’), versus accuracy (seeking a specific answer)?  What are observable behaviors to indicate processing for # of options presented:  one at a time w/partner assisted scanning?  choice of 2?  more?  Presentation in vertical versus horizontal?  Size of symbol?

(4).  Provide structured opportunities for observation and assessment of organization (e.g., categorical, event, PODD):  given a review of options, what is parental reaction?  What are observable indicators of ease of use for partner to augment input and make means of expression available?  Accuracy?  What can we provide for home trial — for example, a simple book of references based around her reported key partners, interests, activities (categorical); a book based around concepts organized for her daily routine (event based); a book based around conversational sequences common for her life events and/or teens (PODD).

Those are just examples, but please refer to the materials I have provided for what Beukelman & Mirenda considers the key areas for assessment, the information and references compiled by the National Joint Committee for the Communication Needs of Persons with Severe Disabilities; and the published materials such as the Communication Matrix;  Functional Communication Profile, Revised; TECEL; Social Networks; and AAC Profile (among others) as means of structuring or focusing our efforts.  Again, always start with your objective (what do you wish to learn), and we can build activities around that.”

It’s a long process and has been argued that may not well match what can be accomplished outside of a University clinic environment.  I hear that argument, and know that there is valid concern on whether my approach authentically prepares clinicians for different environments.  That said, I feel that it is my mandate to align my practices as closely as possible with what is taught in the courses as best practice — that to do otherwise perpetuates poor practices elsewhere.  So I strive to be an example, sounding board, model, coach, etc. towards that goal and hope that students will adapt and advocate over time to the circumstances they face to raise the expectations and practices elsewhere.

End blip.

10.13.13 — Talking about using sign language/gestures in intervention with beginning communicators

Notes on clinical supervision, , , , ,

In working with the family of a young child who has complex needs which include, at present, motor limitations, I had the opportunity to really reflect on my thoughts around using sign language and/or gestures.  These particular excerpts were taken from email communications I was having with the parent.  I believe these principles are also valid for older individuals who are at beginning levels of communication as well though.

“I would say that as a general principle of early intervention, I am strongly in favor of multi-modal communication — that is, using a variety of methods to communicate.  Relative to sign language vocabulary, I want to clarify that at this point I primarily meant incorporating key word references — not signing every single word that is spoken, and not using the grammar structure of American Sign Language (ASL) which is different than English.  The videos on the “Success Stories” section of the AAC Kids PSU website (http://aackids.psu.edu/index.php/page/show/id/2), do a nice job of illustrating what the research at Penn State has focused on with respect to multi-modal communication.  Particularly with the stories for “Genevieve” and “Lili”, you can see Dr. Janice Light (my boss), using speech, some specific sign language vocabulary references, as well as sophisticated voice output technologies with very young kids who have complex needs.

I believe that the benefits of incorporating sign language vocabulary when talking with young children with complex needs include:
+ supports his/her understanding of what is being said to them,
+ supports hearing by adding a visual component,
+ supports learning cause and effect of symbolic expression; that is, the child learns to associate a behavior as a reference to an item or activity and this behavior becomes part of vocabulary he or she understands even if they are not yet using it.
+ at a neurological level, builds networks about language in a different way; that is, s/he may well understand a word that is just spoken, but also learning that word through a gesture can only help the developing mind build more and more connections.
+ presents the opportunity for young children with complex needs to develop a method of expression through imitating what s/he sees, even if just an approximation,
+ as a result of increased opportunities for expanding on a child’s expression (that is, how he or she responds and the complexity of response), it builds his or her sense of interactions with others,
+ if the child develops signs or gestures in their options for communicating, seeing others also sign builds new vocabulary, and shared experience.
+ signs go with the individual every where they go, it is a complete and ‘unaided’ system of communication that works even in a bathtub or swimming pool, without batteries or charging, does not need to be turned on or require maintenance, does not need to be held or presented or carried by someone else, etc.

There are no negatives, and no risks.
-> It will not harm the child.
-> Research has been clear that incorporating signs (&/or other forms of support like pictures or technologies) in addition to spoken vocabulary will not in any way compromise a child’s ability or interest in speaking, or using other means.

