Guest post! Food Chaining: A technique to help your picky eater

Food Chaining:

A technique to help your picky eater

By: Brittany Warby

 We all know a child or two who is what we call “extremely picky.” They won’t eat anything red, crunchy, cold, hot, sweet, hard, soft, etc. They seem to eat the same limited foods everyday and no matter what they seem to refuse anything else. They may push the food away, spit it out, or gag whenever a less desired food is presented.

It is easy to place blame in a situation like this. I often hear “If the parents would just force the child to eat it…” or “Sometimes you just need to lay down the law and not give in.” Unfortunately it is not always that easy. The child who ate a variety of textures, colors, and types of food yesterday may turn into a picky eater tomorrow. 

According to an article, “Feeding Disorders in Infants and Children”, published in the scientific journal Pediatric Clinics of North America, between 25 to 35 percent of children in the United States have feeding disorders, and up to 40 to 70 percent of children with chronic medical problems have problems related to feeding and nutrition.

Causes of Picky eating:

Picky eating habits can be caused by a variety of things such as vitamin or mineral deficiencies, malnutrition, oral aversion, congestion, erratic sleep patterns, or a variety of frequent or chronic illnesses.  Other children will simply refuse a food due to its smell, taste, or texture. In other cases the refusal of food could be physiological struggle with the process of chewing and swallowing.

In order to determine what the main issue is, it is best to seek help from a feeding specialist who can assess the situation and can help pinpoint a cause. For many of these children a technique known as food chaining can be helpful in assisting the child. Food chaining can help the child cope with an aversion and gradually increase the types of food the child is comfortable eating.

What is food chaining?

Food chaining is a child-friendly feeding technique. It is designed to build the child’s successful eating experiences by studying the types of food the child will easily accept and choosing similar food to gradually build the child’s menu. New foods with similar texture, taste, and/or temperature are presented to the child. These new foods create a food chain or link between what the child will easily accept and the targeted food we would like for him/her to eat.

Food chaining can use a variety of methods to make the food presented more desirable. Flavors can be added that will make the child more likely to accept the new food. Examples of this would be adding ketchup or ranch dipping sauce. This masks the flavor of the new food and can offer a means to coax the child to gradually accept the new food.

Another successful method is by using transitional foods. This is done by giving the child a bite or two of a familiar and accepted food followed by a bite of the new food, followed by another bite of the familiar food. Transitional foods can help to reduce aftertaste and help to cleanse a child’s palate when introducing a new food.

When doing food chaining it is important that the feeding specialist rate the child’s reactions to new foods and continually monitor the changes in preferences over time. It is also important NOT TO FORCE foods. Food chaining allows a child to be desensitized to taste and textures enough to allow them to try food in a variety of different food groups and can help in improving nutrition.

Examples of a food chain:

Example 1:

Child’s current accepted food choice: McDonalds Chicken Nuggets

Target food: Baked chicken breast made by mom

Chain:  McDonalds Chicken Nuggets > other brands of chicken nuggets > homemade chicken nuggets > non-breaded/skinless chicken nuggets > small chicken breast

Example 2:

Child’s current accepted food choice: Goldfish

Target food: Mac and Cheese

Chain: Goldfish > other flavors/sizes of goldfish > other brands of cheese flavored crackers > Soft crackers > Shredded cheese > Cheese with pasta > Mac and Cheese

It is important to remember that no single chain will work for all children and that each child may require more or less steps before reaching the target food.  Although there is no one fix all for a picky eater, food chaining is a technique that has proven to help children build variety and types of foods they will accept.

Resources:

http://www.abilitypath.org/health-daily-care/health/growth-and-nutrition/articles/obesity/pdfs/parent_toolkit-_food_chaining.pdf

http://cheriandlaura.blogspot.com

Fraker, Cheri. Food Chaining: The Proven 6-step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child's Diet. New York: Marlowe, 2007.

http://mealtimehostage.com/tag/food-chaining/

Speech Tips for Parents

Speech Tips for Parents

After working in the field of speech language pathology for a couple of years at this point, I have started creating a list of things I wish parents knew, things I wish parents did, and things I wish more people knew about speech. While I addressed these lists to parents in particular, you can replace parent with older sibling, aunt, uncle, grandparent, godparent, friend of the family, etc. I know very few people who have absolutely nothing to do with a child, almost everyone I know has siblings, nieces and nephews, friends who have kids, etc. so I think these lists are pretty applicable to everyone.

