Sunday, January 14, 2018

From Research to Practice: Narrative Studies

As a follow-up to my post last week about narrative skills and abilities in research, I am writing this time about the next article in the Topics in Language Disorders Vol. 28, No. 2; Narrative Abilities: Advances in Research and Implications for Clinical Practice, by D. Boudreau.
Dr. Boudreau notes the importance of narrative skills in academic success and the difficulties of students with language disorders with connected discourse, particularly as they enter the higher grades.
Narrative discourse is defined as, “at least two utterances produced in a temporal order about an event or experience (Hughes, et al, 1997).  Students with language disorders tend to miss the ability to integrate background knowledge with pragmatics - or social language - to formulate an organized recounting.  Boudreau posits that this difficulty in narrative discourse is greater than in conversation.

The author goes on to cite studies showing that 

  • students whose narrative skills are greater than their syntax skills performed better than those who had age appropriate syntactic skills but poorer narrative abilities or tasks for story comprehension and re-telling,
  • the single best predictor of students’ future need for remediation or special education or retention was their earlier performance on tasks of narrative abilities,
  • that narrative abilities in Kindergarten predict students’ vocabulary and reading comprehension skills in 7th grade  
  • that there is a correlation between students’ narrative skills using wordless picture books and their Math skills in school,
  • and more evidence for the role of narrative discourse skills.
So, while we know from the research that narrative difficulties in early years - particularly difficulties with vocabulary flexibility, syntax, and story elements - correlated with academic success, what does this mean for our clinical practice?
Unfortunately, there are studies that contradict the findings of correlation, but for those SLPs who are providing services for these students with impaired narrative skills, we need answers as to what to do.  The bottom line, says Boudreau, is that discourse abilities are crucial in academic success, and, in order to make students with this profile successful, we need to provide remediation in both comprehension and production of narratives.

One factor that is shown to have influence on students’ skills in narrative discourse is early interactions around books and experiences.  The interactions with parents or other adults that provide scaffolding of story telling / experience retelling, that co-construct narratives with children and gradually decrease that support, are critical.  By providing opportunities to interact with partners who provide quality exchanges students develop the narrative skills that they need.
Improved literacy and language skills have been correlated with shared reading.  However, not all shared reading is equally helpful.  Again, the quality of interactions is important particularly interactions that preview the book, predict throughout, providing quality activities before and after the book is read that focus on some aspect of language (retelling, acting out, discussion of elements of the book).
Another factor is the quality of interactions with adults who provide adequate scaffolding and quality exchanges at dinner time. The quality of these interactions is crucial.  It sounds obvious to us SLPs, but parents whose exchanges with their children utilized open-ended questions, contained more complex language and better scaffolding provided better impact that parents whose exchanges were brief, unelaborated, less supported and more brief.
One interesting finding (Spinello & Pinto, 1994; Schneider & Dube, 2005) is that students formed more elaborate narratives when they were not shown picture cues.  Use of picture cues resulted in less elaborate narratives, and those that were more informal rather than what would be expected in a written narrative.
In addition to the elicitation-dependent measures, text-dependent measures were also found to be important.  Students have been found to more reliably remember specific details if the narrative or story presented to them is a more complete episode, than if they hear only fragments of information in less structured contexts.  And if the episode tells about the characters’ goals, motivations, and feelings, students are more likely to remember and retell parts of the story.
In discussing clinical implications of the studies reviewed, Boudreau reminds clinicians to understand the impact of the method they choose to elicit narratives and the types of scaffolding supplied to maximize narrative production.  Clinicians should vary the types of narrative tasks they provide in intervention, so that students can take advantage of the scaffolding of different styles of narratives.  Of particular importance is understanding and use of the causal network that underlies a story.
Also important for clinical practice is parental/caregiver training that strengthens parents’ - especially mothers’ -  strategies used to elicit responses.  Talking about daily experiences, using open-ended questions, describing things, and listening carefully are listed among the parental activities that strengthen children’s narratives.
Boudreau also cites studies that have shown that explicit, structured teaching of story grammar enhances students’ understanding and use of these elements in their narratives.
They key take-aways from this article that reviewed research about narrative abilities and the impact of various intervention types on narrative abilities?
  1. Narrative skills improve when directly targeted in structured intervention
  2. Teaching specific story mapping or story grammar elements is an effective therapy strategy
  3. Providing scaffolding in the narrative production of very young children shows an impact in later academic years.
I encourage all SLPs working with children to remember to include narrative skills in their evaluation processes, and to use more than 1 type of elicitation technique; and to include specific structures of narrative style and story grammar in their therapy plans.

