About Kristin Banach, Senior Marketing Manager

Senior Marketing Manager

One of the best things you can do for your clients with right hemisphere brain damage

By Margaret Lehman Blake, PhD, CCC-SLP
Author of The Right Hemisphere and Disorders of Cognition and Communication: Theory and Clinical Practice

It can be difficult to know what to do with clients who have right hemisphere brain damage (RHD): how to assess them, what to treat, how to treat, etc. It’s not surprising, because (a) there is less collective knowledge within the field and (b) there are limited opportunities to acquire the knowledge that does exist. As for the amount of knowledge, aphasia was “discovered” and named the 1860s. In contrast, the impact of RHD specifically on communication and language has only been recognized since the 1960s, so we are behind by a century! As for the opportunities to acquire the knowledge, the problem starts in graduate school. While a majority of graduate programs have stand-alone courses on aphasia, RHD is typically covered as one of several topics/etiologies in a cognitive disorders course. I would venture that a majority of graduate programs have an expert in aphasia on faculty, while only a minority of programs have anyone interested in RHD. It is equally difficult to find continuing education about RHD after graduate school. In the past three years at the ASHA Convention there have been only between 6 to 9 presentations on RHD each year. In contrast, the number of presentations about aphasia has ranged from 177 to 269.

There is not enough room here to provide tips and advice for how to tackle all of the disorders associated with RHD, so I’ll just mention the one that I think is the most critical: talk to families. While SLPs likely talk to families of all of their patients/clients, it is especially important when working with someone with RHD. The purpose is two-fold: first to get information about how the patient has changed following the stroke, and second to provide information and resources to the families.

Getting information from the families about how (and if) the patient is different is essential. When it comes to pragmatics, there is no clear cut-off between being “normal” and being “a bit odd” as a result of brain damage. Add to that cultural differences in how people communicate (both verbally and non-verbally), and it may be nearly impossible in some cases to determine if someone has a pragmatic deficit or not. For example, just the other day I was assessing a man with RHD for a research project. In the small talk at the beginning of the session, I found out that he was originally from Wisconsin, so I asked him what brought him to Texas. He replied, “a 1972 Chevy truck”. If the exchange ended there, and I had no information about his personality from his family, I could have thought, “Aha! Typical RHD, he’s overly literal in his interpretations” and decide that I might want to target pragmatics in therapy. But the exchange did not end, and he followed up that response with an appropriate explanation of a change in jobs. Additional information from his family regarding whether or not that kind of response was a typical pre-stroke behavior would allow me to make a more appropriate decision about therapy goals.

The second part of talking with families is to provide education. They need education about the variety of problems that may occur and who they can contact for help. While families may get information about unilateral neglect from neurologists, SLPs are the ones who can educate families about pragmatics and communication. SLPs are the ones who can explain how RHD can affect theory of mind, cause a person to no longer accurately interpret another person’s intended meaning, understand their point of view, or become more egocentric and self-focused. SLPs are the ones who can explain that changes in theory of mind and emotional processing may result in changes in empathy. SLPs are the ones who can explain that appreciation and use of humor might change after RHD. SLPs are the ones who can explain that deficits in problem-solving and reasoning can affect communication, such that a person may not be able to notice or fix a communication breakdown, or figure out that the breakdown was mostly their fault. SLPs are the ones who can explain how prosody, facial expression, and body language are critical to communication, and that all can be affected after RHD. And most importantly, SLPs are the ones who can explain that they can treat these deficits.

Educating families about RHD is especially important because some deficits may not become apparent until the patient goes home. For example, an egocentric perspective and limited empathy for others might be considered normal for anyone in the hospital after a life-changing event such as a stroke, so it may not be identified as a deficit until the patient goes home and his spouse observes a lack of empathy in everyday situations. A patient also may seem to have a blunted sense of humor that in acute care may not seem unusual given the situation, but it may become really obvious when she goes home and her husband can’t joke with her like he used to, or conversations just aren’t “normal”.

When these kinds of changes become apparent, most families won’t think, “I should ask for a referral to a speech therapist”, because the person’s speech generally is fine. SLPs need to provide that link for them when they have the chance, so that when the deficits become apparent, the families will know where to go for help.

Despite the limited number of evidence-based treatments, I believe that SLPs can provide effective treatments to adults with RHD. Our knowledge about pragmatics and cognition can go a long way in addressing the deficits that limit participation in activities important to our clients. We just might increase interest in RHD, which would lead to more research, more experts in the field and more opportunities to learn about the problems, which in turn would spark more interest, lead to more research, and on and on.

Effective Mathematics Interventions

By Margaret M. Flores, PhD, BCBA-D, Auburn University
Co-author of Making Mathematics Accessible for Elementary Students Who Struggle: Using CRA/CSA Interventions

 

According to the National Center for Educational Statistics (2016), the 2015 National Assessment of Educational Progress showed that 18% of fourth grade students performed below basic levels of achievement, meaning that they did not demonstrate mastery of fundamental skills. Students’ mathematical difficulties begin with understanding numbers, basic operations and their novice conceptions lead to further difficulties with complex operations and fractions (Fuchs et al.; Jordan & Hanich, 2003; 2016). Students who struggle in mathematics comprise a diverse group which includes students with identified disabilities as well as students without disabilities (Powell, Fuchs, & Fuchs, 2013). There is a critical need for effective implementation of interventions that have been shown to be effective through research. One effective approach that can be adapted across mathematical concepts is the concrete-representational/semi-concrete-abstract sequence (Miller, Stringfellow, Kaffar, & Mancl, 2011; Witzel, Furguson, & Mink, 2012; CRA/CSA).

What Is CRA/CSA?

The CRA/CSA sequence in an instructional approach to mathematics that emphasizes conceptual understanding prior to procedural knowledge and fluency. There are three phases: concrete, representational/semi-concrete, and abstract. The concrete phase of instruction involves the use of objects to complete mathematical tasks or solve problems. During this phase, teachers explicitly teach concepts through the manipulation of objects. The representational/semi-concrete phase continues to focus on the development of conceptual understanding, but problems are solved using pictures and student-made drawings. Once students demonstrate understanding of the target mathematics concept at the representational/semi-concrete levels, they learn to solve problems using just numbers, the abstract phase. During the abstract phase, the focus of instruction is on procedural knowledge and fluency. The benefit of including the CRA/CSA sequence into mathematics interventions is that the concrete and representational/semi-concrete phases provide students with needed remediation in their understanding of whole numbers, the base ten system, operations, and rational numbers (fractions). The physical manipulation of objects, drawing, and visual aid of pictures fill in the gaps that exist in their prerequisite knowledge and understanding about mathematics. Another benefit of these physical and visual aids is that they assist students in making meaning of mathematical language and using language to explain their computation or problem solving.

CRA/CSA and Number Concepts

The CRA/CSA sequence has been shown to be effective in teaching young children and elementary students number concepts. Researchers used CRA/CSA to teach preschool students, with and without disabilities, counting skills. This included number sense in the form of visual counting or recognizing that four objects were represented by the numeral four without physically touching the objects (Hinton, Flores, Schweck, & Burton, 2015; Hinton, Flores, & Strozier, 2015). Elementary students also successfully learned how to count this way using CRA/CSA. In addition, Hinton and Flores (submitted) taught rounding skills using CRA/CSA. Using base ten blocks and drawings representing base ten blocks, students learned how to round numbers to the nearest ten and hundred. After abstract instruction using just numbers, students quickly and accurately completed rounding tasks. Mercer and Miller (1992) taught place value to elementary students with and without disabilities using CRA/CSA.

