The ‘is’ and ‘isn’ts’ of Speech and Language Therapy

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When people ask me what I do and I tell them I’m a Speech and Language Therapist, I’m usually met with 1 of 3 responses:

Response 1- “Oh, I better make sure that I speak properly around you!”

Response 2- “So you work with people who stammer?”

Response 3- “What, with your accent?!” (I’m from Northern Ireland and I work in England…This seems to blow some people’s minds…!!)

It strikes me that Speech and Language Therapy is quite a misunderstood profession.

It doesn’t necessarily bother me that people don’t understand what I do. What concerns me is that if people don’t fully understand the remit of a Speech and Language Therapist (SLT), children with more subtle speech and language difficulties may fly under the radar. They may not be referred for speech therapy because parents or educators may not see the child’s difficulties as being ‘language’ related.

The statistics for undetected and therefore unsupported language difficulties are quite harrowing:

-Children with vocabulary difficulties at the age of 5, have a higher rate of unemployment at age 30,
-Primary school aged children with developmental language disorders are more likely to experience mental health issues in adulthood,
-Up to 60% of young offenders have Speech, language or communication difficulties. *

I could continue to provide you with many similar statistics but they all amount to the same fact- good communication skills = a better quality of life.

That’s why I thought I’d use my blog post today to clear up a few misconceptions about speech and language therapy. Instead of ‘dos’ and ‘don’ts’, this is my list of ‘is’ and ‘isn’ts’- what speech and language therapy is and what it isn’t!

Speech therapy isn’t elocution!
A few years ago I received an email asking if I offered ‘execution lessons’…While I can only assume someone’s autocorrect was playing tricks on them, as much as I don’t offer execution lessons (!!) I equally don’t offer elocution lessons!

SLTs do support children and adults who have difficulties producing speech sounds. This may be a simple developmental issue such as sound substitutions (e.g using ‘t’ instead of ‘c’ so that ‘cat’ would be pronounced ‘tat’) or something more complex such as verbal dyspraxia in which an individual struggles to coordinate their oral muscles to sequence speech sounds.

-Speech Therapy isn’t just something that takes place in clinics and hospitals!

I think traditionally, people view Speech and Language Therapists within a ‘medical model’, based in clinics or hospitals. And yes, some SLTs do work in these settings…But we also work in the community, in people’s homes and in schools.

I split my working week between special schools and mainstream schools. In a school setting, health and education merge to meet the child’s needs. Having a good understanding and use of language is crucial to enable children to access the curriculum.

Speech and Language Therapy isn’t just about talking!

Communication is a complex, multifaceted skill. To chat with others, you must understand the conversation, be able to remember what has been said, interpret body language, select the words you want to say, structure them in a sentence, etc, etc!!

Speech and Language Therapists support people who struggle with any element of communication. That may be by developing a person’s understanding of language, working on auditory memory skills, developing vocabulary, supporting verbal reasoning skills, etc..!

This is what I love about my job- the variety! Of course, all SLTs will specialise in specific areas but we have to draw on our knowledge of all aspects of communication to support each individual.

Speech therapy advice is beneficial for supporting ALL children, not just those with identified needs.

Training is quite a significant aspect of an SLT’s role….And while we provide training on supporting children with speech and language difficulties, SLTs can also provide whole school training on approaches that can benefit all children. Vocabulary development, memory, verbal reasoning skills- these are just a few training sessions I’ve run within school settings, focussing on supporting every child in the classroom! After all, every child can benefit from a language rich environment, with strategies to support their learning!

Speech therapy is tried and tested!

SLTs are getting better at the majorly important concept of evidence based practice! We understand that it is crucial to use tried and tested therapy approaches. The Communication Trust even have this handy database on their website known as ‘What Works?’ (http://www.thecommunicationtrust.org.uk/projects/what-works.aspx) to keep us up to date with researched interventions and their efficacy.

