“I just want to be a speech-language pathologist or an audiologist. Why do I need to learn about neuroscience and the brain?”

By Richard D. Andreatta, PhD

Author of Neuroscience Fundamentals for Communication Sciences and Disorders

I can’t begin to count the number of times I’ve heard some variation of this statement and question from CSD students during the many years I’ve taught communication neuroscience. But, I’ve realized that from the perspective of the student, it is a very important question to ask, one whose answer actually goes directly to the heart and central purpose of any textbook designed and written to educate students about the nature of the brain. Why do we need to study the fundamentals of neuroscience as a CSD student? I could spend hours trying to provide lofty explanations as to the virtues of neuroscience training in CSD, but I very often prefer to answer this type of question by highlighting one inescapable truth that genuinely surprises most CSD students when they hear it for the first time. The rationale for the importance of neuroscience training in the CSD curriculum boils down to one essential idea that none of us can run away from: whether you are treating a child for a misarticulated /s/ or /r/, a person who stutters, a patient whose had a stroke and can no longer use language, or someone who is hearing impaired, the essence of treatment and all clinical improvement is always about changing some aspect of the patient’s behavior, perception, or cognitive state. The moment you invoke the idea of behavioral, perceptual, and/or cognitive adaptations, one must fully realize that what we are really talking about are changes to the structure and operation of the nervous system itself. To put it simply and plainly, everything we do as clinical speech-language pathologists and audiologists WILL have a direct impact on the very nature, anatomy, and function of the client’s nervous system. I often encourage students to let this idea sink in for a bit and then fully appreciate the magnitude of responsibility that rehab specialists assume when they decide to treat an individual. We are actively changing the brains and nervous systems of our clients through our clinical efforts—period. With this realization in mind, how can students not want to study and understand the nervous system! As I tell students in my university courses, rehab specialists across the spectrum are, in effect, “practicing” clinical neuroscientists whether they realize it or not. And, I believe that it is better to realize this reality than not.

I often discuss with my students that neuroscience is actually one of the few topical areas in the CSD curriculum that literally cuts across and is applicable to virtually all CSD content areas. Neuroscience training is applicable to phonology, voice, stuttering, child and adult language, swallowing, cognitive rehab, motor speech disorders, auditory rehabilitation, hearing aid use, and the list goes on. Neuroscience cuts across these areas because of the fact that we are always talking about behavioral, perceptual, and/or cognitive adaptations when it comes to treatment practice and its impact on client performance and outcome measures. As I teach my course, I frequently emphasize that neuroscience training can help a student appreciate and understand why treatments do or do not work. I also emphasize that neuroscience training can help a student: (1) argue intelligently for the benefits of rehabilitation with other professionals or insurance companies, (2) understand scientific literature on the functioning of the brain during normal and disordered speech-language and hearing behaviors, (3) better understand brain-behavior relationships in order to make appropriate clinical assessments and treatment decisions, and lastly (4) become more creative as a rehab specialist by enhancing their own conception of neurorehabilitation and its potential for a given client (Andreatta, 2019).

As suggested by Barlow (1998), our traditional view of speech pathology will require a dramatic shift to embrace and incorporate different yet related scientific areas (Andreatta, 2008). Specifically speaking, the neurosciences are an area fully capable of contributing much to our profession’s conception of therapy practice. Behavioral therapy programs in general, either intentionally or unintentionally, take advantage of principles of experience-dependent neuroplasticity whereby patterns of behavior are remodeled and trained through graded and targeted activities taught by the intervening therapist. At their essence, clinical interventions function to organize the sensory and motor experiences of the patient by controlling the complexity, frequency, and form of various therapeutic tasks (Barlow, 1998).

From the point of view of someone directly involved in the training of students, it is evident that speech pathology needs to continue making up much ground to more deeply understand, embrace, and incorporate neuroscience principles. From simple articulation errors to the complex deficits associated with neurological or congenital disorders, all available evidence points to the conclusion that treatments provided by a therapist directly impact the individual’s nervous system. Principles of neuroscience and neuroplasticity form the means through which the therapist’s impact on a client’s nervous system will be realized (Andreatta, 2008, 2019).