CRA/CSA and Basic Operations

Miller and Mercer (1992) and Mercer and Miller (1992) taught elementary students, with and without disabilities, basic operations using the CRA/CSA sequence. This included addition, subtraction, multiplication, and division. Using objects and drawings, students learned the conceptual meaning of each operation: addition is combining, subtraction is separating, multiplication is combining of groups that are the same size, and division is the separation of groups that are the same size. After instruction at the concrete and representational/semi-concrete phases, students learned a simple strategy to assist in computation using just numbers. This set of steps served as a reminder to (a) attend to the numbers and the operational sign, (b) remember that problems can be drawn if the student has not memorized the fact, and (c) write the answer. Students who participated in this large study become fluent in basic operations and their accuracy in computation increased significantly.

CRA/CSA Complex Operations

Researchers also used the CRA/CSA sequence to teach regrouping skills associated with addition, subtraction, and multiplication (Miller & Kaffar, 2011; Mancl, Miller, & Kennedy, 2012; Flores, 2011; Flores & Hinton, in press; Flores, Hinton, & Strozier, 2014; Flores, Schweck, & Hinton, 2014; Flores & Franklin, 2014). Difficulties faced by students within each of these studies were related to poor conceptions of numbers and the base ten system. The concrete and representational/semi-concrete phases of instruction involved the use of base ten blocks and drawings that bolstered students’ understanding of numbers and why regrouping is necessary in when adding and subtracting large numbers. These studies included students with and without disabilities and led to significant gains in accuracy and fluency.

CRA/CSA and Fractions

CRA/CSA has been shown as an effective way to teach rational numbers or fraction concepts (Butler, Miller, Crehan, Babbit, & Pierce, 2003; Flores & Hinton, submitted). Butler et al. studies the necessity of including a concrete phase within instruction. Students successfully leaned to make equivalent fractions, but those who used fraction blocks prior to drawings performed better than those who only received instruction using drawings. Flores and Hinton taught elementary students equivalency using CRA/CSA as well as comparison of fractions to decimals. At the concrete phase, students made fractions using fraction blocks as well as sets of objects. At the representational level, students shaded shapes and marked number lines. In both studies, concrete and representational/semi-concrete instruction allowed students to understand the proportional nature of fractions which led to their mastery of more complex concepts such as equivalence and relations to decimals.

Summary

The CRA/CSA sequence has been shown to be effective across a variety of elementary mathematics concepts. The materials needed are simple; base ten blocks and counters are readily available in elementary schools. However, it may be difficult for teachers to implement and replicate the research as journal articles are not written in ways that provide detailed descriptions of each lesson component. Therefore, in order to close the gap in mathematical achievement, there is a need for more user-friendly guides for implementation of the CRA/CSA sequence.

References

Butler, F. M., Miller, S. P., Crehan, K., Babbitt, B., & Pierce, T. (2003). Fraction instruction for students with mathematics disabilities. Learning Disabilities Research and Practice, 18, 99–111.

Flores, M. M., Hinton, V. M., & Strozier, S. D. (2014). Teaching subtraction and multiplication with regrouping using the concrete-representational-abstract sequence and strategic instruction model. Learning Disabilities Research and Practice, 29, 75–88.

Flores, M. M., & Franklin, T. M. (2014). Teaching multiplication with regrouping using the concrete-representational-abstract sequence and the strategic instruction model. Journal of American Special Education Professionals, 6, 133–148.

Flores, M. M., Schweck, K. B., & Hinton, V. M. (2014). Teaching multiplication with regrouping to students with learning disabilities. Learning Disabilities Research & Practice, 29(4), 171–183.

Fuchs, L. S., Schumacher, R. F., Long, J., Namkung, J., Malone, A., Wang, A., Hamlett, C. L., Jordan, N. C., Siegler, R. S., & Changas, P. (2016). Effects of intervention to improve at-risk fourth graders’ understanding, calculations, and word problems with fractions. Elementary School Journal, 116(4), 625–651.

Jordan, N. C., & Hanich, L. B. (2003). Characteristics of children with moderate mathematics deficiencies: A longitudinal perspective. Learning Disabilities Research & Practice, 18, 213–221. doi:10.1111/1540-5826.00076

Mancl, D. B., Miller, S. P., & Kennedy, M. (2012). Using the concrete-representational-abstract sequence with integrated strategy instruction to teach subtraction with regrouping to students with learning disabilities. Learning Disabilities Research and Practice, 27(4), 152–166.

Mercer, C. D., & Miller, S. P. (1992). Teaching students with learning problems in math to acquire, understand, and apply basic math facts. Remedial and Special Education, 13(3), 19-35. doi: 10.1177/074193259201300303

Miller, S. P., & Kaffar, B. J. (2011). Developing addition with regrouping competence among second grade students with mathematics difficulties. Investigations in Mathematics Learning, 4(1), 24–49.

Miller, S. P., & Mercer, C. (1992). CSA: Acquiring and retaining math skills. Intervention in School and Clinic, 28(2), 105–110.

Miller, S. P., Stringfellow, J. L., Kaffar, B. J., & Mancl, D. B. (2011). Developing computation competence among students who struggle with mathematics. Teaching Exceptional Children, 44(2), 38–44.

Witzel, B. S., Furguson, C. J., & Mink, D. V. (2012). Number sense: Strategies for helping preschool through grade three children develop math skills. Young Children 89–94

 

Communication Disorders in Aging

 

By Raymond H. Hull, PhD, Editor of Communication Disorders in Aging

Older adults are, in most instances, no different than younger ones other than the fact that they have grown older. They have the same personality they had when they were young; maybe it’s a little stronger, but is basically the same. They look the same except for some wrinkles and skin that may have begun to sag, and are maybe a little shorter due to the pull of gravity over the years.  Their voice will be the same except for the possibility of some change due to the aging vocal mechanism, so pitch may raise slightly, and they may speak a little louder due to a decline in their hearing. Their walking gait may slow just a little since they may not exercise as much as they used to and their joints might ache. They may be wearing reading glasses since there may be a change in their near vision. But, everyone is different, and some people age faster and more dramatically than others. When I was in my first year of graduate school, one of my classmates by the name of Bob was, at age 23, bald, with an ashen—somewhat prematurely wrinkled—face and had a voice that resembled that of an older man. In other words, he looked and acted “old”, at least to me. So, we are all aging differently. I like to think of myself as a younger/older person, but perhaps I am deluding myself into visualizing myself as such.

The one aspect of growing older that seems to be common is that disorders of communication are observed more frequently. Those are the result of stroke and other related diseases and disorders of the peripheral and central nervous system, Parkinson’s disease, hearing impairment, the influences of drugs and medications on their ability to communicate, and the various forms, or shades, of dementia. Further, environmental factors can have a greater impact on the ability of older adults to hear to a greater degree than younger adults.

Counseling must be adapted to take into consideration the age and status of the older adult as compared to the counseling strategies used with younger adults and children. And, if an older adult experiences a dramatic change in their ability to communicate with family and friends, the result can be even more devastating in light of the many other changes that frequently occur as a person ages. For example, the death of a spouse, difficulties with transportation, financial difficulties, restricted mobility due to physical decline, or the inability to hear, can all influence the ability of an older adult to take advantage of, and respond to, the services of the rehabilitation professional.

The book, Communication Disorders in Aging is designed to help people understand the process of aging, its impact on the human organism, the disorders of communication that are more frequently observed in older adulthood, and the impact of those disorders on them. Most importantly, it provides information on how to serve those individuals who experience the various disorders of communication that can affect them. I hope it helps you to understand the frustrations that approximately 32 million adults over the age of 60 experience as a result of various disorders of communication, and ways we can assist them. That is, in a world of people who may not understand the impact of those disorders on older adults, how best to communicate with them, and importantly, in the many places that are not meant for communication.

