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

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

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

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

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

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

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

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

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

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

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

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

 

Talking Hearing Aids with Brian Taylor and H. Gustav Mueller

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

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

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

BT:  Right.  Do you think it did?

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

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

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

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

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

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

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

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

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

 

Cultivating an Awareness of Generational Differences for Effective Communication

By A. Embry Burrus and Laura B. Willis
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Authors of Professional Communication in Speech Language Pathology: How to Write, Talk, and Act Like a Clinician, Third Edition

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Popular literature is filled with descriptions of the term, “generational differences,” and for good reason. There are distinct differences among individuals based on when they were born, and the political, social, and economic environment in which they have grown up. This post will address the various communication styles of individuals who are currently in the workforce. Although there are differences among the generations, according to the Center for Creative Leadership, there are also similarities; namely, most people have the same basic core values: “family, integrity, achievement, love, competence, happiness, self-respect, wisdom, balance and responsibility.”

The Millennial Generation, born between 1982 and 1994 (estimate), represents a cohort distinct from their parents of the Baby Boom generation (1945–1964 [estimate]), and their predecessors, Generation X (1961–1981 [estimate]). Millennials have been generally described as optimistic, team-oriented, high-achieving rule-followers. In addition, aptitude test scores for this group have risen across all grade levels, and with the higher aptitude has come a greater pressure to succeed. It is noteworthy to mention that Millennials are the most racially and ethnically diverse generation in U.S. history. As of 2012, individuals of Hispanic origin accounted for 26.9% of the 21-and-under population (http://www.census.gov), and Asians accounted for 25.6%. Interestingly enough, this generation has been described as more accepting of diversity than past generations.

Research has shown that children of the Millennial Generation were encouraged to “befriend” their parents, as well as their parents’ friends, and as teens they became comfortable expressing their opinions to adults; therefore, they are not hesitant to challenge authority, assert themselves, or ask for preferential treatment. Studies have shown that Millennials view strong relationships with supervisors to be a crucial factor in their satisfaction with their role as supervisee, and that they expect communication with supervisors to be frequent, positive, and affirming.

In today’s society, we are taught that to be successful, we need to be self-confident. Some of the characteristics assigned to the Millennials are that they are self-assured, assertive, and perfectionistic, which, when used constructively, can be very positive attributes. It is important that Millennials are aware that to members of the older generations, this can sometimes be misconstrued as overconfidence. If a supervisor or colleague perceives you to be overconfident, this could create a number of opportunities for miscommunication and misunderstanding. You do not want to communicate to others that you have more ambition than skill, or that you already “know it all” and therefore do not need or want their input. We often advise our students to be mindful that if they are perfectionists, they should not allow this to morph into fear of failure. We remind them that it is okay to admit that they do not know something, and it is much better to do so than to seem falsely competent.

Members of Generation X, the cohort immediately preceding the Millennials, were shaped by many factors. Generation Xers learned independence, autonomy, and self-reliance early in life. They were the first to be described as “latch-key” kids, and they often took care of themselves and their siblings. They grew up in a time when divorce was commonplace, and therefore ended up in single-family or blended-family homes. As a result, they have been described as being more accepting of themselves and others, and embracing of diversity. Members of this generational cohort have been described as valuing flexibility and creativity, as well as encouraging of individualism.

According to Jean Scheid (2010), “Gen Xers aren’t afraid of technology and love new gadgets, even if it takes a little longer than a Millennial to understand how it all works. Their communication style is one brief and to the point, and e-mail is their preferred method.” Gen Xers desire feedback from supervisors and do not hesitate to offer feedback in return. On the other hand, if not kept in the loop, they may become upset and feel left out.

The “Boomers,” as they are often referred to as, make up approximately 29% of the U.S. population and 50% of the workforce. The oldest members of the Baby Boom generation are now mostly retired, and in less than 15 years, one in five Americans (the youngest members) will be over the age of 65. Those who were born at the end of this generational cohort (1960–1964), however, are still a large part of the workforce and may still embody some general characteristics used to describe this group: focused on hard work, ambitious, competitive, and believers in equality.

