The Moderate/Severe Population: Making Intelligibility Strategies Stick

Is Articulation Therapy Functional or Realistic For Adolescents with Cognitive Impairments?

I wish I had the answer to this question!

Case study: I work with a 15-year-old student in a Mod/Severe class who functions cognitively at the 2nd/3rd grade level. His language skills are head and shoulders above everyone in his class and he uses language to tell elaborate stories, comment on just about everything, and sometimes annoy his teachers with his love of speaking. However, he still backs. He still glides. He still reduces clusters. He’s a veritable mess of phonological processes. When I cue him to “say all his sounds,” he can generally stick on a few sounds that were missing previously, but without cueing his intelligibility drops to ~80%, even though he has quite a lot of important information to relay! His IEP goals have targeted correct productions of /s, z, r/ and reducing phonological processes since he was a toddler.

How many of you have students with a somewhat similar profile to the case study I’ve described? (Tell me about your cases in the comments!)

What’s a secondary SLP to do? Continue straight articulation therapy, even though ~12 years of artic therapy have been ineffective? What’s the prerequisite cognitive ability needed to generalize articulation and phonological skills? How do you target intelligibility strategies in students with cognitive impairments? Do you dismiss them? Give up? (Again, I welcome a serious conversation on this topic in the comments!)

So… What Do We Do?

The way I see it, for these students, these are the only 3 realistic options:

1. Intelligibility/Articulation small group therapy
2. Intelligibility/Articulation whole-class instruction
3. Dismissal from speech-language therapy

How do we make these choices? Assessment will likely reveal the same information as previous assessments: severely delayed articulation/phonological errors that reduce intelligibility secondary to global development delay/impairment. We can’t get around that big factor: global developmental delay. Can we really improve articulation skills if, overall, this student’s global delay impacts their ability to remember intelligibility strategies and placement for sounds?

You may have a protocol for handling cases like these. We never discussed these types of students in grad school, so starting off I was at a loss for what to do. I have tried to find research on best practices for providing articulation therapy to students with cognitive impairment and I’ve come up empty-handed (please comment if you have rationale for supporting treatment one way or another!). So what’s a therapist to do?

My thoughts? Rely on the other two legs of the “Evidence-Based Practice (EBP) stool” - clinical judgement and client preferences.

So… Like Seriously, What Do We Do With These Students?

I’ve come to the fact that we need to head straight for intelligibility strategies taught in their classrooms. We can’t very well abandon students if they’re having trouble communicating in class (If they’re 90% intelligible in class, that may be a different story). And while small group therapy is cool, doing lessons with the entire class gives me an opportunity to model use of the strategies, cueing, and prompts for the army of paraprofessionals who work with these students.

I’ve come to the personal opinion that continuing to hammer that /r/ or /s/ or mindlessly shuffling through backing flashcards is a misdirection when working with cognitively-impaired high-school students. Will they suddenly develop the generalization skills they’ve been lacking all these years? My guess is “no.”

So, if the goal is to target intelligibility strategies, how do we do it? There are a million ways to phrase intelligibility strategies. I don’t claim to have the best answer, but I do know that choosing the phrasing and sticking to it is key. The students need to have the same language, visuals, and gestures reinforced all day every day but all staff members.

Using the same cues and prompts will make intelligibility strategies “stick.” For example, earlier this year I was sick and had lost my voice. Upon hearing my quiet, whispery voice, one of my students suggested I use my “strong voice” to be better understood!! Even though I felt miserable from the illness, I was very satisfied that the student so thoroughly understood the strategy that he could instruct me when to use it!

My go-to phrasing:

• Strong Voice: I flex my biceps and stand up tall. Several of the students also like to flex their muscles as well. This is great for students with low volume.
• Talk Slowly: I slide my hand slow in front and away from my body.
• Say All Sounds: I make a circle with my pointer finger and stretch out “allll.” Most of my students who have articulation issues secondary to cognitive impairment are capable of producing the correct sounds… they just don’t have the memory and cognitive ability to do it all the time.
• Open Mouth: I point to my open mouth, of course! This is my go-to strategy for my students with Down Syndrome and their big ‘ol tongues!

What Materials do You Use?

I typically conduct weekly speech-language group sessions in the Moderate/Severe SDC classes at my high school. At the beginning of each session, I distribute laminated rules sheets to each student that list the intelligibility strategies in addition to 2 other “rules” I want them to follow during the session. We review each rule and I call on different students to announce each rule to the class.

You can find an example of the rules sheet I give every student at the start of each session at my TPT store: https://www.teacherspayteachers.com/Product/Rules-for-Speech-Language-Session-2538064

What other strategies do you use when working with this population? What has led to the most effective increases in intelligibility for your students? Let me know in the comments!

As always, it doesn't have to be fancy, just keep it fun and functional!

• Jillian, the No-Frills SLP