We like to think that client improvement is due to our therapy and that there is a single direct line between intervention and remediation. Maybe there is, but maybe there isn't. Maybe something else besides our therapy is having a great effect on our client's communication development. We have belief systems about therapy. Belief systems help us make sense of the world; however, sometimes belief systems become so entrenched in our thinking, that we no longer remember where we learned them or how they came to be.
One type of belief system is called a "closed system." In the field of science, a closed system is an isolated system that does not interact or transfer mass into or out of the external environment. The vascular system is a closed system within the human body. Closed systems theory has been applied in business and education. A closed system does not interact with the greater environment and does not freely exchange information.
In their book, "Leadership in Education," Professors Russ Marion and Leslie Gonzales, described closed system thinking. When we have a closed system perspective, we believe that all variables that influence a given problem are contained within an organization and that a single manager can control the variables. With children, attempting to control all possible variables would require removing children from their natural environments (an immoral proposition). Even if we could put test subjects in a bubble, children would still be growing every day. We can never remove natural maturation.
"Of course, therapy is the most important factor," we may assert, and we may actually need some level of closed system thinking to see the value of our work. However, there are benefits to opening up a closed system perspective. Perhaps there are other highly significant environmental factors that are affecting our client's communication skill development. Maybe a child's grandmother has moved in with the family and she reads books to her granddaughter every night using interactive strategies that we would label as dialogic reading. Maybe a child has play dates with his cousin who has a similar speech sound disorder and they reinforce each other's error productions. When we open ourselves to other factors, we open ourselves to other possible communication partners and facilitators. We can ask questions that are based on variables that affect communication development:
- Which people are influencing the client's communication development and how are they influencing it?
- What types of interactions are influencing the client's communication development and how are they influencing it?
- Which settings are influencing the client's communication development and how are they influencing it?
The idea of analyzing the client's communication partners and settings to describe the child's natural environment is common. We can also consider these same people and settings as influencing variables in an open system. When we stop thinking that we are the sole influence in our client's progress, we start to see the power of everyone and everything else that surrounds them.
I've had orthodontia for most of my life and still wear a retainer at night. When I was in grade school, I had a palate expander to change the shape of my mouth. A strong wire was connected to the back molars that exerted pressure on the hard palate. This was some time ago, when only an orthodontist could adjust a palate expander. I had periodic visits and the adjustments were substantial, not incremental. After the appointments, I would sit on the floor in my bedroom and cry from the pain.
When the palate expander was first installed, it affected my speech and caused a lisp. At school, other children commented and made less than flattering imitations of my speech. I remember thinking to myself, "This is not okay. This is not how I talk." That afternoon, I made a plan. I had a tongue twister book that my aunt had given to me. I read the different tongue twisters out loud to myself until I could speak the way that I used to speak. I think that I read aloud for over an hour, continually adjusting how I was moving my tongue. It's only now, as an adult, that this vignette seems prescient for my future career.
My experience was rehabilitative - not habilitative. Rehabilitative services address skills that were previously mastered and lost. Habilitative services help children meet developmental milestones. I had already met developmental milestones and was able to produce all sounds correctly in all positions. I knew what my speech sounded like prior to the dental appliance. I understood my targets. I wanted to regain something that I had lost.
For children who have developmental speech sound disorders, they have only ever heard themselves producing approximations of adult targets, possibly using a variety of compensatory strategies. They don't have auditory memories (inner voice recordings) of themselves saying sounds correctly. Sometimes they recognize that their speech is different from their peers, but sometimes they don't. Articulation therapy may involve giving clients a new internal recording that they can use as a target.
We can use actual and imaginary audio to help clients recognize when it is time to retain new inner voice recordings:
We have amazing auditory memories. Maybe we can start helping our clients focus their ability "to hear" themselves.
- Audio-record the child's optimal productions and closest approximations
- Have the child listen to recordings of the best productions multiple times
- Compare and contrast recordings of optimal and less than optimal productions
- Have the child pretend to turn on an imaginary recording device to capture optimal productions: "You are doing great! Tell your ears to start listening and tell your brain to remember what you hear."
- Praise optimal productions using listening words: "That was amazing. Remember what you just said so you can hear it again in your head."
Therapy materials can make intervention easier or they can get in the way. Sometimes we don’t need as many materials as we think. In the film, “The Minimalists,” Joshua Fields Millburn and Ryan Nicodemus describe how we can become so caught up with collecting and keeping up with other people, that we no longer appreciate what is truly important.