(Excerpts for this essay were derived from the new textbook by Plural Publishing, entitled Neuroscience Fundamentals for Communication Sciences and Disorders.)

References:

  • Andreatta, R. D. (2008). Sensorimotor elements of the orofacial system: Reviewing the basics. Perspectives on Speech Science and Orofacial Disorders, 18, 51–61.
  • Andreatta, R. D. (2019). Neuroscience Fundamentals for Communication Sciences and Disorders. San Diego, CA: Plural Publishing.
  • Barlow, S. M. (1998). Real time modulation of speech-orofacial motor performance by means of motion sense. Journal of Communication Disorders, 31(6), 511–533.

Navigating Hyperacusis and Disorders of Sound Tolerance in a World of Sound

By Marc Fagelson and David M. Baguley, co-editors of Hyperacusis and Disorders of Sound Intolerance: Clinical and Research Perspectives

The world we navigate is full of sound. As this brief note is being written, the sound of lawn mowers, distant traffic, and snatches of conversations accompanied by rhythmic footfalls stream through windows and doors. When we attend to sounds in the environment, it is impossible not to analyze, and evaluate, and then react. We learn to distinguish information-bearing signals from those whose spectra, we’ve learned as listeners, merit minimal attention and low priority. Some sounds are intentionally attention-grabbing—sirens, doorbells, car horns, shouting—and intended to provoke responses from hearers in the vicinity. Indeed, many alerting sounds are constructed deliberately to be as compelling, and in a sense, as annoying as possible, cutting through distractions and other sounds to demand immediate and sustained attention (Patterson, 1990; Vastfjall et al., 2012). Unfortunately, such sounds may be particularly effective, perhaps overwhelming, for a segment of the population that suffers from experiences of excessive loudness, distraction, pain, and discomfort in their presence. The book Hyperacusis and Disorders of Sound Intolerance offers historical accounts, case studies, and new findings reported by individuals whose work in research labs and clinics focuses upon this underserved population.

At present, audiologists and their patients are adept at estimating thresholds of sensitivity, for example, pure-tone air and bone conduction thresholds. However, it is more challenging in the clinic to obtain important measures of suprathreshold processing, particularly those associated with atypical loudness and sound intolerances. As a result, individuals for whom the world of sound is unusually intense, vivid, perhaps perceived as toxic, endure problems that are difficult to assess and quantify. Interventions lack a substantive evidence base to support specific management approaches. Although most audiologists and otologists know of patients for whom everyday sound evokes discomfort, distress, aversion and in some, pain, such symptoms are difficult to quantify, and management correspondingly difficult to enact. Hyperacusis and Disorders of Sound Intolerance is intended to serve our professions’ abiding and growing need to understand sound intolerance mechanisms and their measurement. If, as is likely, the prevalence of tolerance-related complaints increases and diversifies over time, then the associated challenges will require more effort, empathy, and acceptance on the part of all stakeholders.

The book acknowledges the challenges that will be encountered. Indeed, even the vocabulary used to describe such experiences is varied and imprecise, including decreased, reduced, or collapsed sound tolerance, and several different uses of the term hyperacusis. Sometimes these terms end up signifying more or less the same thing, other times, any one of the terms can be ascribed several distinct meanings. Ultimately, the usage of each of these terms varies; given such fundamental differences, as authors and co-editors Marc Fagelson and David Baguley point out, it is not surprising that data regarding the epidemiology and natural history of hyperacusis are sparse, and inconsistent where it does exist.

From the perspective of recent and emerging investigations, authors Jos Eggermont and Roland Schaette report, in respective chapters, research involving animals and humans. Studies identify physiological mechanisms of loudness and sound-provoked pain perception that remain only partially understood, but whose existence will influence efforts to improve existing assessments and interventions. A group effort from Larry Roberts, Tanit Sanchez, and Ian Bruce reminds us there is lack of translation between the auditory neuroscience and its clinical community’s application of the science that remains difficult to bridge. Don McFerran’s chapter supports this notion as it comprehensively reviews the inventory of medical diagnoses and associated conditions that have influenced, for better or worse, management of sound intolerance.

