Finding the Right Mix of Engagement and Learning in Therapy

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Finding the Right Mix of Engagement and
Learningin Therapy

• ASHA 2006

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Today, we will

• present and analyze examples of effective
  therapeutic strategies and techniques
• share video clips of these therapeutic
  interactions with a child to demonstrate a
  clinicians on-line (i.e., in real time)
  responding to utterances and behaviors

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Our Purpose

• To illustrate that
• mastering and improving on-line intervention
  will demonstrably improve language performance by
  the child
• on-line, real-time strategy adjustments can be
  learned and implemented by clinicians

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Examples of On-Line Therapy Strategies

• recasting techniques
• engagement and motivation enhancers
• following the childs lead

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Evidence Based Practice

• The emphasis on EBP has led to a critical
  analysis of the merits and outcomes of methods
  and approaches in all domains of speech-language
  pathology.
• Yet while our body of knowledge has been growing
  concerning reasonable and measurable outcomes,
  there is still limited understanding about the
  mechanisms within intervention that trigger
  therapeutic advances.

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Children with Language Impairment (LI)

• A demonstrable delay and deficit in the
  acquisition of specific linguistic skills
  including
• lexical management (learning and accessing the
  internal lexicon)
• morpho-syntactic operations (learning,
  recognizing, and activating the underlying
  syntactic rules resulting in word endings,
  inflections, producing word compounding,
  establishing noun verb agreement, etc.).

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Children with LI

• Elman et al. (1996) consider the morphological
  system (at least of English) often to be the most
  vulnerable component, which is often the most
  salient characteristic in children with language
  delay.

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Learning

• Learning requires
• attention
• motivation
• understanding
• engagement
• the ability to discern the new structure

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Its a Tricky Mix

• Cognitive psychology provides ample evidence that
  learning typically does not continually occur
  over a steadfast period, but that a combination
  of factors lead to short moments of learning,
  understanding, and recognition. This
  micro-genesis of a learning moment has been
  characterized as a dynamic tricky mix (Nelson,
  2001).

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Dynamic Tricky Mix

• The dynamic tricky mix approach offers a model
  that describes parameters that, if present in
  the right mix, will increase the likelihood of
  learning.

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Dynamic Tricky Mix

• These parameters of the tricky mix can be
  classified under the LEARN acronym
• L Launching conditions
• E Enhancers
• A Adjustment
• R Readiness
• N Cognitive and Neural networks
• which encompass the ingredients of
• learning

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LEARN Parameters

• Note that these conditions explain micro-moments
  of very rapid learning, i.e. sometimes a few
  short sequences of 10 or 20 seconds during which
  the child grasps a new morpho-syntactical
  structure.
• "Near-misses" for progress, where most but not
  all required conditions converge in contrasting
  micromoments, by the same token help to explain
  puzzling lack of progress by children during
  seemingly supportive conditions at home or in the
  clinic.

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Dynamic Therapy

• Nelson et al. (Nelson, Camarata, Welsh,
  Butkovsky, Camarata, 1996 Nelson, 2000) have
  been able to demonstrate that a dynamic approach
  within conversational episodes can increase
  language learning dramatically if the
  intervention is focused on providing the right
  challenges to the child in a rich positive
  combination of emotional, attentional, and
  processing enhancers.

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Previously Replicated Findings

• rates of complex sentence acquisition can be
  accelerated considerably by new focused
  conversational presentations of challenging
  syntax within recasting dialogues
• across approximately 20 sessions of dialogue
  treatment, children initially lacking passives
  and other complex syntactic structures have
  achieved rapid acquisition

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Recasting

• Recasts provide relevant child-system/challenge
  comparison possibilities regardless of whether
  the child produces an error in their platform
  utterance
• Comparison/learning opportunities are dynamically
  enhanced by how the child's conversational leads
  are picked up by the recasting dialogues, as well
  as by highly positive social and emotional
  qualities in the interactions precisely when the
  challenging input exemplars are occurring

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Effective Intervention

• When intervention procedures include richly mixed
  combinations of challenging syntax (infinitives,
  past tense, relative clauses, etc.) and
  interested, positive adults placing such
  challenges in recasting of children's utterances,
  acquisition rates have been strongly accelerated.

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Effective Intervention

• Evidence that the mix of conditions just
  described underlies the accelerated rates, rather
  than merely modeling the target structures with
  increased frequency, comes from analyses of
  child-therapist interactional engagement and from
  direct comparisons with more standard
  non-conversational treatment procedures.

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Dynamic Mixes

• It is important to take advantage of moments when
  the child has the appropriate motivation,
  emotions, and self-esteem, as well as the
  activation/expression of current language
  structures to teach new aspects of language that
  the child is lacking.

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A Few Strategies to Make the Tricky Mix

• The Focus Principle keep the child focused on
  the topic elaborate, recast, let the topic
  generate sub-topics
• The Multimodality Approach minds usually dont
  work just in spoken form. Minds function as
  integrated multi-layered networks of association
  with representations in different modalities.
• Fast Mapping fast mapping can be triggered by
  well setting up the environment

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Therapy Examples

• Memory - games
• To increase the use of do in interrogatives,
  e.g., Do you like candy?

