Regulation by the Numbers

Making the Case for the Role of Objective Data in the Subjective World of Emotional-Regulation

Emotional-regulation is inherently subjective: my emotions are mine and mine alone. You may agree or disagree with how I should feel, though you can no more control emotions than the weather. When it comes to emotional-regulation, the goal is all about regulating the way you respond (i.e., behave), despite how you may be feeling, in order to meet the demands of the situation.

If the emotions we feel are out of our conscious control, it follows that asking a child to control his/her emotions is a recipe for failure, anxiety, frustration, and disillusionment. The focus, then, must shift to improving intentional, mindful, conscious control over behavioral responses in the midst of strong emotions. For many individuals, increased activity in the limbic, emotional brain is mirrored by decreased engagement of the cortical, thinking brain. In other words, stronger emotions = less critical thinking and more impulsive reacting.

The challenge with emotional-regulation is that however aware you might be that a situation demands certain calm and collected behaviors, parts of the logical brain want to justify the experiences of the emotional brain. This is why we feel so good and justified (in the moment) when we yell at someone who has said something that triggers a strong, angry emotion. No one likes being told to “calm down” or “take a deep breath” at the height of experiencing a dysregulating emotion (however helpful those suggestions might be). In fact, for many children, the feeling of invalidation that comes with being told to “calm down” ultimately triggers greater emotional dysregulation. Kids, especially those who tend towards the impulsive side of the spectrum, are at a developmental disadvantage when it comes to emotional-regulation; the maturity and brain development that comes with reaching adulthood helps to create a bank of personal experience, world knowledge, and anticipation of future consequences that makes it easier to pause one’s initial reactions in order to devise a more useful response during emotionally triggering situations. While we, as adults, might have great regulation advice for a triggered child, the state of dysregulation can make it impossible for him/her to hear and process the advice. The subjective nature of emotions makes for rocky regulation-coaching terrain.

So what’s the solution? Turn a subjective process into what feels like a data-driven, objective process! Words and advice may feel biased, but numbers don’t lie. The Charting Re-Regulation worksheet is a simple way to help a child objectively see his/her patterns of regulation, and how long it typically takes to go from “super triggered” to “re-regulated.” Here’s how it works:

Step 1: Note the triggering situation and emotion(s) being felt (if this is too triggering in the moment, save this step until later).

Step 2: Mark the intensity of the emotion(s)…

• At the time of the trigger
• After one minute
• After two minutes
• Etc.

Step 3: Notice when the emotional intensity reaches 30% or below. This is usually an indication of being mostly re-regulated and ready to logically process and/or problem-solve.

Step 4 (optional): Record what tools/strategies you used at each phase of re-regulation. In other words, what helped at the 80%-100% range? What helped at the 60%-80% range? What helped at the 30%-60% range? Identifying helpful strategies provides a bank of regulating tools for future triggering situations.

Fill out a new worksheet for each of five or more triggering situations in order to have enough data to determine a pattern for how long it typically takes to feel re-regulated. Three minutes? Eight minutes? What children can glean from their own data is the time frame they need to fill with regulating tools before they can expect to feel calm. An average of three to four minutes in the 80%-100% zone might mean a quick labeling of the emotion(s) with three to four minutes of a distracting brain break (i.e., Daniel Siegel’s Connect and Redirect strategy). Does the re-regulation go pretty fast once the child is below the 80% mark? That might mean that he/she needs some quick, simple sensory and/or mindfulness tools to take up the remaining few minutes in the countdown to calm. Does re-regulation tend to take longer? Strategies like a reading or drawing break might be a better fit for a child who needs more time to truly return to a calm, regulated state.

In the examples included here, the child tends to remain highly dysregulated (80%-100% intensity) for two to three minutes across all situations. He reaches a re-regulated state (30% intensity or below) after six to seven minutes. Using the data he generated and collected, we collaboratively determined that an adult should wait at least seven minutes following a triggering situation to talk with him about what went wrong or how things could have been handled differently. In the meantime, he could pull from his bank of previously useful strategies to remain safe and mindful during the re-regulation process. After seven(ish) minutes, his thinking brain was more engaged and he felt ready to strategize with a peer or adult.

How else can charting re-regulating be beneficial?

