This advice-column-style blog for SLPs was authored by Pam Marshalla from 2006 to 2015, the archives of which can be explored here. Use the extensive keywords list found in the right-hand column (on mobile: at the bottom of the page) to browse specific topics, or use the search feature to locate specific words or phrases throughout the entire blog.
Q: I am very frustrated working in the public school. I am forced to see very low functioning children 2-4 times per week, and even with this much therapy they are not progressing in vocabulary, phonemes, nothing. Am I doing something wrong?
Let me be very blunt here.
Warning! Those of you who don’t know me need to be warned that I do not speak with political correctness. I find it to be an imposition on our freedom of speech and therefore a violation of the constitution. I will not be held responsible for anyone who is offended by the following comments…
Again… Let me be very blunt here.
I believe that we need a change of school culture. We are seeing children with very low cognitive skills too much and students with mild speech problems and average intelligence or better too little. I have a long-term goal to change this back to the common sense procedures that SLPs used to use.
I am teaching today’s SLPs to begin to repeat to their teams the following concept: “A child can speak only as well as he understands.”
- Kids whose cognition is below the 6-month level should be saying no words and they should be making very few sounds. They should not even be babbling. They should have no “communicative intent” and should not be able to use signs, gestures, or pictures for any meaningful purpose. They should be encouraged to make sound, any sound.
- Kids whose cognition is at the 6-10 month level are at the stage of “illocution.” This is still a pre-language level. They should have no concept of word and thus they should be saying no words. They should only be making some spontaneous sound, and a few babbling-type noises. Their sounds should be becoming regular, consistent, and repetitive however. In other words, they should have a few sounds that they say to the exclusion of everything else. They should be getting good at repeating these sounds and every sound they make should be celebrated.
- Kids who function at 10-14 months of age should be saying one single word only. But because these kids usually have dysarthria too (due to neuromuscular disorder) they probably still have no words. These children may have a word or two that pops out occasionally but never on demand. They should be in situations in which it is likely that they will say the word they have. For example, if the child can say “keys” he should be encouraged to say keys many times per day. Each time he spontaneously produces the word should be celebrated. “Yeah! David is learning how to say keys!”
- Kids who function at the 14-18 month cognitive level should be saying 1-10 words at best. But because these kids usually have dysarthria too (due to neuromuscular disorder) they probably still have no words. They should be using gestures, facial expressions, objects, and pictures, and some vocalizations to begin to communicate their wants and needs. They should not be able to practice words on demand, but words should be popping out here and there. These should be celebrated whenever they occur.
- Kids who function at the 18–24 month level should be saying 10-25 words (probably fewer), and up to 50 words at the very best. But because these kids usually have dysarthria too (due to neuromuscular disorder) they probably still have very few words. They should be using these words consistently for communication purposes. The words probably will be very hard to understand due to the dysarthria. They probably will lock in on an incorrect way to say a word and they will say it that way for many years. For example, perhaps the child’s name is Kristie, and she calls herself “Tee-Tee.” I would not expect this to change for a very long time.
Kids with very low cognition should not been seen multiple times per week. That is called “Babysitting.” They do not change fast enough to warrant that much therapy. Instead, we should be acting as consultants to the team about how to stimulate for a few basic communication routines that are functional for the child at home and at school. It only takes one time per month to do this, at most.
We need school psychologists to step up to the plate again and put cognitive ages on these kids. In lieu of this information, we need to help the parents and team understand the child’s cognition. We can help them understand the developmental level of the child’s play, his ability to understand vocabulary words, his ability to follow directions, and his ability to answer questions (with word, sound, gesture, sign, or picture).
Again: A child can speak only as well as he understands.
Add to that: A child usually says far less that he understands.
One final note: We should not be assigning children with low cognition and neuromuscular disorder with the diagnosis of “apraxia.” A child with low cognition and neuromuscular has “mental retardation” and “dysarthria.” Three-to-five days per week of therapy will not change his IQ and therefore it will not change his verbal output.