Executive Function, Language Therapy, Random SLP, Random Therapy Ideas

Big Deal, Little Deal? A Lesson in Executive Function

Executive Function/EF/Exec Func.:

We’ve all heard about it, often in conjunction with TBI-related impairments and rehabilitation. As research in our field continues though, we are finding that this small category of impairment may not be so small after all. Executive function (EF) inefficiencies appear highly associated with social-cognitive deficits and difficulties with pragmatic language comprehension and use, an area impacting huge numbers of children (and adults) around the country. So having a solid understanding of EF is critical to appropriately addressing the needs of a diverse population of speech-language patients!

WHAT IS IT? EFs are the mental processes that direct cognitive, communicative, and social behaviors. They allow individuals to successfully plan, initiate, carry-out, monitor, and revise tasks and activities. You can think of EFs as little “secretaries” working around the clock to plan and manage everything going on around you.

WHERE DOES EF LIVE? EF functions stem from frontal lobe areas of the brain. This is why EF impairments tend to be so pervasive in traumatic brain injuries; the coup-contrecoup injuries almost inevitably impact frontal lobe well-being.

I keep hearing about Self-Regulation in association with EF. WHAT’S THE DEAL? Self-regulation of one’s behavior, mood, emotions, etc. is inherently tied to EF abilities. Self-regulation is one of the many processes controlled under the EF umbrella, and children who are often overly impulsive in their behaviors and decision-making will likely demonstrate additional EF challenges under closer scrutiny (including deficits in: planning, initiation/drive, self-monitoring, cognitive flexibility, generative thinking, and self-awareness).

HOW DO WE ASSESS EF? Good question! This is a toughy, mainly because these clients can often “pull it together” and appear ok on standardized tests and tasks performed in controlled testing environments (although admittedly for some, these environments may underestimate real world functioning). A good assessment for EF should always include systematic observations of the client in a variety of real-world contexts! Most standardized tests that exist for looking at EF issues are intended for adult patients (although the Behavioral Assessment of the Dysexecutive Syndrome for Children is one option in pediatrics), so obtaining high-quality assessment data for children requires some creativity and a good awareness of the skills necessary to be tested (ability to inhibit, ability to problem solve/plan/sequence, generative abilities/cognitive flexibility). Beyond standardized testing, here are other assessment measures that should be completed:

  1. Interview: Talk with the client and their family about any personality and behavior changes (especially those that might be difficult to measure out of context). You can also ask your client about a typical day and the challenges they encounter.
  2. Questionnaires: Adaptations of The Brock Adaptive Functioning Questionnaire or The Dysexecutive Questionnaire will allow you to create a questionnaire appropriate for the pediatric population! You can also use options like the Behavior Rating Inventory of Executive Function, which has both a preschool form and an adolescent form.
  3. Task-Specific “Interview”: Determine a task to be completed by the client. The task should include multiple steps and require various types of attention (sustained attention, alternating attention, etc.). Have the client make predictions about the difficulty of the task and projected success level before beginning. Then carefully observe the client during the task, encouraging them to engage in self-monitoring throughout it. Finally, review the task with the client, asking them how they think they did, how their performance compared to their prediction, and what strategies they used to succeed.
  4. Observation: You should observe the client in a variety of naturalistic setting performing multi-step activities. Many of these kids can verbally tell you the steps to an activity, but fall apart when actually tasked with completing it.

HOW DO I MANAGE EF DEFICITS IN CHILDREN? This is a huge, ginormous (new word alert) question. Rather than delve into the chasm of management options out there, I will instead leave you with some functional worksheets I have created to help kids recognize their EF challenges, be able to talk about them, and problem-solve strategies for coping with those challenges.

The biggest treatment benefit I have noticed is incorporating LOTS of repetition of the key words you plan to use throughout intervention, and creating treatment resources that are clear, organized, and simple. Remember, these kids have trouble planning, initiating, persevering, self-monitoring, and controlling impulsivity, so activities with too many parts/steps will go right over their heads. I also find it important and helpful to remind kids why they are working on these skills: to make learning at school easier, to feel more organized, to be able to make friends more easily, to know when it’s the right time to talk in a group, etc. The carryover between these EF skills and improved pragmatic language/social-cognitive skills will impress and amaze you!

Big Deal, Little Deal Flowchart

Many of these kids have a hard time recognizing when a problem is REALLY BIG, and when a problem is totally minor. In other words, every problem is a crisis for them and they need to learn a way to coach themselves through these situations. This easy flow-chart I created is a good way to visualize the “coaching” process. To use the flowchart, begin by asking yourself: “Is this problem a big deal or a little deal?” If you accidentally ripped your paper while tearing it out of the binder, that’s a little deal and one you can go ahead and act upon (getting a new piece of paper). You then can quickly reflect on whether it should have been treated as a bigger deal, or if everything turned out ok. If the problem is a big deal, you should make a plan using the provided steps. Based upon that plan, you act and then review to decide whether your decision was a good one. This also works really well with decision-making for kids who agonize over every little decision. Your goal is to get them to ask themselves: “big deal or little deal?” through self-coaching. I provided you with a link to the PDF of this document-just make sure to ask for permission before handing it out (thanks)!