• Children receive concrete, visual feedback about the abstract, subjective process of emotional de-escalation. This feedback can be an important reminder to a frequently dysregulated child that he/she can successfully re-regulate!
• Using a simple graph to chart the re-regulation process provides opportunities for children to note whether their emotion(s) changed throughout the process. Did they feel varying “shades” of angry the entire time, or did the emotion change to disappointed or confused? It’s important to remind children that emotions can change, and that we often feel multiple emotions at the same time.

You can access the worksheets using the PDF links below:

Charting Re-Regulation 1-10 min. intervals

Charting Re-Regulation write-in min. intervals

Know of other benefits? Share in the comments!

Mini Minute Executive Functioning (EF) Tuck-Ins

This one goes out to all the teachers who are looking for ways to support Executive Functioning without giving up your carefully planned lesson times. I work with a lot of K-8 teachers who are always on the lookout for quick and easy ways to target foundational EF skills within their existing classroom routines. The thing is, EF isn’t something you do separate from your regular curriculum. The more you know about EF, the better you get at realizing that so much of what teachers are already doing is supporting and improving students’ skills. It’s like a hidden super power! The goal of this post is to help teachers become more intentional about using their otherwise lost minutes of transition time to keep that EF momentum going!

Let’s say you have two minutes between the end of your math lesson and the lunch bell. What do you do?

(a) Tell students to take out a book and read

(b) Play the “quiet game”

(c) Use an EF tuck-in exercise

(d) Let absolute chaos reign

Using our own inferential skills, let’s examine the likely outcomes of each scenario:

(a) Your announcement = 20 seconds, getting out books = 40 seconds, opening to the right page = 15 seconds, reading one paragraph = 25 seconds …then…time to clean up (followed by copious amounts of “grumble grumble grumble”). Effective? I think not!

(b) Students are annoyed with having to be quiet, you’re annoyed they can’t be quiet…who wins at the quiet game? No one!

(c) Students have fun and improve their EF skills!

(d) Total destruction of the classroom (and your sanity).

In case you’re still scratching your head, I’ll give you a hint: the answer is C. There are countless EF teachable moments (and I do mean moments) during a typical school day: lessons end a little early, students need something to keep them busy in line, you name it! Here are some ideas to turn those lost minutes into EF learning treasure troves, while simultaneously supporting general education skills.

 

EF Tuck-Ins for Cognitive Flexibility

• Word Association: Begin by saying a random word. Snake through all students in the class, having each student say the first thing that comes to their mind when they hear the word from the student just before them. This fun game strengthens association pathways in the brain and supports cognitive flexibility during conversations (i.e., the ability to connect to others’ ideas).
• Two-Word Association: Create a jar of random words. During the tuck-in, select two words from the jar and ask a student to come up with some way those words can be related. This task encourages strong concept association and mental flexibility.
• Ask students to generate antonyms, synonyms, or a shade of meaning (i.e., a word that means slightly more or less intense than the provided word) for a target word. For example, if the word is happy, the antonym could be sad, the synonym could be glad, and the shade of meaning could be content (less intense) or excited (more intense).
• Ask students to respond to yes/no questions with an answer that doesn’t involve yes or no (e.g., “Do you like carrots?” response: “Only when they are dipped in ranch”). This task requires engagement of “slow thinking” over automatic “fast thinking.”

EF Tuck-Ins for Working Memory (all tasks done verbally)

• Ask students to repeat back increasingly longer sequences of numbers in the opposite order of how you give them (e.g., if you say “3-5-7-2,” students say “2-7-5-3”).
• Give students a target word and ask whether various letters are in the word. This requires students to hold the word in their mind while scanning it for letters.
• Ask students to verbally spell a target word forwards, then backwards. Switch between common, overlearned words and grade-level vocabulary or spelling words.

EF Tuck-Ins for Inferential Thinking

• Provide three attributes of a secret object and ask students to make a smart guess about the object you’re describing (e.g., it’s white, it comes from a cow, you drink it). The more nuanced the clues, the more challenging the task.
• Provide students with an obscure word that has a commonly known root (or a word in a different language). Ask them to make a smart guess about the meaning of the word based on a recognizable root.