They describe how the hunt for the perfect item can take away from valuable relationships. When there is too much stuff, it may affect our ability to interact in meaningful ways with each other. Simplicity expert Courtney Carver shares Project 333, a minimalist wardrobe plan of cleverly combining 33 clothing items for 3 months to show you what you truly need. Minimalist wardrobes often consist of classic and versatile items of high quality that combine easily with other items.
We could consider our therapy materials from a minimalist perspective. When our shelves and cupboards are crowded with activities and games that are overly complex, inflexible and dated, we can’t easily find what we need. If you’ve ever tried to close an overstuffed drawer that wouldn’t close or spent too long looking for dice, you might understand. We can fill our spaces with so many objects, that they become cluttered. Some materials can only be used one way for one purpose. These overly prescriptive games may even reduce the creativity that can come from spontaneous and natural interactions.
We could try a minimalist approach to treatment. We could start by choosing our three favorite materials. It’s likely that these materials are enjoyable for most clients, enable us to target multiple goals and can be used in different ways. We can analyze what is special about these materials and why we like them. Maybe we don’t need another board game or another set of picture cards? Maybe we really only use a total of 33 items (or less) on a regular basis?
We can ask ourselves questions about each of our materials:
· How many different ways can I use this item?
· How many types of goals can be targeted with this item?
· Is it sturdy and durable?
· Is it overly trendy or is it timeless?
· Is it a duplicate? Do I have two or more of the same thing?
· Do I need a lot of other things to make it work?
· Is this something that I don't use much that I could borrow from someone else?
· Is this something that the children and I could create together?
Children enjoy interacting with toys and games, but they also enjoy interacting with each other and with adults. Our clients like to spend time with us. We are considerate listeners and creative communication partners. We provide encouragement and assistance. We can use our words and actions to show we care, and not just flashy toys. Therapy isn’t about the picture cards that are on the table; it’s about the rapport and the relationship!
received some valuable advice years ago. An experienced administrator told me,
“Sometimes it’s just a job, and sometimes it’s your career." I was
confused and I didn’t know what she meant. “Isn’t it always your career?” I
explained that technically, yes, it is always your career, but sometimes it’s
more like a job. When you consider your work to be your career, you are
passionate about what you are doing. You seek out resources to further your
learning. You read research articles. You brainstorm with colleagues. You
attend conferences and continuing education workshops. You reflect on your
practices and challenge yourself to do better. You dedicate time, thought and
attention to your actions and your performance.
a job, you show up for work. You do what needs to be done to meet the
requirements for that day. You still care about your clients and your work, but
it’s different. When it’s a job, for whatever reason, you don’t have the
personal time, cognitive reserves and emotional fortitude to spend extended
amounts of time on honing your skills. Any number of life factors can make your
career into a job — family needs, medical and health issues, personal events,
etc. can all demand your attention. There are times that you need to have your
main focus elsewhere and this isn’t a commentary on who you are as a
interesting thing about advice is that although you may understand it from a
rational perspective, you don’t understand it from a personal perspective until
it happens to you. Often, daily demands build slowly and we are unaware of
their effects. It can feel like the anecdote about the poor frog swimming in
warm water that slowly heats up until he is boiled. You suddenly realize your
intense level of stress and how you have unfortunately neglected things that
previously mattered a great deal to you. You are confused and wonder how to
regain your balance and how to repair what has been left unattended.
advice still matters to me and helps bring me comfort. Even if I don’t realize
my situation until I’m already overwhelmed, I know that I can forgive myself.
We don’t intend to overextend ourselves. In fact, it could even be considered
an internal strength that we overestimate our own abilities — a strong belief in
our skills helps us achieve important goals.
have found yourself with more responsibilities than you can manage, forgive
yourself. If your career is just your job right now, that’s fine, too. It can
be your career again later. You are putting your energies where they need to
be. Trust in your own judgment and know that our professional goals are
lifetime pursuits. We can always learn more and grow more in careers when we
A while ago, I completed an assessment for a student who had transferred from another school district. The student’s family had moved while the evaluation was in process. The sending school had finished the standardized testing, and I completed language sampling, an observation, an interview, teacher rating scales, a hearing screening and the report. The district administrator and clinician from the other district attended the eligibility meeting. I shared results of the evaluation. The student had received a standard score of 79 on a comprehensive language test. The staff from the other district announced that if the student had remained in their district, he would not have qualified for services, as they used a cutoff score of 78. I stated that I weighed multiple factors in the decision-making process and was not required to decide the presence or absence of a disability using one sole numeric criterion.