To summarize, it is important to always show respect by communicating clearly and demonstrating that you acknowledge what your communication partner feels is important, regardless of position or age difference. This does not mean that individuals across the generations cannot understand each other, or learn from each other; it simply means that we must take into consideration that we may have different ways of looking at the same issue. Being part of a diverse workplace may be challenging to some, yet it can provide an environment that fosters rich personal as well as professional growth.

References

Deal, J. (2015). Ten principles for working across generations [Podcast]. Center for Creative Leadership. Retrieved from http://insights.ccl.org/multimedia/podcast/10-principles-for-working-across-generations/

Schied, J. (2010). Types of communication styles: Bridging the communication gap. Bright Hub. Retrieved from http://www.brighthub.com/office/home/articles/76498.aspx

U.S. Census Bureau. (2012). Current Population Survey, 2012 Annual Social and Economic (ASEC) Supplement. Washington, DC: Author.

 

Perspective-Taking for Neurotypicals

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By Stephanie D. Sanders, MA, CCC-SLP, author of The FILTER Approach: Social Communication Skills for Students with Autism Spectrum Disorders

While creating The FILTER Approach, I took exhaustive measures to help students with Autism Spectrum Disorders (ASD’s) identify, comprehend, and explain essential social skills, while putting them into practice.  As I implemented this curriculum, it began a personal perspective-taking opportunity for me.  I noticed weaknesses within my own communication skills in specific situations. A perfect example is my inability to Listen to my family with technology distractions in view (thank you, Pinterest).  Demonstrating social errors as a neurotypical Speech-Language Pathologist (SLP) could likely justify a new DSM-5 diagnosis of “social skills hypocrite.”

The truth is that most of us have room for improvement socially and in considering the perspectives of those with social impairments.  Perspective-taking tasks usually present a challenge to individuals with ASD, due to Theory of Mind.  I’ve frequently referenced the idiom “put yourself in my shoes” with students during these activities. However, SLP’s can also struggle with taking perspective when driven by accountability for pragmatic language goals printed on a report. I become frustrated when my student resists the educationally relevant IEP goals that will undoubtedly transform him or her into a social skills superhero.  An epiphany soon occurred with a hint of witty wordplay.  My mission: try taking a new perspective on perspective-taking.

I began investigating:

  • How do those with social impairments perceive conversation?

I asked students individually, “Why are conversations important?”  The same response was consistently given, “To find out information.”  This perspective came across as task-driven, lacking any element of enjoyment.  Some interrogation sessions I’ve witnessed appear to be information-seeking at its finest.  In other instances, my students feel obligated to be the source of information.  They lecture peers regarding topics of interest, rather than seeking to find out information.  We’ve discussed how obsessive interests and “conversation hog” habits will cause one to miss the Target, socially.  I’ve also taught this concept in the middle school gifted-student classroom during monthly F.I.L.T.E.R. lessons.  Luckily, the “conversation hog” reference hasn’t triggered any speeches about swine or guinea pig fixations!

Other questions on my mind:

  • How are common rules of social language perceived?
  • What are the most stressful things about social situations?

My little brother Zach was diagnosed with an ASD at the age of thirteen and was my primary inspiration for “The FILTER Approach.” As part of this perspective-taking endeavor, I knew it would be beneficial to get Zach’s viewpoint on social rules.  I asked him to speak freely, without concern of giving a wrong answer.

Me: What do you think the expression, “Put yourself in his/her shoes” means?

Zach: It means you should consider the other person’s feelings.

Me: Exactly.  I want to put myself in your shoes to find out what conversation is like for you, having an ASD.  I want to know your perspective about some social rules in conversation.

Zach: Okay.

Me:  What do I mean when I tell you to “use your filter” in conversation?

Zach: It’s what you should or should NOT say in conversation.  If you always say what you’re thinking, then you could look bad as an employee, lose respect, and look unconcerned about feelings.

Me: Great explanation!  Now I want your perspective on some social rules from my book.  How do you feel about making eye contact and looking for Facial clues?

Zach: A little uncomfortable.  A symptom of people with Autism is sometimes having a hard time with eye contact.  I don’t want to give too much and it’s hard for me to know.

