Sunday, January 28, 2018

What’s One More Evidence Based Intervention Tip for Students with ASD?

Naturalistic Intervention has been shown through research to be EBP for building communication and social skills for students of all ages and cognitive levels.

Naturalistic Interventions are a group of strategies to address behavior, specific interaction types, and environmental engineering.  They target building specific skills through use of the student’s interests.

The checklist the National Professional Development Center on ASD provides includes steps to identify a specific target behavior or skill and identify baseline, train team members, identify contexts for providing intervention, arranging the environment in a manner that will elicit the target behavior, engage the student, and use specific strategies to teach and intervene.  
Modeling is a specific strategy identified, as are a time-delay strategy and incidental teaching.

One of the parts of this model that easily overlap with AAC implementation strategies is the planning out of the student’s day and identifying contexts in which to model.  We speak of listing out the student’s daily activities, the partners involved and the vocabulary or function to use, as well as engineering the environment to ensure that the opportunities exist to elicit the target skill.

Just as we, in AAC implementation, want to ensure that the user is engaged in genuine communication interactions, so Naturalistic Intervention speak to following the individual’s lead and “engage the learner in language-rich, learner-directed, and reciprocal interactions…”

The Naturalistic Intervention Module was developed by the NPDC on ASD in 2009.

Sunday, January 21, 2018

AAC and Autism: What's the Evidence?

I have been using voice output devices (VOCA) - otherwise known as speech generating devices (SDG) - for as long as they’ve been around.  And most of my caseload over the years has been full of kids on the spectrum - autism spectrum, for the uninitiated. 

And as concerned as I’ve always been with Evidence Based Practice (EBP), AAC has not always been considered EBP; if only because there weren’t sufficient research studies to make it so.

(Whoo - what a lot of acronyms in that first paragraph!)

The National Professional Development Center on Autism Spectrum Disorders compiles what it considers to be EBP for persons with ASD. To quote them, “ To be considered an evidence-based practice for individuals with ASD, efficacy must be established through peer-reviewed research in scientific journals using: 

randomized or quasi-experimental design studies. Two high quality experimental or quasi-experimental group design studies,
single-subject design studies. Three different investigators or research groups must have conducted five high quality single subject design studies, or
combination of evidence. One high quality randomized or quasi-experimental group design study and three high quality single subject design studies conducted by at least three different investigators or research groups (across the group and single subject design studies).”

They have now, however, found sufficient studies that meet their criterion using AAC.  They have created a checklist for implementation that is well worth a read if you practice in AAC.

Their checklist includes some things we might consider obvious, but I’m here to tell you that I often find these things NOT happening with kids who need or use AAC.
And some of the points for practice are in line with ABA strategies, but not necessarily best practices for AAC.

So, what is a clinician to do?  Read. Consider. Balance. Interpret. And consider again.

For example, after identifying an appropriate device (well, that’s a hurdle right there), they tell teachers and clinicians to introduce the device with only a few symbols and with many blank buttons.

While using a larger grid and hiding buttons is an appropriate tactic for introducing an AAC system, we don’t want to use too few symbols.  We know that our AAC learners need sufficient vocabulary to meet their needs, as well as needing sufficient vocabulary for partners to provide Aided Language Stimulation (modeling, for short).

I have often seen the practice by ABA practitioners of moving buttons around, in order to ‘ensure that the students are really discriminating and not just memorizing location.’  

However, AAC research and practice has specifically taught us that stability of location is important; that language acquisition through motor planning is a real phenomenon.  And that moving vocabulary around only serves to make learning more difficult and to make students frustrated.

They do instruct clinicians and teachers to provide opportunities for exploration with the device, and to provide “engineered” opportunities within the student’s day that are naturally occurring.  They also remind practitioners and other partners to provide minimal prompting.  Too often I have seen well-meaning communication partners reach out and take the individual’s hand and provided Hand Over Hand guidance.

