Category Archives: Notes on clinical supervision

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.

09.22.13 — Talking about cognitive rehabilitation with problem solving strategies

Notes on clinical supervision,

The following was my attempt to organize thoughts/strategies/approaches about cognitive rehabilitation strategies for working with an adolescent.
“Just in quick follow-up to our conversation earlier today, I wanted to send some examples of problem-solving strategies for your consideration. As we discussed, using a strategy-based approach has advantages for the learner, and can potentially support how we define the goals in structured/measurable ways.

I do place a high personal value on applying/modeling these kinds of strategies regardless of whether or not they are targeted/explicitly taught goals, particularly for any (a) young child, (b) individual with language difficulties, and (c) individual with social-pragmatic issues. To these groups, the problem-solving that the rest of do may well appear magical (or that we don’t have problems). Because often adults just manage difficulties discretely or out of sight, or because these populations already have difficulty interpreting language or social cues involved, the actual steps that are happening to cope with a problem are not identified and learned unless explicitly taught. So I did a lot of think-alouds for both actual and manufactured problems. Even for simple stuff — “Oh man! My pen ran out of ink. I wanted to use this pen. That’s frustrating. Okay, I’m flexible. What else do I have? I can use a pencil instead.”

Anyway, the following are some published ideas. I think you will notice similarities among different approaches overall, even with the different acronyms.

A problem-solving approach Dr. Janice Light and Dr. David McNaughton used with the AAC Mentor Project was summarized by the acronym, “Do It!”

Describe the specific problem or goal and explain why this is a problem or a goal
Outline lots of different ways to solve the problem or meet the goal
Identify the consequences of each plan and choose the best plan
Take action
! Celebrate success when the problem is solved or the goal achieved

Phelps-Teraski & Phelps-Gunn (2007) developed their FOCUS strategy based on Norris & Hoffman’s language model (situation-discourse-semantics, or SDS); this was primarily around helping individuals negotiate pragmatics (social dynamics), but certainly could be shaped more broadly around problem solving/emotional regulation:
F: Figure out what you want to say
O: Observe the partner and situation
C: Communicate message
U: Use your eyes, ears and brain to decide if message got expressed appropriately
S: Self-correct, if needed.

If you search using FOCUS under the Resources (password: “m4ter14ls”), the one with “Literacy Modifications” is based off of an actual activity I used years ago (which is why the icons are owls — that was the mascot of the school I worked at then), modified to sort of work as a shared reading piece: some decodable and sight words have been highlighted, although Client may be able to read substantially more than just those. I tried to use both sides of the conversation — one could be used as an example/model, the other for more of a guided practice.

The SPACE Storytelling Outline is from Social Problem Solving: Making Best Plans by K. Noel, 2013, The Chippewa Falls, WI: The Cognitive Press. (c) 2013. In this case, it is structured around story comprehension, but could also be used for problem solving/coping/communication in other ways.
S: Setting = Who is involved? When does it happen? Where does it happen? What’s going on?
P: Problem = What is the problem? How do the characters feel? What do the characters need or want?
A: Action = What did the character do?
C: Consequence = What was the result of the character’s action?
E: End / Evaluation = How did the story end? What was the lesson learned? How do you feel in response to the story?

Also under the Resources is a set of bookmarks (slightly blurry) using this acronymn — search under SPACE bookmark for comprehension.

Singer (2013) summarized a problem-solving approach with EMPOWER:
Evaluate
make a
Plan
Organize
Work
Evaluate
Re-work

This one feels the most contrived to me since the “M” is “Make a” and does not stand on its own.

Finally, Larson (2013) recommends the following for adolescents who may respond to problems/frustration with an emotional reaction (such as anger or abandonment/giving up), or be impulsive and guess; summarized by Stop-Plot-Go-So:

Stop: I can stay calm by [insert personal strategy].