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Susan Berkowitz, M.S.,C.C.C., M.Ed. has been a speech-language pathologist for 40 years. She has worked in a variety of settings, both as a SP and as an administrator. She speaks at local, national, and international conferences, and has published research in peer-reviews professional journals. She is currently the Director of Print Content at 

Boudreau, D. (2008). Narrative Abilities: Advances in Research and Implications for Clinical Practice. TLD (28:2) 99-114

Hughes, D. et al. Guide to Narrative Language: Procedures for Assessment. Eau Claire, WI; Thinking Publications

Schneider, P. & Dube, R.V. (2005) Story presentation effects on children’s retell content; Amer. Journal Speech-Language Pathology, 14, 52-60.

Spinello, A.G., & Pinto, G.  (1994). Children’s narratives under different conditions: A comparative study. British Journal of Developmental Psychology, 12, 177-193.

Sunday, January 7, 2018

Narrative Language Skills: What Do We Know?

Whether I am working with students with language-learning disabilities (LLD) or AAC users with Complex Communication Needs (CNN), I focus a lot of time on building narrative language skills.
In fact, with even my most complex nonspeaking students I want narrative skills to be a goal that we are working towards.

A recent discussion among some SLPs  about narrative skills in assessments sent me looking to the research.  In a  2008 edition of Topics in Language Disorders (vol.28:2. Apr-June 2008) editors Nickola Wolf Nelson, Katherine Butler, and Donna Boudreau quoted Jerome Bruner:

One of the most ubiquitous and powerful discourse forms in human communication is narrative.”  (Bruner 1990).  Narrative is crucial in human interactions, yet often receives the least attention.  Bruner went on to name the 4 areas of grammar critical to narrative production:

  1. A means for emphasizing actions towards obtaining a goal,
  2. A sequential order should be established and maintained; so that events are stated in a linear way
  3. Sensitivity to what forms and patterns of language are acceptable
  4. Containing a narrator’s perspective or ‘voice.’

Narrative has been found (Nelson et al 1989) to capture not only the events of daily interactions, but to encourage interpretation, imagination, and use of self-talk to solve problems.  This particular issue of TLD includes an update from J. Johnston on her seminal work (1982), which signaled a wake-up call to clinicians to consider examining narratives in clinical practice.

Johnston was the first to call attention to the importance of narratives in clinical practice.  She argues for distinct areas of knowledge in order to support narrative skills:
  • knowledge of the content  of narrative
  • knowledge of an appropriate framework in which to build narratives
  • linguistic abilities to form a cohesive text
  • the ability to consider the adequacy of the listener’s comprehension.

This last point is particularly discussed in her update, considering the processing competence of the listener;  how well can he comprehend at the narrative level.

Narrative skills begin to develop in young children and are mediated by parental support.  These early interactions build the foundation upon which children build their narrative and academic skills (Boudreau 2008).  The narrative skills of preschoolers are predictive of academic success in school, as well as social success.  As students with narrative language deficits continue having difficulties in academic and social success, we are reminded of the importance of intervention at the narrative levels.

Johnston’s (2008) update to her original article discusses the value of narrative intervention in school aged children.  While this study is now 10 years behind in current research into narrative development in students, the continuum of crucial skills for SLPs to consider continues along the same path that Johnston took.