The book, Communication Disorders in Aging is intended for use in the academic preparation of all who will serve older adults in a variety of settings, including those in audiology and speech-language pathology, nurses who are preparing to become geriatric nurse practice specialists, those who are preparing to become gerontologists, psychologists, family practice physicians, geriatric medicine specialists, and others who serve or who are preparing to serve older adults.

However, due to the very practical nature of this book, it will also prove to be a wonderful resource for family members and other significant others who, in one way or another, serve older adults who possess disorders of communication. The information contained within this book is that which many persons who know or serve older adults request from me when I speak at conferences and conventions around the U.S., Europe, and Canada.

Raymond H. Hull, PhD, CCC-A/SP, FASHA, FAAA
Professor of Communication Sciences and Disorders, Audiology/Neurosciences
Department of Communication Sciences and Disorders
College of Health Professions
Wichita State University
Wichita, Kansas  67260-0075

Book excerpt – James Jerger: A Life in Audiology

The following excerpt is from the autobiography, James Jerger: A Life in Audiology

American Academy of Audiology

The AAA is now in its 28th year. Younger members may not appreciate what it has meant to our profession. Before the Academy was launched in 1988 we were the step-children of the American Speech-Language-Hearing Association, commonly abbreviated as ASHA. We followed their code of ethics, accepted their certification programs, attended their conventions, and published in their journals. How this came about was essentially an accident of history. Most of the earliest audiologists were people originally trained in speech science and speech pathology. As such, ASHA was their natural home and they were comfortable within its ranks. Raymond Carhart’s doctoral dissertation, for example, concerned a model of the human larynx.  But as younger people became audiologists they did not share the common bond with speech science and speech pathology so typical of their mentors. As the field of audiology grew, some of the younger members began to ask whether we might not be better served by creating our own national professional organization. Expressing this view, however, met with stern disapproval. Our elders insisted that fragmentation must never happen, that we must always remain one profession because you could not separate hearing from speech and language; they were all part of the unique process we call “human communication.”  I always thought this argument specious. For example, you cannot separate the brain from the foot: they are both part of the whole body, but there are quite distinct medical specialties to treat their disorders. Certainly the more you know about language and speech the better, but that doesn’t mandate that you belong to their professional organization.

In any event, opponents of fragmentation failed to appreciate that ASHA itself began as the American Academy of Speech Correction (AASC) by fragmenting off from the National Association of Teachers of Speech (NATS) in 1925. NATS in turn was formed by splitting off from the National Council of Teachers of English (NCTE) in 1914.

In 1958 I was elected to ASHA’s executive board. At one of our meetings, I suggested that we consider setting up special interest groups that would lend some separate identity to various clearly distinguishable groups within the organization. There was much shoe shuffling, and some support from the aphasia people, but little general willingness to pursue the topic. A fellow board member, one of the revered elder statesman in audiology, came over to me as the meeting broke up, put his hand on my shoulder, and said, “Jim, it will never happen. They are afraid we will split off.”  Actually the idea of special interest groups within ASHA did eventually happen, but only after we had formed AAA.

Nothing much transpired for the next few decades, but matters came to a head at the 1987 ASHA convention in New Orleans. Rick Talbot had organized a session on “future trends in audiology.” There were five of us on the panel: Jay Hall, George Osborne, Charles Berlin, Lucille Beck and me. Each presented a thoughtful glimpse at what the future might hold in their particular area. I was the last speaker and my message was simple. I said, “I think it is time for audiologists to form their own professional organization” The response from the audience shocked me. There was a deafening roar of approval, which I truly had not expected. I think that everyone on that stage was also amazed.

Back in Houston I asked colleague Brad Stach what he thought of the idea. He was leery at first, but came around when I drew an analogy with an umbrella organization like the American Medical Association, under which each medical specialty had its own organization, its own publication and its own convention. In retrospect the analogy is not quite apt, but it convinced Brad to take up the cause. We put together a list of 35 audiologists that we considered leaders in their respective areas and sent each one a letter of invitation to come to Houston for a two-day meeting to discuss the possibility of forming a new organization “of, by, and for” audiologists. Only one invitee declined. The rest arrived, at his/her own expense, ready to consider the idea.

We met in the ballroom of a hotel just across Fannin street from the Methodist Hospital. The first morning was chaotic. It was difficult to believe that the group could ever agree on anything. By the end of the second day, however, there was general consensus that the effort at least ought to be attempted. In 2009 I wrote, in my book Audiology in the USA, the following:

 “The first year of the Academy’s existence, 1988, was an uncertain time. The founders were not at all sure that their efforts would succeed. They knew what they wanted to do, and where they wanted to go, but recognized, with some trepidation, the formidable forces arrayed against them. The primary concern was, of course, the ASHA.  It already counted, at that time, more than 8000 audiologists among its roughly 60,000 members, and was not disposed to view this defection in a collegial manner.”

If I were to rewrite that last sentence today, I would undoubtedly use more colorful language, so I had better not try. That passage does illustrate, however, what I perceived to be the most important reason to break away from ASHA. Speech pathologists outnumbered audiologists in the ratio of about 8:1. But, profession-wise, speech pathology is, and perhaps always will be, based on an educational model, whereas audiology is based on more of a medical model. At that time the bulk of speech pathologists worked as therapists in the public schools of America. They worked primarily with children. Most held only the bachelor’s degree.  Our profession, on the other hand, is more like a medical model. Most of us are engaged in clinical services, either in private practice, or in medical environments. At the time we started the Academy, most audiologists held the master’s degree, and there was already pressure to upgrade to the doctoral level, which we have since accomplished with the AuD degree (a move, incidentally, with which ASHA did not initially share our enthusiasm.) Many of us felt that we would never be able to achieve the much-desired doctoral level degree until we were free of dominance by ASHA.

HEARING AID FITTINGS TODAY vs YESTERDAY; IS IT BETTER?

Compression did not begin with digital hearing aids

By Theodore H. Venema, PhD
Author of Compression for Clinicians: A Compass for Hearing Aid Fittings, Third Edition

My career in this field began in 1987 as a new audiologist at The Canadian Hearing Society in Toronto. All hearing aids were analog and provided linear gain, although a few compression circuits floated around too. These used output limiting compression, with its high knee-point and high compression ratio. The knee-point was adjustable, which in turn adjusted the maximum power output (MPO). It was a way to limit the MPO without the use of “peak clipping,” which caused distortion.

Wide dynamic range compression (WDRC) entered the scene with a cannonball splash right around 1990. The action of the outer hair cells (OHCs) was now understood by clinicians as being distinct from that of the inner hair cells (IHCs). As we all know today, the OHCs enable the IHCs to sense soft incoming sounds below around 50 dB SPL. WDRC was thus seen as a rather “intellectual” type of compression, in that it electronically sought to imitate the role of the OHCs. With its low knee-point and a low compression ratio, the focus of WDRC is to elevate the “floor” of hearing sensitivity, rather than to limit the MPO or “ceiling” of loudness tolerance. It is no coincidence that otoacoustic emissions—also known to arise from the action of the OHCs—suddenly emerged as part of clinical practice.

Compression in today’s digital hearing aids hasn’t really changed all that much from then. We continue to use both output limiting compression and WDRC. The point here is that the analog hearing aids of that time (late 1980s, early 1990s) used either one type of compression or another. Clinicians had to know their compression types because their hearing selection for any client depended on this knowledge. Manufacturer fitting software did not yet exist. Today’s digital hearing aids are programmed exclusively by software. Once the audiogram is entered through Noah, the hearing aid signal processing is automatically programmed to provide whatever compression is deemed necessary. We’ve become “dumbed down,” because we no longer have to know how to apply the compression. The manufacturer fitting software takes care of all that!