Plot: My problem is: [identify and label], My options are: [identify and list], Consequences of each are: [identify and evaluate], My choice is: [select one]; social-emotional skills I need are: [identify and label; e.g., to be calm and think things through, to find help, to draw, etc.]

Go: What can I say or do so I actually use my plan?

So: How did my plan work?

Certainly there are others and these all take a broad view of problem solving; that is, the idea that knowing a generic strategy can support/structure across a wide range of concerns. There may be reasonable arguments in favor of a more narrow view: spending time assessing with observations, interview, review of work portfolios, etc. for trends which identify specific concerns. These might include (but are not limited to): (1) paying attention, (2) remembering what he is supposed to do specifically, (3) applying what he is supposed to do with purpose (e.g., not guessing), (4) comprehending the sequence of a situation (social or academic), (5) making plans to set goals or solve problems, (6) making appropriate choices, & (7) self-monitoring/awareness.  There may be much more effective interventions directed towards the unique demands of these needs/concerns.”

End blip.

09.21.13 — Talking about positive reinforcement, instructive feedback, and creative ways to praise

Notes on clinical supervision, , ,

I think most of the students I have worked with for clinical practicum are on board with the value of positive reinforcement (and appreciate receiving it themselves), but I have some particular opinions on what I consider to be truly helpful in promoting skill learning and productive behavior. For one, I’m not a huge fan of generic and/or constant praise — to me, it seems insincere and weird to say things like, “Nice looking” or “Good talking.” There are certainly situations where a clinician needs to focus on whatever positives are available to help promote a better rapport/atmosphere at that time, but I start to get worried if I hear a regular stream of this kind of praise without actually examining if it is in fact (a) true, (b) actually a distraction from learning or adjusting the teaching/situation to get more authentic intervention, or even (c) helpful. Sometimes it feels a lot to me like chatter…just more noise the learner has to navigate through to figure out why they are there. If this is really the best/only praise a clinician can offer, it is time to seriously look at whether or not the goals are appropriate, the teaching has been presented to be well matched to the student need, and the environment has been structured to promote focus and success, etc.

The following is a set of information I organized to emphasize my own belief in the value of instructive feedback — anchoring the praise with the skill and/or why the skill is relevant. With instructive feedback, positive reinforcement can include re-stating the rationale (“You are working hard to learn to read!”), and/or the strategy (“Wow! You looked at each letter and thought of the sound it makes.”). That’s not to say these features would need to be present every trial, but they do keep the presence of why they are working with you, and what they do which promotes their success. This distinguishes what we as SLPs do as unique from praise they may receive elsewhere (it orients the individual to his/her communication or literacy), raises metacognitive awareness to promote self-monitoring, and provides the structure for corrective feedback in a non-threatening way. That is, if the client gets something wrong, the feedback is provided in the same way: “Remember, look at each letter and think about the sound it makes.” is, in my opinion, infinitely more helpful and less threatening than, “No. Try again.”

I would also say that it’s helpful, whenever possible, to keep it sincere and fun.

This is an example of a simple way to have a small gesture of phonological awareness is to match a praise comment with the initial phoneme associated in the task. For example, if a student found the letter /i/ in a letter-sound-correspondence (LSC) activity on the keyboard, to say, “Incredible!” The following try to keep with that principle, but I wouldn’t consider it exhaustive or perfect. In any case, strategies like these should be what you are personally comfortable with.

Absolutely, Amazing,
Beautiful
Cool
Dynamite
Excellent
Fantastic
Great, good (for you), gorgeous
Hooray, holy cow
Incredible!
Joy! Jinkies! just like that,

Kiss your brain!, keep it up!

Lovely, Lookin’ good!

Magnificent, Marvelous
Neat, Nice one/job
Outstanding, Oh my gosh
Perfect, pat yourself on the back, powerful
Quite right
Right on!, Rockin’
Super, sweet, *
Terrific
Up, up and away — you are taking off!
Very nice, va-va-voom!
Wow, woah!, woo-hoo!, Working hard!
X-ray your brain: I need to look at all that learning!
Yahoo!, yipee, yay!, yes!, you got it!
Zoom! Zowie!