EF Tuck-Ins for Problem Solving

• Provide age-appropriate What Would You Do scenarios to students (e.g., “What would you do if your friend got an ugly hair cut and asked what you thought?” or “What would you do if you were invited to a party and didn’t want to attend?”), and ask them to generate the most expected response they can think of.
• Ask students to judge the grammaticality of a sentence. If it’s incorrect, ask them to correct it.
• Present If…Then verbal problems for students to solve (e.g., If Jenny is shorter than Billy, Billy is shorter than Mark, William is taller than Tony, and Mark is the same height as Tony, who is the tallest?”).

EF Tuck-Ins for Categorization

• Provide four+ words or numbers to all students. Ask the students to determine how they can be sorted into two+ categories based on attributes, functions, locations, materials, appearance, etc. You can use random words/numbers or ones that relate to a current lesson.
• Provide four words that all connect through a shared attribute except for one. Ask students to identify which one word does not belong and why. The more nuanced the isolating difference, the more challenging this task will be.
• Provide a category to students (e.g., animals, literary genres, Greek Gods, vehicle types, colors, etc.) and ask them to generate as many items as they can that belong in that category in a given amount of time.

EF Tuck-Ins for Gestalt vs. Details

• Show a picture scene to the whole class. Ask each student to write or say the gestalt (i.e., big idea) of the picture scene and the three most relevant details that support the gestalt. This helps students improve part vs. whole awareness and how parts are relevant to the whole.
• Ask students to tell as many parts of an object as they can think of (e.g., parts of a tree: roots, trunk, branches, leaves, etc.). Encourage students to use a strategy to determine parts (e.g., move from the bottom to the top of the object, move from small to large parts, etc.).

Here’s to a whole new, EF-filled school year!

ANAMAzing Ideas for Therapy! (Thanks Pixar)

While sitting in a day-long conference on school-based SLP challenges associated with qualifying kids from culturally and linguistically different backgrounds, one the the presenters mentioned using the Pixar animated short film, Partly Cloudy, as a great interactive, informal assessment or treatment tool to evaluate a child’s narrative skills, emotional recognition, inferencing skills, etc. This got me thinking that there might be other Pixar “shorts” out there that would be fantastic for use in treatment sessions. Below are some ideas about how you can use a few of these fun mini movies with your clients:

“PARTLY CLOUDY”

What your client can be working on:

• Recognizing and analyzing facial expressions (and explaining why the character might be feeling that way)
  
• Pausing the video at different points and making predictions about what will happen next (immediately next, after an hour or two, tomorrow, etc.)
• Problem solving when the character(s) feel sad/upset/disappointed
• Comparisons between happy/joyful/ecstatic/proud characters and sad/upset/disappointed/angry ones

“LUXO JR.”

What your client can be working on:

• Create a script for one or both lamp characters. This involves perspective taking, theory of mind, prediction, etc. (lots of those tough social cognition/executive functioning/social communication skills that many kiddos struggle to learn and use)
• Inferring how each lamp character feels at different points in the mini movie
• Making predictions about what will happen next (and supporting those predictions with contextual clues from the mini movie)

“DAY AND NIGHT”

What your client can be working on (this short is best for older elementary/middle/high school students):

• Create a script for one or both characters. What kinds of expressions are they likely to be using? Are these characters friends? Siblings? Strangers? How do you know?
• Categorize the differences between things that happen during the day versus at night. Work on finding an efficient way to document all of these examples without having to re-watch the short over and over (this is a critical study skill!)
• Pause the mini movie at various points and discuss how the characters feel and how you know

“THE BLUE UMBRELLA”

What your client can be working on:

• Fill in thought bubbles for each umbrella and notice and discuss the changes in what each umbrella is thinking as the short video goes on. Why do these changes in thoughts/emotions/behaviors occur?
• Make predictions about what will happen next

Media can be such a great way to engage students of all ages in working on therapy objectives. Any other animated shorts out there that folks are using?

Home Is Where The Therapy Is!

Ready…Set…Ponder: Why do speech-language pathologists (and other child development professionals) deliver birth-3 services in the child’s home? Why not just bring all those kiddies into our clinic rooms and bestow our communication brilliance upon them?

I’d say that we go into the home because the focus of our intervention is to engage that child’s caregiver(s) in an ongoing process of supporting his/her communication development. It can’t just be about the hour or 2 a week that we have the child in front of us in a little clinic room, because the first 3 years of life are critical for providing the richest possible language environment we can. And who better to learn how to talk to kids, play with kids, scaffold kids’ language, and foster kids’ social competencies than the parents and caregivers of those kids?!? We go into the home because that’s where 99.9% of that child’s communication development will take place.

