Speech Therapy Works

As a Speech and Language Therapist it shouldn’t really be a revelation to me that speech and language therapy works. Obviously I have always believed in it otherwise I wouldn’t have stayed with it as a career for over 14 years. It’s just that trusting something works because you understand the theory behind it and actually experiencing something on a practical level, within your own home, with your child, is quite different.

Obviously I have experienced success in my professional life, but that has been within the confines of a large caseload and various time and resource pressures. In the latter part of my NHS career, as a more senior clinician, my main role was assessment and report-writing. I rarely did any therapy as we had a structure where skilled assistants carried out care plans under our supervision. It meant I didn’t get to know children as well as I’d have liked and I didn’t get to share in their small steps of progress week by week. I re-assessed and reviewed progress, seeing improved assessment scores but that isn’t the same as cultivating progression yourself.

Now that I’m an independent therapist I’m really enjoying being able to properly get to know the children I work with. I’m completely invested in their therapy and am just as pleased when they move forwards or overcome something as I am when Little Bear does. I do see (and feel) therapy working now.

However, what we have experienced at home has taken my belief in speech and language therapy to a whole other level.

I was recently running a communication workshop (for adopters, prospective adopters & professionals) when somebody asked me a question that made me realise the examples I talk about in it, from Little Bear’s communication profile, paint a bleak picture. The picture is totally accurate and reflective of his communication skills when we first met him, aged 3 and a half. The picture, detailing significant difficulties with attention and listening, comprehension, expressive language and speech sound disorder was bleak. At the time I was fairly overwhelmed by his level of need and the magnitude of the task ahead of us.

Here is a very brief summary of Little Bear’s presentation then:

Little Bear was not tuned into language at all and did not respond to verbal instruction, including his own name. His comprehension was better than it appeared but significantly delayed for his age. Little Bear had a very small vocabulary that didn’t meet his needs. He did not have words for common, everyday objects such as cow, train, television, food items etc. Little Bear couldn’t answer ‘what’s your name’, his only size word was ‘big’, he couldn’t name colours or count and he couldn’t put more than about 3 or 4 words together. The words that Little Bear did have were unintelligible. Little Bear was extremely frustrated and he was often left with no other option but to express himself with his behaviour.

I quickly realised this wasn’t a straightforward language delay and that Little Bear’s needs met the criteria for Developmental Language Disorder

At the time I had no idea what the prognosis would be but I suspected it wasn’t rosy and that speech and language therapy would be a big part of our lives for years to come. It was hard to know where to start and easy to become overwhelmed by priorities. There were times I really questioned my faith in what I was doing and wondered if we’d ever get to where we were hoping to go.

I did not expect, in my wildest dreams, that 2 and a half years later a speech and language therapist would observe Little Bear in his mainstream classroom and say there was no discernible difference in language skills between himself and his peers and deem him ready for discharge. Yes, his attention and listening skills still mark him out and there are some minor speech errors but his comprehension and expressive language skills are now within the expected range for his age.

This near miraculous improvement is due wholly to one thing: speech and language therapy.

Admittedly our circumstances are unusual: most children with DLD do not have a parent who is a speech and language therapist and able to provide targeted intervention on tap 24/7. Little Bear has essentially undergone an intensive 2 and a half year block of therapy. Strategies have been used by the whole family and are an automatic part of the way we talk with Little Bear, not something we use for just a couple of minutes each day. The key strategies have included: using environmental sounds to capture Little Bear’s interest as a way in to listening to language; reducing our language; modelling of vocabulary, sentence structures and sound patterns; repetition; showing, explaining & checking understanding of complex concepts or new words as well as seizing every possible communication opportunity. We have done some direct work on auditory memory, phonological awareness (initial sounds, syllables, rhyme, blending sounds together) and speech sounds.

I suppose at any one time I have always had a current communication aim in mind, whether it has been a specific language concept or speech sound and I have found ways to weave this into play or our usual day to day lives. I have very rarely, if at all, asked Little Bear to sit at a table and ‘do speech therapy’, it has been a much more holistic and inbuilt approach than that.

Little Bear has also been seen by an NHS speech and language therapist throughout the past 10 months or so. She has taken the lead on sorting out Little Bear’s disordered vowels which have been complex to assess and set goals for. Generally she has started us off with a sound or activity and we have carried it on between sessions.

The NHS therapist has also set language goals for school and has provided them with programmes to carry out, which they have done.

All of these strategies, techniques and approaches have worked. Their effectiveness is inarguable. Yes, the sum total of the input Little Bear has had is massive and yes, me being a speech and language therapist does make things different. However, I truly believe that a similar impact could be gained by providing parents with good quality, strategy based communication training alongside regular sessions with a speech and language therapist, who could do the assessing and target setting bits, as well as providing resources and guidance. Similarly, if speech and language techniques can be embedded into teaching and used holistically as part of the curriculum (not here and there for 10 minutes) that too can be highly effective and impactful.