You can find more (with accompanying ‘cheers’ at http://www.drjean.org/html/monthly_act/act_2004/06_june/06_2004a.html — click on the links at the top or bottom of the page that say “Cards 4-6” etc.

*One cautionary note: Please avoid using the word “smart” with kids and parents. This word is remarkably entangled with emotions – not unlike “stupid” or “dumb.” Research has shown that kids who are praised for being smart are less likely to take learning risks than kids who are praised for their effort (Dweck, 2007). So if a situation is presented where they are not confident they can keep the “smart” label, they will withdraw and not try at all because they do not want to appear “not-smart.” Kids who were praised for perseverance and effort (regardless of accuracy), were more willing to try and/or ask questions even when they weren’t sure they knew the answer.

09.21.13 — Talking about interviews

Notes on clinical supervision, ,

During the assessment process for individuals with complex communication needs, I try to provide some coaching to the students around developing interview questions.  Tools like Social Networks Inventory are specific to this effort, and I also encourage the students to keep in mind what information they need for other such published tools like the Functional Communication Profile-Revised or TECEL.  I do not work for the companies and have no interest in whether or not they are used, I present them to students as examples of systematic means to structure their efforts.  Gathering information related to multimodal communication/AAC is a HUGE process, and it’s been my experience that students feel completely at odds with ~how~ to approach it.  So I share these kinds of tools as resources for their consideration to guide their efforts strategically.

After we talk in person, I send a follow-up email to review the key points in written form (in this instance, the client is a “she/her”):

“Thank you for meeting today — we were able to talk about a lot, and it is clear that you have been reflecting on our fundamental questions of “what do we know?” and “what do we need to know?”

Even just in our discussions, I might broadly characterize these questions to be dispersed around three main threads:

– learning more about the client overall (e.g., elements of a typical day, interests, sensory needs, etc.),
– specifics related to her communication (e.g., what she may understand, what she may signal/express with her behavior), and
– partner interaction patterns (e.g., how information is presented, how she is watched for meaningful responses, how responses are confirmed, etc.)

We talked about how the next step will be to carefully consider what the best means of getting this information may be — email, requests for reports, talking on the phone or in person and, if through talking, how to structure and unfold that interaction to “maintain a comfortable and productive relationship” using the information from Westby, Burda & Mehta (2003) as a guide.

(1).  Do you already have a sense of what may be reasonably developed by email or requests for reports?  I think we used as a loose guide that any question where we may want to have an example would be good to have on the phone or wait for them to actually be here because it may be best handled in such a way that you can attend to subtleties of tone of voice, pausing, and more detail.

(2).  If you have not done so already, I strongly encourage you to review the protocols for the published tools we have discussed to begin filling in what has been observed, what areas you would want to ask about (by email or interview) for this part of the process, and what areas you feel you would definitely need to observe (either by video or directly).  Please consider your questions as a means to the end goal of being able to use these published tools to structure information gathering, and informing the process’ next steps.

(3).  In terms of interview etiquette, I would always strongly encourage starting off with introductions and giving a general overview of the goals.  This is an opportunity to establish that the intention is learning/sharing (information discovery) and planning (preparing for next steps), not to judge or criticize (which is often how any questioning format may feel).

As an example, I put this as if Student 1 was the first speaker and covering a general sense of the client — there’s no particular reasoning for that in my thinking, and we could structure this in whatever way you guys felt appropriate; however, it needs to be outlined more specifically for who is asking what so that there is a coordinated plan.

Example:  “Hi, Client Mom, this is Student 1.  It is so great to have this chance to talk.  We have reviewed the information that you sent ahead, and watched the videos.  I just have a few questions for you so that we can get to know Client better.  Then Student 2 is going to ask a little more about Client’s communication.  All of this will help us plan for your visit here.  To start though, do you have any questions or concerns?”

