Larry Medwetsky, Ph'D'

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An Interdisciplinary Approach to
Assessing/Managing CAPD
Larry Medwetsky, Ph.D. VP, Clinical
Services Rochester Hearing and Speech
Center 585-271-680 x 245 lmedwetsky_at_rhsc.org Laur
a Riddle, Ph.D. Assistant Professor Department
of Communication Sciences and Disorders
Nazareth College 585-389-2442 lriddle2_at_naz.edu

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Overview of Presentation

• Overview of Processes Engaged in Spoken Language
  Processing
• Assessment of the Various Processing Domains
  (Audiology and SL Procedures)
• Management of Processing Related Difficulties
• Specific Techniques
• Environmental Modifications/Compensations
• General Compensatory Strategies

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Overview of Processes Engaged in Spoken Language
Processing

• Transduction
• Acoustic stimuli undergo many conversions,
  ultimately resulting in neuroelectric impulse
  patterns that convey intensity, frequency,
  temporal, intonation/amplitude contours, phase
  information.
• Pattern Matching (Decoding)
• The neuronal impulses are relayed via the Central
  Auditory Nervous System to the higher order
  language processing centers in the Cortex and
  stimulate various neuronal combinations
  prototypes in long-term memory (LTM).

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Decoding- contd Language cortical neuronal
regions include - the language centers in the
brain (for _at_ 95 of the population, this is
in left hemisphere) - the rhythmic
processing areas of the brain (for _at_ 95 of
the population, this is in the right
hemisphere) The above occurs because the rapid,
short duration information is processed/analyzed
by neurons in the left hemisphere, while the
slower, longer duration information is analyzed
by neurons in the right hemisphere.
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Short-Term/Conscious Memory Neurons in LTM are in
a resting state. Stimulation of the various
neuronal synapses/connections results in
activation of these neurons, and, if sufficient
attention is allocated, results in conscious
awareness of the item (short-term/working
memory). Integration Somehow, the derived
segmental information from the left hemisphere
language region is integrated with the derived
suprasegmental information from the right
hemisphere.
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• Attentional Allocation
• This is the process whereby the brain determines
  which information to focus on and which to
  ignore. This is because humans are limited to
  how much they can process and attend to at any
  one point in time.
• Attentional allocation is important for
• initial priming/excitation of neurons engaged
  in processing of selected information
• maintenance of neuronal firing to maintain
  information in short-term memory
• selectively attending to target stimuli in the
  face of competing stimuli
• switching of attention when multi-tasking,
  thus, maintaining neuronal firing for multiple
  regions

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• Short-Term Memory (STM) Span
• STM span refers to the maximum number of units/
  chunks that an individual can maintain and
  recall. It is based on the maximum of neuronal
  regions that can be maintained in an active
  firing state.
• Neurons can remain in an active firing state for
  1-2 seconds, unless some sort of stimulation
  attention is directed to that neuronal cluster,
  resulting in renewed activation prior to
  returning to its resting state.
• Recent research suggests that the maximum limit
  is 4-5 neuronal regions firing at a time.
  Chunking allows for bigger sized units (e.g., 7
  digit phone number cab be grouped into three
  chunks /271/ /06/ /80/.

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• Sequencing
• The part of the brain that directs attention
  Pre-Frontal Cortex also somehow maintains the
  sequence in which the information has been
  processed (be it in the receptive or output
  side).
• Selective Attention
• This refers to the ability to focus on a target
  stimulus and to ignore competing stimuli.
• When the competing stimulus consists of
  non-linguistic noise, the brain analyzes the
  different acoustic characteristics and attempts
  to filter the speech from the noise

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• Selective Attention- contd
• When the competing stimuli consists of speech
  (e.g., group listening settings), the brain uses
  spatial cues, fundamental pitch contours, etc.,
  to perceptually separate the incoming information
  and then allocate attention to the source of
  interest and ignore or block the competing
  source.
• Divided/Shared Attention
• The ability to process and activate two or more
  neuronal regions simultaneously some tasks may,
  in fact, involve fast switching rather than
  simultaneous processing (e.g., note-taking) but
  this still requires more information to be
  processed per unit time.