Me: Very true.  We’ve talked about glancing, which works.  You’ve done a nice job of avoiding inappropriate topics in person.  However, you and many other people might post strong opinions on Facebook.  Why do you think that is?

Zach: On Facebook, it’s virtual and like your own little world, so it’s not as real.  It’s uncomfortable in person because you’re actually with them.

Me:  I see what you’re saying.  Do you think it’s hard to Listen during a conversation with someone and why or why not?

Zach: It can be a lot of work. Sometimes I run out of things to say or my mind is off-topic while I’m trying to listen.  The conversation gets stressful if it’s too long and boring.  Sometimes, I think about something totally unrelated, like a conversation with someone earlier.

Me:  Staying focused probably does feel like a lot of work. Why do you think we should try to “hit the Target” socially and what did we talk about for your target?

Zach: We should make goals to be successful. I need to close my conversations with “See you later” and ask about someone else’s interests.

Me: Excellent. Is it awkward for you to End conversations with people at places like church or work?

Zach: Yes, because I run out of things to say.  It’s also difficult to end things at work when my shift is over.  I want to tell my manager I’m ready to leave, but he’s usually busy.  If I just leave, I might look disrespectful like I’m trying to get out of my job.

Me:  Later, we’ll make a plan for leaving work.  Is it difficult for you to Repair conversation mistakes you’ve made and have you used some of the Repair tools we’ve talked about?

Zach: I’ve used some.  Apologizing can be hard and it’s hard to admit you’re wrong.  I’ve asked, “Should I stop now?” when the person was being quiet. I also messaged, “Did I say something wrong?” two times to someone on Facebook who quit talking to me.  He never responded, so I didn’t ask anymore.

Me: I’m so proud of you for trying to Repair social mistakes.  You made a good choice to quit asking when the person on Facebook never responded.  At least you tried.

Me: Overall, what are the most stressful things for you in social situations?

Zach:  It’s stressful because:

  • I don’t know what the other person is thinking.
  • I don’t know if I’ve said something wrong.
  • I don’t know what will happen to that friendship (in the future).
  • It’s tough to start new friendships as an adult.
  • Losing a childhood friendship is discouraging and can’t be replaced.
  • I’ve become shy as an adult.

Me:  Thanks for sharing, Zach.  Therapists need to consider what it’s like for someone with ASD to follow these rules.  It has really helped me to hear your perspective.

From Zach’s outlook, it must be draining to worry about confusing social cues and potential negative outcomes.  If someone repeatedly struggles to use verbal and nonverbal social behaviors in conversation, then it could become a losing battle.  Isn’t it easier to retreat into a virtual world where at least all of the nonverbal challenges are removed?  Many of our students/clients with ASD’s could perceive communication as a lot of effort with little worth.

The challenge is to find pragmatic goals that are realistic, beneficial, and meaningful for our students/clients.  The perspectives of these individuals are usually disregarded as wrong with an immediate need for change. If I truly listen to the individual’s perspective, I can not only set an example of showing interest, but also ensure my therapy approach remains individualized.  I can clearly and personally define the advantages of practicing good social habits now in order to make future social success a possibility. Taking the student’s perspective increases my chances of enlisting him or her in therapy, which will result in a more socially responsible individual. Early investment in the views of my students could allow the opportunity to become an influence in rewriting a lifelong story filled with social struggles and disappointments.

Speech-Language Pathologists Climbing the Steps to Mastery

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Speech-Language Pathologists Climbing the Steps to Mastery
By Lydia Kopel
Co-author of IEP Goal Writing for Speech-Language Pathologists: Utilizing State Standards

Facing the mountain
As a speech-language pathologist (SLP), you are forever tackling a huge mountain called language. There are peaks at the top that you are trying to help your students/clients reach. Do you ever find yourself working on a skill with a student/client who does not seem to be making progress? That peak didn’t seem so far away, but along the way, you encounter twists and turns, making it around one corner only to face an obstacle around the next bend. Frustrating, right? On the inside you’re screaming, “Why can’t he get this? How can I approach this in a different way? What am I doing wrong?”