There is no mention of Aided Language Stimulation or Aided Input, which I see as a major flaw to their checklist.  They address using the least prompting necessary to get a response from the user, but do not allow for a period of modeling without requiring a response.

So, while the evidence is there for use of  AAC with kids on the Spectrum, we want to be careful of what evidence we're following.  Research, learn, and educate yourself - for the good of your clients.

Sunday, January 14, 2018

From Research to Practice: Narrative Studies

As a follow-up to my post last week about narrative skills and abilities in research, I am writing this time about the next article in the Topics in Language Disorders Vol. 28, No. 2; Narrative Abilities: Advances in Research and Implications for Clinical Practice, by D. Boudreau.
Dr. Boudreau notes the importance of narrative skills in academic success and the difficulties of students with language disorders with connected discourse, particularly as they enter the higher grades.
Narrative discourse is defined as, “at least two utterances produced in a temporal order about an event or experience (Hughes, et al, 1997).  Students with language disorders tend to miss the ability to integrate background knowledge with pragmatics - or social language - to formulate an organized recounting.  Boudreau posits that this difficulty in narrative discourse is greater than in conversation.

The author goes on to cite studies showing that 

  • students whose narrative skills are greater than their syntax skills performed better than those who had age appropriate syntactic skills but poorer narrative abilities or tasks for story comprehension and re-telling,
  • the single best predictor of students’ future need for remediation or special education or retention was their earlier performance on tasks of narrative abilities,
  • that narrative abilities in Kindergarten predict students’ vocabulary and reading comprehension skills in 7th grade  
  • that there is a correlation between students’ narrative skills using wordless picture books and their Math skills in school,
  • and more evidence for the role of narrative discourse skills.
So, while we know from the research that narrative difficulties in early years - particularly difficulties with vocabulary flexibility, syntax, and story elements - correlated with academic success, what does this mean for our clinical practice?
Unfortunately, there are studies that contradict the findings of correlation, but for those SLPs who are providing services for these students with impaired narrative skills, we need answers as to what to do.  The bottom line, says Boudreau, is that discourse abilities are crucial in academic success, and, in order to make students with this profile successful, we need to provide remediation in both comprehension and production of narratives.

One factor that is shown to have influence on students’ skills in narrative discourse is early interactions around books and experiences.  The interactions with parents or other adults that provide scaffolding of story telling / experience retelling, that co-construct narratives with children and gradually decrease that support, are critical.  By providing opportunities to interact with partners who provide quality exchanges students develop the narrative skills that they need.
Improved literacy and language skills have been correlated with shared reading.  However, not all shared reading is equally helpful.  Again, the quality of interactions is important particularly interactions that preview the book, predict throughout, providing quality activities before and after the book is read that focus on some aspect of language (retelling, acting out, discussion of elements of the book).
Another factor is the quality of interactions with adults who provide adequate scaffolding and quality exchanges at dinner time. The quality of these interactions is crucial.  It sounds obvious to us SLPs, but parents whose exchanges with their children utilized open-ended questions, contained more complex language and better scaffolding provided better impact that parents whose exchanges were brief, unelaborated, less supported and more brief.
One interesting finding (Spinello & Pinto, 1994; Schneider & Dube, 2005) is that students formed more elaborate narratives when they were not shown picture cues.  Use of picture cues resulted in less elaborate narratives, and those that were more informal rather than what would be expected in a written narrative.
In addition to the elicitation-dependent measures, text-dependent measures were also found to be important.  Students have been found to more reliably remember specific details if the narrative or story presented to them is a more complete episode, than if they hear only fragments of information in less structured contexts.  And if the episode tells about the characters’ goals, motivations, and feelings, students are more likely to remember and retell parts of the story.
In discussing clinical implications of the studies reviewed, Boudreau reminds clinicians to understand the impact of the method they choose to elicit narratives and the types of scaffolding supplied to maximize narrative production.  Clinicians should vary the types of narrative tasks they provide in intervention, so that students can take advantage of the scaffolding of different styles of narratives.  Of particular importance is understanding and use of the causal network that underlies a story.
Also important for clinical practice is parental/caregiver training that strengthens parents’ - especially mothers’ -  strategies used to elicit responses.  Talking about daily experiences, using open-ended questions, describing things, and listening carefully are listed among the parental activities that strengthen children’s narratives.
Boudreau also cites studies that have shown that explicit, structured teaching of story grammar enhances students’ understanding and use of these elements in their narratives.
They key take-aways from this article that reviewed research about narrative abilities and the impact of various intervention types on narrative abilities?
  1. Narrative skills improve when directly targeted in structured intervention
  2. Teaching specific story mapping or story grammar elements is an effective therapy strategy
  3. Providing scaffolding in the narrative production of very young children shows an impact in later academic years.
I encourage all SLPs working with children to remember to include narrative skills in their evaluation processes, and to use more than 1 type of elicitation technique; and to include specific structures of narrative style and story grammar in their therapy plans.