 

Here they are, in no particular order of importance:

What I Wish People Knew About Speech

·         Speech Language Pathologists (SLPs) are professionals who go through a total of 7 years of higher education and training including a national exam before they are allowed to become licensed. While you may know every grammar structure in the literate world and every developmental milestone, a speech therapist is able to use those developmental milestones and grammatical structures inside of research and experience-guided therapy in order to increase your child’s speech and language skills at the greatest possible rate. 

·         Speech therapy does not only include children saying their R’s. Speech therapy can include:

o   Articulation- saying speech sounds correctly

o   Fluency- stuttering

o   Swallowing- that’s right—if you have trouble swallowing, we’re who diagnoses you

o   Language- focusing on your internal grammar abilities. Language can be both expressive (what you say) and receptive (what you hear)

o   Cognition- we work with executive function issues, memory, etc.

o   Pragmatics- this is also known as social language- its everything you say with your body language and tone of voice

o   Voice- this includes vocal nodules, vocal paralysis, etc.

o   Aural Rehabilitation- this works with children and adults who are learning to use the hearing they have or hearing devices to hear and respond to the world around them to the best of their ability.

o   AAC- Augmentative and Alternative Communication- we use everything from a single button to a complex eye-gaze system to help people get a message across to their communication partners

·         Speech therapy is best when started EARLY!!! If your child is 3, they’ve already missed prime therapy time. By 10, there’s only so much we can really do. For adults, speech therapy after a stroke or other neurologic event is best in the first year, after that, there’s only so much we can do. When you break a bone, you don’t wait around for several years saying, “Well, it’s going to heal just fine on its own, so why bother to get a cast?”

·         Speech and Language skills affect everything that we do. Have you ever gone to the grocery store when no one spoke to you? Ever gone on a date? Ever made it through the school day with no one speaking? Ever had to communicate that you were hungry or tired? Ever tried to make it through school without reading or writing?