At the federal level, standardized scores are not specified. The Individuals with Disabilities Education Act (IDEA) states that a communication disorder “adversely affects a child’s educational performance.” It does not list a test score. At the state level, each state receives funds from the federal government for establishing their own rules, regulations and policies to support children with disabilities. At the local level, each local educational agency (LEA), like a school district, is required to have their own “policies, procedures and programs that are consistent with the State policies.”
A few additional notes:
· Significantly discrepant: Some districts use cutoff or guideline scores that they consider to be significantly discrepant from the normative sample (typically -1, -1.5 or -2 standard deviations).
· Performance: Standardized tests measure performance at a given moment in time. We cannot measure underlying knowledge of linguistic concepts. We can only measure an individual’s physical behaviors (speaking, pointing, etc.) in response to sets of decontextualized stimulus items.
· Standard measure of error: There is no true test score. Standard measure of error is an estimate of an individual’s performance on the same measure with multiple administrations (without the effects of learning the test items). It shows the likely range of that person’s performance.
· Optimal cut-score: Researchers determine the best score to prevent over or under-identification of disorders. Sensitivity shows the probability that people who have a disorder will test positive for the disorder. Specificity shows the probability that people who do not have a disorder will test negative for a disorder. Researchers find the best balance of sensitivity and specificity to recommend an optimal cut-score. The Clinical Evaluation of Language Fundamentals-Fifth Edition has an optimal cut-score of 80 (-1.33 standard deviations).
· Missed items: Two different individuals could receive the exact same standard score and miss completely different stimulus items. The score alone does not provide any information about areas of strengths and challenges.
We have a cultural belief that standardized testing is an accurate measurement of knowledge and skills throughout the educational system, with benchmarks from preschool through college. Perhaps it’s time to question the origin of cutoff scores and what one number actually means. We can think about how we are interpreting numerical data and the significance that we give it.
Do you believe that your actions affect your life outcome? Do you believe that you can influence other people by what you say and do? Do you believe that you can be part of a group of people who bring about positive change in the world?
The ability to have power over our own actions and the actions of others is agency. You are an agent — the one doing the action — instead of a recipient, or a person who has things done to them. When we have a sense of agency, we believe that what we do matters — there is an outcome. Agency is empowerment. When individuals do not have a sense of agency, they may become passive (not initiate) and prompt-dependent (wait for another to prompt them), or even demonstrate learned helplessness (feel powerless and ineffective).
Renowned psychologist Arthur Bandura’s work in social cognitive theory described three types of agency that people use in their daily lives:
· Personal agency: the ability to do things to meet your goals.
· Proxy agency: the ability to influence other people to meet your goals.
· Collective agency: the ability of a group of people to work together to meet a goal.
Our work with students affects how they view themselves. We can show students how they are agents in the therapeutic process and within a group.
Personal agency: you can make things better
· Recognize hard work: “You’ve been working really hard on telling your tongue where to go for your /r/ sound! All your work is making a difference!”
· Celebrate progress: “Remember last year when you used to say ‘wed’ for ‘red’? You don’t do that anymore. You changed your speech.”
· Specify goals: “You told me that ‘squirrel’ is a hard word for you to say. You can set a goal for this word.”
Proxy agency: you can influence other people
· Request: “Ask your partner if you can … ”
· Bargain: “Maybe you could tell your partner that he could choose the activity first next time?”
· Convince: “Give you partner two reasons why you think that you should pick the activity.”
· Thank: “Did you see how your partner smiled when you thanked him for letting you go first? You made him feel appreciated.”
· Praise: “Did you see how your partner sat up straight when you said she did a good job saying her /r/ sound? You made her feel proud.”
Collective agency: we can create good things together
· Co-created materials: each student takes a turn decorating a book, or game that will be used by the whole group.
· Co-created stories: each student takes a turn adding an element to a narrative to create a cohesive story.
· Sharing created materials and resources: sharing materials that one group has created with another group or with staff, e.g., “We made a great book of vocabulary words! Let’s share it with the teacher so that other students can use it, too.”
