Bringing Active Learning to Cleft Palate

By: Linda D. Vallino, PhD, CCC-SLP/A, FASHA, Center for Pediatric Auditory and Speech Sciences, Nemours/A.I. DuPont Hospital for Children, Wilmington, Delaware

Dennis M. Ruscello, PhD, CCC-SLP, FASHA, West Virginia University, Morgantown, Virginia

David J. Zajac, PhD, CCC-SLP, FASHA, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina

Authors of Cleft Palate Speech and Resonance: An Audio and Video Resource

Individuals with cleft and craniofacial anomalies represent a complex heterogeneous population. Like their medical presentations, their communication impairments can be diverse in nature and severity, the result of various causative factors.  Although some individuals with cleft palate may have normal sounding speech others will not. Some will present with obligatory errors that occur as a direct result of velopharyngeal dysfunction (VPD) (e.g., hypernasality, audible nasal air emission, nasalized plosives). Others will present with learned maladaptive articulations that occur as compensation for VPD (e.g., glottal stops, pharyngeal stops, fricatives, and affricates). Individuals with cleft palate may also present with obligatory errors as a direct consequence of oral structural anomalies (i.e., frontal distortions). Even still, there are those patients with and without cleft palate who produce unusual articulations such as nasal fricatives (i.e., phoneme-specific nasal emission) (Vallino, Ruscello, & Zajac, in press; Zajac & Vallino, 2017). Any one or more of these errors as well as those errors unrelated to the cleft palate can co-occur. Given the complexity of speech problems in this population, the student of speech-language pathology might find this all quite confusing. Misidentification of errors can lead to misdiagnosis and inappropriate treatment recommendations. The challenge to any instructor is how to effectively teach cleft palate, a complex disorder, to students; and create a successful transfer of evidence-based knowledge and skill to real-life clinical practice that will result in optimal care for the clients they will come to serve.

 

Traditional Teaching of Cleft Palate

A most pressing issue in the area of cleft palate is that clients with this disorder constitute a low incidence population, and many clinicians have limited academic exposure and/or clinical training in this area (Vallino, Lass, Bunnell, & Pannbacker, 2008). The typical, and most dominant, approach to teaching a course in cleft palate speech is pedagogical. The instructor disseminates (didactic) information about the features of the various speech disorders (i.e., resonance, nasal air emission, articulation, phonation) associated with cleft palate and students are passive recipients of this knowledge. Instructors may supplement the material presented with a textbook on cleft palate that includes illustrations using snippets of recorded speech samples of a particular speech feature to which the students simply listen. Presentations of case studies are rare. The students take notes on the information presented, only to recall it on a written examination (Siegel, Omer, & Agrawal, 1997). They are thought to understand the material based on the grade received for the course. As is known, the grade a student receives is not always a valid or accurate predictor of the student being able to apply his or her knowledge (Albanese & Mitchell, 1993).

The advantages of this traditional didactic approach are that it introduces the student to a fairly broad array of speech disorders associated with cleft palate that might not be otherwise covered in any other course, and the instructors have maximum control over the material presented. The disadvantage of this type of teaching is that it is essentially unstimulating, and that information presented this way tends to be forgotten rather quickly. As Jaebi (n.d.) pointed out, the didactic approach lacks student focused learning, emphasis on critical thinking, and process-oriented learning.  Importantly, it lacks interactivity. Students too have different learning styles and preferences, and if the goal in teaching is to make all students successful learners then this predominant one-way approach is not always a good learning fit for all.

The students who sit in our classrooms in 2018 are millennials. They have grown up with and interact constantly with technology, and this is affecting how they want to be taught. For this reason, it only makes sense that technology be used to bring to the student an interactive approach to their learning about speech problems associated with cleft palate. Classrooms are equipped with this technology (i.e., Smart Boards, data projectors and projection screens or LCD/TV monitors, DVD players, audio systems, and capabilities for video conferencing), which can easily provide access to real-life examples. Students learn well and retain information well when they are engaged, when they are active participants in the learning process.

Cleft palate is a specialty in speech-language pathology that particularly lends itself to learning both in the classroom and experientially, through problems and problem solving. The very nature of this “visible” disorder, the complex case histories, and the multiple disciplines involved can present genuine challenges for the student. However, these challenges can be used to actively involve the student in real-life situations.