What I Wish Parents Knew

• Where to look up speech development guides. Most parents don’t really need to know that k, g, t, d, p, b, m, n, ng, and the vowels should be developed by three, s by four, r by 7, etc. But, I have so many parents that ask me if they’re child is ok that I wish more parents had access to the information in the first place.  An excellent resource is www.handyhandouts.com. My favorite hand out for this topic is “When Should I Worry if My Child is Behind?” (available here)
•  Your children model your behavior. Monkey see, monkey do. The more educated you are (about everything), the better model your children have.
• There is nothing better you can do for your child than talk to them and read to them.
• Talking to your child does not mean, “No, stop, don’t.” Talking to them includes talking about your world (“Man, the trees look so nice in the fall, don’t they?”), talking to them about what you’re doing (“Here we go, driving to school!”), talking to them about what they are doing (“I see you throwing that big, red ball”), and talking about how to do things (“First we put the groceries on the belt, then we need to pay”). Guess who teaches your child everything about the world for the first few years? You do!
• I wish you knew WHY your child is being recommended or is getting speech therapy. That includes knowing what goals they’re working on. In one of my most memorable meetings at school, I had a parent who’s child had been receiving speech therapy for at least 4 years who said, “I don’t know why Sue* is getting speech. She talks all the time.” Sue was one of my most severe students for language, but she was pretty talkative. The problem was she talked about nothing to do with anything we were doing and couldn’t answer simple questions accurately. Despite being given evaluations and going to 4 years of meetings, this poor parent didn’t have a clue. I encountered many more like her and I wish parents really strove to understand what speech was doing for their child. (That being said, many parents do make that step). (*Name has been changed)
• Language and learning disorders run in families, if you or your siblings (or in-laws) have one, your kids have a higher chance of getting them. You can ask for screenings from the school therapists or go to a private clinic for a screening to make sure you can get to therapy as soon as possible.
• School therapists are very restricted in what they can and cannot treat. For example, I had very strict guidelines of scores my school would allow me to treat, if a child didn’t score low enough on an assessment, or was performing at grade level in class, or their impairment didn’t have a clearly identifiable educational impact (they could be understood with their bad R for example), I was not allowed to treat them, despite them needing therapy in my professional opinion. I did my best to refer them out to private therapists (I always provided at least 3 options one of which was free) so that they could get the therapy they needed. If you think your child needs therapy, private therapy may be your only option. Speech grad schools also have clinics which may be able to provide therapy at reduced prices. Insurance may help cover some of the cost as well.
• Sometimes therapy everyday all day will not be able to “fix” the problem. Sometimes even the maximum therapy schools or hospitals can’t “fix” the issue. Sometimes kids will not be able to recover to normal. That being said, therapists from speech, occupational therapy, physical therapy, social work, etc. are able to do amazing things to help your child cope with the world with the skills they have. We can help identify strengths and help your kiddo use those strengths to overcome or minimize their weaknesses.
• Googling speech disorders to diagnose your child or tell us what to do is kind of like using WebMD to diagnose the flu and telling the doctor to give you chemotherapy. Remember, SLPs studied for 7 years in order to diagnose speech and language disorders, google will not tell you all you need to know, how to treat the disorder, or the prognosis. SLPs are going to be able to do all of that and provide individualized treatment for your child. That being said, don’t be afraid to approach with ideas you’ve looked up and discuss why you like them with your therapist.
• We are NOT PLAYING. Yes, to the untrained eye, it make look like we are just carving a pumpkin, however we are actually working on following directions, dealing with sensory issues, using focused stimulation to elicit language from your child, using music and finger play to work on imitation, working on social skills, working on joint and sustained attention, helping the OT with her pencil grip goals, and simultaneously trying not to make sure no knife accidents occur.

Things I Wish Parents Did

• Read. Read. Read. Read. Read. Read. Read EVERYTHING: cereal boxes, instruction manuals, picture books, chapter books, shampoo bottles, street signs, movie titles, recipes, pamphlets, text messages, newspapers, magazines, scriptures, coupons, grocery aisle signs, maps, etc. You and your children grow up in a world full of words. The more you read, the more your child realizes that words have meaning. The more words have meaning, the more they understand. Kids learn rules, social structure, vocabulary, etc. from books.
• Fun fact: the only research based method to learn new vocabulary is by reading.
• Fun fact: The difference between children of parents with high income and children of parents with low income is about 30 million words over 4 years. Reading can help bridge this vocabulary gap. (Hart, B. & Risley, T.R. “The Early Catastrophe” (2004) Education Review, 77(1), 100-118
• Did I mention reading? When reading to your child, ask questions, talk about the pictures, talk about the characters motivations and interests, talk about the character’s feelings, talk about your feelings, talk about likes and dislikes, talk about character’s choices… In short, talk about anything and everything in the book. You don’t have to do that every single time, sometimes you can just read the book—other times, make your kid work for the book. 
• Talk to your child. You'll be amazed at what they understand. Don't talk at your child, talk with them. Ask them about their day, what their favorite subject is, what they think about the book you read, what their favorite color is, why do butterflies have wings, etc. I particularly enjoy asking younger children (around 4) deeper questions (why is the sky blue? Did dinosaurs have restaurants?) to watch them really think about things. 
• If you're concerned about a kiddo, I wish more than anything that you would ask questions. Go get an assessment, talk to a speech therapist, talk to your pediatrician, talk to your school. Ask someone you trust and if you can't find answers keep asking.  Kids can't advocate for themselves, they need a loving parent to help them.

Resources for Parents and Caregivers

For a more complete list see the "My Favorite Resources" page on this blog.

