Understanding Language Comprehension

As a speech and language therapist, I often have children referred to me because their language is late to develop. Whilst those who know the child may feel that the main issue is lack of spoken words and may say he/she ‘understands everything’, it often becomes apparent during assessment that things are not what they seem. Children are great little detectives! In day to day life, they are constantly scanning their environment for clues that will help them understand. It is possible for a child to understand an instruction like ‘Go and put your coat and shoes on then wait by the front door’ without understanding a single, solitary word! But how? The answer is ‘Situational Understanding‘.

What is Situational Understanding?

From a very early age, we start to make links between things that happen around and to us, starting with cause and effect. Babies quickly learn that crying (cause) usually results in comfort of some kind (effect – often food or cuddles). As we grow and learn, we start to associate related things and we use this information to make sense of the world. Often, before children can speak much at all, they will do things like go to the table when you open the fridge or the cupboard where the snacks are. This is situational understanding – the child has learned that when you open the fridge or cupboard, the next thing that usually happens is that they get a snack at the table. The child does not need to understand any words to react appropriately, they are using the information from the situation to understand. Situational understanding is an essential skill that we all use throughout our lives. Ever been to a party which features folk dancing you’re not familiar with? Usually we watch what other people do and copy – we use what we see in the situation to understand what to do. That is what situational understanding means.

Let’s think now about our instruction ‘Go and put your coat and shoes on then wait by the door’. Your child will most likely have noticed that when you put your coat on and get the buggy ready, the things that follow are that you put their coat and shoes on then go out through the door. If you deliver the instruction while you are standing in the hall with your coat on and getting the buggy sorted out, your child doesn’t need to process any of the words you have said, they can follow it simply by using their knowledge of the situation they see.

To assess and work on true understanding of language, you need to consider how many words in the sentence the child HAS to understand in order to follow it, these are usually called either Information Carrying Words (ICWs) or Key Words. That means taking into account the environment, the situational information available and the choice of related objects on offer. It sounds mind-bending, but once you get into the swing of it, it’s fine!

What is an Information Carrying Word or ICW?

Quite simply, it’s a word (or short phrase) that gives you the information you need to follow an instruction without any situational clues. Let’s take the instruction ‘Go and put your coat and shoes on then wait by the front door’ and alter the situation to make some of the words carry essential information, i.e. turn them into Information Carrying Words.

First of all, the instruction needs to be given BEFORE you, yourself start getting ready and while you are away from the door. Secondly, words that have a grammar function don’t count when it comes to information carrying words! So we can get rid of a few words straight off: ‘Go and put your coat and shoes on then wait by the front door‘. Now we have 4 candidates to become ICWs! In the examples below, I’ve highlighted the ICWs in red and the things the adult does to support understanding of the additional words in blue.

1 ICW – ‘Go and put your coat (give the child the coat) and shoes on then wait by the front door (point to the door)‘. Here the child has to understand the phrase ‘shoes on‘ to follow the instruction. The situational prompt of being given the coat should be enough to prompt putting it on and pointing at the front door will prompt the child to go there. We’re going to assume that waiting is what the child usually does at the door, so there’s no new information in that word either.

2ICWs – ‘Go and put your coat and shoes on then wait by the front door (point to the door)‘. Here the child needs to understand both ‘coat‘ and ‘shoes on‘ but the point gives a clue as to where to go.

3 ICWs – ‘Go and put your coat and shoes on then wait by the front door‘. This time, you haven’t pointed to the front door so, not only does the child need to understand which items to get but also ‘front door‘ (as opposed to back door) so that they go to the right place.

I hope this isn’t too confusing! The easiest way I find of sorting out how many ICWs I’m giving a child is to think ‘is there a choice for each word in this instruction?’.

Here are some toys that I might use to work on developing understanding Information Carrying Words

Here are some toys that I might use to work on developing understanding Information Carrying Words

If I give the child the items in the picture plus the instruction ‘make Igglepiggle jump on the bed‘, I can be confident that it is a 3 ICW instruction because of the following choices:

  1. Igglepiggle or Upsydaisy
  2. Jump or any other action
  3. Bed, table or chair

Your speech and language therapist will help you to ascertain how many ICWs your child can understand at a time and will help you see if there are any patterns within each level of understanding. For example, a child may understand 2 ICW instructions made up of a person plus an object (eg ‘Give Igglepiggle the chair’) but not ones made up of a person plus an action (eg ‘Make Upsydaisy sleep‘). Usually speech and language therapists will work in 4 levels with ICWs – 1, 2, 3, and 4 ICWs in a single instruction. Beyond 4ICWs, things start to get more complex!