The cables, the cables, the cables…

The emergence of the cables actually began in the very late 1980s, with the first “programmable” analog hearing aids. A cable from a computer (or more often a handheld programming device) was plugged into a socket on the faceplate of an ITE or on the backside of a BTE. Adjustments were made via this “digital screwdriver.” This seemed like a really “cool” alternative to manually adjusting hearing aid settings by trimmers, trim pots, potentiometers, whatever they were called. We simply turned these clockwise or counterclockwise, in order to raise or lower the MPO, gain, low-cut, high-cut, etc. I used to laugh that if the original settings were somehow lost, one could simply set all the trimmers halfway; that way, one could maximally be only half-wrong.

Back to the cables, it is truly amazing just how many different ones exist, even for the product lineup of any one manufacturer! This issue is not at all new, and I am not the  first to complain about that. I must admit to feeling a little odd though, when hanging a weird looking hook around the client’s neck with cables connected to the hearing aids positioned in the client’s ears. The next step is to sit in front of the computer, hoping and praying the manufacturer’s fitting software will read the hearing aids.

Manufacturer fitting software, fitting software, fitting software…

Fitting software emerged at the end of the analog era (mid 1990s) and flourished with the advent of digital hearing aids in 1997. Of course, with each manufacturer, the fitting software is completely different. Oh, there are some similar traits among them, but the look, the feel, the labels, and also the quirks and exceptions, are different for each manufacturer.

Digital technology and software certainly do add flexibility; they also however, invite their best friend, complexity. There are so many parameters involved with fitting now: noise reduction amounts and types, directional microphones and associated polar plots, feedback suppression adjustments, linking binaural hearing aids, and don’t forget about the battery indicator beeps! It gets better; we in separate programs, make combinations of the above-said parameters, in order to specifically address various different listening situations, such as quiet, conversations, and traffic.

Has anyone seen ANSI? Where did it Go? Sometime during the late 1990s, with the advent of digital hearing aids in 1997, ANSI slipped away. It happened in the middle of the night. Since the 1950s for hearing aids, ANSI was intended to be a measurement standard for hearing aid hardware, which consists of the microphone, amplifier, and receiver (aka speaker). Add a few capacitors, resistors, inductors (and trimmers to adjust their behaviors), and you still have nothing but analog hardware. Such was the consistency of analog hearing aids. ANSI ruled in the analog land of hardware, but now fitting software rules. Quaint concerns about OSPL90, Reference Test gain, Harmonic Distortion, and Equivalent Input Noise have almost faded from view. Today it’s all about software. Most clinicians today never bother with ANSI because they are just trying to figure out the fitting software.

The dongles and Bluetooth paraphernalia…

On a semi-annual basis, the goals and deadlines of their product management cycles dictate that manufacturers must pound out new and updated products. The cacophony of their escalating product releases has become deafening. What’s more, hearing aids now come with all kinds of dongles, Bluetooth remotes and gadgets to be used with other devices that work with the phone, television, etc. Of course, these have to be “paired” together to work with the hearing aids. Despite the best efforts of manufacturers to explain things, it does make me feel a bit like “Ted the Cable Guy.”

Clients commonly come back to the office with bags containing unused cords, boxes, television streaming devices, and dongles. It can be quite difficult to get elderly people to make sense of it all! Bottom line: Clinicians today are still constantly “putting out fires,” much like they always did in the past.

Epilogue

It’s obvious that hearing aids today are far better than the squealing, beige “banana-shaped” BTEs of yesterday. The disappointing thing, however, is that the rate of client satisfaction has not risen at the same rate as hearing aid development and complexity. The unwanted byproduct from complexity is confusion, felt by both clinicians and clients.

We have made amazing strides in technology, digital algorithms, and features. The downside is that it has all come at a cost, literally and figuratively, to clients and clinicians. With all the recent progress, I’m not sure clinicians feel that fittings are easier today than they used to be. I also do not believe the monetary cost of hearing aids compared to eyeglasses is at all well understood by clients. Is anyone really surprised at the recent emergence of (and governmental support for) an alternative, namely, those low-cost personal sound amplification products, also known as PSAPs?

Lesson Plans — An SLPA’s foundation for an effective therapy session. Now that I have one, how do I implement it?

Jacqueline_BrylaKraemer_CWSLPA

By Jacqueline Bryla, co-author of Clinical Workbook for Speech-Language Pathology Assistants

Responsibilities of a Speech-Language Pathology Assistant are many and can vary.  One key component within the scope of practice for a Speech-Language Pathology Assistant (SLPA) is to follow documented treatment plans or protocols developed by the supervising Speech-Language Pathologist (SLP). For a new SLPA this can be tricky and requires some experience in order to provide an effective therapy session for their clients and students.

Presenting a Lesson Plan

A guideline will make your clients and students aware of what they will be learning or practicing during the therapy session in addition to keeping them engaged and on task. An SLPA can share the lesson or treatment plan by telling their clients or students what they will be learning.  Providing a visual schedule by outlining the therapy tasks on a tabletop white board (i.e., warm-up; 5 minutes, articulation practice; 15 minutes, homework/carryover assignment, reward) can also be very effective for providing expectations of the therapy session time. Adding icons or photos to illustrate the task can be helpful for those who are not yet readers. Depending on the goals and objectives for the students, an SLPA might spend a portion of therapy time working on an articulation goal (i.e., medial /s/ in sentences) and the rest of the session on a specific language goal (i.e., concepts).  Considering how to incorporate multiple student goals or objectives within a therapy session will come with quality guidance from the supervising SLP as well as practice and experience. Providing a clear agenda for your clients and students at the beginning of the therapy session will be extremely helpful for you and your students to stay on task.

Engagement

When appropriate, offering choices for student and clients can set the stage for a productive therapy session. Allow your students to choose to work on one sound before another (i.e., /s/ or /l/), or to choose a board game or token piece that might be used during the session (i.e., Candyland, Snail’s Pace Race, red or blue token) or to use an articulation card deck or an app (i.e., Little Bee Speech Articulation Station, Smarty Ears Articulate It). Knowing and understanding your students’ interests will aide in keeping them engaged during the therapy session. Some students thrive on verbal positive feedback (i.e., you’re doing great, that was an awesome try), others will likely stay engaged by being allowed to have a little control by choosing the activity and yet others will need some additional motivation by earning a short timed reward at the end of the session or during the session (i.e., using a fidget, receiving a sticker or stamp). Seeking guidance from, in addition to observing, your supervising SLP provide treatment sessions can be helpful in this area.

Tool Box and Resource Efficiency

Become familiar with the materials available to you for therapy. Is there a closet full of games and therapy items at your disposal (i.e., an iPad with apps, articulation card decks, language or pragmatic resources)? Taking time to read the game directions and instructions of use or viewing an app tutorial prior to the therapy time will allow for a more efficient therapy session by allowing an SLPA to instruct their students and clients from the start. Being prepared and familiarizing yourself with materials reduces the opportunities for clients and students to veer off task. Always keep in mind that an SLPA must perform only those tasks assigned by the supervising SLP. Many therapy sessions are only 30 minutes, to provide a quality session for clients and students preparation is of the utmost importance.

Conclusion

There is no one way to describe or predict each therapy session scenario. A lesson plan may not work as well as you expected or go as planned. Do not get discouraged; this is an opportunity for you to learn what may work and what may not work. Being prepared and following your supervising SLPs guidelines will allow you to have the most productive therapy session, one that allows your students to work toward their goals and objectives.

