About Kristin Banach, Senior Marketing Manager

Senior Marketing Manager

From Multiculturalism to Critical Consciousness: Updated Concepts for Providing Culturally Responsive Practices at Home and Abroad

By Yvette D. Hyter, PhD, CCC-SLP

Co-Author of Culturally Responsive Practices in Speech, Language, and Hearing Sciences

In the 1990s a new generation of faculty members in Communication Sciences and Disorders (CSD) emerged, ready to infuse courses or to develop and teach courses focused on “multicultural content,” which was the term at the time. There were a limited number of comprehensive texts on how to employ culturally relevant practices as a speech-language pathologist. Many of the SLP faculty who were teaching courses about “multiculturalism,” or “cultural competence,” often utilized texts from other fields, such as education, nursing, or communication and rhetoric, and relied heavily on published articles in disciplines including anthropology, political science, nursing, and social work. It was not until mid-1990s that one of the more complete books on multiculturalism in communication sciences and disorders (CSD) was published (e.g., Battle, 1993, 2012). Nevertheless, as the world has become more complex and smaller as a result of global processes, new concepts and comprehensive practices that consider causal relations are required.

Multiculturalism is a contested concept, but typically refers to including people from diverse cultural backgrounds (Malik, 2015) in program development or service delivery for example.  Multiculturalism as a concept falls short, primarily because it suggests that inclusion (or assimilation) is the principle issue. Although health care providers and educators offer and provide services to all people regardless of their cultural (or racialized class, ethnic, gender, national, or linguistic) backgrounds (e.g., inclusion), services can remain inadequate or irrelevant if we also do not consider how services might be reconceptualized or changed to meet the cultural premises of those receiving services.

Cultural competence, a concept that emerged in the 1980s (e.g., Cross, Bazron, Dennis, & Isaacs, 1989), is more useful than multiculturalism but is weighed down by preconceived notions of competence. The perception is that “competence” refers to skills or knowledge that one acquires, and that those skills can be completed or mastered (checked off), are static, and independent of context or history (Hyter & Salas-Provance, 2019; Willbergh, 2015). This perception of competence has caused many disciplines in the health professions to move away from it in favor of other terms.

Cultural responsiveness, a term coined by Ladson-Billings (1995), seems to be more accessible than multiculturalism and cultural competence. It refers to engaging in practices that are consistent with or relevant to the cultural values, beliefs, and assumptions of a person or group with whom a solution (or clinical outcome) is co-created. In this manner, responsiveness is inherently dynamic, dependent on context and shared historical memories.  Hyter (2014) has conceptualized culturally responsive practices as those that take place beyond the micro level (individual), but also at the meso (community and family) and macro levels (social structures such as economics, politics, culture, cultural institutions, and state sanctioned violence [Hyter & Salas-Provance, 2019, p. 171]). Culturally responsive practices require knowledge that is not always a part of the CSD curriculum such as critical consciousness—the ability to deconstruct one’s own social, cultural, historical, economic, and political situation and co-construct solutions to problems (Freire, 1974); dialectical thinking—the ability to synthesize conflicting perspectives; cultural humility – believing that cultural practices and perspectives different from one’s own are as valuable as one’s own  (Ortega & Faller 2011; Tervalon & Murray-Garcia, 1998); and cultural reciprocity—understanding and using the client’s cultural beliefs to co-construct (with the client) services provided (Kalyanpur & Harry, 2012). Culturally responsive practices also require an elevation of concepts that are already inherent in CSD clinical practice such as critical thinking, critical self-awareness, and reflection.  To truly work at the level of cultural responsiveness or relevancy in the United States or abroad, as a profession, speech-language pathologists and audiologist need to adapt new vocabulary and new theoretical frameworks that will help us question the dominant premises, change the terms of public and professional debate, and address the shared problems of structurally excluded groups with interventions that acknowledge and incorporate their world view.

References

Battle, D. E. (1993). Communication disorders in multicultural populations. Boston, MA:utterworth-Heinemann

Battle, D. E. (2012). Communication disorders in multicultural and international populations. 4th edition. St. Louis, MO: Mosby

Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989) Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center. Retrieved from https://files.eric.ed.gov/fulltext/ED330171.pdf

Friere, P. (1974). Education for critical consciousness. New York, NY: Continuum

Hyter, Y. D. (2014). A conceptual framework for responsive global engagement in communication sciences and disorders. Topics in Language Development, 34(2), 103–120.

Hyter, Y. D., & Salas-Provance, M. (2019). Culturally responsive practices in speech, language and hearing sciences. San Diego, CA: Plural Publishing.

