Speech Language Pathology, A Collaborative Art

Speech Language Pathology – What is That? By the time the Masters Degree in Communicative Disorders has been awarded to a student from an accredited university, that individual has been educated to provide a broad spectrum of services to those who experience cognitive, voice, speech, language, oral motor, myofacial, articulation, and swallowing disorders. Gaining state licensure, special services credentials, and the Certificate of Clinical Competence require further site-specific training and testing which increases the ability of the Speech Language Pathologist (SLP) to work with clients. Some SLPs choose to work in very specific specialty areas, others remain general practitioners and still others go on to receive more advanced degrees. Some work with their focus on research to glean new insights and develop new therapies. The field is broad and constantly evolving. The work on all levels is to be congratulated. For the purpose of this article it is necessary to narrow the focus of the many areas of contributions made by Speech Language Pathologists. In this article therefore, the individual and collaborative roles of the SLP serving clientele ages 3-18, in school based settings, will be discussed. In this population the most common calls for intervention are based upon the need for remediation in articulation of speech sounds and in language development. The SLP as Speech Therapist and Collaborator In the school based setting children as young as three years of age receive speech therapy for remediation of misarticulated sounds in words. Many factors may contribute to articulation difficulties and is it beyond the scope of these articles to investigate the possible causes. What is important is that children who demonstrate some types of articulation difficulties have been found to be at risk for language and reading delays. This is especially true for children who demonstrate phonological processing difficulties. These difficulties are noticeable in two major forms: whole word and segment related. For Example, words may have sounds deleted, (“Sesame Street” may change to “sisi”) or may have sounds changed (“cat” may change to “tat”). With therapy and the acquisition of sounds the risks for delays in language and reading diminish. When a young child demonstrates articulation difficulties beyond those of his or her peers, Speech Therapy is often recommended. At that point the collaboration between parents, therapist, and the school begins. Schools will evaluate the oral motor function of the child as well as the speech sound production. If a hearing screening has not been performed by the child’s physician recently that will usually be done as well. If therapy is recommended, and agreed upon, remediation will begin. With very young children often the only time they will “work” on speech production is in the clinic or speech room. Parents will frequently be asked to participate only by making sure they model good speech themselves, repeating their child’s utterances in a correct, yet matter-of-fact manner. As the child becomes more familiar with the process, parents may be asked to practice particular oral motor movements or speech sounds at home. It is important that those most involved with the child are informed of the ongoing therapy, and are consistently supportive of it. For example, if a three year old attends day care, the day care center may receive (with the parent’s permission) a copy of the child’s goals and progress toward those goals. They may attend meetings about the child and exchange ideas on how best to help the child. With older children (five years and up) therapy takes place in the therapy room at school and often includes homework practice sheets with daily work recommended. With today’s schedules, this may seem very difficult for parents to accomplish; however, as in any other form of therapy, collaboration is the key. It has been my experience that the children who make the swiftest changes, including generalization of speech skills, are those whose families and school environments participate in and applaud their progress. The SLP as Language Therapist and Collaborator According to the U.S. Department of Education (2000b), 19.4% of students served under IDEA were categorized as having speech and language impairments. More specifically, the department reported a significant growth in autism with lesser, but significant increases in ADD and ADHD (243.9% between 1989 and 1999). The SLP caseloads reflect these changes and increasingly include children with auditory processing and word finding difficulties as well. Let us take a look at the segment of the population of children who have been or are in the process of, being diagnosed with High Functioning Autism, Asperger’s, ADD, ADHD, Auditory Processing Difficulties, NLD, SLI, and Word-Finding Difficulties. This group may appear too large to be considered a “segment” and yet there is a common thread that joins them together. Children with these disorders, generally speaking, all show difficulties in narrative communication, which includes the area of pragmatics, be it written or spoken. They are the children who appear awkward or overly shy, or pushy, insistent, too loud, or too absorbed in their own interests. They may attempt to share ideas but don’t have the perspective taking or imaginative skills that allow for interaction. They are the children who don’t take turns at play or in conversations, yell out their answers in class, and have little patience for their own inabilities or those of others. They may be labeled as shy or appear to ignore other’s feelings; they may sound rude, or overly insistent and demonstrate a limited range of emotions. In other words, they stand out socially. These are the children who will benefit from overall language therapy, with specific segments of therapy targeted to increase semantic, syntactic, morphologic and especially pragmatic aspects of language. The overarching purpose is to help the children realize and express themselves as social beings, as members of a larger society, and as students able to learn in classrooms. In other words the purpose is to develop and provide therapy that expands narrative (social communication) skills. Narrative skills afford us the ability to speak about our experiences. Developed skills include the ability to attend to pertinent information and to organize or sequence ideas into comprehensible linguistic units. Further, narrations allow actions, experiences, feelings, and information to be analyzed and reflected upon and evaluated against the prevailing social, moral, and ethical peer, familial and community standards. As such, narrative skills not only allow us to communicate with others (to be social) but to learn about communication (how one goes about being social) itself. Linguistic Competence involves