Today I’d like to pose the argument that we need to revive the birth-3 model of service delivery in non birth-3-aged kids who need significant, ongoing executive functioning support. I wouldn’t dare to say that these are the only kids who would benefit from this type of service delivery, but you have to start somewhere, right? If you work with kids with general social communication challenges, you likely also see executive functioning deficits in those kids. Making a plan? HARD! Breaking down tasks into individual steps? PAINFUL! Self-talking your way through an activity? YEAH RIGHT! These kids need strategies to frame how they function in the world, not discrete skill training (ok, ok, some definitely need discrete skill training too, but that’s just not the best way to support improved use of executive functioning skills). Some of these kids will likely never reach a point where they can independently use a strategy like Get Ready, Do, Done (see my last post); the strategy is still fantastically helpful, but they’ll need a caregiver to cue them to use it and/or prompt them through it. These are the kids I believe would gain a world of good from receiving services to enhance the use of executive functioning strategies at home rather than in a clinic. WHY?, you ask…

• Intervention in the home = access to actually training everyone in that child’s home. If you’re working on strategy use with kids who likely will need ongoing caregiver support with those strategies/frameworks, you should be training the caregiver right along with the kiddo. Plain and simple. You are not always going to be there to support DudeFriend through the process of making a plan or figuring out what the task will look like when it’s done (at least, I hope you won’t…). But you know who’s likely to be there a lot more often? Mom/Dad/Grandma/Aunt Lulu (the caregivers)! If dad can appropriately cue DudeFriend to use a trained strategy at home, in the car, at the grocery store, AND at the neighbor’s birthday party, then you just scored some serious generalization points. How do Dad/Mom/Aunt Lulu know how to appropriately cue DudeFriend, though? You train them to do it in functional tasks (homework, getting ready for dance class, making a snack, packing a backpack, etc.) in functional settings (at home). I’m under no delusion that SLPs should start following kids and their families around everywhere they go teaching them to use executive functioning strategies in every possible setting, but think of how much more likely your work is to generalize if you train the child and the parents in the environment where they’ll be using that strategy 95% of the time!
• Intervention in the home means that your vision gets to come to life. I’m currently working with one of the caregivers of the client who sparked this post to train her in supporting DudeFriend to use our treatment strategies with various tasks outside of clinic. In my mind, I know exactly how I would set up my Get Ready, Do, Done posters in the kitchen for snack prep. BUT, since I don’t have the luxury of carrying this training out in Dudefriend’s kitchen, I’m stuck trying to describe my vision to her (and it’s hard!). She is motivated, intelligent, and wonderful, but that doesn’t necessarily mean she can read my mind and carry out my vision…and the kitchen is just 1 place where I’m encouraging them to implement this strategy. If I were able to carry this intervention out in Dudefriend’s home, I could be modeling cues and prompts, collaboratively brainstorming the best places to put visual aids, and fitting my vision in with the family’s vision. And THAT would be a beautiful thing.
• Intervention in the home means that you are actually using materials available to that family, rather than your own treatment materials that may or may not be functional for the kiddo outside of your sessions once or twice a week. Instead of handing parents tools and saying, “Here…make this work,” you can strategize with them to use what they have in the home to bring target strategies and frameworks to life. My sense is that you bring about much more lasting change when you’re not putting unrealistic expectations on the family to find or buy materials that are unfamiliar and uncomfortable to them.

In my naivety, I don’t actually know whether SLPs are out there delivering executive functioning services in the home to kids outside the birth-3 range. My gut sense is that if you’re out there, you’re one of the few, and I think that needs to change. As SLPs, we have a valuable service to be offerring not just the clients, but their families too. We work tirelessly to make activities in clinics as functional as possible for kids, so imagine if you could skip the step of recreating “home” in your clinic room and instead work on using strategies in their actual homes!

If this is already your jam, I’d love to know! If it’s not, but it sounds like a cool jam, I’d love to know too! And maybe one day we’ll team up and start a great new wave of service delivery 😉

Ideas for Social-Cognitive, EF, Pragmatic Language Therapy: Part 2

I promised a part 2, and I shan’t disappoint (shan’t…I went there!). As a continuation from my first post with ideas for social-cog, executive function, and pragmatic language therapy, this second post will keep the ideas flowing and hopefully add to your arsenal of go-to activities.