When children develop effective speech, they naturally drop off using signs.  If the child’s speech does not meet their full needs, the sign ~can~ be used to support their efforts (for example, to clarify), particularly in situations when using a technology may not be as fast or may not work well (such as at the beach).  If a child was going to primarily rely on sign language to communicate, there is an incredible body of research, communities, and resources to support on-going learning — however, in my personal experience, this piece has never happened for a child who was not Deaf.

All of this is not at all to suggest that I think I know what is best for your child and your family!  I hear you re: the motor demands and complexity of some signs — I agree completely that coordinating the physical movements and timing are things that should be considered.  I also know for sure that nobody knows your child and family the way you do!  I just wanted to share some of my own thought process around this question because there is no one-approach-fits-all-situations solution.  So we are always invested in a range of strategies to include “no-tech” (does not require any other ‘thing’), “low tech” (supports which are not technology based), and “high tech” (technology based supports).

For this reason, I’d like to share some additional resources you *may* consider helpful.  I truly respect how full life is, so I do not mean to keep adding to the “To Do” list.  If you are not able to get to these kinds of things, I completely understand.

One of my favorite tools is from Siegel & Cress (2002) — The Communication Signal Inventory.  They go into more detail in their book chapter, Overview of the emergence of early AAC behaviors: Progression from communicative to symbolic skills.  (Siegel, E., & Cress, C. J. (2002) In J. Reichle, D. R. Beukelman, & J. C. Light (Eds.), Exemplary Practices for Beginning Communicators: Im- plications for AAC, (pp. 25–57). Baltimore, MD: Brookes. ).  The Communication Signal Inventory is a simple and powerful table for observing and documenting any behavior that an individual does which can be interpreted by partners as an indication of the person’s state of being, convey interest, express specific wants/needs, show rejection of an unwanted item/activity, etc.  There are three columns:  what was observed, what partners think it means, and how partners should respond.

For example:

Behavior:  “Davey’s” muscle tone relaxes, he may slump to one side slightly, his eye gaze may shift down.
We think it means:  “Davey” is tired and may need a break.
Partners should say:  “I see you, “Davey”.  Your body is soft.  Do you want 1 more ball (sign “ball” and pause), or all done  for a break?  (sign “all done” and pause.)  Watch his body and eye gaze — if he shifts and looks toward the ball, say:  “I see you.  You’re telling me 1 more ball (sign “ball”).”  If his muscle tone remains soft and eyes down, say, “I see you.  You’re telling me we’re all done (sign “all done”) for a break.”

Research has found that families often use their knowledge of the person and his schedule/routines, their strong sense of mood/well-being/interests, and remarkably sensitive observation of changes in behavior to meet the needs and engage in social interactions with young children who have complex needs.  The Communication Signal Inventory can be an opportunity to share that knowledge among all partners, to build cause and effect and add more symbolic expression, and to identify needed vocabulary.  I feel like it can work well with the Communication Matrix in documenting the signals and methods familiar partners pick up on, and the reasons the individual communicates/interacts (for example, to make requests, to be social, to get attention, to refuse, etc.).

I would also like to talk with you in more detail about the research of Stephen Calculator (2002), who looked at what he called “Enhanced Natural Gestures.”  He worked with parents of kids with significant disabilities to identify and build on gestures which were not formal signs — often they were shaping existing behaviors to be more consistent and more associated symbolically with an object or event.  An example might hypothetically be if there was a particular side of the high chair a child liked to drop things off of, to really reinforce and praise a small wave at that spot to mean, essentially, “I want something to drop!”  Just like when speaking children are first learning to talk and may say a set of sounds that are only meaningful to a small group of knowledgeable people, it matters less if a sign or gesture is precise than if it is consistently reinforced as symbolic.  Methods like this and using gestures which pantomime what a child does within a familiar routine/activity, or approximations of signs (however closely they get), can be documented on the Signal Inventory so that all partners are able to recognize the attempt and honor the communicative intention.

In any case:  thank you for all you are doing to support our assessment process in addition to all you are doing for your family!”

End blip.