But in simpler terms, within daily working life you can see results occurring- from supporting  someone who was non-verbal in beginning to use a communication aid successfully, to watching a child grow in confidence in communicating with their peers…There are all kinds of little (and large!) victories that can occur with a little help from a Speech and Language Therapist!

 

This isn’t an exhaustive  list of what SLTs do and/or don’t do; just an attempt to make our role a little clearer. As us SLTs continue to fly the flag to promote our cause, I’m curious if I will begin to get a range of new responses when I tell people I’m a Speech and Language Therapist…!

* For more information on the statistics included in this blog post that specifically focus on the impact of speech, language and communication difficulties, this document by The Communication Trust is well worth a read: https://www.thecommunicationtrust.org.uk/media/31961/tct_genadrift.pdf

 

Laminators at the ready! Making an effective communication book

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It’s time to heat up your laminators and get your hole-punches ready…. We’re talking communication books today!

I love high-tech communication aids as much as the next Speech and Language Therapist but I still find it hard to beat a ‘no-tech’ communication book;  it doesn’t run out of battery and even when it’s looking a bit tired and tattered, there’s that satisfying feeling of knowing it’s been well used!

If you have made a communication book before, you will know it is no mean feat…There’s a lot to consider before you even get to the ‘production stage’.

As someone who has made quite a number of communication books, I have found that there are a few general ideas that seem to contribute to putting together a top class communication book! So here are a few points to consider:

  1. Organisation!

Most people who know me would probably say I can be a little disorganised. Now the problem with that is that I can’t always find things when I need them…

Why am I telling you this?! Well, our children need to be able to find what they want to say in their communication book as easily as possible…And the only way to do this is by having an organised system.

I view communication books as having 3 main organisational systems.  Here are some pros and cons to each system:

  • Category based-The contents page is organised in terms of categories e.g. food, people, feelings, etc.
  • category

Pro: This can be useful for children who are verbal but need something to supplement their speech, providing a bit of context. It’s also a very simple, easily understood format for children who may struggle to navigate through a communication book.

Con: It  can limit what a child can communicate about, making it difficult for conversation to ‘flow’.

  • Socially focused- This type of communication book focuses on 2-way conversation, encouraging the communication partner to also use the book to communicate with the child providing aided language input. You may have heard of PODD books (Pragmatic Organisation of Dynamic Display…Thanks goodness for the acronym!!) which are the gold standard for socially organised communication books! They have topic ‘branches’ that enable the child to expand on their message.

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You can read more about PODD here: https://www.novita.org.au/equipment/podd-communication-books/

You can also find PODD book templates on Boardmaker Online by simply typing ‘PODD’ into search!

Pro: PODD books are an amazing way for a child to have a proper, flowing conversation, adding rich detail. Following the ‘branches’ in the book helps the child to develop a motor plan as to where certain vocabulary is stored.

Con: Parents and school staff are sometimes initially overwhelmed when they see a PODD book- they are big and may look complicated. But with a bit of practice, it soon becomes easy to navigate!

  • Pull-out tabs-Some communication books offer constant access to the same core vocabulary with a pull out tab that can be used with every page of the book. This also frees up space for more vocabulary on the pages!

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Pro: Important words are always available and are always in the same place!

Con: It can be a little fiddly and it may be tricky for the child to initially get used to using the page and the pull out-tab. But the consistency of having the same words to hand, helps the child to soon over-come that hurdle!

It doesn’t matter what system you opt for, so long as it is clearly laid out, accessible for the child and frequently modelled, the book will be a success!

2. Sentence Building with colour coding

Imagine a child using a communication book that only gave them access to nouns. Their food page might have symbols for chocolate, yoghurt, banana, toast, juice, apple, etc.

How would the child tell you that they didn’t want their yoghurt? Or that they liked their juice and wanted some more? Or that their apple had rolled off the table and fallen on to the floor?!

They just couldn’t! That’s why we need to consider giving our children access to a wide range of vocabulary on each page, enabling them to build sentences.