We develop an understanding of our place within our community by how we interact with each other. We can highlight students’ roles in their own success, and provide opportunities for contributions and collaborations that help others.
I had to leave a training activity because I was starting to cry. I don't believe that anyone noticed except the person who was sitting next to me. I told him, "This isn't safe." He offered to speak to the instructors for me, but I declined. I left the room, shed a few tears in the bathroom and then got myself together and returned.
We were reading about critical race theory and culturally responsive teaching.1 The articles described how educators could shift their thinking about minorities and underrepresented groups from a deficit approach to an asset approach. Instead of looking for bad things within a community, we could look for all of the good things that supported, nurtured and uplifted a group of people. Every community has its own unique strengths. Educators were encouraged to conduct a form of ethnographic study to learn about the strengths of the different communities of their students. The articles contained noble ideas.
Then suddenly, we were told that we needed to complete a community asset assessment for our own childhood. This may sound like a fine activity to you, and if it does, I'm glad that you had a childhood that you feel comfortable sharing. Not everyone had safe experiences as a child and not everyone trusts others enough to know that they will not be judged for circumstances that were beyond their control. Being asked to complete this activity was not an appropriate task for me. I didn't participate and faced mild disapproval from one of the instructors. Although the disapproval was disheartening, it was insignificant in comparison to the distress I would have felt had I completed the activity.
We often assume that everyone has happy lives that they want to share. We assume that people feel safe with others and willing to disclose personal information. As clinicians, it is common to establish rapport through questions about preferred activities, favorite things, family members, etc. Not all of our questions are safe for children. Not all children feel comfortable answering questions that come from a place of privilege that assumes everyone has only positive experiences.
There are many resources about working with children experiencing hardships. Here are a few minor changes in asking questions that I have adopted:
- Allow students to opt out: "It's okay to pass."
- Give a choice: "Would you like to share about X, or share something else? You can choose."
- Use the word "family" instead of the word "parents."
- Ask if a child celebrates a holiday, instead of assuming that they do. (Even a birthday.)
- Introduce activities around objects before people, e.g., describe a location before the participants.
- Use known shared topics, such as school.
We can think about how we expect a child to respond whenever we ask a personal question. If our expectations for responses are always positive, we may be seeing the question from our own place of safety and assumed values. Imagine a negative response to the question and a description of unpleasant or traumatic events. We can reframe personal questions and recognize that these types of questions are not innocent.
I saw something upsetting this week. I wasn’t sure whether or not I should tell you about it, but I decided that we learn a lot not just from good things, but bad things too. It was a brief incident that highlighted greater concerns at the individual, local and national level.
From the clinic room, you could hear young voices swearing in the hallway. The third and fourth grade students had finished lunch and were waiting for recess. A group of boys were standing together near the first grade and kindergarten classrooms. They were talking loudly and using profanity.
A teacher walked up to the boys without them noticing. When the boys finally saw her, the group became divided. Half of the boys stopped talking, and then made “ooooh” noises, which likely represented “you’re in trouble.” The other half of the boys began to swear louder and dance around. Suddenly, they stopped swearing and switched to racially-based imitations of a foreign language, used in mocking attribution to the racial background of teacher.
The teacher attempted to learn their names, but they all ran off down the hallway and out the door to recess. She followed them from a distance. When she finally reached a few of them, she said, “There are little children in the classrooms. They can hear you. You need to be quiet when you are by the classroom doors.”
The teacher seemed visibly shaken by the incident and I was at a loss of how to help. I could see the confusion and distress on her face. She was not a regular teacher in the building and did not have strong connections to the students and staff. She worked as a special education itinerant and traveled to multiple school sites. I expected that she was simply trying to do her best to provide a positive learning environment for the children she served at that building.
I spent a long time thinking about what happened, and found that I had more questions than answers:
· What are the current national norms for the ages at which children begin to use profanity and derogatory racial and ethnic terms and expressions?
· What are the primary means that children learn racially-based insults?
· Are racially-based insults the new “taboo” words now that profanity has become more commonplace in society and the media?
· Are racially-based insults more or less common between different minority groups, or between dominant majority and minority groups?
· Could behaviors that appear to be defiance actually be rejection of a positive relationship due to one’s own fear of rejection?
· Could positive adult relationships be so rare for some students, that initial rejection is viewed as more beneficial than continued failed attempts?
· Are there recommended ways for staff to respond to racially-based insults from students?