You’ve set your goal(s) for this individual carefully choosing the target skill(s). But, did you think about prerequisite skills? Prerequisite skills are all the skills that lead up to the targeted skill; the building blocks. Every skill has several prerequisite skills; each prerequisite skill has prerequisite skills. With language learning there is a great deal of scaffolding – one skill builds upon another skill, builds upon another skill, and so on. Let’s look at an example related to the skill of the main idea.

To be able to identify the main idea when it is not stated in a text, one has to have success with many other language skills. These include being able to answer factual questions, determine important details from unimportant details, determine how the details go together in the sequence of events, and be able to draw inferences. Of course, each one of these skills has even more prerequisite skills! And it doesn’t end there!

Each target skill also has several steps to mastery. With the same example of the main idea, we probably shouldn’t expect that a 6th grade student will learn the prerequisite skills outlined above and be able to identify the main idea and supporting details from a grade level text in one year. It is more likely that additional scaffolding and instruction will be needed at various steps. The student may first need to identify a supporting detail when given a choice of three and given the main idea in a 5th grade text. Maybe then you can move them to identifying three details that support a given main idea in a 5th grade text. With further scaffolding, this student may move toward identifying the details in a 6th grade text when the main idea is unknown. Going through these prerequisite skills and steps to mastery can increase an individual’s success and decrease therapist and client frustration—making for a much smoother climb up that language mountain.

Peaks and valleys
We all encounter those individuals who have splinter skills.   They have some of the language skills in the developmental continuum but are missing others. There may be no specific order, no rhyme or reason, to what they can and cannot do. If we can tap into the skills that haven’t fully developed, we can help increase performance on the target skills that are lacking.

Let’s look at the semantic skill of compare/contrast. Perhaps you have a client who can label pictures of nouns and verbs. He can tell you the color, size, and shape of single pictured items. He may be able to use comparatives and superlatives. However, he can’t sort items by attribute, identify things that do not belong, or state category labels. His describing skills are limited because he breaks down when more than one item is pictured together in a scene and more than two descriptors are expected.  Would it be reasonable to expect this client to state how two or more items are the same or different? It seems like there may be numerous gaps in his semantic skills that would be imperative to the skill of compare/contrast.

Reaching the peak
As an SLP, do you have students/clients who are lacking some of the necessary prerequisite skills? Taking the time to figure out what prerequisite skills are needed can lead to success with the target skill(s).   Take a step back and work on the missing skills. Sometimes we need to go backward in order to move forward.

When setting goals, consider the amount of prerequisite skills needed and how fast you anticipate the student to progress. Is your anticipated target skill too high? Maybe you need to aim for a smaller peak. Maybe the goal needs to be one of the prerequisite skills. Take it one step at a time and you’ll soon find the individual standing at the peak.

Prerequisite skills, goal writing, and much more are discussed and outlined in the book IEP Goal Writing for Speech-Language Pathologists:  Utilizing State Standards. Check it out!

Please visit our blog Living the Speech Life and feel free to contact us at livingthespeechlife@gmail.com

Lydia Kopel and Elissa Kilduff

Living the Speech Life

Nasal Emission Terminology Should be Evidence Based and Consistent with Physiology and Perceptual-Acoustic Characteristics

Nasal Emission Terminology Should be Evidence Based and Consistent with Physiology and Perceptual-Acoustic Characteristics (1)David J. Zajac, PhD, CCC-SLP, ASHA Fellow

Coauthor of Evaluation and Management of Cleft Lip and Palate: A Developmental Perspective

The term “cleft palate speech” has often been used to refer to hypernasality, nasal air emission, reduced oral air pressure, and compensatory articulations of speakers who exhibit velopharyngeal inadequacy (VPI). Hypernasality is defined as excessive resonance of the nasal cavity during production of vowels and voiced consonants. Nasal air emission refers to the audible escape of air during the production of high-pressure oral consonants, especially voiceless consonants. Reduced oral air pressure is the flip side of nasal air emission. When air escapes through the nose, some oral air pressure is lost. Thus, oral pressure consonantsespecially voiceless ones—may be produced with reduced oral air pressure and perceived as weak or reduced in intensity. Compensatory articulations are maladaptive gestures that are produced at the glottis or in the pharynx as a way to circumvent a faulty velopharyngeal valve. The use of glottal stops to replace oral stops is a classic example of a compensatory articulation. Hypernasality, nasal air emission, and reduced oral air pressure are passive (or obligatory) symptoms of VPI. This means that the symptoms occur as a direct consequence of incomplete velopharyngeal closure. Compensatory articulations, however, are active (or learned) behaviors and may not occur in every individual.