If she is feeling okay about things, my all-time favorite “Descriptive” or “Grand Tour” question for parents or teachers to start is simply:  “Tell me about Client.”  In this case, I might add a clause like, “You have provided us with so much wonderful information with the reports you sent, but it would be great to hear from you:  Tell me about Client.”  A remarkable amount of information can unfold in such a simple question:  the parent or teacher’s frame of reference for that child, his/her conceptualization of the specific concern and/or of disability in general; the most important goal or most critical need; a sense of the child’s personality/interests/activities/family life; parent/teacher anxieties/concerns/fatigue, etc.  Follow-up or “Mini Tour” questions would include asking for use rather than meaning (e.g., “Give me an example of….”), restating (repeating in exact words, do not paraphrase or interpret), and summarizing with the intent of allowing for clarification.   “Tell me about a typical day” is another great descriptive/grand tour question and presents lots of opportunities to follow up with likes/dislikes (what does he do to convey preferences/rejection), sense of mood or energy across the day, motor skills, sensory demands, etc.

Listening to her responses to these kinds of questions may well resolve many of the questions you guys identified on its own, or lead into unexpected directions as well.  A key piece though is anchoring her as the expert of her child; therefore, letting her lead the revelations about her within a gentle structure of getting information we need to get a profile of her skills/needs and plan appropriately.

Student 1 would then ‘wrap-up’ and transition to Student 2:  “Client Mom, I feel like we are learning so much about Client.  Student 2 has a few questions for you which are more specific to her communication but I wanted to confirm if there is anything else you would like us to know about her generally?”

With this piece, there would be a brief overview again and to try and start with a Descriptive/Grand Tour question related to communication; as in, Student 2:  “Good afternoon, Client Mom.  I just have a few questions to clarify our sense of what Client understands and expresses from what you have shared with us so far with the videos and today.  Please share with us your thoughts on Client’s communication.”    More detailed questions about her hearing, vocabulary she may know, functions of communicating (requests, protest/reject, get attention, etc.), behaviors or signals observed, etc., may naturally unfold or can be asked as follow-ups in the same way as described above (use rather than meaning, restating, summarizing).

I would encourage again an opportunity for her to convey questions/concerns, and “Is there anything else that you feel is important for us to know about Client.”

I then close with an Action Plan for what I need from them next; primarily, dates/times that we can share with the parent to schedule the interview, an outline of who is asking what.  I also indicate that they need to be actively thinking about the next step as well:  what information they will need to observe directly, and how they will go about establishing situations and gathering that data.

09.21.13 Supervisory Notes re: iPad and apps

Notes on clinical supervision

Frequently I am asked by students or others about resources related to the iPad and apps.  It’s increasingly becoming a bigger and bigger question.  This is a series of information that I commonly extend:

>> Relative to the iPad as a platform (the hardware), I recently learned of a video that may support efforts when working with the iPad (or other iOS technologies).  It’s just under a half-hour long, and reviews the settings and features of the system, not any particular app.  For example, they review how to use Guided Access and other Accessibility settings (such as “Zoom”).  It is more specifically directed for parents and teachers working with individuals who have autism spectrum disorders, but certainly the features may be appropriate for any variety of learners/communicators: http://www.youtube.com/watch?v=_qQkyrdBcSc&feature=share.

>> The QIAT listserv community compiled a reference for the iPad which reviews its features — it considers demands ranging from required motor skills, implications for individuals with vision impairment, and cost.  This can be found by searching the archives, and their website (http://indicators.knowbility.org/) generally has tons of useful information.