Visuals, Visuals, and More (concrete) Visuals:

I am steadily learning the importance of supporting social communication intervention with tons of visuals. When I think I’ve reached the visuals peak, I cut and laminate one…more…thing. Why? Because so many of these clients benefit from visual supports early on in their therapy. I recognize that you might be worried about setting them up to be dependent upon these visual aids later, but in my humble experience, I usually end up spinning my wheels and banging my head against the wall when I nix the visuals and overestimate how well the client will perform. Here are a couple ways to make Social Thinking concepts more concrete through…(you guessed it…) VISUALS!

Are you working on mind files or friend files? Use an actual file folder to show how these mental files can store information about others. The amazing Sean Sweeney and Pamela Ely at The Ely Center taught me this fun acronym for teaching kids what kinds of information belongs in a mind file. As you can see, I ended up changing “mind file” to “people file” since my client had such a hard time remembering that these files are about people (and not everything under the sun). However you decide to coin the term, think about using concrete visuals to support initial stages of learning!

 

The Social Detective book from the Social Thinking curriculum is a great resource for introducing kids to critical social communication skills involved in being a social detective, but I have found that creating a real (ok, ok…paper) toolkit gives kids ownership over the social communication tools they are acquiring. I let them add the eyes to their toolkit once we’ve finished our “thinking with your eyes” activity for that day. As we target more concepts (like “thinking with your ears,” “brain in the group,” etc.), they get to add those tools to their toolkit. Sometimes it can be fun to pull out the tools you need in a particular situation. Once again, the visuals are just a support for teaching these foundational skills and making sure the information is relatable and concrete. 

Expected/Unexpected By Context Game

I used this activity to probe my client’s current understanding of expected and unexpected behaviors in different school contexts, but you could very easily use this as a teaching tool as well!

 

I start by having the client choose a context/environment/setting out of a hat (e.g., “In math class”). He then has to sort a variety of behaviors (also picked from a hat) to determine whether they are expected or unexpected in that particular context. Even if you only got this far in the activity, you would have some awesome information about how well the client can determine what’s expected versus unexpected in key environments throughout his day. Once this initial sorting is done (and the subsequent discussion has occurred, if you choose to discuss their choices), you then have the client choose a different context from the hat and switch it into the original context’s place. The client must now decide if some of the behaviors that initially were sorted as expected belong in the unexpected category (and vice versa). Some different context ideas are included below:

 

Why does this skill matter? It’s not enough that clients can determine what’s expected or unexpected in a static setting. They need to recognize that expected behaviors may change depending on the context: it’s fine to run around on the playground at recess, but running becomes unexpected when you are in the middle of social studies class. This activity helps to support the cognitive and social flexibility needed to shift expectations between settings.

Thinking With Your Ears: Easy Activity to Introduce Inferencing Skills

I had to start verrrrrrrrrry basic when introducing “thinking with your eyes” and “thinking with your ears” for my current client. Specifically for “thinking with your ears,” we spent a fair amount of time just identifying the sources of sounds with a couple different sounding board apps (Touch the Sound by Innovative Mobile Apps and SoundBoard by Lux HQ Ltd.). Once he was tuned into thinking about what he heard, I moved to the activity I’m here to highlight. I laid out sets of pictures I’d printed, and the client’s job was to think with his ears to choose the picture that best matched my verbally read sentence. I started with very concrete sentences, and slowly increased the complexity to include sentences or utterances that required increasing amounts of inferencing skill. The more abstract the sentence, the more the client had to listen for contextual clues to guide accurate picture choice!

 

Examples of sentences for the pictures above:

Easy/Concrete: “The man wore a tiny hat”

More Challenging: “It was cold outside”

 

Examples of sentences for the pictures above:

Easy/Concrete: “The boy was working on his test”

More Challenging: “All his studying paid off in the end” or “I wonder what the teacher will ask”

 

Examples of sentences for the pictures above:

Easy/Concrete: “The kittens snuggled on the blanket”

More Challenging: “They looked almost identical” or “All three enjoyed being in the sunshine”

Well, that sums up part 2 of my therapy ideas for this tricky, but awesome group of clients! There are so many great resources out there, and I encourage all of you to find ways to share the cool intervention techniques you’re using!