To support sentence building, there are some very clever colour-coding strategies that help children to visually see the building blocks of a sentence.  One of the most popular methods is known as the Fitzgerald Key. Different types of words are represented by different colours. This helps the child to understand the function of words and how they fit together to make sentences.

fitzgerald key

I also like to lay the page out in a logical order, so that common sentence starters are in the first few columns, followed by verbs and/or adjectives in the next columns and then finally, nouns towards the right hand side of the page. This visually helps the child to understand the structure of a sentence.

  1. Personalisation!

It’s important that the child identifies the book as being ‘theirs’. The more personalised, the better! Add photos of important people, places; Google images of favourite TV shows, frequently visited fast food restaurants, etc.

It’s also useful to have the child’s picture at the front of the book and a message from them about how to support them to use their book e.g. “Hi, I’m Becca! This is my communication book. Help me to use it by flipping to the page that I point to…..”, etc.

  1. Protecting the book!

So you’ve spent an entire day, printing, laminating, hole punching….The last thing you’d  want would be for pages to be torn and dog-eared within a few weeks! Communication books are precious! We need to ensure that they are given the respect they deserve!

And for me, the best way to do this is to purchase a sturdy binder…. I love, love, LOVE these purpose made communication book binders from Ability World: http://www.ability-world.com/podd–communication-book-binder-a4—rigid-covers-4475-p.asp

They come in a variety of designs and they are flexible so pages can be flicked through easily. They might be a bit pricier than a lever arch file but they are much more user friendly which is of high importance for communication book users!

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So there you have it- the golden rules that I follow each time I make a communication book!

While it may be time consuming and laborious at times, the results of a well designed communication book are worth the effort. Let’s make great communication books that our children are excited to use!

Right, I’m off to do some more laminating….!!

‘The difficult second word’- Moving from single words to forming phrases

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Thomas Jefferson is famously quoted as saying, “The most valuable of all talents is that of never using two words when one will do”- Wise words that I often try to remind myself of when I’m typing an overly wordy email!

However, most of the time, one word or even a short phrase is simply not enough to convey what we mean.

If you work with children who use AAC you will know that moving from single words to combining words is a big deal!! You know the way musicians talk about ‘the difficult second album’? I sometimes think of it in these terms when working with children who use AAC- ‘The difficult second word’..!

Some children get ‘stuck’ at the single word stage for quite some time. Communicating through single words is not only limiting but it also leaves our message open to misinterpretation.

I’ll give you an example- I work with a young girl who uses an eye-gaze communication aid and who happens to be a Justin Bieber fan (Who doesn’t love a bit of ‘Despacito’?!). It is not unusual to hear her announce, “Justin Bieber!” (2 words but 1 symbol!)

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Now what does this mean? I model combining 2 symbols- “Are you telling me that you  ‘like‘ ‘Justin Bieber’? Or you ‘want‘ ‘Justin Bieber’ on YouTube?” Equally, it could mean, “Look, Justin Bieber just walked past!”

Implausible, yes, but one word can have multiple meanings!

So how do we move our children using AAC past single words on to the tricky concept of making phrases? Here are a few ideas to try!

– Core words are key

Quite frequently, children starting out using AAC will have a very ‘noun heavy’ vocabulary. That’s because requesting has possibly been their main function of communication.

Typically, the most frequently used words by verbal children are NOT nouns- They are modifiers (more, different, some), verbs (help, like, stop), pronouns (I, you, they), etc. These are what we think of as core words.

Core words are the words that we use again and again in a variety of contexts. Here is a lovely list compiled by AAC Language Lab of 100 important core words. This list combines the research of multiple authors, interested in the high frequency words of children:

https://aaclanguagelab.com/files/100highfrequencycorewords2.pdf

The thing about core words is that they are often the foundation for forming a phrase. Have a look at the list and think of how many simple phrases you can make using these words alone! And then when you start to add in all those nouns that a child already knows, there are endless combinations of phrases that can be created and used in multiple contexts!