Although obligatory nasal air emission is a core characteristic of VPI, many confusing, overlapping, and inaccurate terms have been used to describe its perceptual manifestation. The literature is replete with terms such as audible nasal air emission, nasal turbulence, nasal rustle, and passive nasal frication. Because the velopharynx and nasal passage are complex anatomical structures— which may be significantly altered due to both congenital defects and surgical interventions associated with cleft lip and palate—the variety of terms used to describe nasal air emission should not be too surprising. Numerous other terms have been used to describe nasal air emission that is part of active (or learned) nasal fricatives and will not be discussed here. The reader is referred to Zajac (2015) for a discussion of active nasal fricatives as an articulatory error. Rather, this article will focus on terminology used to describe passive or obligatory nasal air escape.

A Brief History of Current Terminology

McWilliams, Morris, and Shelton in the first and second editions of Cleft Palate Speech (1984, 1990) described nasal air emission as occurring along a continuum. First, it could be visible but inaudible, detectable only by holding a mirror under the nostrils of a speaker to see fogging as a result of the air emission. In such a case, the nasal airflow is laminar, moving in relatively smooth fashion, and does not become turbulent, or noise producing. Clinically, visible nasal air emission typically occurs in speakers who have adequate but not complete velopharyngeal closure and normal resonance. Although visible nasal air emission should be noted when it occurs in a speaker, there are no treatment implications. Continue reading

Auditory-Verbal Therapy- Hearing, Listening, Talking, Thinking

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By Warren Estabrooks, M.Ed., Dip. Ed. Deaf, LSLS Cert. AVT, co-author of Auditory-Verbal Therapy: For Young Children with Hearing Loss and Their Families, and the Practitioners Who Guide Them

 

 

Globally, there is a great shift towards listening and spoken language for children who are deaf and hard of hearing.

Amazing auditory options, state-of-the-art hearing aids, and a variety of implantable hearing devices and the pursuit of excellent (re)habilitation by highly qualified practitioners working in partnerships with families, will hopefully become the standard of international health care and educational intervention for children with hearing loss around the world.

It is the work of therapists, teachers, audiologists, surgeons, social workers, and allied practitioners in health care and education to guide, navigate, and coach parents on their search for the treasure chest of spoken communication—to help them help their children discover the valued jewels of hearing, listening, and spoken conversation.  Practitioners everywhere form alliances of hope and trust with parents, and together we polish these precious gems until they sparkle and dance with life.

Why would one ever consider compromising when so much is possible?

We hope that one day we will look back and see an abundance of evidence-based outcomes, all barriers to equitable service gone, and a global focus on literacy with a deep understanding of powerful auditory access to the brain provided by state-of-the-art hearing technologies.

Renaissance man and mentor of many of today’s auditory-verbal practitioners, Dr. Daniel Ling, wrote that “auditory-verbal therapy… developed as a result of the natural outcomes of advances in knowledge, skills and technology.  As such advances occurred, new treatment strategies were devised to maximize their applications”.

Auditory-Verbal Therapy is now widely accepted because more children are acquiring, or have already acquired, the abilities to use spoken language, to interact more freely with other members of society, to obtain higher levels of academic education, and to have a more extensive range of careers, a greater security of employment and fewer limitations on the personal and social aspects of their lives” (Estabrooks, 2006).

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2016 Awards and Honors

We are thrilled to announce the winners of the 2016 Plural Publishing Research Awards given in honor of the late Dr. Sadanand Singh, Plural’s founder. These two scholarships are awarded by the Council of Academic Programs in Communication Sciences and Disorders and the honorees and their faculty sponsors will be acknowledged at the annual CAPCSD meeting award banquet, in San Antonio, TX on March 31.