Creating a hybrid of traditional classroom learning, problem-based learning and experiential learning translates to a student who becomes a confident, competent, resourceful, and effective speech-language pathologist. It’s about creating a student-centered approach to learning.  The goal is to provide the student with the necessary tools and resources to apply the skills learned to real-life practice.


Problem-Based Learning

Problem-based learning (PBL) is a student-centered approach to teaching that uses problem scenarios to promote concept learning and problem-solving abilities (Barrows, 1996; Hmelo-Silver & Eberbach, 2012; Savery, 2006). Its application has been promoted in the fields of medicine and health disciplines, including speech-language pathology (Burda & Hageman, 2015; Whitehill, Bridges, & Chan, 2014). In contrast to didactic teaching in which the knowledge is provided to the student, PBL turns to the student to apply his or her knowledge.  Through a discussion-based approach and questioning, an instructor facilitates students’ critical ways of thinking without providing them with solutions. Students work in collaborative groups to learn what they need to learn in order to solve the problem. They are presented with a case history (or scenario) that involves a challenge—much like in the real clinical world for which they have to provide a solution (see Box 1).

Box 1. Problem scenario (case history)

This is a 6-year-old male with paired bilateral cleft lip and palate. The lip was repaired at 3 months and the palate at 10 months of age. He has a history of otitis media with effusion treated with myringotomies and pressure-equalization tubes. Current audiologic examination showed normal hearing sensitivity, bilaterally. This child has a history of speech therapy beginning with Early Intervention. His speech is characterized by mild hypernasality, pharyngeal fricatives and stops as well as an /r/ distortion. During the perceptual assessment, it was a challenge for him to repeat sentences and he had to be redirected to task several times. The family is concerned about this child’s hypernasality and expressed that his teachers do not easily understand him.

After reading the patient’s history, the students begin by identifying the knowledge they have about the condition. They need to ask themselves, what facts do I already have and what else do I need to understand in order to resolve this problem? The students have to research the areas where they have identified gaps in their knowledge and the uncertainties they must resolve before finding the solution to the problem and making treatment recommendations. During this process, they have to sort through relevant evidence using a variety of resources.

The advantages of this type of learning include developing the student’s ability to make decisions and effectively solve problems, becoming analytical, working as a team, raising awareness of the complexity of issues, developing an ability to extend learning beyond a presented problem, and integrating theory and practice (Gentry, 2000, p. 13).

 

Experiential Learning

Anchored to PBL, is experiential learning (EL). PBL uses realistic problems to set up the learning leading to a diagnosis and recommendation. EL is a continuous process whereby knowledge is created through an authentic experience (Kolb, 1984). As in PBL, the instructor directs and facilitates. EL is a participatory event and, in effect, a holistic approach to learning in which the student progresses through a cycle of four integrated processes: concrete experience, reflective observation, abstract conceptualization, and active experimentation. (Kolb, 1984).  These features are summarized in Table 1. Central to both EL and PBL is encouraging critical and independent thinking in the student.

Table 1. Summary of key features of experiential learning (adapted from Kolb, 1984)

Stages Feature
Concrete experience Actively experiencing an activity
Reflective observation of the new experience Active reflection on experiences based on personal experience or what is known
Abstract conceptualization New ideas about the problem are formed or modifications of previous conceptions
Active experimentation Apply ideas to practical experience

Both PBL and EL are indispensable to learning through problem solving and although they would be particularly meaningful in a specialty as complex as cleft palate, they have been insufficiently explored in this specialty.  The strength of learning comes from an integration of these two approaches. PBL provides an opportunity to apply a student’s knowledge to a relevant problem. EL provides the experience through avenues such as audio and/or video recordings which bring the problem to life. It draws the connection between the history and the actual presentation of the problem, and further supports ongoing problem comprehension. Moreover, in contrast to didactic teaching, the instructor’s role in PBL and EL is transformed from one that disseminates all the information and answers to one of guidance and facilitation. Gentry (2000, p. 11) noted that instructors in this role often experience revitalization about teaching and a renewed interest in the topic being presented.