So when you are introducing an AAC system, don’t forget to always provide access to core words and constantly model their use!

Expand!

This is a standard principle of language development; when a young, verbal child is learning to speak and they say a word such as “Car!”, an adult adds an extra word to model a phrase e.g “Yes, fast car!”

This principle is exactly the same for AAC users! The only modification is that we model this using their AAC device (this may be a high tech VOCA or a simple communication book).

The child points to “Cake” in their communication book and you then expand on this, adding an extra word, pointing to the symbols and saying, “Oh, ‘more’ ‘cake’!”

Repeated phrase structures

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There are lots of set phrase structures that we use in the English language again and again e.g Person + Verb (“Joe is reading”). It makes sense that we introduce our AAC users to certain phrase structures, creating opportunities to use variations of a phrase multiple times in one activity.

Here are a few possible word combinations that can be targeted in motivational activities:

Person + ‘turn’– When playing a group game, give your child using AAC an important role- They have to tell the group whose turn it is using the person’s name + the word ‘turn’. This is a nice way to introduce word combinations as the word ‘turn’ remains the same each time, only the person’s name has to change! Also don’t forget to model ‘my turn’ and ‘your turn’, introducing pronouns.

– ‘More’ + artist’s name– Make a YouTube playlist of your child’s favourite songs. During each song, pause the track at least once. The child then has to request ‘more’ + the artist’s name. To expand on this, add a few songs that they can’t stand! Then you can work on ‘stop’ + artist’s name!

Person + verb-  Play an adapted version of ‘Simon Says’;  the child has to choose a person and then an action for them to perform. Most children particularly enjoy involving class staff in this game (e.g “Mrs Smith dance”)…! Class staff might not enjoy it as much but hey, it’s all in the name of communication!

Opinion + activity- Children like to talk about their hobbies…but even more than that, they like to give opinions! I tend to start with symbols for ‘like’ and ‘don’t like’ and then introduce more specific opinion words such as ‘funny’, ‘boring’, ‘exciting’, etc. This idea works well as a group activity. Each child can choose an activity and then give an opinion e.g ‘Like swimming’, ‘Don’t like cooking’, etc.

– ‘Want’ + body part/clothes- A simple game to play with Mr Potato Head! e.g. “Want eyes”. Easy but effective!

 

Once a child has a solid bank of 2 word phrases, it won’t be long before they start experimenting with adding more words. They will have now established the concept of joining words together and you can continue to model how to expand things further.

In the world of music, the third album is never as difficult as the second…In the world of communication, once those second words become spontaneous, three and four word phrases shouldn’t be far behind!

Reluctant Communicators- When Plan A doesn’t work

In all of my blog posts so far, I’ve talked about how wonderful the power of communication is…I mean, who doesn’t love to chat?! Who doesn’t want to tell a story, give an opinion, ask a question…?!

Well, actually quite a number of children with communication difficulties! I’m sure we have all experienced working with children who don’t have that burning desire to communicate (and how many of us can relate to that feeling ourselves, when we’re running on empty and the caffeine has worn off?!)

Children with complex needs often have fantastically supportive adults around them who can read what they want or need…This telepathy can be a useful skill but the problem is, sometimes our children no longer feel the need to communicate. We see them glance at the telly so we turn it on. Maybe they look a little rosy cheeked, so we take their jumper off. It’s 11am so they are probably hungry, let’s give them a yoghurt…

This pre-empting can often cause one of two problems:
1. The child gets frustrated at not having a choice in what happens to them, resulting in communication through behaviour,
2. The child becomes passive. They have learned that things happen regardless of how they think or feel. Communication seems to have no real value.

Today I’m going to focus on child number 2. How do we motivate a passive child? How do we find a way to develop intentional communication?

Plan A doesn’t always work. I’ve been there before; I’ve tried something that I think is guaranteed to work and then I am baffled when it doesn’t. So I now have a selection of back-up plans- Plans A, B and C!