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• Phonological Awareness
• Over time, if everything develops normally an
  individuals brain derives and stores the
  phonological codes for that language, manipulate
  the phonemes (e.g., deletions, substitutions,
  additions, etc.), and, learns the written
  symbolic code that represents the phonemes in
  their language (i.e., phonics).

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Interdisciplinary Assessment of Processing
Domains

• Role of the SLP
• Use the results of the Auditory Processing
  Evaluation, as well as the presenting
  difficulties, to guide assessment
• Note it is possible that an SLP may
  initially have conducted a basic language test
  battery but subsequent to an auditory processing
  evaluation may conduct further testing based on
  the new results obtained.

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Phonemic Awareness

• Audiology Phonemic Synthesis Test
• Phoneme Blending Test
• Stimulus items are presented 2 seconds apart
• 3-4 phoneme words
• SLP (most of time) Lindamood Auditory
  Conceptualization Test-3
• Discrimination of speech sounds
• Analyzing the number and order of speech
  sounds/syllables
• Tracking speech sound changes at both the phoneme
  and syllable levels

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Phonemic Awareness

• SLP More in-depth assessment of phonemic
  awareness
• Standardized Tests
• Comprehensive Test of Phonological Processing
  (CTOPP) (Wagner et. Al., 1999)
• Elision, Sound Blending, Sound Segmentation
• Blending and Segmentation of real and nonsense
  words
• Rapid Naming (letters, digits, colors, objects)
• Phonological Working Memory (non-word repetition)

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Phonemic Awareness

• SLP More in-depth assessment of phonemic
  awareness
• Phonological Awareness Test-2 (PAT-2) (Robertson
  Salter, 2007)
• Rhyming, syllable blending and segmentation,
  sound isolation, sound blending and segmentation,
  substitution
• Letter-sound knowledge
• Non-word Decoding

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Phonemic Awareness

• SLP More in-depth assessment of phonemic
  awareness
• Standardized Tests
• Pre-reading Inventory of Phonological Awareness
  (Dodd, et. al., 2003)
• Rhyming, syllable segmentation, alliteration,
  sound isolation, sound segmentation
• Letter-sound knowledge

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Phonemic Awareness

• SLP Standardized Tests assessing 1-2 skills
• Phonological Awareness Skills Program Test
  (Rosner, 1999)
• Deletion, substitution
• Test of Phonological Awareness (Torgesen
  Bryant, 1994)
• Sound Matching initial, final

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Phonemic Awareness

• Phonemic Synthesis vs Phoneme Blending (CTOPP)
• Often see inconsistent results but are they
• inconsistent?
• Difference between tests
• Length of Inter-stimulus interval (_at_ 2
  secs vs 1 sec apart)
• Live ( lipreading) vs taped voice
• Shorter vs longer words

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Phonemic Awareness

• Phonemic Awareness Error Patterns
• Position of sound in word
• Type of sounds, e.g., blends
• Number of sounds in the word
• Nonsense vs real words
• Response delays

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Audiological Determination of Lexical Decoding
Speed Difficulty

• Background
• Individual requires more time to process and
  match stimulus to what is stored in LTM.
• Staggered Spondaic Word Test
• Non-Competing Competing Non-Competing
• Right Ear Up Stairs
• Left Ear Down Town
• A pattern indicating decoding speed difficulty is
  more errors on second spondee (due to slow
  processing, attention too long on first spondee,
  and, thus neuronal representation of second
  spondee fades away).
• For sentences if decoding speed is the primary
  difficulty, may see more word errors at the end
  of the sentence

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Lexical Decoding Speed

• SLP Testing (ruling out knowledge issues)
• Semantic Skills
• Vocabulary, Antonyms, Synonyms, Multiple Meaning
  words, Word Definitions
• PPVT-4, EVT, LPT3, Word Test2-E, CELF-4, CASL
• Morphology/Syntax
• CELF-4, TOLD-P3, Language Sample