Love, Talk, Read: Early Intervention Strategies for Infants and Toddlers At Risk for Language Impairment

Celeste_Roseberry-McKibbinRoseberry-McKibbin_ILSSLIB_2e

By Celeste Roseberry-McKibbin
Author of Increasing Language Skills of Students From Low-Income Backgrounds: Practical Strategies for Professionals, Second Edition
and co-author of the forthcoming Comprehensive Intervention for Children with Developmental Delays and Disorders Practical Strategies (10 book set)

Statistics have documented the precipitous rise of children diagnosed with Autism Spectrum Disorder (ASD), language impairment, and other atypical developmental profiles. For example, according to the Centers for Disease Control and Prevention (2016), 1 in 68 children today is diagnosed with ASD. Many times, these children do not receive intervention until they are 4 years old or even older. Recent research has documented very exciting outcomes that can occur when these at-risk children receive early intervention, which can start as early as 6 months of age. Speech-language pathologists can help caregivers begin, very early in their children’s lives, to implement strategies that improve their language outcomes. The strategies can be summed up in three words:  love, talk, read. Let’s start with love.

Love

Relationships are the cradle of all learning. Babies and young children above all must feel attached to their caregivers through love, attention, and bonding. It is critical, in the early weeks and months of life, for caregivers to respond immediately and with love when a baby cries. Immediate responses help infants to bond with caregivers and trust their world. Leaving babies to “cry it out” teaches them that the world is not a safe place, and can create a shaky foundation upon which to build later language interaction. Thus, immediate responsiveness to a baby’s cries is a foundational building block of later language.

Talk

We have all heard the oft-repeated advice, “Talk to your baby.” This is true, and talking to babies and young children is crucial to their developing language. However, research has shown that it is actually parent responsiveness to the baby’s initiations that is even more predictive of early language development (Center on the Developing Child at Harvard University, 2016; Ozonoff et al., 2009; Tamis-LeMonda et al., 2001). When a baby looks at something, for example, the parent can follow his “line of regard” and establish joint attention, where the parent and baby are focusing on the same thing. So when the dog walks into the room and the baby’s eyes land on the dog, the parent can say, “Oh, you see Angel. (pointing to dog) That’s right, Angel just came in.” When the baby points, the parent can look at what the baby is pointing to and comment—“Oh, you are pointing at the red balloon. The balloon is pretty!” When babies make sounds, the parents can respond with immediate imitation and add new sounds as well.

Ozonoff et al. (2009) conducted a study with parents of infants (6–15 months of age) suspected of having ASD. Parents were coached to create pleasurable social routines to increase their children’s opportunities for interaction. Parents used toys and words to attract their babies’ attention, and also imitated their babies’ sounds and intentional actions. The treatment consisted of 12 one-hour sessions with the infant and parent, followed by a six-week maintenance period with biweekly visits and follow-up assessments at 24 and 36 months of age. The study’s results showed that in contrast to a control group whose parents did not receive coaching, the children who received the intervention had significantly more ASD symptoms at 9 months of age, but significantly lower autism severity scores at 18 and 36 months of age. By age 3, the group that received the intervention had neither ASD nor developmental delay.

When the baby begins to say words at around 12 months of age, parents can extend their utterances. Extensions have proven to be some of the most powerful ways to increase children’s language skills.  So, for example, if the child points to the dog and says “doggy!” the parent can say, “Yes, our doggy Angel just came into the room and she is wagging her tail.” If the child says “more juice,” the parent can say, “You are thirsty, and more juice is available. Here you go!” When parents add words and new meaning to children’s utterances, semantic and syntactic skills grow. The best part is that this can be done in any language, even if the caregiver is nonliterate and has little extra time. Extensions can easily be added to families’ daily routines with no extra expenditure of time or money.

Read

Parents can share books even with babies, reading and pointing out pictures. Simple books with colorful pictures are ideal. If parents do not read, they can talk about pictures on the pages. Parents can label pictures and actions in the pictures, saying things like, “Look—there is Thomas the Tank Engine! (pointing to Thomas). Why is he happy? (pause) Oh, he is happy because Percy the Train just came up to him and wants to play.” Babies and some young children will not answer questions, but parents can ask the questions, pause for a few seconds, and then answer the question themselves. This shows the developing child that, eventually, turn-taking is expected. Routines such as this help establish joint attention, reciprocity, and eventually conversational turn-taking. Daily sharing of books with babies and young children establishes pre-literacy skills, which are critical building blocks for later literacy.

Summary

For infants and young children who are at risk for language impairment and other developmental issues, caregivers can focus on three simple strategies: love, talk, read. Research shows that early intervention, beginning in infancy, can have exciting and dramatic results in terms of helping children achieve successful language and life outcomes.

For more information, visit http://lovetalkread.com.

 

References

Center on the Developing Child at Harvard University. (2016). Serve and return. Available at http://developingchild.harvard.edu/science/key-concepts/serve-and-return/

Centers for Disease Control and Prevention. (2016). Autism spectrum disorder. Available from https://www.cdc.gov/features/new-autism-data/index.html

Ozonoff, S. et al. (2009). How early do parent concerns predict later autism diagnosis? Journal of Developmental and Behavioral Pediatrics, 30(5), 367–375.

Roseberry-McKibbin, C. (2013). Increasing language skills of students from low-income backgrounds: Practical strategies for professionals (2nd  ed). San Diego, CA: Plural Publishing, Inc.

Tamis-LeMonda, C. S., Bornstein, M. H., & Baumwell, L. (2001). Maternal responsiveness and children’s achievement of language milestones. Child Development, 72(3), 748–767.

For Aspiring Singers, Ignorance Is Never Bliss!

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By Jan E. Bickel, DMA, author of Vocal Technique: A Physiologic Approach, Second Edition

Singers must understand how to maintain their vocal and overall health in order to keep vocal production at the high levels required of them. In order to achieve this understanding, singers need in-depth knowledge of the anatomic and physiologic function of the complete vocal instrument, a pedagogically well-trained voice teacher, and the knowledge that they can reach out to a team of voice professionals (voice teacher, otolaryngologist, speech-language pathologist, and possibly others) who understand vocal technique and pedagogy as well as voice science and medicine. It is particularly important for aspiring singers to know they have a professional team ready and appropriately trained to help when vocal difficulties arise. The aspiring singer’s trust in this team of professionals must be established at the earliest levels of vocal training. If an aspiring singer is afraid to seek help from the voice teacher, otolaryngologist, and/or speech-language pathologist, valuable time will be lost in vocal development, damage to the vocal instrument may occur, and the aspiring singer may decide to choose another career path. It is imperative that speech-language pathologists and otolaryngologists have some training in vocal pedagogy if they wish to accept singers or aspiring singers as clients, and that voice teachers have a functional understanding of voice medicine and voice science. Ignorance is the quickest path to voice disorders for the aspiring singer.

I wrote Vocal Technique – A Physiologic Approach with the intention of appropriately educating and providing a strong foundation for aspiring undergraduate singers, whether their desire was to enjoy singing as amateurs, or perform as professional singers. In my teaching of undergraduate students, I found these young singers frequently able to produce very beautiful vocal sounds, but having little or no knowledge regarding how their vocal instrument functions when speaking and singing. Most of these singers seemed to have no idea what to do or whom to turn to when their voices were not functioning well. In addition to having a clear concept and understanding of the anatomy and physiology of the vocal instrument, they need to understand how to maintain that instrument on a daily basis; i.e. vocal hygiene, breath management, vocal exercises, careful attention to speaking voice production, and determining what might be detrimental to maintaining healthy vocal folds and bodies. I use Vocal Technique – A Physiologic Approach to teach undergraduate voice classes, initial voice lessons, and again in the vocal pedagogy course in the senior year. I find that students who fully understand the information presented within the book progress much more quickly in the voice studio, and I rarely find them in vocal distress.