learning words and their meanings (semantics), and developing the skill sets necessary to comprehend and construct grammatically (syntactically) correct utterances. Pragmatic Competence refers to the individual’s ability to use language to accomplish social purposes. It involves understanding and using social rules of language to convey messages that are contextually appropriate. Pragmatics encompasses not only the words said, but the style, intended meaning, and purpose of the message. In conversational exchanges a competent participant demonstrates appropriate body language, (including eye contact, modulated tone of voice, posture, and proximity), topic introduction, maintenance, conclusion, or segue, and conversational repair strategies (such as the ability to ask for repetition or clarification). A competent participant, taking into consideration age appropriate behavior, will demonstrate a highly developed Theory of Mind, the ability to think about others and to think about others as having a perspective other than one’s own. When thorough testing indicates the existence of poor pragmatic skills and under-developed perspective-taking skills, and/or narrative discourse deficits, we may expect a child to experience a broad array of difficulties in a variety of settings including school, home, and extra curricular activities. As demands in school based work become more complex and abstract, a child may experience more difficulty. When the problem is compounded, such as when a child experiences both language processing difficulties as well as pragmatic language difficulties he or she may not be able to recognize when important information has been missed, or to express a need for help, clarification, or repetition of important ideas. Moreover, if the child perceives him or herself as not being in sync with classmates, he or she may experience distress. Informed by a solid multi-dimensional Speech and Language evaluation, anecdotal reports from parents, informal and formal assessments from a variety of sources such as teachers, audiologists, occupational therapists, and school psychologists as well as diagnostic reports from medical doctors and/or neuropsychologists, a clear, well thought out plan for therapy may be constructed. At such a time actor/director Ron Howard’s words regarding filmmaking and directing come to mind: “It’s all about imagining something, then somehow facilitating its execution”. A plan needs to be developed that will provide the most benefit to the child, then a way to implement that plan needs to be worked out. Given this perspective, the role of the Speech Language Pathologist, first and foremost is that of collaborator. Parents, teachers, and all who have contributed to developing a “picture” of the child in question need to be taken into consideration as a therapy plan is developed. No goals can be truly accomplished without the participation of all those who have contributed to the plan. Collaboration across settings, among parents, teachers, therapists, and the student needs to be established. Often these children need highly structured environments (including home and classrooms), which make use of consistent behavioral requirements in a supportive atmosphere steeped in sensitivity to learning and interaction difficulties. Compensatory strategies, such as multimodal (visual, auditory, kinesthetic) instruction, rephrasing of complex auditory messages, written as well as verbal directions, and requesting confirmation of comprehension may be needed across environments. While at school, these children should be included in break time conversations and activities rather than left alone. On all fronts they often appear to require assistance in acquiring the skills to easily enjoy the company of others. For Language Therapy in the school setting, individual, small group and full class sessions can be highly beneficial. In determining the best approach for each individual child, it is important to refer back to the test results and distinguish between linguistic competence and pragmatic competence. For children whose dominant need is to develop linguistic competence, individual or small group sessions to build memory, processing, vocabulary, word finding, and/or syntax skills may suffice. In these cases the families become the main collaborators, insuring that the child practices, builds confidence, and is held accountable and is rewarded for their efforts. Teachers and therapists collaborate to insure that progress seen in the confines of the therapy room is generalizing to the classroom situation. When narrative and pragmatic skills appear underdeveloped, the collaborative effort may involve individual, small group and full class intervention. This is especially true when a child is placed in a Special Day Class setting. What ever setting is chosen, all aspects of language should be considered and addressed. For example, a child with very good linguistic skills may test with high vocabulary scores, but have no idea how to understand or use figurative, non-literal language, nuance, or tone of voice in verbal messages. Furthermore, a child with very good linguistic and decoding skills may do very poorly on comprehension checks. Therefore, a well rounded program deals effectively with developing vocabulary (in all of its aspects), and sentence structure, as well as the pragmatic aspects of language. The pragmatic aspects, as has been stated, deal with learning perspective taking, conversation, body-language, emotional inventory and narrative skills. It has been the experience of this author that overall language skills are often best addressed in a full class situation. Here the SLP, working in tandem with the classroom teacher is able to co-instruct students in the totality of language. Lessons can be devised which infuse the study of core literature with increased visualization, social communication, and narrative skills. Still other lessons may involve the entire class in theatre arts, drama, games, and hosting skills. Using the background provided in the course of study necessary to become an SLP, mixed with the knowledge of the classroom teacher, especially when backed up with parental support and participation, a powerful combination of resources is generated which can give a clear advantage to a child in need. It is my very deep belief that the therapy we Speech Language Pathologists offer is not a stand alone entity that can act as a cure-all, but a simple and hopefully well schooled, imagined, and directed offering to support growth. Outside of the purview of schools wonderful therapies are offered that integrate the work of Social Workers, Counselors, Psychological Therapists, Educational Therapists, Occupational and Physical Therapists among others. It was simply beyond the scope of these articles to mention everyone who brings tremendous benefit to our children.