>> Penn State’s technology department has also pulled together a variety of resources at:  http://www.hhd.psu.edu/iss/training/training.html#ipad

>>  Two:  using the iPad should have careful consideration about the implications for the interaction; and, specific to intervention, the teaching piece.  Positioning the iPad (or other technology, such as a laptop running Powerpoint or Keynote), changes the dynamic between client(s) and clinician:  there is now a third thing to direct and share attention between.  Are the two persons now looking down at it instead of at each other, and how does this change the priorities of the SLP re: communication as an act inherently intended to connect between people?   One strategy to preserve more natural face-to-face interaction may be to position the technology held by the clinician at about heart level facing the client; which requires some manual dexterity and stamina on the part of the clinician, likely occupies both hands (pointing?  sign?  data collection?),  and means she/he will probably have to look at the materials upside down.   Who controls the buttons?  Are clients allowed to touch the screen, and what are the boundaries established regarding how hard buttons/screens may be touched?  In terms of teaching, how does the SLP apply visual or gesture references, such as pointing with the iPad or other touch screen technologies without incidentally activating the screen.  I had put forward one idea relative to Instructional Materials related to this challenge in the Resources (password, “m4ter14ls”), search under “iPad.”  My primary point with all of these questions is I feel strongly that there are implications with using the iPad that need to be considered carefully.

>> “There’s no question that Apps have taken the field of Speech-Language Pathology by storm, but I have huge concerns about *how* they are being found/used.  Two, the most important thing in my mind is that the app remains a *tool* not the whole point.  For assessment/intervention, using an app should be a component of an interaction.  It should matter whether or not another person is in the room (it’s not just an idle activity which has no social component); and if we’re using it, it should matter that that person is an SLP.  It is *not* enough that apps are fun or convenient.

>> Apps for SLPs can be categorized in 4 groups:  (1) specific to SLP use, targeting a communication skill; (2) re-purposed from some other area (e.g., literacy), and used in intervention for targeting a communication skill; (3) motivational only, having no particular relationship to communication; (4) for collecting and interpreting data.

>> Why an app is selected for an intervention should be based on Evidence Based Practice, or EBP.  This is the intersection of available evidence/research/theory, the clinician’s personal expertise/experience, and the particulars of the client’s skills and needs.  If there is an imbalance from these components, it will impact the effectiveness of the intervention.  For example, if an app is being used because it’s the one the clinician is most familiar with and there is no research base which connects to the design/approach of the app, and it isn’t fit to the unique individual profile of the client, it *may* be something that client will learn from; HOWEVER, it will take much longer, and demonstrate less functional generalization.  That is, it will not be as effective as it could be if there was better balance among the components of EBP.

>> Clinical instructors for practical experiences (aka, supervisors and mentors), may also find value in a great article about a protocol for clinical supervision which includes app decision-making that was published in the April Perspectives for Administration and Supervision –Technology: Project Using iPads for Clinical Supervision by Karen Brown, Akilah Heggs, and Katie Milican.  Their tool for structuring and documenting the process of why an app is selected and how it will be used strikes me as hitting the key points without being overwhelming.

>> ASHA has a ton of information on their website, but I specifically want to call attention to an ASHA Leader article which talks about EBP for selecting apps is:  http://www.asha.org/Publications/leader/2012/120731/APP-titude–Use-the-Evidence-to-Choose-a-Treatment-App.htm  Unfortunately, this is just a bare-bones article, but it does give the basic structure of the author’s recommendation.  The authors have also put together a two-part series of information on EBP app selection through www.speechpathology.com, both of which I found to be very helpful.

>> Specific to AAC issues, Dr. Light and Dr. McNaughton very recently published “The iPad and Mobile Technology Revolution: Benefits and Challenges for Individuals who require Augmentative and Alternative Communication  Read More: http://informahealthcare.com/doi/abs/10.3109/07434618.2013.784930.  The http://aac-rerc.psu.edu website also has the White Paper on these issues, and is worth knowing about.