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Lexical Decoding Speed

• SLP Testing
• Morphological Awareness
• Spelling lists of words that are morphologically
  different (e.g., kicked, gladly)
• Cloze procedures produce a derived word
• Word judgment tasks
• Suffix addition tasks
• Masterson Apel, 2000

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Lexical Decoding Speed

• SLP Testing
• Word Retrieval Ability
• Single-word level
• Test of Word Finding-2 (German, 2000)
• Discourse level
• Test of Word Finding in Discourse (German, 1991)
• Language Sample with maze analysis Story retell
  and conversation

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Lexical Decoding Speed

• Word Retrieval Difficulty
• Revisions
• Repetitions of words or parts of words
• Word choice errors (substitute one word for the
  target word)
• Word omissions
• Pauses/delays within utterances
• 
  Miller, 1991

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Fading-Memory

• Background
• Individual is unable to allocate attention
  effectively, consequently earlier presented
  information fades rapidly from short-term memory
• Staggered Spondaic Word Test
• Non-Competing Competing Non-Competing
• Right Ear Up Stairs
• Left Ear Down Town
• Individual has more errors on the first spondee.
  
• Also, if individual cant blend on fly, then on a
  phonemic blending task may see more errors on
  earlier phonemes
• If predominantly fading-memory difficulty, on
  sentence recall individual exhibits more errors
  on earlier sentence portions.

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Short-Term Memory Span Assessment Background
STM Span refers to of units that can be
recalled by an individual, usually assessed in
serial fashion. Test of Auditory Processing
Skills examines three different
stimuli Digits Unrelated Words
Sentences The first two tests are rote-memory
tasks (minimal context present), while sentence
recall engages syntax, semantic relations, world
knowledge, prosody.
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Possible STM Span Patterns

• Results on all three tests within normal limits
  (WNL) either no or minimal processing issues
  (though still may exhibit phonological awareness
  difficulties)
• Results on all three tests significantly below
  age norms significant processing difficulties,
  likely impacting on basic language skills
• Difficulty on digit/word STM span, WNL for
  sentences (likely processing related issues and
  is the most common finding at RHSC Audiology)
• WNL for digits/sentences, difficulty with words
  (lexical decoding speed likely the major issue)
• WNL for digits/words, poor sentence recall
  (likely language disorder)
• WNL for digits, significant for words/sentences
  (typically observed in individuals with
  Autism/Aspergers)

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Short Term Memory

• SLP Testing
• Phonological Working Memory
• Non-word Repetition Tasks
• CTOPP (Wagner et. Al., 1999)

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Integration Audiological Signs

• Background
• Individual is either unable to integrate right
  and left hemisphere information, or, reveals
  right ear dominance on competing stimuli tasks
• SSW Test
• Significant Left Competing finding (relative to
  peers, significantly more errors than in the
  other conditions )
• Competing Sentences Test
• Significantly poorer left versus right ear
  selective attention recall score relative to
  peers
• Pitch Pattern Sequences Test
• Verbal labeling of thee tone sequence is
  significantly poorer than non-verbal (hummed
  response)

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Integration

• SLP Testing
• Prosody
• Difficulty processing prosodic cues
• Informal observation of comprehension of
  sentences when stress and intonation are varied
• Structured tasks of processing vary the stress
  on words and determine number of units being
  produced (Wells Peppe, 2003)

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Integration

• SLP Testing
• Prosody
• Difficulty processing prosodic cues
• Emotional Prosody observe response to words
  conveyed with different emotions
• Difficulty producing prosodic cues
• Observe intonation and stress patterns during
  a variety of language sampling conditions

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Integration

• Figurative Language
• Idioms, similes, metaphors, proverbs, humor
• Interpreted using contextual cues, situational
  cues and mental imagery (Nippold Duthie, 2003)
• Standardized tests can be used
• CASL, TLC
• Informal tasks better option
• Interpret meaning of figurative expressions
  commonly heard within environment