 

 

Ideas for Social-Cognitive, EF, Pragmatic Language Therapy: Part 1

I work with a high schooler who (in honor of Thanksgiving) has a cornucopia of challenges in the social cognition, executive functioning, and pragmatic language realms. I am by no means an expert on this population, but I’ve been lucky enough to spend time interning with a few experts in this area of speech-language pathology (Pamela Ely and Sean Sweeney), and also received a scholarship to attend the Social Thinking conference in Portland, OR this past October. These experiences have given me a solid foundation for developing intervention plans for kids who fall somewhere on the spectrum of social language deficits.

Just to complicate things a bit, clients with social communication deficits rarely have isolated issues with pragmatic language. Often, they have concomitant challenges with executive functioning, cognitive flexibility, and overall impaired cognition. As such, effective intervention requires lots of adaptation and a willingness to incorporate ideas and methods from a variety of sources. I love mixing resources from Michelle Garcia Winner’s Social Thinking ® curriculum, Sarah Ward’s executive functioning curriculum, Pamela Ely’s social cognition curriculum, and Bonnie Singer’s self-talk curriculum. This 2-part blog post is all about sharing some of the ideas and visuals I’m using in my therapy with this current client, and highlighting the amazing minds who have come up with the awesome ideas underlying what I’m doing!

Probe for Perspective Taking

Although I did this as a probe to gather some baseline data about my client’s perspective-taking abilities, you could easily use this as a treatment activity to support the development of perspective-taking skills. I used sequence scenes from the following set of cards:

The reason I like this particular set is that it has sequences with 6-8 cards each (which makes the task more challenging for the client). You’ll want to pull out all the cards that relate to a single sequence and flip them over so the pictures themselves are hidden. Ask the client to choose one card and keep it hidden from you while he looks at it. First, ask him who knows what card he has (correct answer: “me”). Next, ask if you know what card he has (correct answer: “no, I’m the only one who knows what’s on the card”). Then, ask him how he could help you know what’s on the card without just showing it to you (correct answer: “I can describe it to you”). The client’s response to each question provides valuable information about their ability to take another’s perspective. Finally, have the client describe the picture to you using whatever details he chooses. Once he’s done describing the card, slide it back into the pile (still face down), shuffle all the cards, and then flip them all over so the pictures are showing.

You then try to guess which card the client had based only on the details he described. Since many of these cards have similar items (bike, boy, mom, helmet) and the client likely didn’t give enough detail to isolate a single card, you can narrow down your choices of possible cards and see if he can provide enough specific details to identify his chosen card from the others. This is a great little task for both determining a client’s current level of perspective taking and for teaching the skills associated with strong perspective taking!

Self Talk Visual

My client requires LOTS of visual support as we tread through the concepts of social cognition and pragmatic language. This is a super easy way to help him contextualize self talk as something that occurs like a thought bubble. Even though we do a lot of audible self talk right now, I’ll eventually fade that along with the visual aid. For now though, I model self talk by holding up this laminated thought bubble (yeah yeah, I know it looks like a laminated intestine…it’s not art class!) and often ask him to do the same. All you need is some card stock, a laminator, and a few straws (covered in tape) for the handle!

Sometimes, I use this same thought bubble to demonstrate when I’m having a red or green thought, and the kinds of feelings those thoughts give me. The beauty of laminating everything is that you can write on them with dry erase markers and then just wipe them clean. I stick my green or red thoughts to the velcro inside the thought bubble and specifically indicate the emotion that I’m feeling:

Conversation Roadmap

Once I taught my client how to introduce short, concise topic statements that let people ask “wondering” questions (i.e., wh- questions), I moved onto the conversation timeline. Little did he know that conversations don’t just involve one person talking for 20 minutes about the topic of their choice. This visual gave him a concrete way to recognize the basic components of a conversation, and even helped to reinforce the idea of talk time I’d previously introduced (color coding the cards made this a piece of cake). Since we were practicing conversations as a pair, I had two differently colored sets of cards. The “topic” card indicated a topic statement for the conversation, the “C” card indicated a comment, the “?” card indicated a question, and the “R” card indicated a response to a question.

