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How do
speech-language pathologists (SLPs) develop unique treatment plans for individual
children with speech and language delays and disorders? How do they plan the very first treatment after assessing a child, and
how do they know what to do from treatment to treatment? Here is a brief outline of
one way these tasks can be tackled.
Assessment
All speech-language pathology intervention is based upon
individual, ongoing assessment of a client's communication skills. The therapist first
"screens" all areas of communicative function, and then does an
in-depth assessment of particular areas that may be problematic. The assessment
may include clinical observations and standardised and non-standardised tests.
The areas assessed in-depth depend upon what the
screening procedures suggest that the "presenting problem" is. If the
client's language development appears to be delayed, then the assessment
will focus on language areas. If
language
development is progressing well, but
fluency
is an issue, then the therapist will evaluate fluency. Other clients
will require
voice
assessment, swallowing assessment,
phonological assessment, assessment of
semantic and pragmatic skills, and
so on. Some clients require detailed SLP assessments across several areas. For example, a
child might have difficulties with speech AND language AND fluency.
The assessment information the SLP gathers is often viewed in conjunction with
the results of investigations carried out by other professionals
(psychologists, medical practitioners, audiologists, etc) and always in
relation to "the history" provided by caregivers and others.
The particular assessment (and therapy) approaches and
procedures used by the clinician will depend on the way the individual client
"presents" and the individual clinician's theory of development,
theory of disorders and theory of intervention (Fey,
1992).
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Levels of
linguistic analysis
For the purposes of description, there are
at least four
levels of
linguistic analysis. It must be remembered that in practice language function is
multi-layered, and it is actually impossible to tease out just one of these
levels. Children's speech and language delays and disorders can be assessed, and treatment planned around, these four levels of
linguistic analysis. The levels are:
1. the phonetic and phonological level
2. the morphological
(grammatical) level
3. the syntactic level, which is closely
interwoven with the
semantic (word)
level
4. the
semantic-pragmatic
(language use) level
Language
processing (comprehension)
In terms of language
processing:
- The phonological
level is to do with how a child understands,
stores and
manipulates speech sounds.
- The morphological
level is to do with understanding and manipulating the
grammar of the language the child is learning.
- The syntactic
level relates to the way children comprehend or
understand word-order and
sentence-types (for example, "The bus is on the table" vs "Is the bus on the
table?").
- The
semantic-pragmatic levels
are to do with understanding gestures, body language, tone of voice and words in social contexts.
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Language production
(expression)
In terms of
language production:
- The phonological level is to do with the way speech sounds are organised and
pronounced (e.g., does a 4 year old have
phonological processes that are characteristic of younger children?).
- The
morphological
level is to do with the way the grammatical rules of the language
are observed (e.g., does the child say "She is going out" or "Her
go out"?).
- The syntactic
level relates to the way children order words when
they construct sentences (e.g., "What you are making?" vs "What
are you making?").
- The semantic-pragmatic (production) levels
are to do with using appropriate words, gestures, body language,
"distance" from a communicative partner, loudness, eye-contact, and so
on, in real communicative contexts. It is about knowing what to say, how to
say it, when to say it, and to whom.
Intervention approaches
With the information derived from carefully chosen assessment procedures, a speech-language
pathologist is helped to formulate an individual diagnosis, and has baseline measures against which to plot progress in therapy.
Examples of treatment goals
Armed with these
baseline measures the SLP is in a position to set three levels of
treatment goal: basic, intermediate and specific (Fey,
1992). As therapy proceeds, ongoing monitoring of progress takes place, and the child's
program is "fine tuned" to their needs.
BASIC GOAL
A basic goal is just
that - basic, and usually obvious to everyone involved in assisting the
child. A typical basic goal for a child with auditory processing
difficulties might be "To facilitate an improvement in ___'s auditory
processing abilities". A basic goal for a child with a
developmental phonological disorder might be "To improve ____'s speech
intelligibility".
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INTERMEDIATE GOALS
At the
intermediate goal level the SLP turns to his or her theories of development,
disorders and intervention, and formulates goals that will target GROUPS of skills under the
headings of: (1) phonology
(2) morphology
(3) syntax
(4) semantics (5) pragmatics (6) discourse, and so forth. For example, in the
targeting semantic - pragmatic skills, a task might revolve around
appreciating the way words are said, and the appropriate contexts in
which to use them.
SPECIFIC GOALS
The
specific goals refer to what is actually attempted (and accomplished) in the
therapy program. Specific goals target specific language "behaviours"
or structures using
vertical strategies (working on a goal until criterion is reached and then treating a new goal);
or horizontal strategies, targeting several phonological, grammatical, syntactic or semantic-pragmatic structures simultaneously. So
parent and therapist might work
on understanding (and then USING in context) "or", or "some of the",
or "all except", or following one-stage commands with an increasing number of
noun-modifiers (e.g., show me the ball; show me the red ball; show me the big red ball; show me the big red ball in the box).
For example, in developing SPECIFIC GOALS for a child with auditory processing difficulties the therapist (and that can mean SLP or parent or teacher) may be involved to a small extent in teaching the
child "to know" concepts such as 'next', 'if', etc. But that is not usually
the main focus of activities, as these ideas can usually be taught fairly easily. The crucial aspect is in devising activities that demonstrate to the
child how to USE and MANIPULATE the information, with the overall intent of having these abilities GENERALISE to real-life situations.
Therapy procedures
The procedures used in therapy
are ALWAYS individual for each child. There are just no "cook book" or
off the rack remedies for children's speech and language delays and disorders.
Procedures used in working on semantic and pragmatic difficulties might
include: distinguishing sarcastic voice vs.
sincere voice; mean voice vs. kind voice; recognising the voice / language / body-language
/ facial expression / "closeness" / language you use to talk to a baby vs. the way you
talk to a teacher. In working on morphology (grammar) a child might have to: (a)
detect the presence or absence of plurals: Show me the bat / Show me the bats; Show me the
mouse / Show
me the mice, or (b) respond appropriately to contrasting verb tenses: Point
to: They are walking vs. Point to: He is walking.
Therapy / Intervention
activities
This is where the fun starts! All the ASSESSMENT INFORMATION and the decisions
made with regard to GOAL SETTING and the INTERVENTION PROCEDURES to
use are converted into INTERVENTION ACTIVITIES which may encompass a wide range
of games, stories, rhymes, drills and tasks.
Materials
Materials for implementing the
intervention activities are
often "home made" by clinicians, adapted or based on ordinary games
and toys (that is, ones not originally intended for
"therapy" purposes), centred around a particular child's own toys and
games, and so on.
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