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Integration

• Conversational Skills
• Individual must attend to facial expression,
  body language in addition to oral language to
  interpret messages
• Individual must divide attention to accomplish
  this
• Conversational samples in both paired and
  group settings

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Integration

• Conversational Skills
• Analyze topic initiation, topic maintenance and
  turn taking skills
• Analyze ability to look at partner, respond with
  appropriate facial expressions
• Analyze pre-suppositional skill takes listener
  perspective uses clear referents
• Analyze repair strategies
• Analyze response delays

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• Sequencing
• Staggered Spondaic Word Test
• Non-Competing Competing Non-Competing
• Right Ear Up Stairs
• Left Ear Down Town
• Individual has to recall at least three of the
  four words. Examples of sequencing errors may
  be /Up-town/ /Down-Town/
• The Lindamood Auditory Conceptualization-3 test
  involves significant sequencing ability on three
  of their tasks, and, it is likely that for many
  children with phonological awareness difficulty,
  it may be due to higher order mental
  manipulations of phonemes/ syllables involving
  sequencing difficulties.

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Sequencing

• Oral Directions
• Token Test for Children-2 (McGhee et. al., 2007)
  CELF-4 (Semel, et. al., 2003)
• Assess informally within classroom
• To assess sequencing, child must have the
  concept knowledge

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Organization

• Narrative Language
• Story Generation and Story Re-tell
• Test of Narrative Language (Gillam
• Pearson, 2004)
• Analyze for story grammar, cohesion,
• inference

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Organization

• Written Language
• Skills needed
• Planning and organizing
• Drafting
• Revising and editing
• Knowledge of text structure (narrative,
  expository)
• Language knowledge discourse, sentences, words
• Writing conventions

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Organization

• Written Language
• Standardized writing tests (TEWL-2
  TOWL-3 OWLS Written Language Scale)
• Authentic assessment approaches (informal
  assessments examining writing samples)

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Reading and Spelling

• Reading Assessment
• Word Recognition Skills
• Word Identification (sight reading)
• Word Decoding (decode nonsense words)
• Woodcock Reading Mastery Tests-Revised
  (Woodcock, 1987)

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Reading and Spelling

• Reading Assessment
• Text level reading
• Accuracy (words read correctly), rate, fluency
• Reading Comprehension
• Gray Oral Reading Test-4 (Weiderholt Bryant,
  2001)
• Gray Silent Reading Test Weiderholt Blalock,
  2000)

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Reading and Spelling

• Reading Assessment
• Reading Miscues
• Insertions, Omissions, Substitutions
• Self corrections and Repetition
• Analyze for syntactic acceptability, semantic
  acceptability, graphic similarity, sound
  similarity, self-correction
• Reading Miscue Inventory (Goodman, Watson
  Burke, 1987)

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Reading and Spelling

• Spelling Assessment
• Test of Written Spelling (Larsen, et. al., 1999)
• Spell Performance Evaluation for Language and
  Literacy (SPELL) (Masterson, et. al., 2002)
• Identifies underlying linguistic deficits in
  phonemic awareness, orthographic knowledge,
  vocabulary, morphologic knowledge and mental
  orthographic images

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Selective Auditory Attention Tests

• Background
• Individuals with processing issues are at great
  risk for difficulty hearing in background noise
  (surrounding non-linguistic noise, group
  settings)
• Speech-in-Noise test speech embedded in shower
  noise
• Competing Sentences Test listen to/recall
  sentences in one ear and ignore sentences in
  other ear (binaural separation)

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Divided Auditory Attention Tests

• Background Individuals may break down when
  required to share attention among different
  stimuli/multi-task (e.g., note-taking)
• The following are organized by level of
  difficulty
• Dichotic Digits Test recall paired digits from
  both ears
• Competing Word/Spondee tests recall both
  competing words
• Competing Sentences Test recall both competing
  Sentences

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Temporal Resolution

• Background
• Individuals with phonological awareness
  difficulty may have an underlying difficulty of
  temporal resolution (though at older ages, this
  may have become normal but still residual
  phonological awareness difficulties.
• Random Gap Detection Test one or two tones
  (separated by varying degrees of minimal gap
  between two tones) and indicate if heard one or
  two tones.
• Gap-in-Noise Test Determination of the smallest
  gap threshold within embedded noise that an
  individual can detect at least 66.7 of the time.