Impulse control is really hard for this population, so giving these kids a clear definition of when it’s appropriate to speak your thoughts and when it’s not is super important! With something as basic as the page above, you can practice writing out thoughts that need to stay in your head (because blurting them out would be inappropriate/hurt someone’s feelings/make someone feel uncomfortable/etc.). You can even theme the bubble thought activity: what are some thoughts you are likely to have in X class at school that should stay in your head? Or, what are some thoughts you might have when talking to X that should stay in your head?

Helping these kids to figure out how they learn best and then supporting them in becoming strong self-advocates is a great tool for school success! I would pair this resource with a simple document like the one below, so kids can choose a few methods that work well for them and regularly review them to make sure they are using/asking for those modifications and supports when necessary!

I sincerely hope this post has given you a good place to start when it comes to incorporating EF treatment into your intervention plan for kids with these types of challenges! Let me know how the treatment goes 🙂

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A Good Laugh, Random SLP, Uncategorized

Dora the Explorer…Like You’ve Never Seen Before!

I don’t know if it’s the sun, the pool, vacation as a whole, or just the mere fact that I have one year of grad school down and 5 weeks free of lectures, tests, and report-writing, but I am pretty sure the blog could use a good, old-fashioned dose of awesome-hilarious-ness right about now. If you work with kids (like…even for 1 second), you have heard of Dora the Explorer. In fact, you could probably sing along to the opening song and might have picked up some Español in the interim (although it’s more or less limited to hola, vámanos, and lo hicímos).

I would bet that most of the pediatric therapists out there have at least one DTE (oh yeah, I totally abbreviated right there) game, reinforcement toy, or coloring book lying around for those youngin’ clients. Anywho, for your viewing pleasure I have decided to share a link to one of my favorite College Humor videos of all time: <;a href="http://www.collegehumor.com/video/6789072/dora-the-explorer-movie-trailer-with-ariel-winter“>;.

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If only Dora and Diego really were this intense and awesome…

A Good Laugh, Just for Students, Random SLP, Uncategorized

You Still Know You’re An SLP Grad Student When…

5. Your friends ask if you want to consider a Caribbean cruise in the fall and your response is: “Sorry guys, I’ve got ASHA…” (although let’s be honest, they were never going to pull the cruise plan off anyway!)

image from: cobusbahamas.com
image from: http://www.asha.org

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. You high-five the person next to you in the computer lab because your pediatric client’s final case summary for the short, 8-week summer quarter is only 12 pages long! FOR THE WIN!

3. The kids you nanny for decide to play “word association” in the car on the way home from camp and you subconsciously start taking an inventory of their semantic networking skills

2. Your initial reaction while watching The Dark Knight Rises is: “Holy mama, Batman is going to have some serious nodules if he keeps that phonotraumatic voice going much longer!” http://www.collegehumor.com/video/6643191/batman-chooses-his-voice (warning for one tiny quick moment of bad language!)

image by Warner Brothers

AND…

1. Listening to the following link is actually a legitimate part of studying for your AAC class final: https://faculty.washington.edu/dowden/sphsc540/Notes/TextSpeechSample.wav. I think we can all agree that NO ONE WOULD PICK WENDY!!!!!

Apps, Articulation Therapy, Language Therapy, Random Therapy Ideas, Worth Every Penny

Sundaes Everyday! (Crazy Cat App Review)

I’m always on the lookout for fun, free apps that can be applied for a variety of clients in a variety of settings. The family of _____ Maker (Sundae, Salad, Cake, Donut, etc.) apps by Crazy Cats Inc. fit the bill just right. I have decided to walk you through the basics of one of their apps (Sundae Maker), provide a few pictures of additional Crazy Cat apps that I love to use, and talk about how to use these apps in a number of different ways! All of the apps I’m highlighting in this post are $free.99 (FREE!!!!!), so you can download them without fear!

Sundae Maker begins by allowing the user to choose their sundae bowl or cone. The pictures in all of these apps are the real-deal, so they should really resonate with your clients! There are a good number of images available for each option (bowl choice, ice cream choice(s), topping choice(s), etc.), and you can always unlock more through in-app purchases.

Once your bowl has been chosen, you get to fill it with ice cream. Want 1 scoop? You’ve got it! Want a double-decker-super-size-straight-to-your-hips sundae? Go for it!

 

 

 

 

 

 

 

 

 

 

 

No sundae is complete without toppings, toppings, and more toppings! Choose anything from candy to nuts to chocolate sauce to whipped cream-the sky’s the limit! Once your sundae is all dolled up, it’s time to “eat” it! You can tap, tap tap the screen to take “bites” out of your sundae until it’s all gone (or half gone, or 1, 2, 3…target # of bites are gone).