Kalyanpur, M., & Harry, B. (2012). Cultural reciprocity in special education: Building family-professional relationships. Baltimore, MD: Paul H. Brookes.

Ladson-Billings, G. (1995). Toward a theory of culturally relevant pedagogy. American Educational Research Journal, 32(3), 465–491.

Malik, K. (2015). The failure of multiculturalism. Foreign Affairs, 94, 21–32.

Ortega, R. M., & Faller, K. C. (2011). Training child welfare workers from an intersectional cultural humility perspective: A paradigm shift. Child Welfare, 90(5), 27–49.

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125.

Willbergh, I. (2015). The problems of ‘competence’ and alternatives from the    Scandinavian perspective of Bildung. Journal of Curriculum Studies, 47(3), 334–354.

Can the SLP Help Make RtI Part of the Educational DNA? Y-E-S

By Wayne A. Foster, PhD, CCC-SLP/A

Author of The Role of the Speech-Language Pathologist in RtI: Implementing Multiple Tiers of Student Support

Is there a role for a speech and language pathologist (SLP) in Response-to-Instruction/Intervention (RtI) beyond the application of special education services (Tier III in a three-tiered model)? Some will say that an SLP can play a (limited) role in the application of pre-referral interventions. I wrote this book to argue that there is a very special but previously poorly defined role for the SLP. In fact, in the absence of support for the RtI process by those who understand the principles of child development, it is likely that RtI will fail to thrive.

Response-to-Instruction or Intervention (RtI) makes great sense as a system to support struggling students in America’s K–12 educational system. In short, RtI refers to the application of academic and/or behavioral support that is linked to the student’s functional level within a given domain and is provided at an appropriate intensity and frequency. This support is monitored for effectiveness and modified as needed. The ultimate goal is to close the gap between a student’s functional level and the level needed to progress in the standard curriculum.

While RtI makes sense it is relatively rarely implemented with the fidelity necessary to generate the type of success needed to help it become part of the DNA of the educational process. In many schools RtI never takes root and where it has been implemented it is constantly under threat of being dismantled in favor of more traditional educational processes.  Today it seems no easier to implement and sustain a multi-tiered system of student support (such as RtI) than it was two decades ago. Why is it so difficult to make a multi-tiered system of student support work?

One answer became clear to me at a 2008 workshop on literacy I presented to the kindergarten through fifth grade teachers in a moderate-sized school district. At this training session the developmental progression of literacy skills was outlined via a series of slides. The initial slides associated the development of language to the development of early phonological awareness. With each slide the teachers could see how literacy skills transitioned and ultimately led to the ability to comprehend lengthy, complex, and abstract text. They were fascinated and most admitted that this was the first time they had ever learned about the development of literacy over time (and grades). The teachers in the room clearly understood the standards of their grade level curriculum but were not aware of normal patterns of development for literacy. In fact, far too many educators have not been trained in the patterns of child development for language, literacy, mathematics, or behavior (including socio-emotional development).

Implementation of RtI demands knowledge of development. How is one to address the needs of a student who is functioning in one or more domains well below a grade-level curriculum? One answer is that you must meet the student at their functional level with an intervention that helps close their developmental gap.  This requires a rather detailed knowledge of development. In workshop after workshop  I realized that general educators across America had not been adequately trained in the language of development. I came to the conclusion that there exist two major educational languages spoken in America’s public schools—the language of curriculum and the language of child development. Unfortunately few educators are fluent in both.

In most tiered systems (such as RtI) the initial application of support is provided through differentiation of instruction within the general classroom. Many educators understand this differentiation to mean appreciation of different learning styles (e.g., visual versus auditory versus tactile/kinesthetic) and how to modify instruction to allow students to access the curriculum via the learning style that maximizes their learning potential. This is a correct view but differentiation also means assisting a student who may be delayed in development of skills. Differentiation can mean breaking down instruction into smaller steps and providing meaningful feedback. If differentiation is not successful then individual or small group interventions are applied and monitored for progress (Tier I in the RtI model). If this level of support is not sufficient, then a more intense, frequent, and individualized intervention may be necessary (Tier II in the RtI model).  Think about what this requires on the part of the professional. First, they must identify where in the developmental progression the student is functioning. Second, they must select an appropriate treatment (i.e., intervention) that moves the student forward. Third, they must monitor progress and know when the appropriate skill level for the child’s age is attained.  This is a developmental perspective, clearly more of a developmental perspective than a curricular one.

If RtI is to work in a school those professionals who understand child development must support those charged with implementing the early Tier I and Tier II level interventions. RtI will flounder as an educational paradigm if there is poor integration of the two languages and poor coordination between the professionals who are fluent in those languages. Unfortunately, that has been the case in many of the schools I have visited over the past decade.