Each time someone added something to the conversation, they mapped out their addition by laying down the corresponding card. This gave us a concrete way to go back and consider the parts of our conversation and what worked/didn’t work! It also let him see how often each person was contributing (if one person dominated the whole conversation, there would be only one color).

My second post will include a couple more therapy ideas and visuals to consider when working with kids with social-cognitive/pragmatic language impairments. Hopefully these ideas spark your own creativity!

When it’s Always a BIG Deal: Using the 5-Point Scale

As I was reflecting back on my last couple of posts, I realized I should have included a small discussion (however one-sided it may be) about what to do when you introduce the idea of self-talk/self-coaching through the Big Deal/Little Deal flowchart, and EVERY problem or decision the child encounters is experienced as a BIG deal. The clients who tend to need some extra instruction about how to effectively use self-talk/self-coaching are also likely the ones who will have a hard time discerning between major issues and small glitches, because in the moment they genuinely may feel that even a small ordeal is a crisis.

Kari Dunn Buron and Mitzi Curtis introduced a fantastic resource for these moments: The 5-Point Scale. Since the scale can ultimately be accommodated to meet just about any situation where scaled decisions can be made, I highly encourage SLPs to understand how to use this scale and have it in their treatment toolkit. As you might imagine, the 5-point scale is simply a scale that helps clients to quantify and qualify their problems/decisions/reactions/volume/etc. into a more appropriate realm. In my Big Deal/Little Deal post, I said the following: 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?” While self-coaching through the flowchart steps is an important foundational skill for these kids, it’s also helpful to have a plan for when they simply tend to categorize everything as a big deal, and this is where the 5-point scale comes in.

Imagine that Johnny Q comes to you in hysterics because the blue marker, which is his favorite, is all dried up and no longer works for coloring the assignment. For most people, some Big Deal/Little Deal self-coaching would kick in and they would recognize that this is a pretty minor deal-one that could be solved by using a different color, asking around for another blue marker, or asking the teacher is there is another set of markers from which to pull a blue replacement. So how will you use the 5-Point Scale with Johnny? Begin by asking him where on the scale he thinks this problem falls. It’s important to point out that he (and all other clients) should previously have been taught how to distinguish between the numbers (ideally by letting the students pick examples for each number). A 1 is a minor glitch (like a broken pencil tip that can be almost momentarily fixed by sharpening the pencil). On the other hand, a 5 is a crisis (like a natural disaster-something that might take weeks to solve). 2-3 fall somewhere in the middle. Again, this scale can be highly individualized to each client. Your 5-Point Scale discussion with Johnny Q might look something like this:

You: Johnny, on our 5-point scale, where do you think this blue marker problem falls?

Johnny: A 5!!!!!!!!! (while crying hysterically)

You: Hmmm, I can see that it might feel like a really big problem right now, but remember…we decided that a 5 is something huge, like a natural disaster, that might take weeks to solve. Do you think this problem is going to take weeks to solve?

Johnny: No

You: I don’t think so either. So now that we’ve thought about it a little, where does the problem fall?

Johnny: A 4!!!!!

You: A 4 sounds better than a 5, but I still think it might be too high because we decided that a 4 is still a really big deal, like breaking your arm and having to go to the hospital and maybe even wear a cast. Do you think we can bring our marker problem even lower?

You would continue coaching Johnny through this process until he lands on a more appropriate number (1 or 2). Even though the client’s initial reaction might be to hugely overreact, it’s important to acknowledge how they are feeling and remind them how they agreed to represent each of the numbers (with specific examples assigned to each number) so they can more accurately define their problem. It may take Johnny a few times using the scale before he can really assign an appropriate number to a problem, and that’s ok! The goal is simply to keep moving him towards accurate self-talk, even if that is a process rather than a fast transformation.

image from- 5pointscale.com

The 5-Point Scale can be altered to fit a variety of situations: volume level (1 = whisper and 5 = screaming), decision-making (1 = no thought necessary and 5 = lots of consideration with pros/cons list), etc. Regardless of how you choose to incorporate the scale into a client’s therapy, it’s a great way to help them visualize the severity of problems/volume/decision-making and more accurately use their self-coaching skills.

Here are some ideas for integrating the 5-Point Scale into your therapy!

image from- burroughs.mpls.k12.mn.us

image from 5pointscale.com

 

 

Best of luck!