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Management Techniques

• Does knowing the results of CAP testing inform
  our practice?
• Is there a relationship between CAP and language
  testing and a childs functioning at school or
  home?
• Does therapy with children with CAPD differ from
  children with language impairment?

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General Management Language Processing

• Gillam, et. al., (2002, p. 43)
• good language intervention is
• also good information processing intervention.

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General Management Techniques Listening
Comprehension

• Determine purpose of listening
• Focus attention on topic
• Orient to features of the text
• Assess background knowledge
• Use graphic organizers
• Use text with simpler language at first
• Use questions/key words
• www. nclrc.org

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Listening Comprehension

• Make predictions
• Make inferences
• Keep writing to a minimum while listening
• Use visuals
• Teach child to monitor comprehension
• Teach child to ask for help
• www. nclrc.org

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Specific Management Techniques

• Listening in Noise
• Type of noise
• White noise, instrumental music, music with
  words, cafeteria noise, competing speakers,
  monologue (Tillery Cinotti, 2008)
• Processing Power (Ferre, 1997)
• Increase loudness in increments
• Vary the complexity of the listening task

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Phonemic Awareness

• Purpose is to facilitate reading and spelling
• May improve working memory/lexical decoding speed
• Teach segmenting and blending
• Teach in conjunction with letters
• Focus should be at the phoneme level

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Phonemic Awareness

• Treatment Options
• Computer programs
• Fast ForWord Step ForWord
• Earobics
• LocuTour Multimedia Literacy
• (Gillam, 2008 Medwetsky in Geffner Swain,
  2008)

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Phonemic Awareness

• Treatment Options
• Structured Programs
• Road to the Code
• The Phonological Awareness Kit-Primary
• Lindamood Phoneme Sequencing Program
• Informal activities

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Phonemic Awareness

• Transfer phonemic awareness to reading and
  spelling
• Work on word decoding skills
• Closed Syllables
• Single syllables (increasing from 3 to 6 sounds),
  Multisyllabic
• Vowel-Consonant-e Syllables
• Open Syllables
• Wilson Reading
  System (Wilson, 1988)

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Phonemic Awareness

• Transfer phonemic awareness to reading and
  spelling
• Word Sorts by different patterns (e.g.,
  short vowels, blends, etc.)
• Word Families (onset rime)
• Read words in sentences and paragraphs

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Lexical Decoding

• Semantic knowledge
• Semantic mapping
• Depth of word knowledge
• Antonym/synonyms multiple meaning words, word
  definitions
• Strategies for learning unknown words
• Context cues, identify word roots

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Lexical Decoding

• Teach child to use context cues Use series of
  cloze sentences
• Provide series of cues that progressively provide
  more information
• Example
• I went to Disney World and rode_______.
• I went to Disney World and rode_______. It went
  very fast.
• I went to Disney World and rode sp____. It went
  very fast
• I went to Disney World and rode spa____. It went
  very fast.
• (technique adapted from Gillam Gorman
  (2004)

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Lexical Decoding

• Syntax knowledge
• Identifying parts of speech
• Paraphrasing concepts
• Formulating sentences with key words
• Sentence combination tasks
• 
  Scott, 1995

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Lexical Decoding

• Word Retrieval (German, 2005)
• Retrieval strategies
• Phonetic cues, semantic cues
• Self Advocacy
• Accommodations
• Extended time, multiple choice exams, cue cards
  with key words and prompts

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Working Memory

• Phonemic awareness activities
• Improve language knowledge
• Active Listening promote attention
• Strategies for older children

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Working Memory

• Memory strategies (rote)
• Rehearsal chunking
• Mnemonics
• Visualizing
• Memory strategies (sentence/discourse level)
• Paraphrasing and organizing information
• Cues such as key questions or words, summaries or
  pictures
• Visualizing
• Montgomery, 2002 Gillam Hoffman, 2004

