Executive Function, Pragmatic Language, Social Cognition

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 😉

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Executive Function, Random Therapy Ideas, Social Cognition, Uncategorized

With the End in Mind

What does it look like when it’s done?

Sarah Ward, M.S., CCC-SLP brings us this fabulous question from her executive function-directed therapy. The concept is rather simple: start with the end in mind…then go back and figure out how to get there. Despite its simplicity, I am finding that structuring tasks around this one little question can radically alter the outcomes for the better. Although it’s often promoted as a great strategy for working with kids who have social cognition and executive functioning deficits, I would argue that Sarah’s method is relevant in just about every nook and cranny of our lives!

Toddler, child, adult…we rely on this structure all the time. “You’re done with dinner when your broccoli is gone.” “I’ll know you’re ready to have a cookie when all the toys are put away.” “We’ll leave the house when you’re completely ready to go…not with only one shoe on.” I even came across an example while walking through the hair-care aisle at Walgreens: boxed hair dye! The first thing you’d consider when buying a box of hair dye is: What’s the end result? Or as Sarah Ward would say: What does it look like when it’s done? Not only is this question paramount in helping you decide whether to buy the dye in the first place (yes, blond and purple are verrrrrrry different colors), but it also gives the critical visual cue of “See this little swatch of color on the bottom? We call that Maple Walnut Espresso Chocolate Surprise. That is what your hair shall look like in a mere 25 minutes. If it’s lighter than Maple Walnut Espresso Chocolate Surprise, leave it on longer. If it’s darker…oops.” Only after you’ve internalized the end result do you go back and figure out what tools you need for those luscious new locks (dye kit, towel, comb, etc.) and the steps you should follow to get to the end result.

College courses are on board with “What does it look like when it’s done?” every time a professor passes out a syllabus. As professors, we give syllabi to our students to tell them: “This is what your quarter/semester will look like! These are the projects you must complete, here are the dates for their completion, and these are the specific instructions for each project.” The students know what the expectations are before class 1 even begins, theoretically giving them a chance to organize their time to meet those expectations.

So why do we use this structure in so many parts of our lives? Because it works! In my very humble opinion, recognizing the power of starting with the end in mind should be pervasive in how we plan and present our therapy each and every day. For those already working with kids who have executive functioning deficits, this is your jam! For those who work with other populations, though, here are a couple simple ways you can begin to embed Sarah Ward’s “What does it look like when it’s done?” mindset into your daily routines:

  1. Before starting therapy with any new client, take the time to tell them and/or their parent (or guardian) what it will look like when it’s time to exit from therapy. None of us have crystal balls that can confidently determine how much progress every child or adult can make. That being said, I lately have been hearing from parents that they go into into therapy with no clear idea of what their child is supposed to look like at the end. Although this is a great strategy for kids with clear-cut challenges (e.g., “We’ll know Dudefriend is ready to leave therapy when he can say his “s” sound correctly in conversations.”), it may be even more important for clients with more pervasive impairments. What does the end of therapy look like for a child with moderate autism? Or Down syndrome? Does it look like a typically developing child? I don’t think so. Instead of leaving parents and clients in this realm of uncertainly, “What does it look like when it’s done?” can more clearly outline therapy benchmarks or exit times for everyone on board! If it doesn’t make sense to define the very end of therapy right at the get-go, start by defining your first benchmark: “We’ll know it’s time to move onto new goals when Dudefriend looks like X/can do X/ meets X expectations…”
  2. Use the “What does it look like when it’s done” strategy to provide clients with clear expectations for a task. Instead of saying, “Now I want you to use your skinny “s” to read this sentence,” you can say “Here’s what reading looks like when it’s done…” with a model of the skinny “s” in all the target words in a similar sentence. Kids with social-cognition challenges benefit from this structure ten-fold. I go so far as to take a picture on my iPad of what the task looks like when it’s done so we have an extremely clear model available. What does reviewing Social Detective terms look like when it’s done? It looks like all the visuals are put back into my client’s paper tool kit and he’s sitting with a calm body (I literally take a picture of that before we start actually reviewing the term). Only when that model is in place do we go back and gather the tools we’ll need for completing the task, determine the necessary steps, and begin working. It should be no shocker to anyone that kids perform better when they understand the expectations being placed on them ahead of time. We should never assume that our clients can read our minds to know what we want them to do (I mean, come ON, when has that ever worked with a kid?!?). Working with them to determine what the end result looks like at the onset can be the difference between success and significant frustration!

I highly encourage readers who are unfamiliar with the rest of Sarah Ward’s Get Ready, Do, Done method to learn more about it and begin implementing it with your clients. This structure for completing tasks can be replicated in the clinic, in the classroom, at home…you name it! I am a big proponent of strategies that are applicable in all settings for a given client, and this is one that’s right on the mark!