• Handy Handouts- wonderful handouts put out by SuperDuper Inc. which explain speech and language issues and concepts in parent friendly language. They also provide lots of additional resources and tools parents can use at home. www.handyhandouts.com
• American Speech Language Hearing Association- this is the national association for Speech Therapists. There are wonderful resources for both parents and therapists as well as a search to find a therapist if you need an assessment or a new therapist should you move. 

·          

Picture Sources 

1. http://amorganslp.blogspot.com/2009/05/things-to-know-about-speech-therapy.html 
2. http://www.hasdpa.net/Domain/86
3. http://www.zazzle.com/speech+therapy+posters 
4.  https://carmenwiki.osu.edu/display/hdfs361sp20119489/Children+Speech+Therapy+By+Brooke+Laird

What to Expect When You're Assessing

What to Expect When You're Assessing

Being told someone you love needs a speech assessment can be a frightening, stressful, and confusing time. While dealing with the concept that your child might not be "normal," you are also most likely dealing with insurance, physician referrals, making appointments, and other stressful new experiences. Be not afraid.  An assessment is just a long paper which uses tests, descriptions, and informal measures to give a therapist a snapshot of a client.  

Any therapist that works with a child or adult wants to see what the client can and can't do in comparison to the developmental norms so that they know where to start or where to continue in therapy with your child.  Sometimes, Speech Pathologists utilize assessments to demonstrate that a client does not require therapy because they are performing so well or to help inform caregivers that the client might need to be in therapy after all. Speech Pathologists can also use assessments to help diagnose disorders of language, speech, fluency, or swallowing.  

As mentioned above, an assessment is a snapshot of how a person communicates during a particular day at a particular time with a particular partner.  In my experience, with most clients, the first assessment they receive is with a stranger (meaning a new clinician they most likely have never met before). Sometimes this provides a fantastic picture of exactly what the kid can do, other times, the child or adult has an "off" day or is shy of strangers and their assessment does not provide the most accurate picture.  Remember that an assessment is just a picture of one day. A good clinician will use the assessment, data taken during therapy sessions, observational data, etc. to continue to update their picture of the client, to form goals, and to create future therapy plans.  

Most assessments will include a few or all of the following elements- they may even include extra elements not mentioned.

1. History and Background- assessments should include a background of how the client came to be assessed, what concerns they may have, observations from family members, etc. Additionally, for children, pertinent information regarding developmental milestones such as sitting up, crawling, walking, etc. can be used to establish whether a disorder is global (more than just speech) or if it only affects speech and language issues.
2. Behavioral Observations- these observations would mention if a client had difficulty paying attention, if they required breaks, how they act around their family or other familiar partners versus the examiner, etc.
3. Oral Motor Mechanism Exam- this quick and easy peek into the client's mouth shows important details for speech like a tongue tie, cleft palate, severe bite problems, etc. It also looks at the face and mouth in general to make sure that all of the facial features are able to perform speech functions.
4. Hearing- even if informally assessed, hearing is an important component to any speech and language assessment. If a client has difficulty hearing, it may seriously affect how they perform on any evaluation.
5. Standardized Tests- These are tests which compare the client to other people of similar age or grade based on statistical similarities and differences within that population.  Occasionally, a "criterion-referenced" test is used instead of a standardized test- these test compares the client to another population, however it does not use statistical measures to do so.
1. Expressive Language- this test or combination of tests will assess how the client expresses him/herself.
2. Receptive Language- this test or combination of tests will assess how the client understands language.
3. Expressive Vocabulary- this test will assess the vocabulary the client uses to express themselves
4. Receptive Vocabulary- this test will assess the vocabulary the client understands
5. Fluency- this test will assess the fluency of the client's speech looking specifically at blocks, prolongations, and repetitions.
6. Articulation/Phonology- this test or tests will examine how the client pronounces different sounds and the patterns they use to pronounce those sounds
6. Informal Measures- These are observations or other tools which may have clinical significance, but are not statistically measurable and may include:
1. Informal voice evaluation- essentially, this would be observations about the quality of a client's voice (abnormally high, strained, etc.)- often abnormalities would lead to more serious testing
2. Bedside Evaluation for Swallowing- unlike a "Modified Barium Swallow Study" (or MBSS) this test may be a quick trial of different thicknesses of food and drink to determine if a Modified Barium Swallow Study may be warranted.
3. Informal language observations- this may include a language sample which can calculate several different measures which can be compared with the developmental norms (although not statistically). For example, clinically we know that a child who is 3 should be using 3 "morphemes" (meaningful unit of language) on average per sentence. If we did a language sample and the child only used 1 morpheme on average per sentence, we would know that the child is behind compared to what the child should be doing at that age.
4. Informal Pragmatic language evaluation-  these observations focus on the use 
7. Validity Statements and Explanations of Tools used-  assessments should explain what tools were used and what the score the client received means.  For example, it should be stated that the exam was given according to the instructions and how the scores for each assessment "work."
8. Recommendations- Speech Pathologists should recommend a course of action after finishing the assessment.  It may include seeking out therapy, some tasks to help out at home, that results should be shared with other professionals, etc.