>> I also strongly encourage folks to watch this free webcast on Mobile Devices and Communication Apps:  Current Trends and Future Directions (http://aac.psu.edu/?p=841).  There is also a link to Boston Children’s Hospital which has good information about this process, and a feature matching toolhttp://www.childrenshospital.org/clinicalservices/Site2016/mainpageS2016P19.html

>> Blog/article regarding communication and language apps: http://speechdudes.wordpress.com/2012/05/03/stop-with-the-little-words-grab-bag-in-aac/  It’s very much in keeping with what has been talked about at PSU & Colloquium for some time now relative to how *language* is represented and organized (although with a spunky hipster tone) and he makes a well-reasoned, succinct, and impassioned point.

>> http://www.speechtechie.com/ is one example of site that has considerable information about using mobile technologies.  It is written by an SLP who works in the schools and his “FIVES” criteria may give some structure to deciding what apps may be worth an SLPs time.  He also oversees a Google.docs collection of apps relevant to SLPs.  Since the “F” in his acroynym refers to Free (or nearly free), these tend to be very cost effective.  Of course, none of these apps replace effective, thoughtful, data-based intervention.  Recently he had a thorough discussion on how to manage the iPad’s digital space.

>> As “review” lists go, I think this one has some positive aspects and is better than many I’ve seen http://www.spectronicsinoz.com/article/iphoneipad-apps-for-aac)

>> This is a slightly different perspective on Apps (originally developed for Elementary education):  But I do find Harry Walker’s work in the Baltimore schools interesting and I think his rubric does a tremendous job for educational Apps (article at http://embedit.in/Wp28yIHnc2.swf, rubric itself at:  http://iteachthererforeipod.blogspot.com/2011/11/evaluation-rubric-for-ipodipad-apps.html)

>> Finally, relative to out-standing or underdiscussed issues for me:  I feel somewhat nervous about the notion of people using their personal technologies for assessment and intervention.  I don’t know what the legal responsibilities are; for example, if an SLPs personal iPad gets damaged by a client/student, who pays for that?  If an SLP in a school uses an iPad with a student, could the parents therefore have reasonable grounds to petition the school to buy the student one (clearly the SLP already places a value on it…); or, alternatively, if a client/student brings in a Mobile Technology of their own (which is increasingly common), whose responsiblity is it to program/maintain it?  I have not found what I consider to be sufficient discussion on these kinds of issues to help guide SLPs to know how best to respond.

>> Hopefully that will give you a place to start!  I know that this is a lot to take in, but be patient and strategic with yourself and your time.

>>Thanks,
j.

>> p.s. At less than a minute long, it’s definitely worthwhile to check out Sesame Street’s, “There’s an App for that”:  http://www.youtube.com/watch?v=EhkxDIr0y2U

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01.17.15 UPDATE Supervisory Notes — Talking about beginning vocabularies (originally posted 9/20/13)

Notes on clinical supervision

I regularly have conversations with students about the challenges around figuring out appropriate vocabulary to feature in assessment or use as target focuses in intervention which features multimodal communication/AAC for beginning communicators (either within Early Intervention and a true “first lexicon,” or when serving individuals with complex profiles and may be chronologically older but communicating at earlier levels), and the following is a summary of my thoughts evolving from those discussions and subsequent reading I have done.

As per the research by Light & Drager (http://aackids.psu.edu/index.php/page/show/id/6), appropriate vocabulary should reflect the interests/needs of the communicator (determined with interviews, observations, survey tools, Communication Signal Inventory); and developmentally appropriate vocabulary based on the individual’s age/life experiences.

In terms of Resources relative to the first piece — individualized vocabulary of high personal relevance as per the recommendations of Drs. Light & Drager — the Vocabulary Selection Questionnaire for Preschoolers Who Use AAC from Fallon et al (2001) is an excellent resource available for free download at the http://aackids.psu.edu website. This can also be adapted for older communicators or used as an example for how we need to consider various contexts/environments.

I have also tried to pull together a couple of options under the Resource link above (password: “m4ter14ls”), including:  (1) a “Kid Culture” Alphabet of a range of characters, movies, places, toys, etc. that may be of appeal to younger audiences, and (2) an adaptation on the work of Laura Molleur/M.Ed — she had put together a really solid Interests and Preferences summary through Victoriesnautism.com.  I added a little detail related to teasing out what observable signals, behaviors, or expressions lent to impressions of likes or dislikes.  That’s titled “Review of Interests and Preferences.”