Johnston (1982) listed on the 4 areas crucial in narrative development, and reviews and elaborates on it in the 2008 update.
  1. The speaker must know the content of the narrative; both general qualities and specific details
  2. The speaker must have understanding of a narrative framework, in order to turn the facts of the event into a story that includes context and emotion.
  3. The speaker must have understanding of the forms of language, in order to create a cohesive story whose sentences blend together well with appropriate parts of speech.
  4. The speaker must be able to shape the narrative to meet the linguistic needs of the listener; must be able to tailor the content of his narrative to the processing and knowledge levels of his audience.

Johnston goes on to discuss the cognitive difficulties of narrative creation.  Narratives require planning ahead for content and structure, for cohesion, and for adjusting to the partner’s abilities.  This is a huge cognitive load.  In addition, Johnson points our that the listener’s needs may change over time during this narrative, and the speaker must be able to process this information, change his narrative to meet it, and continue with the narrative.

Johnston continues with an interesting notion based on the research results of Gillam and Pearson, (2003).  That while language-competent students were equally in both form and content in their narratives, students with language disorders tended to be stronger in one area than another.  This was seen to indicate that focusing cognitive energy in one area left the other area weak. 

Narratives are important because they allow us to move away from the “here and now,” and to focus less on our personal experiences, while allowing students to talk about what is not immediate, but rather the decontextualized language of the classroom.

There are 3 basic types of narrative scripts: personal experiences, scripts, and fictional stories (Hudson & Shapiro, 1991). Personal narratives are the easiest place to begin in intervention with children.  And they are the most often used types of narrative.

Narrative interventions have been used to improve listening skills; by providing a supportive framework of story elements  for listening.
They have been used to improve reading comprehension. The link between oral language skills and reading success has been verified (Catts, et al, 1999); making it appear that oral language facilitates literacy.  Students who understand and use the general narrative schemes use this knowledge to help the understand and grab meaning from texts.

By focusing on narratives in our language intervention, we can explore processing limitations, create opportunities for using decontextualized language, facilitate social relationships, provide practice in constructive listening, improve reading comprehension, and identify language learning strengths and weaknesses.” (Johnston 2008)

By focusing on use of core words and important fringe, and by moving from single symbols to sequences of symbols for generating novel utterances, we need to keep our AAC users moving on the "oral" - literate continuum.  This means teaching AAC users to construct messages and sequence ideas in order to engage in meaningful conversations.

→The editor's of Topics in Language Disorders are offering a tremendous savings to my readers. Use this code:  WHE005GN
for a 35% savings (that's about $45.) Here is the link.
I am not an affiliate, nor do I profit in any way from this deal. It's just for you!

Susan Berkowitz, M.S.,C.C.C., M.Ed. has been a speech-language pathologist for 40 years. She has worked in a variety of settings, both as a SP and as an administrator. She speaks at local, national, and international conferences, and has published research in peer-reviews professional journals. She is currently the Director of Print Content at 

Boudreau, D. (2008) Forword. Topics in Language Disorders, 28 (2), 91-92

Catts,H et al (1999). Language basis of reading and reading disabilities: Evidence from a longitudinal investigation. Scientific Studies of Reading, 3(4), 331-361.

Gillam, R, & Pearson, N. (2003)The Test of Narrative Language. Austin, Tx: Pro-Ed.

Johnston, J. (1982). Narratives: A new look at communication problems in older language-disordered children. Language, Speech, and Hearing Services in the Schools, 13, 144-155.

Johnston, J. (2008). Narratives: Twenty-five years later. Topics in Language Disorders, 28 (2), 93-98

Sunday, December 31, 2017

3 Little Words That Mean a Lot

I find a lot of professionals and parents alike who don’t really understand what AAC means.
So, first, to break it down, let’s look:

A= Alternative
A = Augmentative
C = Communication 

Alternative is typically what we’re talking about in AAC.  These students need an alternative to speech because they are completely non-speaking, or because they have so few words that they cannot meet their communication needs at all.

Augmentative is the one part people tend to forget.  To augment is to add to.  And that’s what we do with AAC for individuals who have some speech, but not enough to meet all of their communication needs. It’s also what we do for individuals who have speech, but their speech is unintelligible so much of the time that  they need a functional repair strategy, so that they can fix the breakdowns in communication when others don’t understand them.