Excellent singing requires appropriate posture, refined breath management skills, efficient phonation and resonation techniques as well as the ability to articulate in multiple languages without disturbing the vocal production. Professional classical singing requires perfect phonation; i.e. a clear and resonant tone quality, the ability to create a variety of tone colors, excellent dynamic control, accurate pitch, and the ability to infuse the vocal tone with many appropriate emotions. This means the aspiring singer must have the discipline and dedication to become a vocal athlete with the creativity and imagination of the best professional actor. Learning to sing well enough to perform for the public requires much more than the average person can even imagine. Singers cannot afford to be ignorant about any aspect of their profession if they are to be successful.

There are issues beyond vocal technique that can cause a very well-trained singer to have difficulty with his or her voice – respiratory infection, acid reflux, allergies, inability to “support” the voice appropriately because of bodily injury or illness, interruption in sleep pattern, stress, aging, dehydration, fatigue, and many more. A singer must know intimately his or her voice and how it functions when healthy so that when it is not functioning normally, he/she is fully aware and comfortable reaching out for support from the appropriate professional. A voice teacher can be of great assistance in many cases, but sometimes a singer needs to see a laryngologist, a speech-language pathologist, or a vocal specialist for proper diagnosis and treatment. The demands of professional singing necessitate excellent health, physical conditioning, and careful use of the speaking voice as well as the singing voice, so the aspiring singer must learn how to maintain his or her instrument early in the learning process.

I posed the following question, among others, to 35 undergraduate and amateur singers participating in a choral ensemble and/or a freshman level voice class: “Do you think singers, in general, are reluctant to see an otolaryngologist (ENT) or a speech-language pathologist (SLP) for problems with their voices? 16 responded “yes,” 18 responded “no,” and one did not answer. Of the 16 who responded that singers are indeed reluctant, three had actually seen an ENT or an SLP for a vocal issue. One singer who said she had not seen an ENT or SLP wrote about having “muscle tension dysphonia,” which would seem to indicate that she actually had seen an ENT or an SLP for diagnosis, but did not want to acknowledge this visit. Another respondent wrote that he had “strain and discomfort when singing,” but had never seen an ENT or SLP. Of the respondents who answered that singers are not reluctant to see an ENT or SLP, only two had seen an ENT or SLP, while eight of the respondents made the following statements regarding their own vocal health: “trouble with speaking voice,” “lost voice completely,” “voice hurts when I sing,” “belting created vocal problems,” “laryngitis due to asthma, allergies and bronchitis,” and “unresolved tinnitus, causing problems with pitch matching.”  It follows that these singers might have been helped by a laryngologist or speech-language pathologist, but chose not to reach out to make an appointment.

When asked why an aspiring singer might be reluctant to see an ENT or SLP, the respondents made the following statements: “Singers think the problem is fixable by themselves,” “Fear of being told that there is irreversible vocal damage,” “It can be seen as embarrassing or you don’t want to admit you have a problem,” “Some singers simply resign themselves to discomfort or stop singing altogether,” “Singers feel they can resolve issues themselves by rest and homeopathic methods,” “They don’t want to admit there’s a problem because of the competitive nature of auditions. . . ,” “Perception is the ENT does not care about solving vocal problems for amateur singers,” “It is hard for a singer to admit there is something wrong with their vocal mechanism,” “Singers assume a referral means the voice is bad/sounds bad.”

When asked the same question, two professional singer/voice teachers responded with these comments: “I feel strongly that singers, myself included, are afraid to hear that something may be wrong. I also think that singing is a very expensive endeavor, and the thought of having to spend more money on doctor visits, or treatments, in addition to the cost of taking lessons, and coachings and paying tuition, or fees for applications and auditions, is daunting,”  “The ENT I saw did not at all quell my fears. He told me that I had polyps (which I later found out was not the case) and suggested that I start coming in once or twice a week to help rebuild my voice. I had such an uneasy, unpleasant feeling about it that I went maybe twice. He did some pathetic vocal warm-ups that didn’t teach me anything and sent me to work with an SLP down the hall. Likewise, those exercises felt silly and I never felt reassured that this was going to make me better in any way.” This singer later went to a laryngologist and an SLP, both specifically trained to work with singers, and the results were entirely different as stated: “He was very kind, performing a gentle procedure to examine my vocal cords. He printed out photos and explained very thoroughly what I was looking at . . . the SLP was very kind as well. Her exercises were thoughtful, helpful and specific. She gave me reasoning behind every one of them. I actually followed through and did them every morning.” This singer went on to complete a Master of Music degree in vocal performance and to sing several opera roles successfully and is now a professional actress. Clearly, appropriate preparation of the otolaryngologist and speech-language pathologist in working with singers is important. There is no place for ignorance in the area of vocal technique and pedagogy for these professionals if they wish to take on singers as clients/patients.

Aspiring singers spend much one on one time with their voice teachers, perfecting their technique, and learning to trust the voice teacher implicitly. This trust is built up over time, and is an essential part of the training of the singer. “Singing teachers are not only music educators, they are also guardians of their students’ voices. An astute teacher does not just help prevent vocal difficulties by providing a student with expert, healthy singing technique; he/she also is often the first person to detect a vocal problem and is usually regarded by the student as the source of all knowledge about anything vocal.” (Heman-Ackah et al., 2008)

 When a vocal issue arises, the voice teacher is usually the first to hear it in the singer’s voice, and the singer naturally trusts the voice teacher to “fix” the problem. When the teacher is unable to help the singer resolve the issue, the student begins to feel uncomfortable, worried, and even desperate. Their thinking follows the path – if my voice teacher can’t “fix” the problem, it can’t be fixed. I find that undergraduate student singers are particularly fearful of a referral to the laryngologist, even when I explain that this doctor is trained to diagnose and help resolve the vocal difficulty, not to criticize or place blame. I find that many singers find the idea of getting “scoped” to be quite frightening, even though I introduce this procedure in the freshman voice class, showing a video of a singer in the process. I want them to understand this is not painful and will help to diagnose the problem. Perhaps more importantly, for the aspiring undergraduate singer there is a clear social stigma attached to visiting a laryngologist, so if the singer does make an appointment, he or she will keep it a secret.

When the laryngologist refers a singer to an SLP, this seems to be even more difficult for the singer to accept. It says to the singer that it is his or her own fault that he/she has a vocal problem. If the SLP is not knowledgeable regarding vocal technique, and works with the singer as if he/she is the same as every other client who comes into the office for voice therapy, I will have a very difficult time convincing my student singer to continue with appointments as advised by the laryngologist. An SLP working with singers MUST have some training in vocal technique and vocal pedagogy and should be willing to work in ways that are familiar to the singer from voice studio work.

If there is a diagnosis of vocal nodules, even though the voice teacher may have suggested this might be the case, it is always a shock to the singer. The singer generally comes back to the studio depressed and feeling as though his or her singing life is over. Frequently, vocal nodules can be removed through careful vocalizing and establishment of healthy speaking and singing technique, but aspiring singers want an instant cure. Many will choose to do surgery, even when the laryngologist says it is not really necessary, so they can put this diagnosis in the past as quickly as possible. The singer does not want to consider the need to do preoperative speech therapy, surgery followed by vocal rest, postoperative speech therapy, and, finally, slowly bringing the voice back to the ability to sing with excellent technique. If the singer continues to speak incorrectly or without support the outcome, even after surgery, will not be good.