The experiences of individuals with reduced sound tolerance is heterogeneous, and can vary on a day-to-day, or hour-to-hour basis. In some individuals tolerance is modulated by emotional and psychological state, personal history of trauma or trauma associations in addition to, or interacting with, the auditory environment. Gerhard Andersson’s history of applying psychological techniques of assessment and management for this patient group provides context to the oftentimes uneasy marriage of cross-disciplinary care. Similarly, as pointed out by Melissa Papesh and her co-authors, auditory-processing changes associated with traumatic brain injury require management that challenges standard audiologic rehabilitation.

Tools to assess the extent and severity of loudness tolerance symptoms are crude, and in some cases may be deeply uncomfortable for the patient, as may be the case in some methods of ascertaining the threshold of loudness discomfort using sound stimulation. Because patients with sound intolerance issues express unique impairments and aversions, the need to assess the patient’s self-assessed condition accurately requires validated intake instruments that are both comprehensive and specific. Kathryn Fackrell and Derek Hoare have each collaborated on intake and evaluation forms for sound-related disorders; their chapter addresses the development and use of these essential diagnostic components. Glynnis Tidball reviews audiologic measures that, while imperfect, remain in use and that, when interpreted reasonably, provide value to an intervention’s use and monitoring.

At present, the literature offers little in the way of hard evidence regarding therapy, and which interventions might be optimal for which type of symptoms or patients. Enriching or enhancing the patient’s auditory environment supports improvements in tolerance as well as accuracy monitoring the dynamic sound world. Grant Searchfield and Caroline Selvaratnam provide suggestions for hearing aid fitting approaches and clinical results that indicate the potential benefits of appropriately-fit devices for even the least tolerant patients. Influences of sound intolerance on pediatric patients remains underreported and poorly understood, however many relevant examples and interventions may be accessed, as indicated in the chapter by Veronica Kennedy and her co-authors. Also included is a chapter by musician and music engineer Rob Littwin. His is the story of a patient who received over many years information of mixed accuracy and effectiveness from many sources as he strove to recover from a dramatic, and career-threatening change in sound tolerance. His chapter includes specific listening regimens intended to change tolerance limits through the use of measured and safe sound experiences. Mr. Littwin’s history of sound recording gives a unique perspective to his experiences as a patient and as a seeker of solutions.

Marc Fagelson
David M. Baguley

 

Patterson R.  Auditory warning sounds in the work environment. Philos Trans R Soc Lond B Biol Sci. 1990;327(1241):485-92

Vastfjall D, Bergman P, Sköld A, Tajadura A, Larsson P (2012) Emotional Responses to Information and Warning Sounds. J Ergonomics 1:106. doi:10.4172/2165-7556.1000106

 

Practicing Clinicians Need Practical Ideas

Phonological Treatment of Speech Sound Disorders in Children: A Practical Guide

Jackie Bauman-Waengler, Ph.D., CCC-SLP and Diane Garcia, MS, CCC-SLP

Why should I buy this book? What is unique about it?

The first unique feature of this workbook is that it is intended for practicing clinicians who work with children with speech sound disorders. From this workbook’s inception, the goal was to make something user-friendly that clinicians could use in various ways with a limited investment of time.  Another distinguishing feature is its summary of several of the most frequently used approaches for treating phonological disorders in children. While there are other textbooks that give a broad-based understanding of treatment of phonological disorders, this workbook offers a more in-depth discussion of eight different approaches. It describes the type of children this therapy would be optimally suited for, the diagnostic information needed, how to select targets for treatment, how to structure therapy, how to monitor progress, examples of intervention goals, and group therapy ideas. And, for every therapy concept, it provides examples of research which support evidence-based practice with this treatment protocol.

What are the strengths of this book?