→The editor's of Topics in Language Disorders are offering a tremendous savings to my readers. Use this code:  WHE005GN
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Susan Berkowitz, M.S.,C.C.C., M.Ed. has been a speech-language pathologist for 40 years. She has worked in a variety of settings, both as a SP and as an administrator. She speaks at local, national, and international conferences, and has published research in peer-reviews professional journals. She is currently the Director of Print Content at 

Boudreau, D. (2008). Narrative Abilities: Advances in Research and Implications for Clinical Practice. TLD (28:2) 99-114

Hughes, D. et al. Guide to Narrative Language: Procedures for Assessment. Eau Claire, WI; Thinking Publications

Schneider, P. & Dube, R.V. (2005) Story presentation effects on children’s retell content; Amer. Journal Speech-Language Pathology, 14, 52-60.

Spinello, A.G., & Pinto, G.  (1994). Children’s narratives under different conditions: A comparative study. British Journal of Developmental Psychology, 12, 177-193.

Sunday, January 7, 2018

Narrative Language Skills: What Do We Know?

Whether I am working with students with language-learning disabilities (LLD) or AAC users with Complex Communication Needs (CNN), I focus a lot of time on building narrative language skills.
In fact, with even my most complex nonspeaking students I want narrative skills to be a goal that we are working towards.

A recent discussion among some SLPs  about narrative skills in assessments sent me looking to the research.  In a  2008 edition of Topics in Language Disorders (vol.28:2. Apr-June 2008) editors Nickola Wolf Nelson, Katherine Butler, and Donna Boudreau quoted Jerome Bruner:

One of the most ubiquitous and powerful discourse forms in human communication is narrative.”  (Bruner 1990).  Narrative is crucial in human interactions, yet often receives the least attention.  Bruner went on to name the 4 areas of grammar critical to narrative production:

  1. A means for emphasizing actions towards obtaining a goal,
  2. A sequential order should be established and maintained; so that events are stated in a linear way
  3. Sensitivity to what forms and patterns of language are acceptable
  4. Containing a narrator’s perspective or ‘voice.’

Narrative has been found (Nelson et al 1989) to capture not only the events of daily interactions, but to encourage interpretation, imagination, and use of self-talk to solve problems.  This particular issue of TLD includes an update from J. Johnston on her seminal work (1982), which signaled a wake-up call to clinicians to consider examining narratives in clinical practice.

Johnston was the first to call attention to the importance of narratives in clinical practice.  She argues for distinct areas of knowledge in order to support narrative skills:
  • knowledge of the content  of narrative
  • knowledge of an appropriate framework in which to build narratives
  • linguistic abilities to form a cohesive text
  • the ability to consider the adequacy of the listener’s comprehension.

This last point is particularly discussed in her update, considering the processing competence of the listener;  how well can he comprehend at the narrative level.

Narrative skills begin to develop in young children and are mediated by parental support.  These early interactions build the foundation upon which children build their narrative and academic skills (Boudreau 2008).  The narrative skills of preschoolers are predictive of academic success in school, as well as social success.  As students with narrative language deficits continue having difficulties in academic and social success, we are reminded of the importance of intervention at the narrative levels.