With the second piece (developmentally appropriate vocabulary based on the individual’s age/life experiences), there are a couple of resources that may be helpful.

>>With Early Intervention with young children, the MacArthur-Bates Communicative Developmental Inventories are now available online through the CLEX website and even includes gestures:  http://www.cdi-clex.org/  This can give insight into terms by age and gender that may be relevant for review and consideration.

>>In 2009, Susan Lederer presented “First Words, First Books and Focused Language Stimulation” for www.speechpathology.com.  She discussed a review she had completed of a number of resources to develop a list of 30 possible targets that met the following criteria:  mastered by 50% of children by 20 months (Fenson et al., 1994), mastered by 80% of children developing typically by 24 months, and mastered by 80% of late talkers by 36 months (Rescorla, Christine, & Alley, 2001).

She also stipulated that “these 30 words could be demonstrated easily by gesture, picture, or sign; are meaningful and pragmatically useful; include substantive and relational words from all of Bloom & Lahey’s (1978) early content categories; and are phonemically simple.”

In subsequent research (2007), Lederer added words that 50% of children with developmental delays acquired by age three (bring her total under review to 42).

Substantive
Existence/People: mommy, daddy, baby, me
Existence/Animals: bird, cat, cow, dog, duck
Existence/Foods: apple, banana, cookie
Existence/Toys: book, bubbles, bus, car, ball

Relational
Action: eat, go, hug, kiss, open, wash, drink
Greetings: bye, goodnight, hi
Attribution: big, dirty, hot
Locatives: down, in, off, on, out, up
Recurrence: more
Rejection: no
Non-existence: go away
Possession: (none)

I very much appreciate that the above list is specific and covers a range of semantic categories/communicative functions — it’s not just all nouns to be used in “I want…” sequences.  I also find her Focused Language Stimulation and premise through shared storybook reading activities to be very compelling — consistent with the research here at PSU as well.

Then she has another presentation on www.speechpathology.com on the first lexicon and there she adds that as of 2010 she has revised her position on “more”:  specifically, delaying using it until a child is at a point to combine words/concepts — that “more” is not a stand-alone concept, it’s really “more toys” or “more milk” or whatever.  That blew my mind.  For many years, I have always felt comfortable using and teaching it, but I have also seen the patterns Lederer identified as problematic — that kids may not get the concept as “more+,” they learn and use it as a complete request on it’s own, like “[I want] more.” or “more [partner fills in based on situation or guesses],” and as a result it may actually limit vocabulary growth.  Two, that many kids may know that it is a communicative act along the lines of “I do this thing and stuff happens for me” but not associate it with a specific message — so beginning communicators start to use it indiscriminately in a variety of situations (such as to start interactions or convey protest), not just express a request to continue.

Anyway, as a starting point:  I like her list, and LOVE her book list.

>> The University of Nebraska-Lincoln has done considerable research around vocabularies (as well as other AAC-related work) for a wide variety of age groups and population profiles.

>> In September of 2014, the SIG 12 Perspectives article, “Promoting Academic Achievement for Early Communicators of All Ages” by Lois Geist, Penny Hatch, and Karen Erickson argued strongly in favor of strongly considering the DLM Core:   “The DLM Core is intended to be flexible enough for repeated and frequent use across a variety of contexts. Words were prioritized based on their frequency of use in oral and written language and necessity for academic engagement, learning, and demonstration of knowledge.”  There is substantial information available about this at Department of Allied Health Sciences Center for Literacy and Disabilities website, but I find the DLM Core first 40 vocabulary the easiest to read as a basic start.  As an aside, I found the Geist, Hatch, Erickson article to be compelling on a number of levels — lots of solid information relevant to school-based SLPs.

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