10.13.13 — Talking about speech relative to AAC/Multimodal communication

Notes on clinical supervision, , , , ,

A recent online discussion on the ASHA Special Interest Group for AAC (SIG 12), got me thinking about the various resources that have fed into my collective sense of how to relate to the question:  “Will speech be [negatively] impacted by AAC?”  The following is my attempt to have some sense of organization to the range of materials which contribute to my own thought process when having this conversation with families or school teams.  For the sake of ease/time/effort (always in limited supply), much of this is cut and pasted from other places — which sometimes results in odd formatting and abrupt font mixes.  My apologies for that.

(1) Dr. Light and Dr. Drager at Penn State did extensive research on Early Intervention with kids as young as six months old who had developmental disabilities such as autism, cerebral palsy, Down Syndrome and others.  Their work is profiled at their Early Intervention website with comprehensive discussions and video clips of the principles of intervention which fully incorporated the range of no tech (e.g., intonation, vocalizations, speech, gestures, sign language), low tech (e.g., print materials such as photos, picture symbols, communication boards and books), and high tech computer technologies.  The FAQ page on the site goes into some discussion about the question of benefits of AAC and implications on talking, and specifically references an intensive review of the literature  which found no evidence of negative impact:

–> Millar, D., Light, J., & Schlosser, R. (2006). The impact of augmentative and alternative communication intervention on the speech production of individuals with developmental disabilities: A research review. Journal of Speech Language Hearing Research, 49, 248-264.

I have sometimes found that using these video clips or those from the Literacy Intervention website  can help illustrate that speech is always modeled, supported, and reinforced.  Using case studies like these can sometimes add an objectivity or emotional distance from the conversation:  I can talk about my thought process around the individual(s) profiled and how decision-making and/or priorities might be considered without it being quite as personal.  In particular, the Success Story of Sandra on the Literacy website illustrates beautifully (and heartbreakingly) what access to multimodal instruction in literacy has meant to her as she speaks in her own words about being underestimated much of her life to that point.  Her profile further explains that she uses speech, gestures and a communication book to communicate as well as a computer with speech output.

(2)  The next two are from books or journals written for SLPs, so they may be pretty dense reading to someone less familiar with the jargon.