Little Bear is living and breathing proof of the efficacy of speech and language intervention. Prior to treatment when I’m almost certain that no strategies were in place, he made negligible progress. In fact, on entering pre-school shortly after coming home, Little Bear was assessed as having a delay of more than 2 years in all areas of his development, with speech and language and numeracy being the most delayed areas. Within 2.5 years of therapy, that gap has closed (meaning that Little Bear has essentially made 4.5 years’ worth of progress) and his comprehension and expression now measure within age expectations on standardised assessment.

Speech and Language Therapy works.

Whilst his progress has been phenomenal, I should point out that speech therapy is not a panacea. Little Bear still has DLD and I suspect it will impact him to a greater or lesser degree into adulthood but what therapy has done for him is allowed him to reach his communication potential, despite having DLD. Little Bear still finds it difficult to learn new vocabulary and to figure out the sound patterns in new words but we know what to do and the strategies work. The approaches that we have built into our daily lives will continue as Little Bear is still going to need them and it is imperative we continue to strive for that meeting of full potential. As the demands of the curriculum increase, we might find we need to access formal therapy again and that would be okay too.

I feel extremely proud of Little Bear’s progress and find myself constantly marvelling at the things he can say now. Last week he took part in his second school assembly. He learned more than double the words he managed last time and was able to recite them in front of the school without any prompts at all. The naughty streak in me did notice that other children in his class had to read their lines or forgot them completely (I don’t mean that badly, it’s just he has never been able to keep up with them before, let alone outshine anyone and he’s more than earned his moment of glory). Not only that but he sat really well throughout, no teacher attached to his side like previously, and he spoke loudly and clearly. Several people came to me afterwards to comment on how well he had done, the difference being so stark in comparison to previous public appearances.

I am truly grateful to speech and language therapy for not only giving me a career I love but for unlocking my son.

 

 

I think I had better make some changes to my workshop too. Although people need to see the bleak picture, they also need to see the sunshine over the rainbow picture that can be gained by using the strategies and applying them diligently. Little Bear’s prognosis appeared extremely poor so his progress really is a beacon of hope.

 

 

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Speech Therapy Works

Our Just-Right Challenge

The term ‘just-right challenge’ was first coined by well-known Occupational Therapist (OT) Jean Ayres. She was referring to finding activities for children that are neither too easy nor too hard. The secret, she said, was pitching a task just above their current level of functioning – so that it was definitely attainable but not so difficult that they would experience frustration and not so easy that they wouldn’t develop any new skills. I think it’s a concept well-known and used within the field of OT.

The just-right challenge is like the sweet spot of learning, when you pitch something just perfectly and you can see your child grasping a concept right before your eyes. The just-right challenge is essential for developing confidence and turning the I’m Stupid feelings on their head. It’s a crucial, yet largely underrated skill in any parent, teacher or therapist.

The idea first came to my attention when I attended a Sensory Integration training course, an approach also derived by Ayres, several years ago. Despite practising it all the time without actively labelling what I’m doing, the term just popped into my head the other day, probably because we have been having some issues with finding the just-right challenge for Little Bear.

Little Bear attends swimming lessons every Saturday and has been doing very well, so well in fact that his teacher said he was ready to move up to the next group. Little Bear seemed pleased with himself and I took him along the following week. I popped back to the pool a few minutes before the end to wait for Little Bear with his towel. When I got there I was shocked to see he was crying. “What’s the matter?” I asked the instructor who was closer to me than he was. “He’s just cold” she said.

Well that didn’t stack up because Little Bear is one of the toughest children I’ve ever met, he’s practically a Marine, he doesn’t cry because he’s cold.

Little Bear’s lesson is now at the deep end of the pool and he, along with the other children, was standing along the furthest edge, preparing to jump in. I noticed that Little Bear was about a foot smaller than the other children who appeared about 8 or 9 years old. Little Bear looked extremely uncertain but did jump in. He swam straight to the edge, got out, came to me and dissolved into a crying wreck. It just wasn’t like him. What on earth was wrong?

After a lot of cuddling and drying Little Bear managed to tell me that it was too deep and he was scared. I said I would speak to his instructor as I could already foresee a problem with next week’s session. I went back into her, wondering if he’d accidentally gone into the wrong group. No, she said, he was absolutely fine, he could keep up with the lesson. He was fine; he’d be fine next week. She said ‘fine’ a lot. I don’t find ‘fine’ particularly reassuring.

The following day Grizzly took both Bears for a fun swim, thinking it would boost Little Bear’s confidence. They had fun, they dived in, and it was all good. It was fine.

When the next swimming lesson rolled around I was careful to keep an upbeat approach. It was working until we got to the front door of the pool building when Little Bear began crying and wouldn’t go in. He didn’t have to do the jumping in bit if he didn’t want to I reassured, I would come back early for him. Anyway, the long and short of it was that when we entered the pool area Little Bear was crying and gripping on to me for dear life. This is not like him: he usually skips in on his own. The new instructor, who I was quickly growing annoyed with, told him to get in, he’d be fine: cue more crying and clinging to me. The instructor continued to teach the other children and made no move to come to Little Bear, reassure him or anything else remotely useful.