At the MS/AuD level, the award went to Chelsea Hull of the University of Nebraska-Lincoln. Working with advisor Dr. Sherri Jones, Chelsea is researching the impact of Sound Field Amplification (SFA) devices, specifically the REDCAT amplification system, on student academic outcomes and teacher perspectives of this amplification system on academic improvement.

CAPCSD Scholarship Chelsea Hull

Chelsea Hull                                                         Au.D. Student                                             University of Nebraska-Lincoln

At the PhD level, the award was given to Nancy Quick of the University of North Carolina. Under advisor Dr. Melody Harrison, the focus of Nancy’s research is on investigating the impact of underlying linguistic sources of knowledge on spelling among children with hearing aids, cochlear implants and normal hearing, utilizing a multilinguistic analytic approach.

CAPCSD Scholarship Nancy Quick

Nancy Quick, M.S. CCC-SLP               University of North Carolina at Chapel Hill PhD Candidate in Speech and Hearing Sciences, Class of 2017

Congratulations Chelsea and Nancy on your achievements!


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Healing Voices

Healing Voices (1)By Leda Scearce, MM, MS, CCC-SLP author of Manual of Singing Voice Rehabilitation: A Practical Approach to Vocal Health and Wellness

Singing is a part of virtually every culture and is fundamental to our human experience. In the United States, singing is enormously popular, as evidenced by the vast number of people engaged in all kinds of singing activities. Over 30 million Americans participate in choral singing alone (Chorus America, 2009). Shows such as The Voice, America’s Got Talent, and American Idol illustrate how passionate we are about singing. From the amateur recreational singer to the elite celebrity, we sing as soloists and in ensembles, with instruments and a cappella, in classical and contemporary styles, on stage, in concert, and in the shower.

Every person’s voice is unique and identifiable, and our voices can be a big part of our identity and how we see ourselves in the world. This is especially true for singers, for whom the voice is not only intricately tied to self-image and self-esteem but also may be a source of income and livelihood, creative expression, spiritual engagement, and quality of life. For a singer, a voice injury represents a crisis. Because of the specialized needs of singers, it takes a team—including a laryngologist, speech-language pathologist, and singing voice rehabilitation specialist—to get a singer back on track following an injury or voice disorder. Singing voice rehabilitation is a hybrid profession, requiring in-depth clinical and scientific knowledge married with excellence in teaching singing.

Voice problems are rarely isolated in etiology—usually multiple factors converge to create an injury. These factors may include poor vocal hygiene, inadequate vocal technique, an imbalance in vocal load and medical problems (allergies and reflux are common in singers, but thyroid, pulmonary, neurologic, and rheumatologic conditions are among the illnesses that may affect the voice). The singing voice rehabilitation process must encompass all elements that may be contributing to the problem: medical factors, vocal hygiene, vocal coordination and conditioning, vocal pacing, and emotional factors. Continue reading

The Changing Indications for Cochlear Implantation

Theodore R. McRackan, MD Otology, Neurotology, and Skull Base Surgery

By Ted McRackan, MD, co-editor of Otology, Neurotology, and Skull Base Surgery: Clinical Reference Guide

Cochlear implantation is the gold standard for treatment of severe to profound sensorineural hearing loss. Cochlear implants (CIs) were approved by the Food and Drug Administration (FDA) in 1985 and have been suggested to be the most successful neural prosthesis created to date. Over 300,000 cochlear implants have been performed worldwide, with over 50,000 performed in the past year alone. Cochlear implantation involves a surgical procedure whereby an electrode array is placed in the cochlea of the inner ear, which is organized in a tonotopic fashion with decreasing characteristic frequency along its length. Modern CIs contain between 12 and 22 electrodes, which are spaced with the intention of each electrode stimulating a unique area of the spiral ganglia of the auditory nerve. Cochlear implants work by having an external microphone and an external processor convert an acoustic signal to an electrical signal. It is then sent to a speech processor, which is designed to enhance the signal and reduce noise before sending the information to the spiral ganglion through the CI electrode array.