· Are rewards and punishment appropriate methods to address these issues?
· How can we help staff remember that child behaviors are not personal?
If something upsetting has happened to you at school, I am profoundly sorry that you had to experience it. This story was about me. I was the itinerant specialist in the school building. The only way that I have been able to process what happened thus far is from a distance.
Every day is a chance to make a positive difference in the lives of clients, families, and colleagues. Our daily activities are important and have immediate effects. When days are hectic, it becomes easy to feel rushed and overwhelmed. Reflecting on the primary motivation of our work can guide us. We can see how our time matters.
Speech-language pathologists support communicative growth and foster social engagement for clients. When we take a moment to list just a few of our plans for one week, we can highlight the incredible work of our field.
We use data from previous therapy sessions, client input, partnerships with staff and families, and research to guide our intervention. Here are a few highlights from my upcoming week:
• Articulation: Respond to the teacher’s comments about the child’s oral reading skills in the classroom and analyze why the “ire” sound, as in “fire” is the most challenging /r/ sound for the child to produce.
• Fluency/Stuttering: Continue a heartfelt discussion with a student who shared that he is afraid that he won’t be able to warn somebody in time if there is an emergency because of his stuttering.
• Voice: Begin a lesson on the basic anatomy and physiology of the vocal mechanism by watching the YouTube video “Inside the Voice” featuring a narrated endoscopic view of the larynx for a child who has a diagnosis of vocal nodules.
• Language: Practice retelling events with two and three-part picture sequences to show the relationship between the concepts “first/then” and “before/after” for a child who has attention and executive functioning challenges.
• Language and Literacy: Use the Reading Rockets Word Study lesson on word families, phonological awareness, and orthography for the multiple spellings of the “o” sound (no, know, bow, dough, etc.) for a child with a language learning disability.
• Pragmatics/Social Language: Begin a lesson on how positive and negative comments in conversation affect the feelings of peers for a child who has a diagnosis of Autism Spectrum Disorder.
• Collegial support: Share resources to conduct a small group activity on asking questions and stating preferences for adolescents with significant developmental delays.
• Family partnerships: Prepare and send home practice materials for a child who has mastered “or” and “ar” r-controlled vowels, as in “four” and “far”.
• Medical partnerships: Prepare a letter to the primary care physician detailing concerns about oral anatomy, tongue range of motion, and likelihood of ankyloglossia (tongue tie), which may be affecting progress in speech sound production.
When we list just a few of the many different tasks we perform within a week, we can see direct connections between our time and positive outcomes. What are you going to do this week?
While assessing a middle school student for the presence/absence of a language disorder, I asked the student the following question, “Jan saw Pedro. Dwayne saw Frances. Who was seen?” The student did not respond correctly to this trial item and benefited from repetition and modeling. To answer the question correctly, you need to understand passive sentence construction.
Typically developing children begin to understand passive sentences between ages 5-6 years old and begin to produce passive sentences at between ages 7-8 years old. In English, the general declarative sentence structure for a statement is Subject + Verb + Object (SVO). Different languages use different word order. SVO is the second most common word order represented in languages of the world, with SOV having the greatest representation.
SVO word order, as in the sentence “The dog chased the cat”, has the agent (the dog) + the action (chased) and the object (the cat). The dog was performing the action and the cat was receiving the action. Objects can be animate, like the cat, or inanimate, as in “The boy ate the cookie.” Declarative sentences use an active voice where the initial focus is on the entity that brings about the change.
In a passive sentence, we rearrange the word order and may add elements, such as past tense (was/were) + past participle (chased) + the preposition “by”. The recipient is listed before the agent, e.g., “The cat was chased by the dog”. The instrument used to complete the action appears before the agent, e.g., “The cookie was eaten by the boy.” Passive sentences have Object + Verb + Subject (OVS) word order.
To answer the question, “Who was seen?” the student would need to convert both declarative sentences into passive sentences, e.g., “Pedro was seen by Jan. Francis was seen by Dwayne.” Passive voice is powerful because the emphasis is on the recipient and not the agent. We even use passives to highlight outcome and remove cause or blame, e.g., “The window was broken”, where no agent is included. Textbook authors often use passive voice to describe historical events in which the exact agents (individuals) may not be known, e.g., “A mighty fortress was built.”