– Hustad, Morehouse, and Gutmann (2002).  “AAC Strategies for Enhancing the Usefulness of Natural Speech in Children with Severe Intelligibility Challenges.”  From _Exemplary Practices for Beginning Communicators:  Implications for AAC_.   This book chapter is dedicated to discussion of what kinds of multimodal or AAC supports may be put into place for individuals with compromised speech either some (in which case, clarification strategies may be predominantly appropriate), or all of the time.
— King, Hengst, and DeThorne (2013).  “Severe Speech Sound Disorders: An Integrated Multimodal Intervention”  Lang Speech Hear Serv Sch 2013;44;195-210:  This presents research which had evidence that incorporating multimodal communication (options in addition to or in support of talking), IMPROVED speech as well as demonstrated gains with communication overall.
A slightly more parent-friendly “print” reference includes:
— Closing the Gap put together a report on Evidence-based AAC interventions for individuals with autism spectrum disorders in April 2013.  In particular, it includes a  sample AAC Implementation Plan — it is a table that reviews the kinds of opportunities that may be available across the school day, and the variety of additional supports that may be put into place/made available to support effective communication opportunities.  It really resonated for me across a wide variety of individuals because I think often one of the challenges school teams have is identifying situations and what kinds of supports will be meaningful and can be reasonably adapted.  The SETT model is a framework for reviewing opportunities like this; it stands for:  Student, Environment, Task, Tool, and represents the kinds of questions we should ask when trying to identify what the learner’s skills/needs are, what are the demands/obstacles (and, therefore, adaptations) in the Environment, what does the learner need to be modeled/taught/practice in order to do, and what are the strategies and supports which will help him/her learn and achieve.  I really like the Closing the Gap sample review because it shows that there are a wide variety of methods/tools (including speech or speech approximations) that may be appropriate for a particular situation.   Closing the Gap does have a Facebook presence, and promoted the report last April (I don’t know if this will work, but here’s the link to that — https://www.facebook.com/permalink.php?story_fbid=530197533685800&id=137354302970127)
The report is available here, from their archives of last April: http://www.closingthegap.com/solutions/articles/2013-04-01
They have a 2-day free trial, but overall they have a lot of great information.
(3) Taking a slightly different perspective perhaps directed more around Strategic Competence (Light, 1989):  reviewing that we all have different strategies for the people and situation, and that we need to consider Family Quality of Life (Saito & Turnbull, 2007; Granland, BjÖrck-ÅKesson, Wilder, & Ylvén, 2008), within our process of recommendations (if the intervention has too great demand on the stress, resources, etc. of the family, outcomes suggest it is not likely to be sustainable).  The UW AugCom web review of the Continuum of Communication Independence may lend insight into the value of effective expressive symbolic communication across environments — so at home, with familiar partners, a person may be entirely independent and effective with speech only even when there are challenges to intelligibility; and using minimally demanding strategies may be the best decision for the family health as a whole.  However, as service providers and educators our goal is also to work towards competence and strategies broadly with everyone everywhere (especially relative to full access to education and social relationships with peers in the schools).  Again, this has to be framed within a context of what is achievable.   I also LOVE LOVE LOVE the additional modules they have at the left margin.
(4) There is also an increasingly robust body of research in favor of augmented input or Aided Language Modeling (ALM).  Examples also include (but certainly are not limited to):
– Drager, Postal, Carrolus, Castellano, Gagliano,  & Glynn (2006).  The effect of Aided Language Modeling on Symbol Comprehension and Production in 2 Preschoolers with Autism.  American Journal of Speech-Language Pathology Vol.15 112-125 May 2006. doi:10.1044/1058-0360(2006/012)
– Dada & Alant (2009).  The Effect of Aided Language Stimulation on Vocabulary Acquisition in Children with Little or No Functional Speech.  American Journal of Speech-Language Pathology Vol.18 50-64 February 2009. doi:10.1044/1058-0360(2008/07-0018)
But truly there is a lot that can be found in this area — some specific to particular methodologies, such as with the work by Porter & Cafiero relative to PODD.  The website/Facebook/Pinterest presence at PrAACticalAAC also has numerous articles and references.

(5) Last, but absolutely not least, there may be a huge, huge value in first-person accounts from other parents.

Rob Rummel-Hudson, dad to Schuyler, writes the blog “Fighting Monsters with Rubber Swords”, as well as articles for Support for Special Needs and he has a presence on Facebook.  Rob is unflinchingly honest about his emotions around Schuyler’s challenges, the value of AAC in her life, and how both he and Schuyler continue to fervently wish for a day when she will be able to “speak like her friends” even as they recently made the decision in her IEP to discontinue that as a target in favor of focusing on her fluency with multimodal communication.  Rob is deeply eloquent in his discussions of family life, interacting with schools, and I rarely leave his writings without feeling deeply moved.

In April of 2013, Dana Nieder published “An Open Letter to the Parent of a Child with Speech Delays” on her family blog, “Uncommon Sense” about their family’s experience loving and supporting her daughter, Maya, and coming to terms with decisions around AAC.  She is honest about the process — the importance of feature matching, the impact on family life — and provides resources parent-to-parent for others to reflect on what may be best in their own lives.

I imagine there are first-person accounts from the other side of parents/families out there who made the decision to focus entirely on speech, successfully…but I do not know of those.  My ~guess~ is that these may be associated with specific interventions (and substantial investments financially, and in practice/focus both in and out of therapy).  I don’t want to fall prey to a Bias of Fairness and assume that there always is an equally relevant, balanced other side to the argument — I think sometimes that the effort in seeking one out is a distraction from what could be authentic and functional change and/or feeds false hopes .   But neither do I mean to be closed minded and beyond surprise — so I certainly acknowledge that there may be profiles/characteristics/indicators which could be of value to families and SLPs trying to make this judgment call of how to best allocate limited time, energy, and resources.

For now, for me:  speech is always anchored solidly within a deep belief around Multimodal.  From there, it is a process of the evidence, the family values, response to intervention, functional outcomes, and prognosis.

End blip.