One of the biggest groups I see with this difficulty is those individuals with cerebral palsy whose speech is so dysarthric that it is unclear to most of their listeners much of the time.
Another group I see with this need is children with apraxia of speech who may have some speech, but it does not function for their all of their needs.

AAC as a repair strategy is a novel idea for some, and is a “hard sell” sometimes.  We speech-language pathologists take the ‘speech’ part very seriously. But when we’re not meeting the needs of our students, we need to step back and remember that our goal, really, is communication; that last pesky letter in AAC.

AAC as a way to augment what speech the user has is often delayed while teams work on speech to the point where students themselves are frustrated with their inability to communicate.

One of the most persistent myths about AAC is that it shouldn’t be used for students who have some speech.  That it will delay their speech further or become a “crutch.”
However, research now tells us that far from delaying speech, AAC used consistently can actually help students develop their speech skills more.
And, far from being a crutch, it is a tool that helps students develop their language and communication skills.

So, what, exactly, is communication?   According to the National Joint Committee for the Communication Needs of Persons with Severe Disability, it is:

  • “any act by which one person gives to or receives from another person information about that person’s needs, desires, perceptions, knowledge or affective states.  Communication may be intentional or unintentional, may involve conventional or unconventional signals, may take linguistic or nonlinguistic forms, and may occur through spoken or other modes”

This definition puts the focus on the extent to which there is shared meaning between the communicator and his partners - NOT on whether the interaction is spoken.
AAC refers to all modes that make communication easier; and can include gestures, facial expressions, alphabet or pictures, computers, and signs.
So, before you say, "He's note ready for AAC,” remember - even babies communicate. No one is too impaired to learn some communication skills.
I’m pretty sure that if you look at your students who “aren’t communicating,” that you will find that they truly are.

Ascribe meaning to what they do do, and……… keep on modeling.

Sunday, December 24, 2017

What 3 Kinds of Books Should You be Reading?

This is my last gift-giving post, and today I want to talk abut books.  I have always been a big fan of giving books to children as gifts.  They may not be quite as welcome as the latest video game or electronic toy, but I love instilling a love of reading - or being read to. 

The fact is that while we provide lots and lots of opportunities to interact with books to neurotypical students, we’re slower to provide those to students with complex communication needs.

We recognize 3 types of text; enrichment, transitional, and conventional.
Enrichment texts are books you read to students that are rich is both text and graphics. They develop background knowledge; which  can be crucial for these students who do not get the same richness of experiences as neurotypical students.  These books support learning concepts and are full of rich vocabulary and variety of sentence types.

These books should be used at home to build rich experiences and at school to build vocabulary and language form.  These readings should be interactive and the students should be engaged in learning about book structure, story structure, and specific contexts or topics.

We build language skills when we provide mediation and scaffolding during reading, and when we provide structured Before-During- and After language activities.

A Before activity activates background knowledge, preteaches concepts, and learn both how to use words and how to find them in the AAC system.

A During activity involves the same type of activity - with the same specific language target - while reading the book.  A purpose for reading should be set; i.e. let’s listen for the different types of animals the children see, or listen for the words the author uses to describe the place where the story takes place.

An After activity is the follow-up activity the students have now been primed for, where they practice the language skill being targeted.

It is crucial to build into this practice the ability to retell the story.  We can prime students for this by starting with simple sequences from routines - the steps of a daily living task, the order of events in a day.  Use visual cues to show first - next - last, or a numbered sequence, or symbols for story elements.

By providing students with practice opportunities to build retelling skills they gain confidence in telling stories to their friends, parents, dolls, stuffed animals, and pets.  This is the kind of opportunity that our students with CCN don’t normally get.  They don’t get practice with vocabulary and syntax, with sequencing events and describing.

If we can give them symbol supports for telling stories, we can increase their engagement in story reading and increase their opportunities to practice language skills.

Have a fun and safe holiday season and Winter break from school.  And remember, keep on talking …. and reading!

Musselwhite,C.R., Erickson,K., Zoilkowski,R. (2002 ). The Beginning Literacy Framework. Don Johnston Inc.