 

 

 

 

 

 

 

 

 

 

 

So, what are some other great Crazy Cat apps to consider?

Salad Maker:

Cake Maker:

Donut Maker:

Not convinced yet? Here are some suggestions about how to incorporate these apps for all kinds of clients and sessions:

  • Childhood Apraxia of Speech clients: sessions often involve LOTS of practice for getting those accurate motor pattens down. Use these apps as an opportunity to practice target words and phrases a handful of times in context before moving on to the next target term/utterance: pour it, pour it, pour it, pour it, mix, mix, mix, mix, mix, roll out, roll out, roll out, more, more, more, more… This works great in the Donut Maker app since you have to add each ingredient, stir lots of times, combine doughs, fry the donuts, frost them, etc.
  • First, next, last practice: “First we tap the bowl button, then we choose the bowl we want, last we tap the bowl picture.” I did this with my client yesterday as we made a salad, but you could just as easily talk about the order of a functional activity (making a cake) with each choice being its own step (rather than doing first, next, last practice at each step). I just wanted to get as many opportunities in as possible.
  • Articulation clients: Choose options that align with your target sounds/words/phrases and practice, practice, practice!
  • Adjective practice: “What kind of ice cream did you choose?” “Let’s add red gummy bears.” “Hmmmm, can you find the purple icing?” “I’m thinking of a green vegetable to add to the salad. Can you find it?”

There you have it! I hope you find these ideas helpful for your next session with these fun apps!

Articulation Therapy, Just for Students, Language Therapy, Random SLP

How Do You Do Data-Collection? Tips and Resources!

It seems that finding effective, efficient methods of data collection is a task for seasoned clinicians and new graduate students alike. There are sessions when I can cruise through on-line data collection without a backwards glance, and there are other sessions where I get so caught up in a client’s complex issues that I find myself struggling to keep track of what kinds of prompts/support I had to give to elicit a target behavior. I used to throw together my own data sheets before sessions, but the time commitment that turned out to be was insane on the grad-student timeline! SO, imagine my joy when one of our fab UW clinical supervisors introduced us to some great data-collection resources from the Treatment Resource Manual for Speech-Langauge Pathology by Froma P. Roth, Ph.D. and Colleen K. Worthington, M.S. (at the University of Maryland). We were given a handful of pre-made data collection sheets included as appendices, and I have decided to share my all-time favorite (and go-to data collection method) with all of you!

Data Form 1

The form is simple: in the left hand column, you can write the name or description of a task you’re using during your session. In the smaller columns to the right of that, you indicate the accuracy (or lack thereof) of the client’s response to your antecedent during each trial. You can also track the prompts the client required for each triel. This sheet is a fast way to gather critical information in an organized fashion, AND it’ll be fast to find previous data if you know what your data collection sheets look like! Now that you have the basics down, here are a few tips for making on-line data collection simple, organized, and functional!

1. Make an “accuracy key” that’s functional for each specific client and write it at the top of your data collection sheet!!!

  • It might be as simple as + (correct), A (approximated), (incorrect).
  • OR, you might want codes for varying levels of prompting/support you have to offer each trial, especially if you’re working on fading prompts. For prompt codes, I tend to use: Rp (repetition of the initial cue), Ch (characteristic hint: a verbal hint about a characteristic/a descriptor of the target response to clue the client in the right direction), G (gestural pompt), Vs (visual prompt), Ph (phonemic prompt), IM (indirect model), and DM (direct model). Now, don’t get me wrong-I don’t necessarily use all of these for the same client in a single activity. BUT, it’s nice to have your own hierarchy of prompting down for when you need to keep track of it!
  • You might need to make your codes abstract if your client catches on to +/ types of coding. Consider things like: O (old)/T (target), or even just pick random symbols that you assign meaning to: ^/X. Just make sure your coding system doesn’t get overly complex (because then you’ll spend more time trying to remember how to use it than actually using it effectively). Data collection is supposed to be efficient!

2. If your client makes lots of approximations of the accurate response (more common in artic therapy), consider using a numerical scale to capture how close their approximations are to the correct production.

  • This way you can track progress even if the productions aren’t 100% correct. I like to use a 1-5 scale, where 1 is completely incorrect, 5 is perfect, and 2-4 are scales of accuracy in approximated productions. Then, write the number into each trial number spot on the data collection sheet!

3. Write an abbreviated version of your client’s behavioral objectives/goals at the top of their data sheets before each session.

  • Why? Because this serves as a fantastic reminder of what they are working on. I can imagine that goals start to blend together when you have lots of clients on your caseload, so this is a simple strategy to keep you on track and help you shape activities to the client’s individual goals when you’re using more client-directed activities in a session! You can write these down on a data sheet before filling anything in, and then just photocopy that initial data sheet to be used for additional sessions!

This last sheet is one option for aggregating your individual session data into a graph to track progress over time.

Percentage Record Form

Alrighty folks, I hope some of this resonated with you and potentially helps you out the next time you take some awesome, rockin’ on-line data!