Cochlear implantation is currently at an exciting time point due to the combination of improving technology and proven outcomes that has led to rapid expansion of its indications. The FDA approved the first single-channel CI electrode for adults in 1984, followed by the multichannel electrode in 1987. Cochlear implants were then approved in 1990 for children older than 2 years, in 1998 for children over 18 months, and ultimately in 2000 for children older than 12 months. There has been a recent push to implant children younger than 12 months due to evidence that children implanted at this age are more likely to catch up to normal-hearing peers at an earlier time point. Three major obstacles have hampered this movement. First, obtaining accurate hearing diagnostic testing in a timely manner can often be difficult in those less than 12 months. Second, there is a slight increased risk of surgical complications due to the low blood volume in this age group. Third, it can be extremely difficult to perform cochlear implant programming in this age group. Nonetheless, the clear benefits of early implantation likely outweigh these risks. Pediatricians, audiologists, and otolaryngologists are encouraged to identify infants with hearing loss as soon as possible for hearing rehabilitation. The earlier this is performed, the earlier children with profound hearing loss can be identified, and the earlier they can be implanted, leading to better CI outcomes.

Use of cochlear implantation in patients with residual hearing has been another area of rapid expansion. It was initially thought that all hearing would be lost with cochlear implantation and that if hearing was preserved, patients would not be able to process electrical and acoustic hearing. However, through the trials of the Cochlear Hybrid electrode and the MED-EL EAS electrode, it appears that both are possible. Through these and other trials, most patients had preserved residual hearing after cochlear implantation. Additionally, these patients showed improved hearing outcomes compared to patients without residual hearing. At the present time, it is not clear whether this preserved hearing is sustainable over time. This is an active area of investigation and will continue to be studied for years. Nevertheless, this technology has greatly expanded the indications for cochlear implantation beyond traditional candidacy.

As discussed above, it was previously thought that individuals would not be able to process combined electrical and acoustic hearing. However, cochlear implantation in patients with residual hearing proved this incorrect. This has led to the more widespread use of CIs in individuals with single-sided deafness. Current standard treatment for single-sided deafness includes devices that essentially ignore the deafened ear. However, with cochlear implantation, hearing can be restored to that ear. This was initially performed in patients with severe tinnitus in the deafened ear but is now being more commonly performed in the absence of tinnitus. Further work is certainly needed to develop a more comprehensive understanding of cochlear implantation in this population, but preliminary data show decreased head shadow effect and improvement in binaural summation, spatial release from masking, and potentially sound localization.

Beyond cochlear implantation, the use of auditory brainstem implants (ABIs) in children is another area of expansion. Although this has been performed in Europe for years, it is only more recently being performed in the non-neurofibromatosis type II population in the United States. Several centers have active clinical trials to perform ABIs in children unlikely to benefit from cochlear implantation due to either absent cochlear nerves or cochlear malformations. This is an unfortunate population as they have limited hearing rehabilitation options. Auditory brainstem implants provide an opportunity for hearing in this population, and the neurotology community is excited to hear the results of these trials.

We have come a long way since Bill House developed the first single-channel CI. As outcomes and technology continue to improve, the indications for cochlear implantation will grow. The audiology and otology communities are eager to see what the future holds for cochlear implantation.

About the Author
Dr. Theodore R. McRackan is an assistant professor of otolaryngology at the Medical University of South Carolina. He received his medical degree from the Medical University of South Carolina and completed his otolaryngology residency at Vanderbilt University. Dr. McRackan then completed his fellowship in neurotology-skull base surgery at the House Ear Clinic. His professional interests include neurotologic outcomes and quality of life research. Dr. McRackan and Derald E. Brackmann, MD co-edited Otology, Neurotology, and Skull Base Surgery, which serves as both a study resource for qualifying exams and a portable clinical reference guide. This text features a concise and approachable outline format, contributions by leaders in the field, and key topics such as anatomy and embryology, hearing loss, cochlear implantation, skull base tumors, vestibular disorders, and pediatric otology. View sample pages and place your order at www.PluralPublishing.com.