We can help students understand passives by providing multiple opportunities to convert active to passive and vice versa by manipulating sentence elements. We can explicitly teach the movement of words using index cards, with each word on a card, in order to rearrange the sequence and insert additional words. We can use picture cards of entities and objects (Jan, Pedro, dog, cookie, etc.) to show the roles of “agent” and “recipient”. Understanding how to interpret and generate passive sentences allows an individual to change the focus of an action, its nuance, and its significance.
1. Owens, R. (2016). Language development : An introduction (9th ed.). Boston: Pearson.
2. Matthew S. Dryer. 2013. Order of Subject, Object and Verb. In: Dryer, Matthew S. & Haspelmath, Martin (eds.) The World Atlas of Language Structures Online. Leipzig: Max Planck Institute for Evolutionary Anthropology. (Available online at http://wals.info/chapter/81, Accessed on 2016-09-26.)
Tip elevation: Does your tongue tip lift to the top of your mouth, right behind your front teeth, to the little speed bumps of your alveolar ridge? The tip elevates and the right and left surface portions of the tongue push against the alveolar ridge causing a dip (narrow passageway) to form for airflow. The tip hoovers in space near the top of the mouth.
Blade elevation: Does your tongue tip point downward and lightly rest (stabilize) on the inside of your lower bottom teeth with the flat blade of your tongue contacting the alveolar ridge? The blade is the broad portion right behind the tongue tip. You can feel the blade resting on your alveolar ridge when your mouth is closed and your tongue is molded across the roof of your mouth. Blade productions may be considered mild distortions.
For typical speakers, fricative phoneme /s/, and its voiced cognate /z/, are produced at the alveolar ridge. The tongue is lifted forming a narrow constriction (tiny tunnel) for rapid airflow that causes friction. Air rushes quickly through a thin channel making a high frequency sibilant sound.
Sometimes it’s hard for children to control and balance the tongue to form and maintain a narrow opening. Speakers may develop any number of compensatory strategies for /s/ and /z/, such as changing tongue placement and airflow. Some individuals substitute a blade production, raising the broad section of the tongue with the tip contacting the lower teeth.
When treating /s/ and /z/, it’s beneficial to determine whether the client is producing all alveolar sounds with tongue tip elevation. In English /t/, /d/, /n/, /l/, and the tap sound, (middle consonant sound in “butter”, and “matter”, which is a fast sound that is something in between /t/ and /d/), are made with tip elevation.
We need to have the client’s mouth slightly open to see if their tongue tip elevates (rising movement) or lowers, or even if it tries to stick out, or move toward one side or the other. We need a window to view tongue movement. To make a window, you can use a flavored tongue depressor or the client’s pinky finger to keep the teeth slightly apart:
• Tongue depressor: Have the client lightly bite on the tongue depressor with one end at the molars and the other end sticking straight out of the client’s mouth.
• Pinky finger: Have the client place the very tip of their pinky finger on the back molars and lightly close their mouth (but don’t bite).
Shine a penlight flashlight into the client’s mouth. Have the client smile to increase the width of the window (so you can the sides of the mouth through the opening).
Check for tip elevation by having the client produce words for the alveolar consonants:
/t/: “ten”, “take, “talk”
/d/: “did”, “dig”, “dog”
/n/: “nine”, “net”, “neat”
/l/: “light”, “let”, “lock”
tap sound: “letter”, “kitty”
Remember that having your mouth open for a while can make you drool, so take quick breaks between words and have some tissues available. You can have the client watch their own productions in the mirror so that they can learn about their tongue patterns, e.g., “Let’s watch and see what your tongue likes to do for the /t/ sound. Look it lifted up high” (or “Look the tip went down”, or “Look it tried to stick out”).
Remember tongue placement is language-specific and it is important to review the phonetic inventory of every language to which a client has been exposed.
It helps to know whether or not all alveolar sounds are elevated before we ask for alveolar placement with tongue tip elevation for /s/ and /z/.
Children who have challenges with pragmatics and social language often struggle with recognizing that people have different perspectives on the same situation. People interpret actions, behaviors, and events from their own unique viewpoint. One of my colleagues recently shared an interesting technique to teach multiple interpretations through perceptual differences. Visual imagery can inspire a discussion of different ways to view the same stimuli. Optical illusions are designed to evoke variable interpretations. Using optical illusions provides students with specific examples of how we can see the same things differently.