 As was mentioned before, assessments are just a little snapshot in time and the examiner will do their best to provide the best overall picture of a client as they possibly can.  Assessments can be scary, but in my experience the information they provide is so priceless that they end up being worth the overall hassle, time, and energy that it takes to get the finished product.

If you have any questions about assessments, if you would like to receive assessment, or if you have had an assessment that you do not understand, don't hesitate to contact a speech language pathologist who can counsel you and explain everything to your understanding.

My toddler isn't talking!!! What do I do?

My Toddler Isn't Talking!!! What do I do?

I have been approached more times than I can count by concerned parents who have a 1-2 year old and are concerned about their speech progress.  I'm always excited when parents come ask me questions, because it gives me a chance to let them air some of their concerns and also to give them some comfort and guidance.  Every parent I know wants the best for their children and not speaking or learning to talk slower than peers is very concerning. When I am approached, I ask a few questions to ascertain the child's progress and compare it to developmental norms.

The first thing I always ask is, "How many words do they have?" 

Children should start speaking around age 1 (some speak a little earlier, some speak a little later, but it averages to 12 months). By age 2, children should have 50 words and begin putting 2 words together to form simple sentences (for example, "more juice" or "mommy walk"). At 3, children should be using 3-4 word sentences and have approximately 1000 words in their vocabulary.

Secondly, I ask, "What percentage of the time can you understand them?"

By age 2, your child should be at least 50% intelligible.  All children babble or use jargon (groups of sounds strung together that sound like words with intonation, but aren't really words), but by age 2, someone who has never met your child should be able to understand half of what they say. (By 3 that intelligibility increases to 75% and by 4, 100%). 

Thirdly, I ask, "Can your child follow simple 1-2 step commands?"

At 18 months, a child should be able to follow simple 1-step commands (for example, "pick up the shoe"). By 2, however, your child should be able to follow 2-step commands (for example, "pick up the block and put it in the toy box"). At 3, a child should be able to follow 3-step commands (for example, "pick up the shoe, put it by the front door, and come back here"). 

Lastly, I ask, "What have you already tried?"

Perhaps not so surprisingly, answers vary widely here.  Some parents have tried everything from reading every day, talking all the time, using flash cards, singing songs, teaching sign language, and using pictures around the house.  Often, others are so overwhelmed they don't even know where to start and haven't done anything and don't know if they even should do something. 

My number 1 recommendation is READ. Read everyday. Read all the time. Read to your child. Talk about the pictures. Make funny animal noises when you read about animals, act out stories like the three little pigs or Goldilocks, do crafts with the characters in the story, eat green eggs and ham.  Reading is the only research-proven method to increase vocabulary in children.  Again--Reading is the only research-proven method to increase vocabulary in children.  No matter how many flash cards you try, your child will not learn as much as quickly or as effectively as if you read. For more information and ideas of how to teach vocabulary while reading, see the references at the bottom of this post.