This workbook has several areas of strength. First, its structure is a strength. Every therapy chapter offers a brief overview of the method, examples of supporting research, target selection procedures, sample goals, data collection strategies, treatment guidelines, and group therapy ideas. This structure provides the clinician with an easy to follow process from beginning implementation to monitoring therapy progress. Second, many worksheets are offered which can be tailored to meet the needs of individual children. This saves the clinician time during the assessment and intervention process. Third, case studies are offered in each of the chapters to demonstrate the concepts. There is also a separate chapter at the end of the book which is devoted to four children of different ages with varying degrees of severity. Assessment data for each child are given as well as a brief glimpse of a portion of therapy. Fourth, group therapy ideas are included in many of the chapters. To account for increased caseloads, many clinicians must often structure therapy within a group. These ideas offer group application possibilities for children with speech sound disorders and possibly language impairments.

How will this book help me practically in my job setting?

Many clinicians in a variety of settings are working with children with phonological disorders. With caseloads increasing, we often do not have a large amount of time to become experts in the various treatment options available, nor to decide which treatment protocol might be the most effective for an individual child. This workbook gives clinicians a streamlined version which is easy to use while offering specific data collection forms and protocols which assist and guide the therapist throughout the entire process. It also offers a large quantity of practical information that can be immediately used in therapy. Clinicians will find the progression through each of the treatment options easy to follow and practical to implement. In addition, every chapter contains two case studies that demonstrate the application of assessment information to structuring therapy. These case studies will give clinicians further support in developing appropriate intervention plans for their own clients.

What phonological intervention approaches are addressed in this workbook and how were they chosen?

The eight approaches in this book are: Minimal Pair Therapy; Multiple Oppositions; Maximal Oppositions; Complexity Approaches; Phonotactic Therapy; Core Vocabulary Intervention; Cycles Approach; and Phonological/Phonemic Awareness.  These eight were selected based upon several factors: research demonstrating positive evidence-based practice, frequent use of the method, ease of implementation, and availability of resources to support application.  Some of the approaches included represent comprehensive therapeutic protocols, while others primarily describe a specific target selection strategy.  All are designed to remediate phonological difficulties, yet do not necessarily exclude the principles which govern a traditional sound-by-sound approach.

What are the characteristics of children who would most benefit from phonological intervention?

As the name implies, phonological intervention approaches are designed for children with phonological disorders.  That said, all children who demonstrate a speech sound disorder, regardless of etiology, may potentially benefit from the principles of phonological therapy.  Appropriate recipients typically demonstrate more than one or two speech sound errors. They may demonstrate pervasive sound error patterns and exhibit highly unintelligible speech. With specific methods it is important that the child demonstrates a collapse of phonemic contrasts. In other words, one phoneme replaces many other phonemes. For example, the child uses “t” for “s”, “z”, and both the voiceless and voiced “th” sounds.  With other therapy protocols the child fits best if a very restricted phonemic inventory is noted.  Specific characteristics of children who would benefit from each therapy approach, such as age, severity, and types of errors, are provided in this workbook.  This information gives clinicians concrete and verifiable guidelines for selection of appropriate intervention methods for individual children.

What are the advantages of using a phonological intervention approach, as opposed to a traditional motor approach?

There are many advantages!  Phonological intervention targets often include patterns or groups of phonemes, rather than individual sounds.  This results in broader change across a child’s entire phonological system.  Phonological approaches have successfully demonstrated generalization to other sounds or patterns through careful selection of targets according to specific guidelines (Gierut, 2007). On the other hand, the traditional motor approach focuses on correct remediation of the physical production of individual sounds in a sound-by-sound manner. The traditional approach can take a much longer therapy time and generalization to other sounds does not seem to occur (e.g., Bowen, 2011; Dinnsen, Chin, & Elbert, 1992). In addition, phonological therapy targets the linguistic function of sounds, that is, the use of phonemes to create meaningful words.  This shift in focus allows clinicians to facilitate functional communication in natural contexts, thus improving children’s ability to communicate during daily interactions.

I have just been using the traditional-motor approach. Is that wrong?