School-based SLPs are highly trained in the realm of child development and are well positioned to provide support of the RtI–multi-tiered system of student support. The major reason for writing The Role of the Speech-Language Pathologist in RtI: Implementing Multiple Tiers of Student Support was to provide a description of the differences between curricular and developmental perspectives and explicate the role of the SLP in making RtI successful without dramatically increasing the workload of the school-based clinician. Further, there did not seem to be a resource available that could help an SLP better understand their own educational approach (development) much less come to a strong appreciation of the general educator approach (curriculum).

Finally, a coding and reimbursement book written specifically for audiologists, otolaryngologists, academic institutions, and staff!

By Debra Abel, AuD, editor of The Essential Guide to Coding in Audiology: Coding, Billing, and Practice Management

The Essential Guide to Coding in Audiology: Coding, Billing, and Practice Management is that necessary and essential one stop shop office resource for coding, billing, and compliance written specifically for independent audiologists and their office staffs, for otolaryngologists and their office staffs, and for academic programs, with information contained in one repository that has been historically scattered in other places. This book includes many contemporary topics including the critical tools, codes (CPT, ICD-10-CM, and HCPCS) and guidelines necessary for compliant audiology billing, reimbursement, and payment. Medicare, considered the gold standard by most commercial payers, has an entire chapter devoted to those requirements applicable to the audiologist, often an anomaly in payer policies when compared to other health care professions.

The basic tools don’t end there. With an increase in commercial insurance third-party payers and third-party administrators, those payers often don’t speak the same language as the audiologist, which can lead to confusion and heartburn. Kim Cavitt, AuD, a nationally known audiology coding and reimbursement expert, offers a chapter on insurance that includes a glossary of terms and processes for negotiating if you choose to successfully incorporate these commercial payers into your practice. Stephanie Sjoblad, AuD, a pioneer and expert in successful itemization for hearing aid services in her university clinic that functions as a private practice, brings over 10 years of how-to’s to successfully itemize in your own practice. For those practices considering a transition to this process, this chapter will be a major guiding force. Kim Pollock, another nationally known coding and reimbursement consultant, offers a chapter on managing your revenue, something not usually provided specifically to audiologists in a written format, by one of the most knowledgeable sources who has performed audits and risk management for otolaryngology/audiology practices for many years. The final contributor, Doug Lewis, PhD, JD, MBA, an audiologist with significant credentials, has a chapter on the federal regulations that impact the practice of audiology, a compendium of all those requirements essential to maintaining compliance while offering services. Finally, the concluding chapter is a checklist of the fundamentals and the components needed when one considers and establishes a private practice.

Apart from the chapter devoted to revenue, each data-driven chapter on coding, reimbursement, and compliance, was written by audiologists for audiologists, unprecedented at the time of publication. This is a necessary resource for every audiology office and academic program!

Meet the Author Sessions at ASHA 2017 Convention

MEET THE AUTHORS AT ASHA!

SCHEDULE:

Thursday, November 9

11:00 – 12:00 pm: Celeste Roseberry-McKibbin and Priya James, co-authors of Comprehensive Intervention for Children With Developmental Delays and Disorders (10 book set)

1:00 – 2:00 pm: Wendy Papir-Bernstein, author of The Practioner’s Path in Speech-Language Pathology: The Art of School-Based Practice

2:00 – 3:00 pm: Raymond H. Hull, editor of Communication Disorders in Aging

3:00 – 4:00 pm: Françoise Brosseau-Lapré, co-author of Developmental Phonological Disorders: Foundations of Clinical Practice, Second Edition
Friday, November 10

10:00 – 11:00 am: Debra Abel, editor of The Essential Guide to Coding in Audiology: Coding, Billing, and Practice Management

11:00 – 12:00 pm: Erna Alant, author of Augmentative and Alternative Communication: Engagement and Participation

12:00 – 1:00 pm: Anthony DiLollo, co-author of Clinical Decision Making in Fluency Disorders, Fourth Edition

1:00 – 2:00 pm: Margaret Lehman Blake, author of The Right Hemisphere and Disorders of Cognition and Communication: Theory and Clinical Practice

Saturday, November 11

10:00 – 11:00 am: Christina Gildersleeve-Neumann, co-author of Phonetic Science for Clinical Practice (textbook and workbook)

11:00 – 11:30 am: Ryan W. McCreery and Elizabeth A. Walker, co-authors of Pediatric Amplification: Enhancing Auditory Access