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Sequencing/Organization

• Narrative language
• Sequence events temporally and in cause-effect
  relationships
• Organize events into story grammar
• Story maps and flow charts
• Scaffolding using key questions

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Sequencing/Organization

• Narrative language
• Story maps, story frames, story grammar cues and
  story prompts (see Roth, 2000)
• Use oral and written narratives
• For older children recognize text structure when
  reading to enhance reading comprehension

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Integration

• Prosody
• Modify prosodic aspects of input to children
• Higher pitch level with exaggerated
  variability in pitch
• Increased loudness
• Slower rate
• Gerken
  McGregor (1998)

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Integration

• Prosody
• Determine meanings of words based on syllable
  stress
• Become aware of pauses corresponding to clausal
  boundaries
• Probably one of the most important areas in
  processing needing research

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Integration

• Figurative Language
• Strategy based intervention
• Teach figurative expressions within a context
• Contrast literal to non-literal meaning
• Explicit teaching of contextual cues
• Role-playing scenarios in which the expressions
  can be used
• (Abrahamsen Smith,
  2000 Power et al., 2001
• Norbury, 2005
  Paul, 2007 Nippold, 1991)

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Integration

• Figurative Language
• Use forms in a variety of spoken and written
  stories
• Teach the communicative function of expressions
• Keep notebook or journal and record expressions
  heard include contextual information
• 
  
• (Abrahamsen Smith, 2000 Power et
  al., 2001
• Norbury, 2005
  Paul, 2007 Nippold, 1991)

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Integration

• Conversation
• Topic initiation and maintenance
• Appropriate change of topic
• Clarification requests
• Clear referents
• Teach one aspect of conversation at a time
• Teach rules of conversation
• Use conversational/social scripts
• Pay attention to prosodic cues, facial
  expressions and body language

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Self-Advocacy

• Comprehension Monitoring
• Understanding learning styles strengths and
  weaknesses
• Strategies for getting help
• Ask for what you need, tell someone you are
  having trouble

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Environmental Modifications/ Compensatory
Strategies

• Modification of Listening Environment
• The goal is to reduce noise levels and
  reverberation (echoing). Examples include
  carpeting, acoustically treated tiles, drapes,
  balls/sliders on chairs, etc.
• Overhead Projectors/Power Point Presentations
• These allow for speech-reading, increased talker
  loudness (projecting forward allows for increased
  talker intensity), while still providing for a
  visual reference to information at hand. Both of
  these techniques are better than the blackboard.
  For middle and high school, power point
  presentations allow for accompanying handouts
  (3 slides/page with adjacent lines to take
  notes), while overhead projector allows for
  ad-libbing.

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• Provision of Instructions
• Instructions should be provided when there is
  little commotion (such as students preparing to
  leave for recess/lunch or when going home). If
  assignments are on the blackboard, the teacher
  should allow the students to write instructions
  down before elaborating on the assignments. For
  those with severe organizational skills, teacher
  check of agenda or provision of written homework
  assignments.
• Use of Earplugs
• The use of earplugs in test taking or quiet study
  times may allow the student to better focus on
  the material at hand without using mental
  resources to block out external stimuli.

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• Test-Taking in a Separate Room
• This can minimize the amount of noise and less of
  a psychological need to rush in order to finish
  at same time as other students.
• Preferential Seating
• Sitting in the front rows (if traditional
  seating, 2nd row to allow for better viewing of
  students on side/behind when they talk) is often
  recommended to increase the perceived intensity
  of the teachers voice (thus, making it easier to
  process information). This is a good technique
  if the teacher never strays too far from her
  desk.
• In reality, preferential seating does not exist
  too often in real life. Thus, 7 is often
  recommended.