PLAN A- Find a motivator… and then stop

Before I start working with any child, I always like to find out from class staff or family what the child is interested in…What really floats their boat!

And I always bring along my trusty tool kit of motivators which includes all of the usual things that SaLTs cram into their handbags- bubbles, a ball, an iPad filled with pre-stored music (theme tunes, chart hits), chocolate buttons, a cause and effect type toy, etc, etc! As you can imagine, my work bag is pretty big…!

Having a strong motivator provides the child with a reason to communicate. But the catalyst for communication really occurs when we suddenly stop that motivational activity- when we put the lid on the bubbles or pause the music.

And then we wait.

We wait for the child to indicate that they want more of this activity. This might be through a vocalisation or grasping for the object. Or it might be something as simple as making direct eye-contact.

After the child has initiated communication through some means,  I then like to introduce the symbol for the word ‘more’. I model its meaning and allow the child to become familiar with using the symbol as I frequently pause their motivational activity.

Sometimes I record ‘more’ on a Big Mack switch if the child needs more auditory reinforcement.

‘More’ is always a powerful word to start with when working with a reluctant communicator…and then once they’ve mastered ‘more’, you can introduce the symbol for ‘stop’ to increase their control of the activity!

PLAN B- The red herring

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Choice-making is often a great starting point for communication. But it’s not quite as simple as holding up 2 toys from which a child can make a choice.

Think of it this way- If you present a child with 2 highly motivating activities to choose from, the chances are that the child might think, “Both of these activities are fun…I don’t care which one we do!”

The child appears passive because they know they will get to play with something that they like regardless of what they do.

This is why I like to introduce a red herring-something that the child is disinterested in. I try to find the most boring thing possible, like a paper towel or a sock.

The child might think you are crazy, but they quickly realise that they better make a choice before they end up playing with a sock!

Once you have established some definite choice-making, you can gradually phase out the red herring and develop choice boards or simple choice pages on low or high-tech AAC devices.

The image below is a template for a Go Talk 4, looking at choice making when singing nursery rhymes, also incorporating ‘more’ and ‘finished’.

PLAN C- Creative silliness

I used to work with a child who was a bit of a puzzle to me. I tried every possible motivator I could think of, but nothing seemed to interest him.

One morning, I was supporting him in his classroom during an art activity. Whilst walking across the classroom to get some coloured card, I tripped- a full on, comedy fall, with my arms waving above me!

Then I heard a giggle.

I looked up and my ‘hard-to-motivate’ child was grinning at me! Yes!!! I’d found something that he liked!! Some of the children who we typically find difficult to motivate simply don’t find communication fun…And it’s our job to show them just how fun it can be!

So I made some ‘Simon Says’ style eye pointing boards with 4 symbols. He immediately loved this activity, enjoying the element of control by making me pretend to sleep, dance, cry or fall!

Children love a bit of creative silliness! ‘Simon Says’ is just one example but basically the sillier the better!

Another fun example is a game of ‘dress up’- you can get the children to choose an item of clothing and then who they want to wear it. You can even introduce symbols such as ‘like’ and ‘don’t like’ to expand on the communication, making comments as well as requests.

 

The important thing to remember is that once a child starts to demonstrate intentional communication as a result of Plans A, B or C (or other variations…!), build on that! They are demonstrating that yes, they DO want to communicate but they need reasons to do so. Let’s not be so quick to jump in, assuming the child’s wants and needs. Let’s give them a little time and the vocabulary to take back some control!

 

A sprinkle of ‘Pepper’- How to be an effective communication partner

We’ve all been there- that moment when a friend or colleague introduces you to someone new at a party or a work function.

You greet each other and then your friend gradually steps away…

And that’s when you realise that this conversation is not going to ‘flow’.

You struggle to find common ground. That horrible, awkward feeling starts to infiltrate the atmosphere. Speaking is so effortful that you frantically concoct a reason to excuse yourself…

 

I think of this feeling when I consider how some of the children who I work with must feel, especially when they are learning to use a communication aid.