Thankfully, Little Bear’s previous instructor, who was teaching a class in the middle section of the pool, noticed what was happening and asked if he would like to re-join her group. “Sometimes the jump to the next group is too much,” she said, “don’t worry about it, he can come with me”. I thought Little Bear would have been relieved (I certainly was) and would have hopped straight back in. He didn’t though, continuing to cry and hold onto to me. He managed to tell me that although he did want to go back to his old tutor he now didn’t know any of the children in her group because the time of his lesson had also changed. Evidently this was unsettling him.

The old instructor listened, took him quickly into the pool, introduced the other children and had him swimming a width before he had time to protest further. She was like a swimming fairy and I couldn’t have been more grateful. The would-be new instructor was unfortunately more like a wet lettuce.

I watched the rest of the session from the side, in the bit where parents are forbidden to be, as I had promised Little Bear I would and he kept checking I was still there. As I stood, I reflected. The thing is that we want our children to do well and we want to be able to celebrate their achievements with them. When children work hard and succeed they are generally rewarded by being able to move up a group or go onto a harder task or level. That is the usual way of things in school and sporting situations. However, what is often not considered (and I failed to consider on this occasion) is that moving up means leaving behind everything familiar to you. In this case it meant leaving the instructor Little Bear knew and was comfortable with. It meant leaving the children he knew and was familiar with. Although he would still be going to the same place, it also meant he would be in a different part of the pool: a deeper, more challenging part. As a transition I had underestimated it.

Yes Little Bear was doing really well at swimming but moving him up a group was not the just-right challenge for him. It was a too-far-out-of-the-comfort-zone challenge.

That is the tricky thing for children who have experienced developmental trauma or who struggle with attachment: finding the just-right challenge for them (obviously it’s very different child to child). You cannot simply base the level of challenge on their skill level. Clearly in terms of Little Bear’s swimming ability, he was capable of being in the harder lesson. However, that didn’t take into account his emotional or attachment needs which, at the moment, mean that taking the leap away from everything familiar leads to him feeling unsafe. He would probably have coped better (it’s all good in retrospect) had the whole group and the tutor moved to the deep end; or had they stayed where they were and just done harder swimming.

I suspect also, that Little Bear has had a bad experience in water in the past as he was terrified of it when he first arrived and clung onto me the first time we went into a pool – arms tight around my neck, feet wedged between my thighs, clutching on limpet-like. It was ironic really as I dislike water and can barely swim but it was undoubtedly good for bonding as I kept him safe, successfully hid my fear and he slowly found his confidence. Grizzly takes the boys swimming a lot now and Little Bear had seemingly fully conquered any fears he used to have. That’s the thing about trauma though, it pops up when you least expect it and perhaps something about standing at that deep end, already out of his comfort zone, staring into the aqua depths triggered something? A memory? A fear?

We couldn’t really have anticipated the possible trigger but with hindsight I think we should have been able to see that moving up a group was a challenge too far. For now, doing very well in the group he is in is the just-right swimming challenge for Little Bear.

When it comes to education, finding the just-right challenge for him has been even trickier. Not only do we have to consider his skills, his attachments and familiarity but we also have to consider his self-esteem and sensory needs (he is pretty confident physically and sports meet his sensory needs well). In addition, as with many children, what Little Bear is capable of on any given day can fluctuate. If he’s particularly anxious or hungry or unwell or excited he is unlikely to manage as much as if he is calm and relaxed. The just-right challenge can vary minute to minute and task to task and requires an adult to really know him to be able to differentiate demands accordingly. My post Jigsaws is a good example of me getting the just-right challenge bob-on and the positive outcome that resulted from it.

Too often we don’t hit the right challenge level, usually making the challenge too hard, resulting in upset, frustration and even aggression. As a rule we have now learned that Little Bear’s just-right challenge tends to be a little below his full ability when all the stars are in alignment. Pushing him too hard causes a panic, even if we know he is able to achieve whatever it is.

In a recent meeting with school, his teacher told us that he is doing well in his Maths group and they are considering moving him up. Whilst it is fabulous that our little dude who couldn’t count for toffee on school entry has overtaken some of his peers and has taken to extending his own learning (why do tens and units when you could do twenties or thirties and units?!), knowing him as we do, the just-right challenge for him is being the best in the group he’s in, not struggling to keep up in the next group. Yes, he would probably be able to do some of the work but he would find it hard and his confidence would suffer. I think he would enter scared-mode. Where he is, he can succeed nearly all of the time which is just-right for now.

 

 

*It’s difficult in a situation like swimming where the teachers don’t know anything about Little Bear or his background so aren’t aware of the need to make reasonable adjustments. I never know whether I should try to tell them or not but, practically, it would be difficult as they are in the pool and I would need to shout!

**Whilst I have spent the whole post pointing out the problems, I shouldn’t omit to point out that Little Bear did fabulously being able to let his emotions out and putting his fears into words and telling them to me. It’s not so long ago that he would have had a meltdown or punched somebody instead. Progress comes in many forms.

 

 

 

 

Our Just-Right Challenge