Integrating PBL and EL in the Classroom for Cleft Palate        

The experience of audio and/or videotape recordings can be effective when in teaching a course in cleft palate where it is important to integrate coursework and an experience, while also addressing the learning preferences of the student. The recordings are more than just a speech sample, and when presented alone, are ineffective in learning about cleft palate. The true value of these recordings along with case histories and other supplemental information is the added “real-life” dimension to teaching that is unavailable in textbooks even with their short speech samples. They help explain concepts and act as a trigger for discussion. Because the recordings can be played over and over again or stopped at various points, students have an opportunity to hear those aspects of speech that they may have missed or did not understand the first time and to also engage in further discussion about the problem.

A true experiential learning in cleft palate involves audio and video recordings and all of the steps and processes from PBL and EL. Figure 1 illustrates this type of learning within the classroom.

The first step involves a concrete experience in which an audio and/or video recording of the case is presented. The second step involves making observations and reflecting on what was heard and seen in the experience, facilitated by the instructor, and engagement with peers. Using a white board, a systematic approach to problem-solving can be illustrated. Here, the facilitator or instructor can be helpful in offering guiding questions that lead to further understanding of the problem.  Third, the remarks and discussions lead to abstract conceptualization (analysis) and conclusions about the problem and recommendations. During this time misinformation and confusion about the client and speech can be clarified. The fourth step is to test this new-found knowledge during independent practices using real-world problems and/or clinical placements.  This process is a valuable guide in understanding any case regardless of complexity.

In summary, a hybrid of didactic, problem-based learning, and experiential learning will enhance the training experience of the student studying cleft palate. Audio and video recordings can be effective in this process where integration of theory and actual practice are so vital. The role of these recordings is to provide concrete experience along with other steps in the learning process. Given that there have been so few opportunities like this in the past, we have written our new textbook, Cleft Palate Speech and Resonance: An Audio and Video Resource, to facilitate problem based and experiential learning in the classroom (Vallino et al., in press).

 

References

Albanese, M. A., & Mitchell, S. (1993). Problem-based learning: A review of literature on its outcomes and implementation issues. ACADEMIC MEDICINE-PHILADELPHIA, 68, 52.

Barrows, H. S. (1996). Problem‐based learning in medicine and beyond: A brief overview. New Directions for Teaching and Learning1996(68), 3–12.

Burda, A. N., & Hageman, C. F. (2015). Problem-based learning in speech language pathology: Format and feedback. Contemporary Issues in Communication Science and Disorders42, 47–71.

Gentry, E. (2000). Creating student-centered, problem-based classrooms. University of Alabama in Huntsville. URL: http://www.scimas.sa.edu.au/scimas/files/SCIMAS/Articles/Education/project_based_classroom.pdf

Hmelo-Silver, C. E., & Eberbach, C. (2012). Learning theories and problem-based learning. In S. Bridges, C. McGrath & T. L. Whitehill (Eds.), Problem-based learning in clinical education (pp. 3–17). Dordrecht, the Netherlands: Springer.

Jaebi, I. “Disadvantages of traditional classroom training.” Synonym, http://classroom.synonym.com/disadvantages-traditional-classroom-training-7866705.html. Retrieved March 10, 2018.

Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.

Savery, J. R. (2006). Overview of problem-based learning: Definitions and distinctions. Interdisciplinary Journal of Problem-Based Learning, 1, 1, Article 3.

Siegel, P. H., Omer, K., & Agrawal, S. P. (1997). Video simulation of an audit: an experiment in experiential learning theory. Accounting Education, 6(3), 217–230.

Vallino, L. D., Lass, N. J., Bunnell, H. T., & Pannbacker, M. (2008). Academic and clinical training in cleft palate for speech-language pathologists. The Cleft Palate-Craniofacial Journal, 45(4), 371–380.

Vallino, L.D., Ruscello, M., & Zajac, D.J. (in press). Cleft palate speech and resonance: An audio and video resource. San Diego, CA: Plural Publishing.

Whitehill, T. L., Bridges, S., & Chan, K. (2014). Problem-based learning (PBL) and speech-language pathology: A tutorial. Clinical Linguistics & Phonetics28(1–2), 5–23.

Zajac, D. J., & Vallino, L. D. (2016). Evaluation and management of cleft lip and palate: A developmental perspective. San Diego, CA: Plural Publishing.

 

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).

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

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.

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!

Jan_Bickel Bickel_VT2E

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

Christine_MaulMaul_BPCD

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.