The Conversation Tree: A Visual Support for Conversational Mapping

I’d like to dovetail on my previous post about executive functioning and its impact on the development of social-cognitive skills and pragmatic language. In its role as the brain’s “secretary,” executive functioning helps to regulate an individual’s ability to map/plan a conversation and then to follow that plan. This isn’t to say that every conversation should be planned out ahead of time-that would be completely crazy and impractical, as conversations are organic, dynamic, and sometimes take unpredictable turns based upon the participants’ perspectives. What I mean by a conversational map is some kind of mental/visual representation of the essential components of a conversation. These maps are what help us to recognize the main topic of the conversation, ask relevant questions that maintain the conversation and include each member, and make relevant comments that support the main topic.

Conversational maps take many forms: I have seen everything from a conversation umbrella to a conversation house. I strongly believe that therapy strategies should be as individualized as possible, so whatever visual schema works for a particular student, alrighty! Use it! I merely want to offer another way to conceptualize the general map of a conversation. I led a group of students with social-cognitive and pragmatic language challenges in a summer wrap-up camp last week at The Ely Center in Newton, MA. During one particular discussion about building skills to support social success with old and new classmates, I introduced the idea of the Conversation Tree. Like an umbrella, a house, or even a flowchart, this is another way you can help kids to visualize the basic components of a conversation!

One application of the Conversation Tree is to literally present the necessary components of a conversation: the main topic/main idea, the sub-topics that help to maintain the conversation, and the details that develop the sub-topics and connect them back to either the main topic or other sub-topics. I highly recommend introducing the Conversation Tree in a group therapy context, since conversations tend to develop more with peers than in 1:1 settings with a child and a therapist. Here are the steps for building a Conversation Tree during your next session:

1. Choose a main topic/main idea. This will be the trunk of the tree. In other words, this main topic is what will support the rest of the tree/conversation. Clients may need to be regularly reminded to do a self-check through the self-talk skills discussed in my last post: “Am I connecting my thoughts with the trunk topic, or am I building another tree altogether?” It’s important to redirect kids when they jump to a new conversation tree and help them find a way to connect their thoughts with the trunk topic.

2. Once you have your trunk topic determined, you’ll need to add some sub-topic branches. Work with the kids in your group to decide what kinds of sub-topics relate to your main trunk topic. Another way to approach this is to add a sub-topic branch each time the conversation moves in a new direction (and addresses a new subtopic). This method involves building your tree simultaneously with the conversation (which relates more to self-monitoring in a conversation than mapping ahead of time-totally ok and awesome!).

 

3. If you were to stop a conversation after only introducing a main topic and the sub-topics, it would feel sparse and bare…much like the tree above. In order to make the conversation flow and feel cohesive and connected, you need details! These get added as leaves on each sub-topic branch. The details help to connect the branch sub-topics to the main trunk topic and also to connect branch sub-topics to one another. Leaves represent clients’ individual experiences around each sub-topic. You could even give each student a different colored leaf to add to each sub-topic branch to represent their talk-time within each sub-topic!

 

Once you’ve fully mapped the conversation, the tree might look something like this:

As I stated above, there are numerous applications for the Conversation Tree as a language therapy tool. Another way to use the tree idea is to visualize the use of Wh-Questions as a means of maintaining conversations, showing interest in a conversation, and being an active, on-topic participant in a conversation. You can use the same tree template, but instead of branches representing the sub-topics, they can each represent a Wh-Question. Each time a client asks a relevant Wh-Question, he/she gets to add a leaf to that branch (I cut leaves out of green sticky notes so they would automatically stick to my paper). The goal can be to fill up each branch with a variety of on-topic questions. You can also use this as a fun way to practice embedding the “wh” word into the question rather than always starting with it (e.g., rather than asking “When did you go to New Hampshire?” you could ask “Did you go to New Hampshire when the leaves were changing?”).

 

Executive functioning impairments are not easy to assess, quantify, or treat. Often, we have the most success targeting those deficits within the context of other social-cognition and/or language goals. Providing clients with a visual support to conceptualize these challenging planning/mapping processes can be an invaluable tool when addressing executive functioning deficits, and I look forward to hearing how this activity  (and any others you’d like to share) are working to address clients’ needs within this realm!

 

 

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 🙂