Johnston’s (2008) update to her original article discusses the value of narrative intervention in school aged children.  While this study is now 10 years behind in current research into narrative development in students, the continuum of crucial skills for SLPs to consider continues along the same path that Johnston took.

Johnston (1982) listed on the 4 areas crucial in narrative development, and reviews and elaborates on it in the 2008 update.
  1. The speaker must know the content of the narrative; both general qualities and specific details
  2. The speaker must have understanding of a narrative framework, in order to turn the facts of the event into a story that includes context and emotion.
  3. The speaker must have understanding of the forms of language, in order to create a cohesive story whose sentences blend together well with appropriate parts of speech.
  4. The speaker must be able to shape the narrative to meet the linguistic needs of the listener; must be able to tailor the content of his narrative to the processing and knowledge levels of his audience.

Johnston goes on to discuss the cognitive difficulties of narrative creation.  Narratives require planning ahead for content and structure, for cohesion, and for adjusting to the partner’s abilities.  This is a huge cognitive load.  In addition, Johnson points our that the listener’s needs may change over time during this narrative, and the speaker must be able to process this information, change his narrative to meet it, and continue with the narrative.

Johnston continues with an interesting notion based on the research results of Gillam and Pearson, (2003).  That while language-competent students were equally in both form and content in their narratives, students with language disorders tended to be stronger in one area than another.  This was seen to indicate that focusing cognitive energy in one area left the other area weak. 

Narratives are important because they allow us to move away from the “here and now,” and to focus less on our personal experiences, while allowing students to talk about what is not immediate, but rather the decontextualized language of the classroom.

There are 3 basic types of narrative scripts: personal experiences, scripts, and fictional stories (Hudson & Shapiro, 1991). Personal narratives are the easiest place to begin in intervention with children.  And they are the most often used types of narrative.

Narrative interventions have been used to improve listening skills; by providing a supportive framework of story elements  for listening.
They have been used to improve reading comprehension. The link between oral language skills and reading success has been verified (Catts, et al, 1999); making it appear that oral language facilitates literacy.  Students who understand and use the general narrative schemes use this knowledge to help the understand and grab meaning from texts.

By focusing on narratives in our language intervention, we can explore processing limitations, create opportunities for using decontextualized language, facilitate social relationships, provide practice in constructive listening, improve reading comprehension, and identify language learning strengths and weaknesses.” (Johnston 2008)

By focusing on use of core words and important fringe, and by moving from single symbols to sequences of symbols for generating novel utterances, we need to keep our AAC users moving on the "oral" - literate continuum.  This means teaching AAC users to construct messages and sequence ideas in order to engage in meaningful conversations.

→The editor's of Topics in Language Disorders are offering a tremendous savings to my readers. Use this code:  WHE005GN
for a 35% savings (that's about $45.) Here is the link.
I am not an affiliate, nor do I profit in any way from this deal. It's just for you!

Susan Berkowitz, M.S.,C.C.C., M.Ed. has been a speech-language pathologist for 40 years. She has worked in a variety of settings, both as a SP and as an administrator. She speaks at local, national, and international conferences, and has published research in peer-reviews professional journals. She is currently the Director of Print Content at 

Boudreau, D. (2008) Forword. Topics in Language Disorders, 28 (2), 91-92

Catts,H et al (1999). Language basis of reading and reading disabilities: Evidence from a longitudinal investigation. Scientific Studies of Reading, 3(4), 331-361.

Gillam, R, & Pearson, N. (2003)The Test of Narrative Language. Austin, Tx: Pro-Ed.

Johnston, J. (1982). Narratives: A new look at communication problems in older language-disordered children. Language, Speech, and Hearing Services in the Schools, 13, 144-155.

Johnston, J. (2008). Narratives: Twenty-five years later. Topics in Language Disorders, 28 (2), 93-98