The Moderate/Severe Population: Telephone Scripting

Functional Communication: Where Does it Happen?

This year, I discovered that many students in my school’s 3 Moderate/Severe Special Day Classes have their own personal cell phones. This includes one student who is about 30% intelligible when context is known! Does that surprise you? It certainly surprised me.

As I began working with these students, it occurred to me that functional situations replete with language use happen every day over the phone. Even if some of my students do not have their own personal cell phones now, they likely will when they move onto their group homes or day program placements in the near future. And let’s be real, cell phones aren’t going anywhere. I decided it was imperative that these students graduate with functional phone communication skills.

Ring, Ring! ….Silence.

I started with a probe to see if my students could answer the phone. I handed an old, battery-less cell phone to one of my students and, using my own personal cell phone, I played a ringtone to simulate the student’s phone ringing. She excitedly held the old cell phone up to her ear, a grin on her face. She said nothing. I stopped the ringtone on my phone from sounding. Nothing. I cued her with an expectant face and waved my hand to motion her to say something. A solid 10 seconds later, she produced a “Hi, Ms. Hall!”

 

The rest of the class didn’t fare much better. We clearly had some work to do.

Powerpoint is My Best Friend!

Whenever I plan lessons for my Mod/Severe students, visuals are always my first thought. A few of them have basic reading skills, but most rely heavily on visuals for new learning. My go-to strategy for these classes is the ultimate, customizable visual tool: PowerPoint. Fortunately, all the classrooms I push-in to have SMARTBoards I can use to display powerpoints, videos, and other digital media to my students. If they did not, I would upload the PowerPoint onto my iPad and use is as handheld visual as I roamed about the class.

I set up a simple script that I wanted my students to learn for a specific phone situation: answering the phone and the person calling them actually needs to speak to someone else (e.g. their parent, teacher, caregiver, classmate, etc.).

The first time I ran this lesson with my classes, the script went as follows:

1. Hi!
2. Yes or No (in response to asking for the other speaker)
3. It’s for you! (hand the phone over)

The Part 1 PowerPoint I used to teach this activity can be downloaded here at my TPT store: https://www.teacherspayteachers.com/Product/How-Do-We-Answer-The-Telephone-Phone-Scripting-Activity-2544908

Each student was able to practice this script with me twice in our allotted 30 minute session. Many of the students struggled with the overall concept; I knew this would become a recurring lesson to “keep in my backpocket.” Essentially, it shows up every so often in my rotation of classroom-based lessons. When I am feeling particularly uninspired, it’s an important relevant lesson to whip out in no time.

So, that brings me to  the second time I ran this lesson. I decided to add in a new step between 2 and 3: asking “Who is this?” For my students who were beginning to master the original lesson, this was a great step forward for them.

This updated Part 2 PowerPoint can be found at my TPT Store: https://www.teacherspayteachers.com/Product/How-Do-We-Answer-The-Telephone-Phone-Scripting-Activity-Part-2-2544922

On the second time around, the students performed more independently overall; however, asking “Who is this?” was difficult when the students could see me at the front of the room. In the future, I may try asking several paraprofessionals to step outside of the room and actually have the students make a real phone call in order to practice asking “Who is this?” in a more realistic context (since they won’t know exactly who is calling them).

But back in what actually happened, I did turn the situation into somewhat of a game - the students quickly realized that each time they “answered the phone” that I would alter my voice to pretend to be a different staff member. They greatly enjoyed the farce of me pretending to be other staff members and it reinforced the necessity of asking the new question “Who is this?”

How Do I Differentiate This Activity?

• My non-verbal students participated in this activity by selecting appropriate messages on their AAC systems (e.g. “Hi.” “How are you?” “Yes/No.” “Take this.”) to respond to the demands of the “caller.”

• My students with intelligibility issues practiced their “good speech strategies” (see Blog Post #2 for more info) when speaking on the phone.
• I have the ability to modify how long I “stay on the phone” in order to elicit more language from my students who have higher language skills. I can ask open-ended, social questions like “How are you?” “What are you doing right now?” and “How was your weekend?” I can ask closed questions like, “Are you busy now?” or “Are you at school?”