Smith, M. (2009). Vocabulary Instruction and Aided Communication. AAC by the Bay Conference. San Francisco

Kent-Walsh,J. & Binger,C. (2009) Addressing the communication demands of the classroom for beginning communicators and early language users. Practically Speaking: Language, Literacy, and Academic Development for Students with AAC Needs. Brookes Publishing.


Sunday, December 17, 2017

Three Keys to AAC Implementation Success

If you've been reading this blog for a while, I'll bet you can tell before you even begin what my 3 top tips might be.  They're the 3 basic steps to start with when teaching a child/student to use an AAC system.
And if you don't know them, didn't learn them in graduate school, haven't run into them yet in your career, or are a parent who's never been told, then please, keep on reading.
And even if you think you know what they are, please keep reading. We can all use some reminders, refreshers, and  a bit of reinforcement that what we're doing is right.

Tip #1: Knowing how to balance core and fringe vocabulary
Core words are important.  But you can’t forget the important fringe words, either.  Don’t exclude them.
Why is this important?  We focus on core words because they are crucial for generating the majority of utterances.  But every speaker has words that are important to him or her to which we should not leave them without access.
This tip is important because the user’s earliest communication often centers around those things that are uniquely important to him.
How is this important to get better AAC implementation results?  Early interactions with the AAC user will focus on daily routines, routine activities that are important and motivating to the user.  While core words, function words, are important in all of these interactions, the users will also want to specify those items that are important to him within this routines.  To maximize the user’s comfort and engagement, make sure to in crude these words, too.

Tip #2: Knowing how to create a descriptive language environment so students can use core words
One of the keys to maximizing the functionality of core words in the classroom - and minimizing time spent programing minimally useful vocabulary into an AAC system - is training teachers to use descriptive, rather than referential, language.
Why is it important? Again, we want to give the AAC user the most communication impact for his system “real estate.”  With a limit to the number of words on a page, we want those words to count - and be useful over and over again.
This tip is priceless to those of us who used to spend hours and hours adding vocabulary into each student’s AAC system, only to have it be useless the next year - or month!
How ca you implement this tip to get better AAC implementation results?
Here's how: Train teachers to think about Bloom’s Taxonomy.  They’ll already be doing this if they’re thinking about the Common Core Standards.  Rather than having a student recall or identify (What is the name of the place where this story took place?) have them think more descriptively, summarily, or analytically.  For many students, the best way is to ask; “Can you describe where this story takes place?”  It might be “green,” “trees,” “dark,” “cold,” if the story happens in a forest, for instance.  Three out of those 4 words are core words that the user will find in his AAC system and use over and over again.  No need to program in the name of the particular words or forest.  That’s much less important.
My favorite example is one Gail Van Tatenhove uses, explaining why programing the names of the layers of the Rainforest into an AAC system is significantly less useful than asking the student to describe, for example, the Emergent Layer.

Tip #3: Knowing how to teach more vocabulary regularly
Introduce new vocabulary in as many ways as you can.  Providing a context for the vocabulary is crucial; particularly for students with special needs who may not have the same life experiences as their neurotypical peers.
If you can’t provide the context in real-life, then bring life into the classroom or therapy room.  If you’re teaching the story of the 3 Pigs, bring in pieces of straw and sticks and brick for students to feel.  Make a pile of each.  How easy is it to blow each of them over?
If even that is not possible, try creating role play and simulations.  I don’t think I know a speech-language pathologist who has never held a mock-birthday party in her room.  Gather plastic figurines, laminate pictures of objects to manipulate.
And, of course, read.  Reading text provides a context for which a student may have no experience.  It’s a little circular, I know.  We provide experiences to teach the vocabulary in books, and use the context in the book to teach the vocabulary.  But it is the very nature of providing these multi-faceted experiences that help the student learn what the word is, what it means, where and when to use it, and then…… how to find it in the AAC system.

Now that you've got the advanced tips for AAC implementation success down, I'd like to invite you to get even MORE advanced help with your (free) instant access to "Top Tips and Strategies for Teaching AAC"