I also tell parents to TALK. Talk all the time. Talk about everything you're doing.  For example, if you're making dinner, narrate what steps you're following.  "Right now I'm cutting the tomato.  Tomatoes are so lovely and red. I love tomatoes. They are delicious. I have to be careful with the knife when I'm cutting. Now the tomatoes go in the bowl." There are two kinds of "vocabulary-building" speeds your child uses: slow-mapping and fast-mapping. For fast-mapping a kid can hear a word 1 or 2 times and remember it and use it correctly. For slow-mapping, a child needs to hear the word 30 times to remember it and use it correctly.  For a child who is slower (for example a child with a language disorder) that child will need to hear the word 100 times or more to remember it and use it correctly. If you narrate what you're doing just like the example, you have used the word "tomato"4 times. That means if your child is "slow-mapping" their vocabulary you'll need to say it 26 more times.  Repetition is how kids learn so get ready to repeat, repeat, repeat.  You'll feel like a crazy person talking to yourself, but your child will be able to really soak it all in.

Lastly, I often tell parents to SABOTAGE. Your child has favorite things.  All children do. Whether it is goldfish, Thomas the Tank Engine, or bubbles, your child has some favorites.  Communication is all about using language to get something you want.  

If your child's favorite things are easily accessible it's time to put them out of reach and require your child to ask you for them.  The official therapy name for this strategy is "withholding." For example, if the goldfish are currently on a lower shelf, put them on a higher shelf so you have to get them instead of your child helping themselves. You are withholding something your child wants until they can ask for it. If Thomas is on the floor, put Thomas in a rubbermaid bin that your child cannot open by themselves and have them ask you to open it. We use this strategy a lot in therapy and I've seen kids make huge strides. If your child is not talking at all, start with having them point or bring the bin to you.  After a few weeks of that, move on to grunting. After that, move on to using a single word (train, fish, etc.). Soon, your child will realize that in order to play with the bubbles, they must ask you--they learn that communication is key to getting what they want.

When your child has improved in asking for items, you can start to sabotage situations to require them to ask for more things.  For example, if your child loves Goldfish, start by giving them 1 instead of the 10 you usually give them. They will have to ask for more. If your child loves bubbles, give them the wand, but keep the bubble solution so they have to ask for more. You can "lose" items, you can withhold parts of items, you can give them items that don't work, you can give them items they didn't ask for, etc. All of this sabotage has one goal: communication. A little frustration can help your child realize that they must communicate with words to get what they want.

One final note: Many parents ask me very specifically about sign language.  Sign language is a fantastic tool for learning spoken language.  My personal advice is to teach specific words.  For example, don't teach the word "more." Instead, teach the words for what the child might want more of (cracker, juice, blocks, cars, etc.).  When you generic words (like "more") your child will learn that one word will get them all kinds of things.  The sign for more will get them crackers, pancakes, juice, cars, etc. If you teach the child specific signs though, you are giving them a chance to build and expand their vocabulary and teaching them that they must use a specific word to get what they want.

If you have any concerns about a child who does not meet the developmental norms we talked about in the beginning, do not hesitate to get an evaluation from a speech language pathologist.  Early intervention can work wonders and can eliminate or diminish many speech and language disorders.  For every $1 spent in Early Intervention, you will save $7 in later therapy, so never be afraid of getting an evaluation to ensure that your child receives the most effective, efficient therapy available to them.

References

• Language Development Information 
• Teaching Vocabulary While Reading
• Sabotage and Withholding
• Early Intervention

Cycles Approach

The Cycles Phonological Pattern Approach

Many children and some adults have difficulty producing the sounds of speech.  The child might have a lisp, a problem with r, or just be so difficult to understand you don't know where to begin. A basic guideline to see if your kids may need some help is:

By 2, a child should be 50% intelligble.

By 3, a child should be 75% intelligible.

By 4, a child should be 100% intelligible.