Furthermore, as a carry-over strategy, I encouraged the teachers in the class to allow the students to practice by answering the classroom phone. Our school phones list the last name of the school personnel that’s calling, so I suggested that they make decisions about which teachers or staff members would be the best conversational partners and to have the students answer the phone when those specific staff members call (Because realistically, not all staff at my school would make good, patient, conversational practice models for my students!).

I hope that you find that you can easily implement this activity with the Mod/Severe population. I love this activity in particular because students can always use more practice with phone skills and it takes very little preparation now that I created the PowerPoints. And even better, the students have great fun! The students find it hilarious when I “call” them and alter my voice to pretend to be another staff member. Some of them have even altered their own voices to pretend to staff members themselves - which caused very appropriate laughter and classroom camaraderie. We all have a good time with this lesson and it reinforces functional, age-appropriate communication skills.

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

• Jillian, the No-Frills SLP

Higher-Level Language: Asking Open and Closed Questions

How many of you have inherited those Speech-Language Impairment (SLI) students who are really “language only” students? They may be in a Mild/Mod or RSP program, or perhaps they’re just a lower-performing general education student. In elementary and middle school, their therapists probably drilled grammar, gave them opportunities to practice using more complex expressive language, and hammered story grammar structure.

Then, they reach high school, and you watch the real-life consequences as they receive Fs in their ELA, history, science and math classes. You call them in for their weekly sessions (because you haven’t yet had an IEP to reduce their hours!) and you wonder what on earth you’re going to target. Maybe they have a main idea goal, maybe they have an expressive grammar goal, who knows. What you do know is that this student has no study skills and is going to flunk all of 9th grade if you don't so something. What can you do to target their academic skills while still operating within a language framework?

Metacognitive Processes! What? Why?

In my opinion, one of the best ways we can help students who fit this profile is by being a teacher of “how to think about your thinking” (or in technical terms, “metacognitive skills,”). There are lots of reasons to teach metacognitive skills - the biggest one in my book being that our students don’t naturally learn these skills in the way neurotypical students naturally pick up on them. But our higher-level students certainly have the ability to use metacognitive skills when explicitly taught. And who else will teach them these skills but us? It’s certainly not something I’ve seen tackled in my school’s freshman curriculum.

One metacognitive process I like to start with it the concept of “asking yourself questions.” You probably do it all the time often without noticing. People who are “good at learning” ask themselves things like, “What did I just read?,” “Do I agree with that?,” “Why is this important?,” and “Why should I trust this author?”  

But did you notice something? Were any of those questions “closed questions?” As in, could they be answered with a short, factual statement? No, good learners with high language skills tend to ask themselves “open questions” - questions that require a decent amount of thinking and language in order to answer correctly. And in asking open questions, our comprehension of the material is confirmed, our misunderstandings are brought to light, and new interpretations of the material takes place.

When we teach students the difference between open and closed questions, they are learning the cognitive skill of thinking about their own thinking. They are forced to think, “Am I asking comprehension questions?,” (Probably not).  “If I am, am I asking basic closed questions or am I stretching myself and asking open questions that require me to come up with a more complex, deep answer?” We want them to go through this process in order to better engage with the material they are reading or listening to!!

When all is said and done, I wish every student at my entire high school could be given this lesson. The importance of understanding your own thinking cannot be understated at this age in development!

So… How do I Teach The Open/Closed Question Strategy?

I was first introduced to this metacognitive skill when I read Claudia Dunaway’s fabulous book “Think and Speak Successfully.” Sometime in the future, I’ll write a blog post on my favorite mass-produced products (hint: there aren’t many) and Claudia’s book will be at the top of my list. It’s a must-have for any SLPs that work with adolescents with higher-level language processing deficits. I won’t go into the specifics of her strategy here, but I did create a tool to augment the teaching of this concept.

This tool functions like a flowchart. At the top, it helps students identify what kinds of question they’re asking based on the language they’re using. As the flow chart moves down, it helps remind them why practicing each type of question is most effective in a certain situation (e.g. answering a multiple-choice test or a free response).