The traditional motor approach, sometimes called the phonetic approach, is not intended for every child with a speech sound disorder. Decades of research have documented that some children make faster, and more broad-based progress with some of the phonological treatment options (Gierut, Elbert, & Dinnsen, 1987; Gierut, Morrisette, Hughes, & Rowland, 1996; Tyler & Figurski, 1994 ). If you have children on your caseload with multiple errors, then the traditional approach, going sound-by-sound through the child’s errors, can take an enormous amount of time. This is time they are spending in speech therapy and not within the classroom. The goal is to get these children out of therapy as soon as possible. Phonological treatment methods are one very successful way to do this.

 

Bowen, C. (2011). Target selection in phonological intervention. Retrieved from http://www.speech-language-therapy.com/ on 8/12/2018.

Dinnsen, D. A., Chin, S. B., & Elbert, M. (1992). On the lawfulness of change in phonetic inventories. Lingua, 86, 207–222.

Gierut, J. A. (2007). Phonological complexity and language learnability. American Journal of Speech-Language Pathology, 16, 6–17.

Gierut, J. A., Elbert, M., & Dinnsen, D. A. (1987). A functional analysis of phonological knowledge and generalization learning in misarticulating children. Journal of Speech and Hearing Research, 30, 462–479.

Gierut, J. A., Morrisette, M. L., Hughes, M. T., & Rowland, S. (1996). Phonological treatment efficacy and developmental norms. Language, Speech and Hearing Services in Schools, 27, 215–230.

Tyler, A. A., & Figurski, G. R. (1994). Phonetic inventory changes after treating distinctions along an implicational hierarchy. Clinical Linguistics & Phonetics, 8, 91–107.

Gender Biases in Traditional Voice Education

By Liz Jackson Hearns and Brian Kremer

Authors of The Singing Teacher’s Guide to Transgender Voices

Nowhere else in the musical arts are gender roles as staunchly established and upheld as in voice. The binary gender system presides over voice parts, repertoire choices, role casting, competitions, costuming, dressing rooms, and more. Because the established social gender roles of singers have never been deconstructed or recalibrated, the prevalence of the binary system is so ingrained that it often goes unnoticed until someone who does not fit into the system disrupts it. That disruption leaves many voice teachers and music educators at a loss for means to guide their students in ways that support them artistically and help build their careers in such a heavily gendered environment. It also leaves many gender diverse singers, or would-be singers, unable to find or rely on culturally responsive and pedagogically competent teachers, alone in trying to discover their own authentic, true voice. By engaging in discussion and education about gender-inclusive voice care for singers, we can develop new ways of hearing and guiding voices that affirm, welcome, and hold a place for all singers of all genders.

Voice Part Categorizations

One of the more obvious places that gender binaries impact singers and singing education is voice part classification. The traditional Fach system is, in many ways, an antiquated guide for the modern singer, and especially so for a gender diverse singer. Even choral voice parts are delineated and described as they relate to the gender of the singer. Two singers could have identical voice ranges, weight, color, and style; they could sing the same repertoire and audition for the same stage roles, but each might have a different voice part category because of their gender. Does the gender of the singer somehow change the sound of their voice?

Choosing to adopt a particular voice part category requires that the singer choose a gender, essentially. This can be limiting for transgender and gender nonbinary singers because of the traditionally gendered associations that accompany voice classifications. Female low-voiced singers, male high-voiced singers, and gender nonbinary singers are left without any appropriate voice part category. The ensuing confusion on the part of the casting directors may prevent transgender and gender diverse singers from being considered for stage roles, choral contracts, solos, or competitions, because these singers do not fit the mold. Rather than consider the validity and usefulness of the system and make room for growth beyond its outdated modes, educational institutions and casting agencies attempt to box these diverse and boundary-defying singers into established gender norms. Trans singers are then left bewildered with nowhere to belong, and face enormous obstacles to artistic and career development.