The SLP began with a basic lesson on visual perception based on physical location. She sat across from the student and opened her laptop computer. She proceeded to exclaim loudly and theatrically, “Oh, that’s so awesome! That’s amazing!” She used Google images to search for pictures of the student’s preferred topic and began to comment on the details. The student, who could only see the back of the laptop, reacted to her statements about his favorite topic and said, “What? What is it?”
The SLP stood up and walked over to the opposite side of the table where the student was siting and said, “Oh, I guess from your perspective, all you can see is the back of the computer. From my perspective, I could see pictures of (student’s favorite things). Why don’t you come over to this side of the table and we’ll both have the same perspective of the screen?”
Next the SLP used a series of images of famous optical illusions with two interpretations, such as the duck or rabbit combination, and the old lady or young lady. The student would label what he saw in the picture and then the SLP would say, “Hmmm, well, from my perspective, I see (alternate image).” Soon, the SLP and the student were working collaboratively to find both possible images for the pictures.
The SLP then presented hidden animals artwork, which required flexible thinking to see how objects could represent other objects, e.g., how a cloud could be shaped like a horse in Jim Warren’s painting “Seven Horses”. The SLP repeatedly used the words and phrases, “perspective”, “my point of view”, and “from here, I can see X”. She periodically praised them both by saying, “Wow! I think we’re seeing this from the same perspective!”
We all have different sensory experiences. With food, music, art, etc., what is positive to one person, isn’t necessarily enjoyable to another person. Our sensory systems and our life experiences affect how we respond to stimuli. Optical illusions showed the student how two people could look at the same picture, one single shared stimuli, and construct different meanings.
When I talked with my colleague about this creative approach, she laughed and said, “How could I start telling him that people have different thoughts about something without physically showing him that people actually see different things?”
We know that we make positive changes in the lives of our clients, but our work can also make a meaningful difference to the next generation of speech-language pathologists.
Many years ago, when I was learning to be a clinician, I observed Dr. Bob, a speech-language pathologist in private practice. Dr. Bob specialized in working with children with Autism Spectrum Disorder (ASD). On the day that I observed, he spent 30 minutes with a precocious five-year-old boy who had ASD.
Dr. Bob and the child sat side-by-side at a table to complete a wooden alphabet puzzle. Each puzzle piece was a letter of the alphabet and had a colorful drawing of an animal that matched the letter. They took turns placing the alphabet pieces into the board. With each turn, they alternated between multiple tasks:
• They looked at the puzzle piece together, and looked at each other while Dr. Bob made expressions of interest and curiosity about its design
• They pretended to put the piece in the wrong way before fixing it, or pretended to give the animal the wrong name
• They traced the letter’s shape
• They made the sound of the letter
• They labeled the animal, e.g., “that’s a giraffe”
• They described the animal, alternating between physical characteristics, habitat, actions, etc.
• They pretended to be the animal or pretended to see the animal in the room, raising their hands up to their eyes as hand binoculars
This one simple puzzle was used to address social, language, and literacy goals:
• Social reciprocity and turn-taking
• Problem solving and absurdities
• Letter and sound correspondence
• Orthographic knowledge
• Phonological awareness
• Naming and describing
• Asking and answering questions
• Imaginative and dramatic play
Dr. Bob was laughing. The child was laughing. It looked like fun. They were both having fun throughout the session. The half-hour passed quickly. I saw how the therapy was engaging, interactive, and enjoyable. It took years before I understood how much had happened within that short time frame. It wasn’t until I learned more about intervention, disorders, and clinical management that I fully realized the complexity of the session.
My observation was just a moment of time within his busy day, as new clients arrived every half hour. I was one of countless students who observed, as teaching and clinical training were foundational values of the clinic. Allowing university students to observe is a form of generosity. When our therapy sessions are open and welcoming to university students, we are giving ourselves to our clients and to the future of the field.
I am grateful that Dr. Bob taught me essential skills:
• Incorporating multiple goals into a session
• Managing therapy time efficiently
• Using materials in creative ways
• Infusing social development into every activity
Even though no one is as skilled as Dr. Bob was, we still do have a lot to offer. We have clinical experience. We provide intervention that benefits clients and can enrich university students’ education. Open the therapy room doors and let everyone observe the fun! Our work changes lives and Dr. Bob’s work changed mine!