Over several sessions, we then practice applying this flowchart and the principles to real life examples in several situations. I typically provide the students with a short article and we discuss how we would approach one of the following scenarios in regards to what we’ve just read:

• Preparing for a multiple-choice exam (i.e. practice asking closed questions to double-check that you know the answers!)
• Preparing for free response essay questions (i.e. practice asking open questions to make sure that you can interpret the material correctly)
• Preparing to complete book reports, essays, and other writing assignments (i.e. practice asking open questions to make sure that you can interpret the material correctly)
• Participating in classroom-based academic conversations where students are expected to ask each other questions about a topic

You can download this tool here at my TPT Store: https://www.teacherspayteachers.com/Product/Metacognitive-Language-Strategy-OpenClosed-Question-Flowchart-2544952

What About Carryover?

Carryover with metacognitive strategies is tough. You can’t follow the student around to all their classes to ensure that in class they are engaging in asking themselves open questions, after all! I have distributed copies of this flowchart to some of my general education ELA teachers in order for them to make copies available to students when they are engaging in academic conversations. It would also be possible to shrink down the flowchart in order to make a small copy that could be affixed to a student’s planner, journal, binder, etc. In the end, what we want is for our students to use this strategy as often as possible so it becomes like second nature!

If you have any ideas on how to ensure that your students actually use this strategy in the “real world,” I’d love to hear about them in the comments!

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

• Jillian, the No-Frills SLP

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

Tech Timer Saver: Using Fillable .pdfs For Teacher Questionnaires

Hi Mr. Smith, Can You Fill Out This Form About Johnny?

Johnny has his triennial coming up. Johnny has 6 teachers and you’d like feedback from at least some of them. I don’t know about your school/s, but with nearly 100 teachers and a huge campus, getting them to return Johnny’s questionnaire or rating scale is an absolute nightmare.
In one of my grad school internships, I remember my supervisor tasking me with delivering printed out rating scales and questionnaires in teacher boxes with the desperate promise of a “speech treat” (i.e. candy) in exchange for a completed form. At her school, she’d actually get a few back when using this method because the teachers actually checked their boxes in the teachers’ lounge!

At my current schools, this culture of box-checking does not exist. For starters, there are two teacher lounges on opposite ends of campus. I only get one box! Do you suppose a teacher will trek across campus to deliver a questionnaire? Do you suppose a large number of my teachers even check their boxes in the first place? I quickly realized that the old method of printed out questionnaires would not work at my large, comprehensive site.

So, what’s a no-frills SLP to do? As I typically do when faced with an obstacle, I took to the internet to find out how to make technology work for me. I decided everything would need to be completed over e-mail. 

But how? Sending out a word document can get cumbersome when the formatting shifts between recipients. It could work, but it wasn’t the ideal option. Using .pdfs ensures that formatting never changes, but editing a regular .pdf takes knowledge of newer Adobe software and requires actual work. Not ideal at all. 

Then, it hit me. Why not utilize fillable .pdfs? 

With fillable .pdfs, I could e-mail out my rating scale or feedback form with no printing required. All the teachers have to do is download the form, fill it out on their computer, save it as a different file name, and e-mail it back to me. Simple. Even my technophobe teachers could manage that! There is no printing, no writing, no boxes, no trekking across the campus. It’s all digital, it’s all easy. 

So How Do You Do It?

The best free website I’ve found for creating fillable .pdfs is pdfescape.com. It’s free, it’s easy, and it has all the tools I need (e.g. check boxes). Simply upload a PDF (which you create by saving any Word Document as a .pdf extension) and start editing! Create check boxes, lines for extra comments, drop down menus… the options are endless. I took a .pdf fluency rating scale I found on-line and used pdfescape.com to allow my teachers to fill it out online. Chances are, the rating scales you already use just need a quick conversion in pdfescape.com!

I’ve included a link to my Teachers Pay Teachers store where you can download a fillable .pdf I created for my RSP/gen ed teachers. Feel free to use my form at your school/s. However, I encourage you to use it as an example of what can be accomplished so you can make teacher feedback forms that are more fitting for your individual school/s.

Link to my example on TPT: https://www.teacherspayteachers.com/Product/Communication-Skills-Form-Fillable-pdf-2535962

Fillable .pdfs are an awesome tool - the uses are endless! Parent questionnaires, teacher questionnaires, recording student work… I’m sure you all can generate event more ideas and I’d love to hear about any ideas you have in the comments below! Questions are welcomed and appreciated!

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

• Jillian, the No-Frills SLP