So, what I am proposing here is that voice teachers give their aspiring singers an excellent foundation in vocal technique – posture, breath management, phonation, resonation, etc., and carefully teach them about the anatomy and physiology of speaking and singing so they understand the importance of establishing an appropriate speaking pitch, not screaming at the college football game, not speaking over noise at the local club, singing music from the correct voice category, and so many other directives coming from the teacher. Voice teachers should insist that their students see videos such as the ones for which links are provided on the companion website for Vocal Technique – A Physiologic Approach, demonstrating the anatomic function of the larynx, lungs, diaphragm, and surrounding muscles. There are many YouTube videos demonstrating the use of the laryngoscope so that singers will know exactly what to expect when they visit the laryngologist’s office. In addition, voice teachers must coordinate with speech-language pathologists in their universities.

Speech-language pathologists need to understand and be able to demonstrate the diaphragmatic-costal breathing that a singer would use when projecting his/her voice in an opera house without a microphone. SLPs wishing to work with singers don’t need to be professional singers, but they must have a strong understanding of what is required for a singer to produce vocal tones worthy of the concert and opera stage, and it would help greatly for them to have formal training in vocal technique and pedagogy. I think this will change the way they interact with singers, and will certainly help gain the respect of their singer/clients. This should help to improve the communication between the two, and will keep the singer coming back to complete the therapy as prescribed. It will be important for SLPs working with singers to be able to use non-traditional forms of voice therapy that have a solid basis in anatomy and physiology. In order for speech therapy to be successful, the singer must be fully invested in the process, and the process must produce results quickly so the singer can get back to singing within a short period of time.  Because singers have developed higher than normal levels of vocal stamina, and phonation skills, they expect to be treated differently as a client of an SLP. If they are not, they will not comply with prescribed treatment and probably will not complete therapy sessions or exercises at home.

It is equally important for the otolaryngologist to understand vocal technique and pedagogy when accepting a singer as a patient. If the otolaryngologist understands the hesitation and fear that is present when a singer makes an appointment to see him or her, this will help the singer remain calm and accept the diagnostic procedure and the diagnosis and prescribed treatment suggestions. “As vocal athletes, singers require special diagnostic and treatment consideration when voice difficulty develops because they must maintain higher-than-normal levels of phonatory agility, strength, and stamina to repeatedly execute complex laryngeal maneuvers” (Zeitels et al., 2002). It seems best that it is a laryngologist, specialized in the care of disorders of the voice and larynx, who treats a singer, but this is not always possible. When it is not possible, the otolaryngologist must take extra care to understand how the singer thinks and uses the voice.

In addition, there must be open and complete communication among the voice teacher, the speech-language pathologist, the laryngologist, and the singer in distress at all times. As the singer generally has full confidence in his or her voice teacher, but perhaps not as much in the SLP and/or laryngologist, this communication will help the voice teacher to motivate the singer to do the appropriate exercises. If the speech-language pathologist has a good understanding of vocal technique and the mindset of the aspiring singer, this will open the door to communication and success. In this regard, two of the professional singer/voice teacher respondents to my questionnaire stated:

“I have raised concerns about my inability to speak or sing, or concerns about how     medicine will affect my singing voice. I understand that I don’t have a medical degree,   but I do know that my voice is largely responsible for my income, and my emotional       health. Concerns raised by patients should be addressed professionally and respectfully,”

Medical professionals and SLPs should “make sure you know how emotionally      connected we are to our voices. Singing is our life, an echo of our very soul. For our       singing voice to be in turmoil is as scary as telling a runner that they ruptured their          Achilles’ tendon. It’s a very big deal.”

Let’s make sure we all do our part in fully educating aspiring singers to the best of our abilities. Every singer needs to be as educated as possible about the anatomic and physiologic function of the vocal instrument in addition to the many other areas of study. Understanding these concepts fully will allow every singer to seek out an outstanding voice teacher, and will certainly help to remove fear and anxiety about reaching out to the laryngologist, speech-language pathologist, or a voice specialist when vocal problems arise. If the voice teacher, laryngologist, speech-language pathologist, and other voice professionals understand voice science, medicine, technique, and pedagogy to an appropriate extent, and communicate clearly with one another when working with a singer in vocal distress, the outcome will surely be a good one. If we communicate well with one another on a regular basis, we cannot help but replace ignorance with knowledge for our singers, clients, patients, and ourselves.

References:

Heman-Ackah, Y. D., Sataloff, R. T., Hawkshaw, M. J., Corln, V. D. (2008). Finding a voice doctor and voice care team. Journal of Singing, 64 (5), 583–592.

Zeitels, S. M., Hillman, R. E., Desloge, R., Mauri, M., & Doyle, P. (2002). Phonomicrosurgery in singers and performing artists: Treatment outcomes, management theories and future directions. Annals of Otology, Rhinology and Laryngology Supplement, 111(12), 21–40.

 

 

 

When a Client’s Behaviors Interfere with Delivery of Effective Treatment: Evidence-Based Behavioral Approaches

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By Christine A. Maul, PhD, CCC-SLP, co-author of Behavioral Principles in Communicative Disorders: Applications to Assessment and Treatment

A 3-year-old child badly in need of one-on-one language stimulation clings to his mother and cries inconsolably whenever she tries to leave the clinic room. An adult being seen for elective accent reduction therapy asks numerous questions that increasingly consume valuable therapeutic time. An elementary school-aged child being treated for a fluency disorder with a token economy system coupled with response cost reacts with torrents of tears whenever a token is taken from her. All of these are cases of behaviors that interfere with the effective delivery of therapy, taken from real-life clinical situations. In all of them, the behaviors were reduced through behavioral techniques: for the 3-year-old, a modified version of extinction was applied; for the adult, questions were reduced using differential reinforcement of low rates of responding; and for the elementary school-aged child, a modification was made of response cost, which is often coupled with conditioned generalized reinforcement, such as a token economy.

Extinction. After consulting with the mother of the 3-year-old child with delayed language, it was decided that a modified version of the process of extinction should be utilized to decrease the child’s crying behavior. Extinction removes the reinforcing contingencies for a person’s undesirable behavior. Ideally, a clinician should work with a board certified behavior analyst (BCBA) to identify the exact reinforcing contingencies for a targeted behavior. In this clinical case, however, the clinician, in consultation with the mother, determined that the mother’s continued presence and the attention she gave the child in the clinic room was probably reinforcing the child’s crying behavior.
Therefore, for the next clinic session, the clinician arrived with a bagful of toys and books she hoped would be appealing to the child. The mother agreed to take the child into the clinic room and then leave. The expected tantrum behavior occurred. The clinician positioned herself in front of the door, blocking the child’s “escape” path, with her back to the child and began pulling out toys, one by one. The clinician played with each toy, remarking about how much fun she was having, but keeping her back turned toward the child. She engaged with each toy for only a brief amount of time, and, if there was no reaction from the child, she would exchange the toy she was playing with for another item. She did this with several items, none of which seemed to interest the crying child. Then she pulled out a pop-up book that made a “ding-dong” doorbell sound every time she turned the page and began reading it. The child continued to cry, but every time he heard the doorbell sound, he cried less and less, and began to approach the clinician. The sobs subsided more and more as he peeked around her back to look at the book. Finally, to the delight of the clinician and the mother observing through a one-way mirror, the child crawled into the lap of the clinician who gently started evoking one-word productions from the child through her storybook reading. The whole process took no more than 10 minutes, from the time the clinician turned her back to the time the child approached her, and the child went willingly into the clinic room for all subsequent sessions.