While there are many tools SLPs use to address many of these concerns, I wanted to write a special article on my personal favorite-- The Cycles Phonological Pattern Approach. Also called the "Cycles Approach," this treatment technique for articulation disorders was created by Barbara Hodson to treat extremely unintelligible children. The original approach has eight underlying principles:

1. Typical children learn language by listening.
2. Gaining sounds (also called phonological acquisition) is a gradual process.
3. The sounds around a target sound (also called phonetic environment) can help or inhibit correct sound production.
4. Children use sound and movement sensations to self-monitor their productions. 
5. Children generalise new speech skills to other targets (for example, if they are learning /s/, they may use /s/ for /s/, /z/, /th/, and /f/ because they are similarly produced.
6. A good developmental ‘match’ facilitates learning (for example, if the child is 3, the clinician should work on sounds that a typical 3-4 year old would make)
7. Children learn best when they are actively involved/engaged in therapy
8. Enhancing a child’s metaphonological skills facilitates and enhances the child’s speech. improvement and also development of early literacy skills. (For example, working on learning what a syllable is can help both reading and speaking) (See CPPA by Caroline Bowen)

Additionally, Dr. Hodson uses a very specific pattern for target selection (what the therapist will work on during therapy) which begins with easier, earlier developing speech patterns and then advances to more difficult speech patterns.

There are four main intervention procedures:

1. Cycles: Each target is presented for a 1 hour (normally that means 2 sounds per 1 hour therapy session, but could also mean 2 sounds for 2 30-min sessions). After each hour, other targets are introduced until you have an initial "cycle" of 6-18 hours (dependent on how unintelligible the child is). Each "cycle" is then repeated or phased out upon mastery of the target. The  very unintelligible child will take 3-4 cycles (approximately 30-40 hours) to become intelligible.
2. Focused Auditory Input or Auditory Bombardment: This is when a child listens to words that utilize their target sound at a slightly louder level than typical. The theory is that children learn sounds by listening and this will help them "tune in" to the targets they are working on.
3. Facilitative contexts, Active involvement, Self-monitoring, and Generalization: Using activity to learn and models and cues to help the child produce target sounds correctly each time, the child gains new auditory and kinesthetic memory for the correct production of each sound. The child actively participates in a drill-play activity (for example: playing candyland while producing target words on each turn). For homework, the child will listen to words read by their parent/guardian and then attempt to produce a few target words.
4. Optimal Match: Essentially, Dr. Bowen asks that you use developmentally appropriate targets to both challenge the child and allow the child to have success in therapy. (For example you would not work on the /r/ sound with a child who is 3, as that would not be developmentally appropriate for them to produce yet).

I love using cycles therapy with kids and adults. I have seen some amazing growth with my clients while utilizing this approach. When I use cycles therapy, it helps my clients to avoid boredom by working on different sounds. While I modify the cycles approach somewhat to better target the goals from my clients, I try to stick to as many of the main research-based principles as possible. Additionally, I like to utilize further articulation research and work on just voiceless sounds (t, k, s, sh, ch, f, p) to help those sounds generalize to the voiced sounds (d, g, z, dj, v, b). The evidence I have seen while using this approach is overwhelming that it is effective.  I will continue to use it with my clients and hope to see more exciting growth!

Resources

• CPPA by Caroline Bowen
• Published CPPA by Dr. Hodson
• When Should I Worry If My Child is Behind?
• Artic vs Phonology...What's a busy therapist to do?

Social Communication

Social Communication

The way we use language is called pragmatics. People use the social context of the situation to use words to mean different things. As my mother often said, "It's not what you say, but how you say it." If someone says, "Good morning," on the street they mean, "Hello." When another says, "Good morning," they may imply that their morning is excellent. When one says, "Good morning," sarcastically, despite the dictionary definition of the words, they mean that the morning is not good at all. Each use of the same phrase has a different pragmatic meaning. Typical developing children and adults become adept at using social cues including eye contact, tone of voice, distance from the speaker, etc. to decide each different meaning. Some individuals, such as those with autism, need to be explicitly taught these pragmatic skills.