They know that some people ‘get it’ and will help them to feel relaxed, making it easier for them to communicate. But others? Well, it’s like the party analogy; communication breaks down and everything just feels uncomfortable.

We want to strike the right balance-  supporting our children in learning to use their new communication system but also ensuring that they feel motivated to communicate. And that can be tricky…!

I came up with an acronym to remind myself of some tips on being a better communication partner…It just so happens to spell the word ‘Pepper’ (SaLT and Pepper, anyone…?!)

So here’s how we can sprinkle some pepper on our conversations:

Presume Competence-

This little phrase comes up again and again in AAC literature. It goes without saying- just because someone is non-verbal it doesn’t mean that they don’t have anything to say! Our children using communication aids can become very competent communicators with the right support.

We need to set achievable targets and when they meet those, then challenge them a little bit more! Presume that our children can always initiate more, tell us more, begin to use more vocabulary, etc…Let’s give them the opportunity to show us their full potential in a supportive, communication-rich environment!

Eye Contact-

People who use communication aids often take a bit more time to formulate their message. The temptation is to look away during an uncomfortable silence.

But we need to demonstrate to our children that we are interested in what they are saying; that we are listening.

In any interaction, we do this by making appropriate eye-contact.

This shouldn’t obviously be an intense ‘under-pressure’ stare (!)- the goal is to let the speaker know that we value what they are saying and that we respect them as a communication partner.

Pause-

Sometimes It can be tricky for someone using a communication aid to ‘enter’ a conversation; to find a way in.

How do we support them?

By pausing frequently!

Pausing invites our children to make a comment on what has been said, to ask a question, to share their own stories… Don’t forget to make your pauses long enough to give the child time to process what you’ve said and to come up with their response.

Prompt- 

So you’ve paused to invite your child using AAC into the conversation and they don’t respond. Maybe they don’t have anything to add. Or maybe they’re unsure of what to say/how to say it- after all, learning to use a new communication system is tough!

We can gently prompt our children by guiding them in how to continue a conversation.

Let’s say, for example, their friend is talking about their weekend… and then there is that pause, signalling it’s someone else’s turn to talk.

I tend to use a bit of a hierarchy of prompts:

I like to start with an indirect prompt e.g “I wonder if Ben did anything interesting at the weekend…?”

If this doesn’t spark a response, I might move on to a direct prompt e.g “In your activities page there are some things you might have done at the weekend”.

For children struggling to navigate through their new device, I might need to provide a manual prompt, taking them to the correct page while talking them through each step.

Don’t rush each prompt; your child might just require a little extra time!

Engage-

Going back to the ‘awkward party conversation’ analogy- if we are not engaged in a conversation, we lose interest. We try to step away; to find a way of escaping.

It’s exactly the same for our children! We need to engage with them in conversations that interest them. To do that, we need to follow their lead; pay attention to the things that they are interested in and then create opportunities to talk about those things!

-Restate

A child learning to use a communication aid will sometimes make mistakes. They might say the wrong word, leave words out, jumble up their ideas…

And that’s ok- we all frequently make mistakes in our speech or struggle to find the right words. Count how many times you say ‘umm’, ‘erm’, ‘like’, etc in a conversation and you’ll see what I mean! Our speech isn’t always fluent.

When a child forms an incomplete phrase or says something that others may not fully understand, we can model the sentence back to them or summarise what they have said (restating).

For example, a child might join 2 or 3 words together to make a short phrase e.g. “Mr Tumble favourite”- we know what they mean and to demonstrate that we can say, “Oh Mr Tumble is your favourite?!” To support them in developing their use of phrases, we might even point to the symbols as we say the words, demonstrating how they can expand on their message.

So just to re-cap:

P-presume competence, E- eye-contact, P-pause, P- prompt, E- engage, R- restate

Maybe a little pinch of pepper might enhance our children’s conversations?! Let’s try not to be like that awkward party guest that our children using communication aids want to avoid…!! After all, a good communication partner = good communication!