There are important things to remember if a clinician wants to try extinction, or this modified version of extinction. First, the process must be thoroughly explained to the parent, and the parent must be in agreement with the procedure. Second, the first time extinction is applied, an “extinction burst” is likely to occur, when the undesirable behavior escalates to even greater heights. When this happens, the procedure of extinction should continue to be applied; if not, all the client will have learned is how much of the undesirable behavior must be displayed before reinforcement is given. Third, extinction should never be used for physically aggressive or self-injurious behaviors.

Differential reinforcement of low rates of responding. In the case of the adult being seen for foreign accent reduction, the clinician suspected that the excessive question-asking behavior was probably negatively reinforced by providing escape from therapeutic tasks. Sometimes, maybe even often, clients find therapy to be aversive, and if a behavior puts off the hard work involved in therapy sessions, it is likely to increase.

The clinician decided that the rate of question-asking was so high, the most that could be done at first would be to employ a technique designed to reduce, but not entirely eliminate, the question-asking behavior. In differential reinforcement of low rates of responding (DRL), the client is warmly reinforced for performing an undesirable behavior at a lower rate. The clinician in this case explained to the client that the amount of time spent responding to her questions was seriously interfering with the effectiveness of treatment. She asked the client to limit her questions to only three per session. The clinician kept her responses to the questions very brief, and kept a tally of the number of questions asked during each session. If the client met her goal, the clinician warmly congratulated her and let her know how much her cooperation was appreciated. If the client had been a child, the clinician could have reinforced the reduced rate of undesirable behavior by offering a small prize at the end of the session; for adults, however, just warm acknowledgment of a job well done is usually enough.

Clinicians should be aware of the disadvantages of this technique. First, the technique will only serve to reduce a behavior. After the behavior has been reduced through DRL, further techniques will have to be employed to eliminate it. Second, a phenomenon known as generalized suppression of a behavior may occur. Consider the fact that asking questions is not an entirely undesirable behavior. People ask questions to seek out new information and to clarify that which is already known. If the client in the scenario provided eventually ceases to ask a reasonable number of well-considered questions altogether, generalized suppression has occurred.

Response cost and conditioned generalized reinforcement. A token economy system, such as the one employed by the clinician treating the school-aged child with a fluency disorder, is based on the behavioral principle of conditioned generalized reinforcement. People learn to work for conditioned generalized reinforcers that provide access to many other tangible reinforcers. In the natural environment, money is the most commonly sought after conditioned generalized reinforcer. In the clinic room, tokens such as poker chips, stickers, points, or happy faces can be given to a child to reinforce correct responses. The child can then exchange tokens earned at the end of the session for a prize in the clinician’s “treasure chest.”

A token economy can be even more effective when coupled with response cost, a corrective technique in which a token previously given for a correct response is taken away for an incorrect response. Children will usually work hard to keep the tokens they have earned, but sometimes, as is the case in the given scenario, a child may react emotionally when a token is taken away for an incorrect response.

Sometimes clinicians decide to simply cease administering response cost as a corrective technique when a child displays such emotional reactions. The clinician in this case, however, decided to adapt a slightly modified version of response cost. Each fluent response the child made was lavishly reinforced with three or four tokens, placed in a plastic cup. When the child exhibited a dysfluency, the clinician took one token out of the cup but did not remove it from the child’s view. Instead the clinician held the token over the cup, gave the child an expectant look, and encouraged the child to try again—“Come on, I know you can smooth it out!” Almost always, the child was able to produce the utterance fluently, and the token was plopped right back in the cup. Administering response cost in this way increased the child’s production of fluent utterances and eliminated undesired emotional reactions.

These are but a few examples of cases in which the application of techniques based on behavioral principles resulted in the reduction of undesirable behaviors that were interfering with the delivery of effective treatment. There are many other techniques that can be employed to decrease undesirable behaviors and to increase the desirable communicative behaviors SLPs seek to teach their clients. Much more detailed information regarding these and many more techniques, accompanied by protocols for session planning and recording data, are provided in Behavioral Principles in Communicative Disorders: Applications to Assessment and Treatment.

 

Talking Hearing Aids with Brian Taylor and H. Gustav Mueller

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Fitting and Dispensing Hearing Aids, a popular introductory textbook, has just been published in its second edition in September. We managed to listen in to a conversation between its two authors, Brian Taylor and H. Gustav Mueller, who were exchanging some thoughts regarding their new 2nd Edition.

BT:  You know Gus, when we wrote the first edition of this book, I remember us talking about the fact that there seemed to a fair number of professionals who maybe weren’t following Best Practice when they were fitting hearing aids.  We thought that it might simply be because they didn’t exactly know what was called for in Best Practice, or maybe it never had been laid out for them in an orderly manner.

HGM:  And we thought a book like ours might help . . .

BT:  Right.  Do you think it did?

HGM:  I’d certainly like to think so.  We sold a lot of copies, so that’s a good start!  But honestly, when I travel around, I don’t see as much change over the past five years as I thought might happen.  Let’s take pre-fitting testing for instance.  We have some great speech-in-noise tests available for clinical use like the QuickSIN, the BKB-SIN and the WIN.  We talked about all of these in the book, provided step-by-step guidelines, yet I just don’t really see an uptake—for some reason, audiologists and hearing instrument specialists seem to have a love affair with monosyllables in quiet, which really have little use for the fitting of hearing aids.

BT:  Maybe we’re expecting things to happen too fast.  I think it’s good we expanded that section on pre-fitting speech recognition testing in the current book—hopefully more readers will take notice.  And as you know Gus, I’ve always been a fan of the ANL.  I just saw that there has been over 40 articles published on that test in the past 12 years!  That’s another easy-to-do test, and it really provides information that you cannot learn by doing speech recognition testing.

HGM:  Part of Best Practice is picking the right technology for the right person.  I recall you spent a lot of time researching all the new technology that has come out in recent years for this 2nd Edition.

BT:  Things change pretty fast in that area.  I think we’ve added some great new sections on wireless connectivity, frequency lowering, and audio data transfer between hearing aids. Like the first edition, rather than getting into the intricate technical details of various features, we focus on how this technology benefits the patient. For example, in the chapter that covers wireless connectivity and audio data transfer between hearing aids, we write about how these new features enhance benefit in background noise, and how candidates are identified.

HGM:  And, of course, verification of the fitting is critical.  The best hearing aid in the world is no better than a PSAP if it’s programmed wrong.  I think our new section on speechmapping will be extremely helpful for people who are just getting started using probe-mic measures.  As we described, recent research clearly has shown that you can’t simply rely on what you see simulated on the software fitting screen.  As, of course, all those special features that you talked about, such as frequency lowering, need to be verified in the real ear too!

With all that said, however, we also know that verification alone is not enough to demonstrate to patients, their families, and even third-party payers that a new set of hearing aids is worth the investment—so, we can’t forget about outcome measures.

BT: Yes, Gus, it seems there are always a couple of new outcome measures to talk about. With all of the recent research on the impact of untreated hearing loss on other conditions, like cognitive function, social isolation, and overall mental health, we added a section on validated self-reports to measure the impact hearing aid use may have on these common conditions.  Even if you’re not inclined to measure those types of downstream outcomes, we added more detail on using the International Outcome Inventory for Hearing Aids (IOI-HA). As you know, many audiologists and hearing instrument specialists neglect to conduct any outcome measures. We cover the reasons this is a bad idea, and suggest, if you are only going to use one measure, it ought to be the IOI-HA.

HGM:  And you know, some people suggested that it was a little silly for us to use our chapter themes of country music, movies, wine tasting, baseball, and all the others, but I’m glad we kept that going in this 2nd Edition.

BT:  Me too.  Who said you can’t have fun and learn about hearing aid fitting at the same time?  After all, it’s worked all these years for the two of us!