Think Developmentally Speech–language pathologists must choose from a plethora of goals and approaches when treating speech and language disorders in children with disabilities. For example, children with Down syndrome usually have multiple disruptions in communication development. Many have concomitant difficulty with speech intelligibility, receptive and expressive vocabulary, receptive and expressive grammar, and ... From My Perspective
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From My Perspective  |   April 01, 2012
Think Developmentally
Author Notes
  • Stephen Camarata, PhD, CCC-SLP, is a professor of hearing and speech sciences at the Bill Wilkerson Center at the Vanderbilt University School of Medicine. He is an affiliate of Special Interest Group 1, Language Learning and Education. Contact him at stephen.m.camarata@vanderbilt.edu.
    Stephen Camarata, PhD, CCC-SLP, is a professor of hearing and speech sciences at the Bill Wilkerson Center at the Vanderbilt University School of Medicine. He is an affiliate of Special Interest Group 1, Language Learning and Education. Contact him at stephen.m.camarata@vanderbilt.edu.×
Article Information
Development / Speech, Voice & Prosodic Disorders / Special Populations / Genetic & Congenital Disorders / Autism Spectrum / Language Disorders / Attention, Memory & Executive Functions / From My Perspective
From My Perspective   |   April 01, 2012
Think Developmentally
The ASHA Leader, April 2012, Vol. 17, 36-37. doi:10.1044/leader.FMP.17052012.36
The ASHA Leader, April 2012, Vol. 17, 36-37. doi:10.1044/leader.FMP.17052012.36
Speech–language pathologists must choose from a plethora of goals and approaches when treating speech and language disorders in children with disabilities.
For example, children with Down syndrome usually have multiple disruptions in communication development. Many have concomitant difficulty with speech intelligibility, receptive and expressive vocabulary, receptive and expressive grammar, and language-related reading skills, as well as some difficulty with social development. Intervention choices include—just to name a few—sign language, nonspeech oral-motor activities such as blowing whistles, sensory activities such as wearing a weighted vest, articulation drills, vocabulary training, and syntax training.
Our time with individual children is limited, so we have to make choices about what communication skills are targeted, how the skills are taught and, perhaps most important, whether there is a developmental window in which teaching the skills will be most effective.
Should intervention be focused on oral-motor exercises designed to strengthen the muscles associated with articulation in the hopes of improving speech intelligibility? Or is the child’s valuable learning time better used in learning grammar? If receptive language is a primary focus, will there be a crossover into expressive vocabulary so that intervention time can yield an expressive and receptive “two-for-the-price-of-one?” Is it important to teach prerequisite skills such as speech discrimination for the child to comprehend words and phrases? Or can the clinician target speech and language skills more directly?
These and other clinical questions can be addressed from a developmental perspective—that is, incorporating what is known about typical speech and language development when making decisions about what to teach and how to teach it to children with disabilities.
It is always important to bear in mind how typical children learn language: Typically developing children learn speech and language within the milieu of everyday interactions between the child and caregivers, teachers, siblings, and peers. A number of studies have shown that these interactions occur in hundreds of thousands, or even millions, of social transactions between the child and others in the child’s environment, from birth through the preschool years. Therefore, the important starting point in strategic decision-making for facilitating speech and language development in children with disabilities is to determine the barriers for accessing the information potentially available to the child within these transactions.
For example, a study by Koegel and her colleagues indicated that teaching children with autism spectrum disorders (ASDs) to ask the question “What’s that?” was associated with significant growth in expressive vocabulary (Koegel, Camarata, & Valdez-Menchaca, 1998). It is noteworthy that the children learned new vocabulary words by eliciting information from an adult in the context of a social transaction—there was no direct instruction or confrontation naming provided to teach the words. From a developmental perspective, this method parallels how typically developing children learn new vocabulary: They ask questions such as, “What’s that?” and parents, teachers, and peers incidentally provide responses that facilitate vocabulary acquisition. Koegel and her colleagues argued that teaching children with ASDs to ask questions of this nature would leverage clinic time so that the children would incidentally access learning opportunities outside of the clinical situation in a developmentally appropriate fashion.
Similarly, if a child displays a receptive language deficit, as often happens in ASDs, Down syndrome, and language disorders, it may be worthwhile to target comprehension while also teaching parents to use vocabulary and grammar appropriate for the child’s developmental receptive language levels. Receptive language ability appears to be an important predictor of language and academic outcomes—a further reason to make these skills a high priority.
The “When” Question
In addition to thinking developmentally about what should be taught, clinicians should also consider when it is appropriate to teach a particular goal using a particular approach. For example, because typically developing children first use words at an average age of 12 months, it is unrealistic for a clinician to attempt to make a 6-month-old with disabilities speak words. Similarly, it is important that clinicians keep reasonable developmental expectations in mind when planning treatment.
For example, is it usual for typically developing 2-year-olds to sit for 30 minutes or more in a chair and imitate nonspeech motor gestures or generate multiple productions of phonemes such as /s/, /g/, or /r/ in isolation? If not, is it reasonable to treat speech disorders in 2-year-old children with disabilities using this approach? Can typically developing 3-year-olds complete speech discrimination drills?
