Repeating Patterns…and Breaking Some Cycles

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Nature is full of repetition – and patterns

Nature very much operates on the adage, ‘if it ain’t broke, don’t fix it.’ This adage leads to a lot of repetition and redundancy. It’s why a 5-digit forelimb like our hands is actually a very old structure in evolutionary terms. We share this bone structure with cats and whales to name literally a couple of other species who also have 5-digit forelimbs. (The innovation was the opposable thumb.)

I advocated repetition, repetition, repetition in the last post. And, I very much stand by what I said as far as using repetition as an intervention technique.

But repetition is not always a successful strategy. How many times have you repeated something just because you’ve always done it that way? When I hear ‘we’ve always done it this way’, I immediately ask, ‘well, why?’

I think ‘traditional’ speech therapy is broke. I think we need to fix it.

As I’ve mentioned, I’ve had the opportunity to work with a cohort of bachelor’s level speech-language therapists who are working in a local school district. They’re returning to complete their Master’s degree in speech-language pathology. Let’s leave aside all of the arguments aside regarding the appropriateness of this for now. I want to focus on what I’ve learned from the students in this cohort and consider what’s learnable for the field as a whole.

The first thing I’ve learned is that those of us with an interest in higher education really need to think about what we’re teaching at the undergraduate level. At the very least, we need to reframe what we, as higher ed educators, expect from undergraduate students in CSD. I think we need to add more practicality to how we’re training undergraduates. ASHA’s SLPA certification program provides a good guide to this, I think. More on that in another post later.

Teaching cultural responsiveness also needs to be at the forefront of all undergraduate and graduate education. This has become readily apparent to me working with one mainstream culture grad student. Currently, the grad students are placed with me in a home health setting. The majority of the families I work with are from culturally and linguistically diverse backgrounds. Many are low-income. These families experiences are clearly outside of the student’s own. But, that doesn’t excuse the student from learning to adapt to the needs of the families. In fact, it makes it more critical that the student acquires these skills.

I’ve also learned that conventional wisdom needs to be challenged if we’re going to grow as a field. I think the time to challenge much of what we hold to be conventional wisdom in the field is now. Strike while the iron is hot (very hot out here on the West Coast!). It’s time to use the brain power our opposable thumbs afforded us to rethink some things (preferably in a sustainably-cooled environment). Let’s dive in.

What’s ‘broke’ ?

Last week, I observed one of the students attempt to simplify the language input to a 7 year old, nonverbal child in a Spanish-English speaking home the way they’d previously had been taught to do. The way we’re all initially taught to do because that’s what children who are severely language impaired require, right? The student was targeting 1-step directions, at least gesturally prompting every opportunity, and simplifying the language of the directions to ‘put in’ with mainstream culture child directed speech intonation patterns. Again, the student was doing what they’d been taught to do previously with a client like this child.

Let’s think through this. Somewhere along the line, it became conventional wisdom to simplify the English input to clients like this child to the point where it’s ungrammatical. I want you to ask yourself why do we do this? Why has this become accepted practice? We would never say, “put in” to a typically developing child even at the 2-word stage. We would model, “put it in.” Why do we model ungrammatical utterances for clients who by definition are not learning language like typically developing children? Keep in mind that the same instruction in Spanish would always be provided with the direct object present – ponerlo adentro (literally, put it inside).

As SLPs, why do we feel the need to prompt every opportunity we provide to children with language impairments? (And yes, gestural prompts are prompts.) Here again, this is not something we do to/for typically developing children. We instinctively provide opportunities for typically developing children to try to figure it out on their own. We need to be aware of how much we’re prompting. We need to become more comfortable with quiet. We need to teach grad students and families the value of waiting quietly. We need to make sure that adults provide the opportunity for our pediatric clients to show us what they’re capable of on their own.

Let’s talk about child directed speech (CDS). It’s not universal across cultures. Even when it is used within a culture, it generally is not used past toddlerhood for human children (pet directed speech is its own animal). Is it EBP to use CDS with a 7 year old mainstream culture student? Is it appropriate to use CDS with 7 year old children from a culturally and linguistically diverse background? If you’ve answered ‘no’ to either of these questions, then it’s time to become more mindful of how you’re interacting with older children and/or children from culturally and linguistically diverse backgrounds.

Thinking about how to fix what’s broke with the field in general…

When you drop a rock into a still body of water, you get a pattern of concentric wave like the ones in the image above. The size of the waves are dependent upon the mass of the rock and how much water it displaced when it was dropped. The more mass the rock has, the more water it will displace. As a consequence, the concentric – that is, repeating – waves will initially be larger and will travel further from the center. We call this a ripple effect.

What if speech-language intervention was the rock? What if we put our energy into selecting the rock with the most mass for each client? What if we thought more about the ripple effects from the very onset of therapy planning? What if we considered the ripple effect during intake, evaluation, and therapy? What if we considered the ripple effect when interacting with clients and families on a day-to-day basis?’

Thinking about how to fix what’s broke when working with families…

Here’s how I try to think about intervention with my clients with complex disorders and/or are from culturally and linguistically diverse backgrounds. I try to imagine myself in their shoes. How would I feel if:

  1. I was non-verbal and everyone was talking about me instead of to me – and I was right there?
  2. I was 7 and everyone talked to me like I was 2?
  3. I was 13 and asked to interact with toys designed for toddlers?
  4. I was a mom who spoke English as a second/other language and didn’t share the same view of parenting as the mainstream culture ‘expert’ telling me what I ‘should’ do with my child – in English?
  5. I was a mom from a low-income environment doing the best I could in my current circumstances and felt judged by the clearly middle-class, mainstream culture clinician coming into my home?

Trying to look at situations through the eyes of my clients and families changes my perspective on what’s functional. Trying to think about how I’d feel makes me more aware of the ripple effect I’m having on their lives. It makes me rethink why SLPs practice providing ungrammatical input to children who are developing language atypically. It makes me rethink how I talk to a 7 year old, even if I’m simplifying the language. It makes me rethink what materials I need to use with a 13 year old to achieve the same goals. It makes me think about how I sound and look and present myself to a mom who comes from a different background than me.

As you go about your day, try thinking about the ripple effect you’re having in your clients lives. Why are you doing what you’re doing? How can you do things differently to have the optimal ripple effect for each of your clients? How can you plan for intake or evaluation/assessment or therapy differently if you consider the rock you are dropping into your clients’ ponds? What’s learnable for you today?

As always, thank you for reading and I look forward to reading your comments.

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