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• Enhancement of the Desired Speech Signal
  
• Examples include use of assistive listening
  systems such as PA systems, FM sound-field
  personal systems (that resemble hearing aids) and
  the most complex technique of all, that is,
  moving closer to the listener.
• The key aspect of assistive listening systems is
  that they mimic being close to the listener
  (i.e., decreases the distance between the
  talker/listener) in turn, this maintains the
  intensity of the talkers voice, thus, keeping it
  sufficiently louder than the background noise.

74

• General Compensatory Strategies
• The following strategies are of benefit to
  individuals with processing difficulties, hearing
  loss, or, even second language learners, though
  the mechanisms by which they assist the
  individual differ.
• Modification of Talker Delivery Style
  
• Depending on the listeners difficulty, this may
  include using clear speech newscasters speech
  style, insertion of pauses, extra
  inflection/stress, sentences of less grammatical
  complexity, etc. This makes it easier for the
  listener to keep up.

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• Modification of Speaker Delivery Style- contd
• A conceptual formula that can guide speakers
  presenters is
• The more complex the material, the more
  important it is to slow down the overall rate in
  which material is presented- not by exaggerating
  speech patterns but by articulating words
  clearly, emphasizing prosodic stress patterns
  within speech, inserting pauses between clauses
  and concepts to provide additional processing
  time, and the use of visuals.

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• Familiarizing the Listener to Information
  Beforehand The more familiarity the listener
  has with the topic/content, the less they have to
  rely on the acoustic signal, and, the more they
  can use their linguistic/world knowledge to help
  process the incoming information. For students,
  this can be done by informing students/parents of
  the content, vocabulary, concepts prior to being
  covered in class (pre-viewing technique).
• Extended Time for Task
  If the
  individual needs additional processing time, they
  would likely benefit from extended time.
  Self-esteem issues may need to be
  considered/addressed.

77

• Presenting Directions/Instructions
• The talker can state one direction at a time and
  have the individual first repeat/internally
  visualize each direction and then summarize these
  directions at the end (unless too young or
  significant integration difficulty, may not be
  able to internally visualize- check if student
  can do it). This will ensure that the child has
  retained all key information in addition, this
  serves as a training technique.
• For older students/adults, may just insert longer
  pauses between directions and then have them
  summarize at the end to ensure what
  processed/retained. An alternative is to
  highlight the sequence of steps on a
  blackboard/paper.

78

• Clarification of Information Presented
  For important
  directions, content, etc., the talker can check
  with the listener to determine if the information
  has been perceived correctly. For example
• The talker can ask the listener to repeat
  instructions/ directions in their own words to
  ensure that the listener has indeed processed and
  recalled all of the information provided. If
  not, then the talker can fill-in the
  missed/forgotten information.
• Divided Attention Difficulties
• If divided attention difficulties are present,
  older individuals will benefit from outlines,
  handouts, guided notes (such as power point
  slides, three slides/page with adjacent lines for
  adding notes), and, if necessary, a designated
  note-taker.

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• Phonics Difficulty
• If student has significant spelling difficulties
  present, on tests where content crucial element
  (rather than spelling) then spelling variance be
  applied. If spelling deemed crucial, then
  notebook computer with spell checker be provided
  (depends on keyboarding skills), or, availability
  of word bank.
• Assistive technology to minimize writing
  requirements (auto-capitalization, word
  predictions, punctualization) to reduce overall
  mental load as well as reduce spelling errors is
  another alternative.

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• Writing Difficulties
• For older students, after having completed a
  written assignment, they should either read out
  loud to themselves what they have written or
  have someone else read to them (while they
  follow along).
• This may allow the student to pick up on and
  correct any organizational issues, spelling
  errors, and any punctualization errors.
• Individuals may also benefit from writing
  software that increases organization skills, such
  as Draft Builder and Kidspiration.

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• Altering Class Schedule
• If possible, difficult subject matter is covered
  in the morning when the student is less
  likely to be fatigued. If the child is in
  middle/high school, avoid having two
  difficult subjects back-to-back.
• If the students attention seems to be drifting
  and appears to be becoming overloaded,
  listening breaks should be provided.
• For adults, the goal would be to arrange meetings
  in the morning or have handouts made available.