Speech perception studies suggest that typically developing children have not yet developed an adult perceptual map and often fail to discriminate many phonemically contrastive pairs that are later mastered. Does it make sense to expect children with disabilities to learn perceptual skills their typically developing peers do not posses? If adult levels of speech perception are a prerequisite for speech and language learning, then how do typically developing children who do not possess adult competence ultimately develop speech and language skills without this training? As intervention services have become increasingly available to younger and younger children, we can lose sight of the fact that what may be an appropriate developmental approach in a 6-year-old with disabilities may not be appropriate in any preschooler, whether typically developing or not.
Beware the Quick Fix
Another important developmental consideration is how typical children do not learn speech and language. This aspect of intervention is key because in this age of clinical “magic bullets” marketed to parents and clinicians, we may forget that typical children by the millions learn to speak without the benefit of the these largely untested “treatments.”
For example, typically developing preschoolers do not receive rhythmic training via a metronome, a method increasingly used with children with disabilities to regulate movement, develop attention modulation, or learn to talk. Indeed, toddlers are clearly immature with regard to speech and language ability, motor skills, and attentional regulation, yet they develop these skills without the benefit of metronome training. The question then becomes whether children with disabilities will directly or indirectly benefit from this kind of treatment and whether it will induce improvements in speech and language abilities.
More important from a clinical speech and language perspective is whether a child’s valuable learning time is better spent acquiring communication skills, such as increased expressive and receptive vocabulary, or whether a rhythmic metronome approach is somehow a precursor or direct causal agent in speech and language development and therefore worth incorporating. Because children with disabilities are often able to learn from the hundreds of thousands of social transactions in the ambient environment, it is not surprising that nearly all will show some degree of “spontaneous” or untreated growth. Therefore, testimonials of speech and language growth after exposure to a rhythmic metronome or any other intervention is not credible evidence of treatment efficacy. Rather, what’s required is evidence that the intervention produces significant gains over what is expected with spontaneous recovery.
The Developmental Lens
Dozens of credible studies indicate that targeting speech, vocabulary, and grammar directly during speech and language intervention is associated with significant gains in diverse groups of children with disabilities, including ASDs, Down syndrome, and language impairment (Camarata, Yoder, & Camarata, 2006; Koegel & Koegel, 2006; Leonard, 2000). Stated simply, the evidence suggests these children will learn in the context of developmentally appropriate intervention. In contrast, there is no credible evidence that developmentally anomalous approaches, such as rhythmic metronome training, nonspeech oral motor exercises, auditory integration therapy, wearing weighted vests, or similar activities are needed or useful in improving speech and language skills in children with disabilities.
Another important aspect of thinking developmentally is to consider long-term consequences and utility of the skill being taught. If the clinician has a choice between improving a distorted /r/ or improving social interaction in a child with an ASD, what should be the higher priority? Are there language goals such as complex sentence use that may have direct implications for associated academic skills, such as reading comprehension? From a developmental perspective, clinicians should always be asking whether the goals they are teaching are the most important for that child at that point in the child’s development.
Although specific clinical trials have not been completed for all speech and language skills across developmental levels and disabilities, there is a large body of evidence that supports employing a developmental framework when treating speech and language disorders in children with disabilities. Because of this evidence, one could argue that the burden of proof lies on those marketing or implementing training that is not aligned with developmental principles or not directly focused on speech and language skills. That is, there should be a strong, credible theoretical rationale and systematic evidence-based support beyond testimonials if one deviates from a developmental framework when treating speech and language disorders in children with disabilities.
Sources
Camarata, S., Yoder, P., & Camarata, M. (2006). Simultaneous treatment of grammatical and speech-comprehensibility deficits in children with Down syndrome. Down Syndrome Research and Practice, 11, 9 – 17. [Article]
Camarata, S., Yoder, P., & Camarata, M. (2006). Simultaneous treatment of grammatical and speech-comprehensibility deficits in children with Down syndrome. Down Syndrome Research and Practice, 11, 9 – 17. [Article] ×
Koegel, L., Camarata, S., & Valdez-Menchaca, M. (1998). Setting generalization of question-asking by children with autism. American Journal of Mental Retardation, 102, 346 – 357. [PubMed]
Koegel, L., Camarata, S., & Valdez-Menchaca, M. (1998). Setting generalization of question-asking by children with autism. American Journal of Mental Retardation, 102, 346 – 357. [PubMed]×
Koegel, R., & Koegel, L. (2006). Pivotal response treatment for autism: Communication, social, and academic development. Baltimore: Brookes Publishing Company.
Koegel, R., & Koegel, L. (2006). Pivotal response treatment for autism: Communication, social, and academic development. Baltimore: Brookes Publishing Company.×
Leonard, L. (2000). Children with specific language impairment. Cambridge, MA: MIT Press.
Leonard, L. (2000). Children with specific language impairment. Cambridge, MA: MIT Press.×
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April 2012
Volume 17, Issue 5