Speech-Language Pathologists Working in Early Childhood Intervention

By Kathleen D. Ross, MS, CCC-SLP
Author Speech-Language Pathologists in Early Childhood Intervention: Working with Infants, Toddlers, Families, and Other Care Providers

Misperceptions and questions surrounding the role of speech-language pathologists (SLPs) in various settings persist. Our title is not yet a common term within everyday households. Speech-language pathologists working in early childhood intervention are no exception to these persistent misperceptions. When SLPs are labeled as the “speech teacher” who corrects lisping, how can one possibly teach an infant to make sounds appropriately when they don’t yet make /s/? How can an SLP train a toddler to change his behavior when he has no idea that he’s responsible for his own actions and behaviors? Education and advocacy continue to be an integral part of an SLP’s role in all settings.

Early childhood intervention SLPs tend to go beyond some of the traditional roles. Part C of the Individuals with Disabilities Education Act (IDEA) presents a practical philosophy for working with infants and toddlers: coaching parents and caregivers to guide children to functional communication efforts within daily routines in natural settings. Guiding parents to utilize new interventions with their children within daily routines truly is best practice for this young age, who do not yet have the cognitive ability to easily generalize an isolated task learned in a clinic setting to other situations. An infant and toddler’s social world is typically small, with greatest focus on the family constellation and primary caregivers. Teaching in the moment with familiar trusted learning partners (the parents) is often the most adequate way to make the synaptic connections that create useful memories. This practical application manifests the functionality of a learned task almost instantaneously.

In early intervention, SLPs enter the lives of young children and their families to thoughtfully observe their natural interests and interactions, and to become involved in the relationships that are most central to the children. In this way, they are at ground zero if you will, at the heart of the developing child and family.

Adults recognize that infants enter the world as helpless beings, needing continual support and guidance to progress through each day. Infants seek relationships with loving adults who provide routine care and consistent positive responses to their every need. They expect and rely on those responses, developing rhythms and trust with the adults around them. But not all situations are the same, and for a variety of reasons, there are times when infants do not receive the care they need and, thus, cannot develop the daily rhythms and trust of others. SLPs become integral in coaching parents to understand and develop these rhythms with their young children. Parents learn to carefully observe and listen, then positively and consistently respond to their child’s needs. Parents and primary caregivers are guided to develop or alter behaviors with young children—shaping unwanted behaviors into positive functional skills.

Our early experiences affect who we become as adults. Acknowledging this as early interventionists allows us to unhesitatingly advocate for infants, toddlers, and families within IDEA’s Part C program. Recognizing the influence of personality, prior knowledge, birth and early experiences, and a child and family’s degree of tolerance for stresses and outside influences, is crucial for success. As SLPs, we give tools and strength to a child and family to effectively communicate their needs and wants in various situations.

Speech-language pathologists who understand the connections between social, emotional, cognitive, and communication growth—the developing whole child—will work judiciously and respectfully to collaborate with other service providers and the family to enrich the child’s life and create practical interventions. We know that young children thrive on familiar and caring positive relationships through the routines of the day. We support parents and caregivers to guide children to reach their potential as they become threeyear-olds, when they transition from Part C to Part B services, if eligibility continues. Through meticulous and developmentally appropriate evaluation to diagnosis, and maintaining ongoing assessment for up-to-date programming, we provide accurate treatment measures to match the child and family’s needs.

Each family constellation presents a unique dynamic for all service providers to consider. We need to fully comprehend how both children and families develop, and the dynamic nature of both in order to work diligently within unique parameters. Knowledgeable SLPs respect and work with cultural and linguistic differences in each family, understanding the invaluable nature of these circumstances, while also recognizing the controversial elements that may present. SLPs will provide best practice when we acknowledge these complexities, especially in the face of our own preconceptions. Each human possesses their own perspective of their world as an individual. Service providers who early on grasp the concept that diversity is what makes us human, will be most successful in working in human services.

Speech-Language Pathologists in Early Childhood Intervention: Working with Infants, Toddlers, Families and Other Care Providers by Kathleen D. Ross, aims to inform SLPs who are considering work in early intervention. The text is also intended for early interventionists and service providers who wish to know the specifics of working with infants, toddlers, and families, and collaborating with others in this specialty area. Scenarios are presented as practical application examples to reinforce concepts discussed.

The rewards within this level of care are boundless. Working with both the child and the family presents satisfaction at two age levels simultaneously. Early childhood intervention sets the base for developing communication success. Where there previously existed frustrations, we now send children and families forward with a solid base of competence to function positively within their daily lives.