According to the Audiology and Speech Language Hearing Association (ASHA), pragmatic skills involve three major communication skills:

• Using language for different purposes, such as
  • greeting (e.g., hello, goodbye)
  • informing (e.g., I'm going to get a cookie)
  • demanding (e.g., Give me a cookie)
  • promising (e.g., I'm going to get you a cookie)
  • requesting (e.g., I would like a cookie, please)
• Changing language according to the needs of a listener or situation, such as
  • talking differently to a baby than to an adult
  • giving background information to an unfamiliar listener
  • speaking differently in a classroom than on a playground
• Following rules for conversations and storytelling, such as
  • taking turns in conversation
  • introducing topics of conversation
  • staying on topic
  • rephrasing when misunderstood
  • how to use verbal and nonverbal signals
  • how close to stand to someone when speaking
  • how to use facial expressions and eye contact

 Those who demonstrate difficulty with pragmatic skills may

• say inappropriate or unrelated things during conversations
• tell stories in a disorganized way
• have little variety in language use

For those who have seen the movie, Guardians of the Galaxy, the character Drax (pictured above), is a perfect example of an individual with a pragmatic disorder. Here is a quote from the movie.

Peter Quill: [about Gamora] She betrayed Ronan, he's coming for her. That's when you...
[draws his finger across his throat in a cutthroat gesture]
Drax the Destroyer: ...Why would I want to put my finger on his throat?
Peter Quill: No, that's the symbol for slicing his throat.
Drax the Destroyer: I would not slice his throat, I would cut his head clean off.

From this small quote, you can see that despite a clear message from Peter, Drax does not understand the meaning because he only sees the literal meaning of the message. He is not able to understand the nonverbal signal or the verbal message because he is unable to see the double meanings in the way Peter uses the phrase. 

Here's another great example from the movie:

Rocket Raccoon: [about Drax] Metaphors go over his head.
Drax the Destroyer: NOTHING goes over my head!... My reflexes are too fast, I would catch it.

Drax is unable to understand that metaphors cannot literally go over his head and that Rocket Raccoon is implying that he doesn't understand figurative language.  In fact, a tumblr user named merryweatherblue wrote a fantastic article about taking her brother who suffers from autism to see Guardians of the Galaxy and how he completely identified with Drax because her brother has many of the same troubles with language.

In addition to defining pragmatics, ASHA also has several ideas to help those with pragmatic difficulties understand social communication. Parents, siblings, caregivers, teachers, and friends can use some of these techniques to help those with pragmatic disorders utilize appropriate social language and understand when their communication partner uses it as well.

Using Language for Different Purposes

• Ask questions or make suggestions to use language for different purposes:
• Respond to the intended message rather than correcting the pronunciation or grammar. Be sure to provide an appropriate model in your own speech. For example, if an individual says, "That's how it doesn't go," respond, "You're right. That's not how it goes."
• Take advantage of naturally occurring situations. For example, practice greetings at the beginning of a day, or have the individual ask peers what they want to eat for dinner or request necessary materials to complete a project.

Changing Language for Different Listeners or Situations

• Role-play conversations. Pretend to talk to different people in different situations. For example, set up a situation (or use one that occurs during the course of a day) in which the individual has to explain the same thing to different people, such as teaching the rules of a game, or how to make a cake. Model how the person should talk to a child versus an adult, or a family member versus a friend of the family.
• Encourage the use of persuasion. For example, ask the person what he or she would say to convince family members or loved ones to let him or her do something. Discuss different ways to present a message:
• Polite ("Please may I go to the party?") versus impolite ("You better let me go")
• Indirect ("That music is loud") versus direct ("Turn off the radio")
• Discuss why some requests would be more persuasive than others

Conversation and Storytelling Skills

• Comment on the topic of conversation before introducing a new topic. Add related information to encourage talking more about a particular topic.
• Provide visual cues such as pictures, objects, or a story outline to help tell a story in sequence.
• Encourage rephrasing or revising an unclear word or sentence. Provide an appropriate revision by asking, "Did you mean...?"
• Show how nonverbal signals are important to communication. For example, talk about what happens when a facial expression does not match the emotion expressed in a verbal message (e.g., using angry words while smiling).

 

References

ASHA Social Language Use (Pragmatics)

Guardians of the Galaxy Quotes

Tumblr article on Drax and Autism

ASHA Pragmatic Language Tips