The Whole is Greater than the Sum of the Parts

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It’s been a little over a month since I made the change in my ‘day job’ from pediatric home health to early intervention.

For the most part, it’s been a good change. I enjoy the challenge of mostly getting paid to think.

But, as I said at work last week, I’m currently being asked to do a lot of things I’ve always taught students to never do. (More on those evaluation practices later…)

For now, I’d like to delve into the extremely pervasive thinking regarding where intervention in early intervention in speech-language pathologist should be focused.

For those of us who evaluate and treat communication disorders, we look at both receptive language and expressive language. Receptive language is what we understand. Expressive language is what we’re able to produce. We can broaden these terms to receptive and expressive communication. If we broaden ‘language’ to include all forms of ‘communication,’ then receptive communication begins to include things like following directions, answering questions (especially yes/no questions at the early ages), and being able to answer so-called display questions in mainstream culture. (Display questions are questions where the adult & child both know the answers and the adult & child both know the other knows the answers. For example, when looking at a book, a mainstream culture parent may ask, “Where’s the ball?” Display questions are NOT universal!) Receptive communication also involves being able to understand nonverbal forms of communication like body language/positioning and others’ facial expressions. Nowadays, it includes being able to understand written forms of communication including texts and (bit)emojis as well as print. Expressive communication includes the individual’s attempts to express their needs and wants by crying, whining/screaming, pointing, joint attention, signs, word approximations, words, phrases, and/or sentences and questions. Expressive communication also includes body language and positioning and facial expressions. These days, expressive communication also includes using written/printed forms of communication including using (bit)emojis, texts, and other forms of print.

The pervasive thinking in early intervention (EI) is that receptive communication should be the focus of intervention. But, parents are reporting concerns regarding their children’s expressive communication. Hmmm….

I get it. I understand where this focus on receptive communication comes from. It comes from an extremely pervasive assumption that receptive communication development precedes expressive language development. However, this is an assumption and an assumption only.

And yet, parents are contacting EI programs because their children are not progressing in their expressive communication development.

I’d like to argue that as SLPs we can work smarter, not harder AND address families’ primary concerns all at the same time. Here’s why:

From a data collection perspective, even when we’re supposedly addressing receptive communication, we’re judging expressive communication output. Huh? Let’s say there’s an outcome that a child will follow 1-step directions without gestures – a ‘receptive language’ outcome. But, we judge whether a child has met this outcome by determining whether the child’s expressive response matches the 1-step direction that was given. No matter what, we’re addressing receptive communication by judging whether the expressive response was correct or incorrect.

(Research sidebar: from an evaluation/assessment perspective, those supposedly earlier developing receptive communication skills actually require more linguistic workload than expressive communication tasks. If I show you a picture plate with four images on it and ask you to point to “ball”, you have to hold “ball” in your working [short-term] memory while you look at all 4 pictures to match what I said [“ball”] with the images in front of you. Conversely, if I show you a picture plate with just a ball on it and ask you, “What’s this?”, all you have to do is recall the word “ball” and tell me. It’s a lot less linguistic work to answer expressive questions than receptive questions. Not only that, measuring expressive communication skill is much more inclusive and culturally and linguistically appropriate than measuring receptive communication. More on that later…)

So, if families are primarily concerned with their children’s expressive communication and it’s easier to effectively & efficiently measure progress in these skills, why not address expressive communication first? Is it fair to restrict young children to only using words/word approximations or signs/sign approximations as ways to expressively communicate? Why aren’t SLPs recommending more “light tech” forms of assistive technology (AT) or alternative/augmentative communication (AAC) for young children who aren’t or who can’t approximate words or signs? Why can’t joint attention outcomes be written so that the child is responsible for initiating the interaction? (ProTip on this one: The adult *should* already be able to respond appropriately to others’ attempts to initiate interactions!) Why aren’t we coaching families to prompt less and wait more? Again, we know the adult knows how to communicate. The child needs the opportunity to use their developing expressive communication skills.

Wouldn’t it be more prudent to focus on outcomes which measure the child’s expressive communication skills? Instead of writing outcomes that focus on mainstream culture phenomena like pointing at pictures in books on the parents’ request, wouldn’t it be more functional and appropriate to write an outcome focused on making choices by pointing, words/signs, or eye gaze as appropriate to the child? What about developing outcomes that focus on teaching the child to initiate interactions in supported contexts? Those contexts could range from having the child fill in the blank during favorite songs & fingerplays; tapping the adult’s arm to get their attention appropriately; or learning to pair vocalizations & natural gestures to direct others’ attention to something.

As always, dear reader, thank you for your time. I would love to hear your thoughts on 1) treating expressive communication skills before working on receptive communication skills and 2) working on the whole before working on the parts.

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