Personal Attitudes about Professional Wellbeing

By Wendy Papir-Bernstein, author of The Practitioner’s Path in Speech-Language Pathology: The Art of School-Based Practice

Within our profession—whether student, professor, researcher or practitioner—we connect with people from a diversity of fields.  Have you noticed how some seem happier than others?  They excel at their work and communicate a sense of enthusiasm, passion and professional fulfillment. It shows on their faces and use of body language, their social interactions, and of course through their work.  Researchers from the field of positive psychology tell us that happiness, whether personal or professional, is driven by the same themes:  we want to make a difference, we want to be useful, we want to connect with something greater than ourselves, we want balance in our lives, and we want community (Haidt, 2006).  It all seems pretty basic and yet it can be our greatest challenge.

One reason may be that we sometimes think of ourselves as consummate caregivers, and this culture of self-sacrifice is naturally carried over into our work setting.  I remember the moment many years ago when I first thought this idea.  I was on a plane, traveling out of the country.  The flight attendants spoke about safety regulations, demonstrated oxygen masks, and I thought I knew the drill well.  This time, however, I really heard it for the first time.  When they explained how important it was for you to put on your own oxygen facemask first—before helping anyone else with their own—I understood and took it to heart.  After returning to work, I made some immediate changes with priorities and strategies for my own self-care.

Bottom line—our work reflects our personal attitudes about our own wellbeing, as much as it does about the wellbeing of our patients, clients, and students. In fact, these attitudes are an integral component of clinical expertise, and will drive the success of our practice.  The significance of “personal attitudes and qualities” has recently been expanded in both ASHA’s 2014 clinical competency standards as interaction and personal qualities, and in the 2015 revision of standards for accreditation of graduate programs as professional practice competencies (ASHA, 2014; 2015).  Attitudes provide the framework and the context for what happens within the clinical and educational processes, and are thus the most critical “tool” in the profession. As it has been discussed within the medical profession, the most valuable part of the stethoscope is the part that rests between the ears.  And so, prescriptions for our own self-care and wellbeing must be at least as important as care for the people who receive our services (Traux & Mitchell, 1971).

What do we mean by professional wellbeing? While wellbeing is difficult to define and measure, we do know that it involves maintenance of equilibrium easily offset by life’s challenges.  It is sometimes linked to Aristotle’s idea of “eudaimonia”, the belief that the overarching goal of all human actions is to flourish (Bradburn, 1969).  Martin Seligman, another leader in the positive psychology movement, developed a theory about the building blocks for a life that flourishes, which he coined PERMA: positive emotion, engagement, relationships, meaning and accomplishment (2011).  All of this contributes to a feeling of success.  Wellbeing has been compared to quality of life, which is defined by The World Health Organization (WHO) as “an individual’s perception of their position in life in the context of the culture and value systems in which they live in relation to their goals, expectations, standards and concerns” (WHO, 1997).

Paths, roads or ways are metaphors for the possibility that there is a connection between all we are and do.   Our chosen path is the practitioner’s path, where our work becomes about who we are as well as about what we do.  As we think about building, supporting, traveling and ultimately manifesting our path—we create a sense of passage within phases of our professional life that fosters balance, self-care, and reflective practices. As we approach the inevitable forks on our professional paths, let’s reflect upon the values we live by, the qualities and attitudes we embody, and the examples we model for others.  Nothing becomes more valuable than establishing our own set point for wellbeing, and building strategies for maintaining that sacred balance between our personal and professional self.

References

American Speech-Language-Hearing Association (2014) Standards for the Certificate of                  Clinical Competence in Speech-Language Pathology. Retrieved from                  http://www.asha.org/Certification/2014-Speech-Language-Pathology-                               Certification-Standards/

American Speech-Language-Hearing Association (2015). Proposed Revised Standards                 for Accreditation of Graduate Education Programs in Audiology and                                 Speech-Language Pathology. Retrieved from
http://caa.asha.org/wp-content/uploads/Accreditation-Standards-for-                                 Graduate-Programs.pdf

Bradburn, N. (1969). The structure of psychological well-being. Chicago, IL: Aldine.

Haidt, J. (2006). The Happiness Hypothesis. New York, NY: Basic Books

Seligman, M. E. P. (2011). Flourish – A new understanding of happiness and well-being                 – and how to achieve them. London, England: Nicholas Brealey Publishing.

  Traux, C. B., & Mitchell, K. M. (1971). Research on certain therapist interpersonal skills                  in relation to process and outcome. In A. E. Bergin & S. L. Hartfield (Eds.),                  Handbook of psychology and behavior change. New York, NY: Wiley.

World Health Organization. (1997). WHOQOL Measuring Quality of Life. Geneva,                           Switzerland: World Health Organization.

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.