Repertoire

Because the singing instrument is the only instrument that creates words, singers are tasked with telling understandable and compelling stories, either as themselves or through character interpretation. The gender identity of the singer may prove to be a factor when deciding if a piece is the right fit, so that the artistic intent of the singer complements the artistic intent of the composer or librettist. Voice teachers may be inclined to suggest repertoire for their students that is either overtly or deceptively gendered, which may be appropriate for the voice quality but grossly inappropriate for the singer. There are very few, if any, pastoral pieces for bass-baritone or songs of sexual and military conquest for soprano. Trans singers may have few options when creating performances or audition books to find repertoire that aligns with both their technical skill and personal identity.

Voice Pedagogy Language

Voice teachers and students form deep personal and artistic bonds inside the voice studio, and it should be a safe place for discovery and exploration for all singers, regardless of gender. Traditional voice pedagogy assumes a level of comfort with one’s body and voice that is likely not present for a transgender or gender nonbinary singer. Trans singers sometimes must overcome the difficulties and limitations that arise from gender dysphoria, especially around voice. Voice is a characteristic through which we categorize people by gender, subconsciously and automatically, and trans people are often acutely aware of the ways that voice can influence how the world sees and hears us. That awareness can lead to extreme discomfort around making vocal sound at all, discomfort with the body as it relates to voice, discomfort or disconnection from sensations in the body, or hypervigilance about parts of the body or the sound of the voice.

Gender-inclusive voice pedagogy can include language that differs from traditional ways of teaching voice by giving agency and autonomy to the singer when learning new skills or taking on new vocal tasks. Gender neutral language also helps alleviate—or at the very least prevents exacerbation of—some symptoms of gender dysphoria for singers, especially when referring to the parts of the body needed for singing or qualities of vocal sound. Rather than describing the sound of a voice as “masculine” or “feminine,” the teacher is challenged to use more specific descriptors, which may actually improve pedagogical efficacy for all students, including trans singers.

First Steps

Transgender voice care is a burgeoning field and serves a population in need of qualified teachers and practitioners. As voice teachers, our responsibilities are to support our students and to help them meet their musical, artistic, personal, and career goals. This often requires us to push ourselves beyond our comfort zones and work together toward changes in the systems that hold our students back. There is still much to learn in this realm of voice, and the first steps involve recognizing and reframing our own subconscious judgments, self-perceptions, perceptions about others, biases with regard to voice, and other factors that we may carry into a lesson with a trans student that could pose serious barriers to that student’s success. The Singing Teacher’s Guide to Transgender Voices aims to aid in the development of a successful vocal pedagogy for the training of transgender singers, help the academic community understand the needs of transgender students as it pertains to vocal training, and engage in a broader discussion about the presence of transgender students in lessons and classes and how this positively impacts teaching, curriculum, and classroom environments.

Putting Theory into Practice through Hands-On Experience

By Bre Lynn Myers, Aud, FAAA

Author of Vestibular Lab Manual, Second Edition

Putting theory into practice can be one of the largest obstacles students and clinicians face particularly when the subject matter appears complicated. Guided hands on practice is necessary in order to obtain the confidence and skill set critical to properly instruct, collect, and analyze data from each test accurately.  In addition to guided practice, it is also helpful when learning something new, to have someone who is able to explain complex ideas with everyday examples. The Vestibular Lab Manual, Second Edition does both. The text begins with an overview of a well-equipped vestibular/balance lab and suggests observation and reflection as a means to begin the appreciation of vestibular diagnostics. Every student interested in learning a skill, be it in the health care field or humanities, should have an appreciation of the “final product” before beginning to dissect each part.  Following the introductory chapters, subsequent chapters break down vestibular assessment protocols piece by piece. Each chapter provides general instructions, tips, and guidance, suitable for practice with any manufacturer’s equipment.

Learning is also more fun and less stressful when you have a friend beside of you. Chapter exercises are designed to be completed with a partner or small group in approximately one hour, allowing for each participant to serve as clinical operator and “patient.” Once students complete the “guided practice” portion of the chapter, reflection and review questions or case studies are provided to reinforce theory with practice. By setting learning objectives, providing a little background and specific goals students and clinicians can move through each chapter at their own pace, freeing up lab instructors to provide specific feedback and address questions as they arise.

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.

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!

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.