Are you new to a school building this year? There are, of course, the obvious tasks:
• Make friends with the secretaries and custodial staff
• Connect with administration and share how happy you are to be at the school
• Complete a monthly calendar for annual IEP and re-evaluation due dates
• Access or create a caseload spreadsheet with student names, grades, service minutes, communication domains (articulation, language, fluency, etc.), and additional special education services
• Begin the on-going process of scheduling students (magically triangulating student needs, school/class schedules, special activities, additional services, teacher feedback, etc.)
• Start a data collection and attendance system to document services
There are a few more activities that might be beneficial:
• Clean-out the space
• Look at the room from a child’s perspective
• Thank the prior clinician
Clean out the space: Colleagues have recently spent hours cleaning out neglected speech rooms. There were file cabinets with materials from the 1980’s, including moldy felt board storybooks, and mimeograph worksheets for an old paper-duplicating machine that was discontinued with the invention of the photocopier. There were two nonfunctioning Language Master Systems (early recording and audio systems that used magnetic tape) and prior editions of standardized tests that are no longer valid. As tempting as it is to just close the file cabinet drawers and leave the mess for another 10 years, don't do it. By leaving piles of already worthless materials untouched, you may be subjecting a newly hired clinician, who just graduated from college, to start the year completing an archeological exploration into the history of Speech Language Pathology. Recycle, donate, discard, or repurpose materials!
Child’s Perspective: Adults are not the same height as children. Sit on the floor. Sit on your knees. Change your height and look all around the room. Think about what you notice, what you can and can’t see, and what you can and can’t access. Design the room from the point of view of the child.
Thank the Prior Clinician: Every child can make a card for the prior clinician.
• Use blank cards or construction paper and art supplies to have students make cards
• Provide a model of the typical layout and format of a card with the correct spelling of the clinician’s name and common words
• Provide a choice of three different writing prompts:
o Thank you: “Let’s think about speech class last year. What kinds of things did you do? What kinds of things did you learn? This is a thank you note. What’s one thing that you want to say thank you for?”
o Advice: “Your speech teacher from last year has a new job. What is some great advice that you want to give your speech teacher for their new job?”
o Summer news: “You might have done some interesting things this summer. Let’s think about what fun/interesting/funny things happened this summer. What summer thing do you want to share with your old speech teacher?”
• When all the cards are completed, you can send them as a packet to the prior clinician
We can start the year with closure, with gratitude, and with an organized fresh start!
I hate making clinical mistakes. They make me feel bad about my skills and myself. Mistakes may often be based on lack of information, which affects the development of a relationship. Sometimes the desire to make a difference as quickly as possible negatively affects the collection of comprehensive background information and prolonged rapport-building activities. Often mistakes can come from not knowing our clients as well as we should.
Lack of information can be in any area:
• Client history
• Client temperament, personality, and interaction styles
• Child preferences and interests
• Client communication and learning strengths
• Family understanding of communication disorders
• Family grief stages and fears
• Family expectations
• Teacher concerns
• Classroom curriculum and objectives
• Peer interactions and behavioral concerns
A lack of information combined with the false pride of “expertness” is a dangerous combination. We may know about communication disorders and be highly trained in providing intervention, but that doesn’t mean that we automatically know about the needs of every single client.
Gathering information takes time. Mistakes are often based on rushing to act before learning as much as you can about a client.
When I make mistakes, I move through stages:
• Discomfort: Something about that session or interaction didn’t feel right.
• Confusion: What made it feel off?
• Shame: I can’t believe that I didn't do a good job.
• Anger: Why is this so hard!
• Self-righteousness: I’m a skilled professional. What I do is important.
• Reflection: There are lots of different ways to accomplish a goal.
• Awareness and understanding: I know how I could have made it better.
• Remorse: I wish that I could go back in time and do it over.
• Learning and planning: I will design systems and strategies to prevent this from happening again.
• Apologies and amends: I will let the client and the client’s family know that I am sorry and provide suggestions about what might work better in the future.
Whether we are new clinicians or have many years of experience, we may still need basic systems and procedures to make sure that we aren’t skipping steps and starting with only limited information. We can create our own checklists, reminders, routines, forms, etc., that require us to slow the process and proceed methodically.
Rapport comes from knowing and understanding our clients and their needs. Although we may be able to intuit a great deal of information based on our clinical experience, we can also incorrectly assume that we know more than we do. Taking time to learn about our clients lets us create a therapy plan that matches who they are. I still make mistakes sometimes, though fortunately, mistakes help us learn. There’s always something new to learn because every client is a unique individual!