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A Crucial Ingredient in the Tricky Mix
Engagement

• Types of engagement
• cognitive engagement
• behavioral engagement
• emotional engagement
• The tricky mix will be most effective if all
  types of engagement are present.

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Factors Contributing to Engagement

• attention issues
• socio-demographic issues
• child characteristics
• environmental factors
• During child intervention, we can work on 1, 3,
  and 4.

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How to Increase Engagement in Therapy

• Consider
• childs interest following his/her lead
• attending to childs non-verbal cues
• seizing the moment
• recasting
• being available and flexible

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SPLASH at University of Virginia

• Group speech and language sessions
• Therapy provided for children with variety of
  speech and language delays/disorders
• Two hour sessions meeting 2-3/week for 7 weeks of
  summer

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SPLASH 2006

• Group 1 met for three two-hour sessions each
  week
• five males ages 4-6 years old
• three with diagnosis of autism
• one with diagnosis of developmental delay, and
  possible apraxia
• one with bilateral hearing loss

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SPLASH 2006

• Group 2 met for two two-hour sessions each week
• six children (4 males and 2 females) ages 3-4
  years old
• two with diagnosis of autism
• one with diagnosis of apraxia
• one with mild articulation delay
• two with phonological disorder

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SPLASH 2006

• Group 3 met for two two-hour sessions each week
• five children (4 males and 1 female) ages 5-6
  years old, with one child age 9
• two diagnosed with autism
• one diagnosed with childhood disintegrative
  disorder
• one presenting with global delays
• one diagnosed with mild articulation delay and
  bipolar disorder

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SPLASH 2006

• Each group had
• consistent clinical supervisor
• four student clinicians
• same session schedule
• same circle and art activities based upon weekly
  themes
• small-group sessions to target individual goals
• large-group play to target goals, as well as
  social interactions with peers
• strong literacy component

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Animal-Assisted Therapy (AAT)

• Goal-directed intervention in which an animal
  that meets specific criteria is an integral part
  of the treatment process
• Designed to promote client improvement in
  physical, social, emotional, and/or cognitive
  functioning
• Directed and/or delivered by a health/human
  service professional with specialized expertise,
  within the scope of practice of his/her
  profession
• Provided in a variety of settings and may be
  group or individual in nature

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Therapy Dogs

• http//charlottesvilletherapyanimals.com/index.htm
  l

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Overall Child Progress

• Overall, children made improvements in
• Mean Length of Utterance (MLU)
• Vocabulary
• Play
• Peer interactions
• Attention to task

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Tracking Child Engagement

• PB
• Individual progress observed during SPLASH
  program
• MLU
• Pre-SPLASH 2.16 to Post-SPLASH 2.55
• Increased Attention Span
• Increased Engagement
• Improved Play
• Improved Mood

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Lets Watch

• Video Clip 1
• Look for the Clinicians on-line changes to
  maintain child engagement
• Video Clip 2
• Observe how child engagement can assist with
  progress

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Examples of On-Line Therapy Techniques

• Provide Visual Supports
• Touch
• Rewards
• Behavior Management Strategies
• Proximity
• Voice
• Auditory Models
• Recasting

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Skills Helpful to a Clinician

• Many of the SPLASH clinicians felt they learned
  strategies and skills during the experience that
  will be helpful to them as future speech-language
  pathologists
• The following graphs are based on comments from
  SPLASH clinicians regarding engagement, the group
  setting, and peer interactions

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What strategies/techniques did you find most
effective for Gaining Children's Attention
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How were your language facilitation strategies
impacted by other factors Peers
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Positive Benefits of Peer Interaction
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Benefits of the Group Setting
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Make Therapy ExcitingAdd Therapy Dogs to the Mix
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Our Purposes REVIEWED

• On-line, real-time strategy adjustments are
  learnable by therapists
• Good examples of mastered strategies
• Encouraging child engagement
• Use of touch and/or proximity
• Use of voice
• Following a childs lead/interest

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Our Purposes REVIEWED

• Mastering and improving on-line intervention will
  demonstrably improve language performance by the
  child
• Results illustrating this
• PBs MLU grew from 2.16 to 2.55
• Other interesting individual MLU changes
• CYs MLU grew from 2.25 to 3.66
• CRs MLU grew from 1.33 to 2.46
• Average MLU for all groups increased from 2.64 to
  2.72
• Improved play skills and interaction between
  children

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Measures of Success

• Progress with our clients, e.g., children in
  SPLASH
• Growth and change as a clinician

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• Questions?
• Thank you for coming!

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Presenters

• Jessica J. Norton, M.S., CCC-SLP
• University of Virginia
• jj8d_at_virginia.edu
• Filip Loncke, Ph.D.
• University of Virginia
• ftl4n_at_virginia.edu
• Keith Nelson, Ph.D.
• Penn State University
• k1n_at_psu.edu

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Presenters

• Mary Harrell, B.A.
• University of Virginia
• mlh4j_at_virginia.edu
• Mandy Spear, B.S.
• University of Virginia
• als4fb_at_virginia.edu

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Other UVa Students Involved in Project

• Libby Burchmore, B.S.
• Rexie Chamer, B.A.
• Amy Hammond, M.A. (Linguistics)
• Cheryl Trott, B.A.
• Alyssa Weltman, B.S.
• As well as several other graduate students who
  provided therapy during SPLASH