Bridging Between Levels

Once your child consistently understands a variety of instructions at the level you are working on, your SLT will advise you on how to ‘bridge’ to the next level. That usually involves using real objects, visual aids like pictures, sign language and/or pointing to give your child a clue about the extra ICW you have added. For example, if you are wanting to help your child get from 2ICWs to 3 using the materials in the picture, you might do the following to support understanding of ‘make Igglepiggle jump on the bed’:

  • Give the child Igglepiggle first
  • Sign ‘jump’ as you say it
  • Give the child the symbol for ‘jump’ as you say it
  • Point to the bed

The choice of materials is still there because you’d use all of the objects to maintain the choice for each ICW but you are making it a little easier by helping the child with one of the choices.

I hope that this article goes some way towards demystifying the concept of Information Carrying Words or ICWs ! Please leave me any comments or questions and I will do my best to answer them!

A Beginners Guide To Grammatical Terms

User Friendly Dictionary of Grammar

My well-loved copy of TUFDOG

If you are either a parent of a child who has a language disorder or you’re planning to train as a speech & language therapist in the future, then this post is for you! When I went to my very first Linguistics lecture way back in October 1992 the lecturer, one Professor Jim Hurford (you’ll find his biog here if you are interested!), handed us all a bundle of paper which he dubbed ‘The User Friendly Dictionary of Grammar’ or ‘TUFDOG’. This document contained definitions of pretty much every grammatical term you could think of from ‘noun’ to ‘relative clause’. Prof Hurford’s reasoning was that, since schools had moved away from teaching the meanings of such terms and a clear understanding of such vocabulary is essential for students of linguistics, he’d best make sure we all knew our adverbs from our adjectives. Over my 4 Years studying Linguistics at Edinburgh, TUFDOG was invaluable and, as you can see, I still have my well-thumbed copy!

I am happy to tell you that TUFDOG was formally published in 1994 in much flashier format as ‘Grammar: A Student’s Guide‘ and it is still available from Amazon!

Anyway, getting to the point of this post, it occurs to me that if you are not someone who uses grammatical terms on a daily basis (so pretty much the whole world except for SLTs, language teachers, journalists, writers and editors) then I thought it might be helpful to have a brief explanation of the basics. This will be particularly useful if you are the parent of a child who has a language disorder as you will most likely be asked to work on one or more of these areas with your child.

Noun – a noun is the name of something. ‘Common nouns’ are the names of objects like ‘ball’, ‘sock’ or ‘house’. A good way to check if something is a common noun is to see if it makes sense if you put ‘the’ before it. For example ‘the house’ makes sense but ‘the drinking’ feels like it’s not finished and ‘the beside’ just plain doesn’t make sense! The names of people and places are also nouns but form a subgroup called ‘proper nouns’. Proper nouns don’t make sense with ‘the’ and typically have a capital first letter; eg ‘Isla’, ‘Edinburgh’, ‘Scotland’

Pronoun – a pronoun is a short word that you can use to replace a noun in a sentence so that you don’t end up repeating yourself all the time.

By way of example, you could say the following: ‘I saw James at the park yesterday. James said James was at the park to meet Polly. James and Polly were planning to go for ice cream together. Polly loves ice cream, Polly says ice cream’s Polly’s favourite food’ however, that sounds a bit repetitive with all the ‘Jameses’ and ‘Pollys’. Most people would probably use some pronouns to make it sound a bit better ‘I saw James at the park yesterday. He said he was at the park to meet Polly. They were planning to go for ice cream together. Polly loves ice cream, she says it‘s her favourite food’.

As you can see, we have different genders of pronoun: male, female, gender neutral as well as plural pronouns. There are also variations on each of these depending on where they come in a sentence. This can be really confusing for children who have a language disorder and they generally try to simplify the system by using only one gender and typically only one variant. In my experience, it is typically the male pronouns a child like this will stick to and if there is only one variant used, it will be either ‘he’ or ‘him’ (eg ‘him is washing him hands’). In English our pronouns are:

A list of English pronounsAdjective – quite simply, an adjective is a word that describes a noun. Some examples of adjectives are colours, sizes like ‘big’ or ‘enormous’ and attributes like ‘nice’, ‘long’ or ‘soft’. If you’re not sure if a word is an adjective, try it with a noun and see if it works; ‘the chair is soft’ works but ‘the chair is in’ sounds unfinished and ‘the chair is quietly’ doesn’t make sense.

Verb – ‘verb’ is another word for ‘action’, it is something you do. Examples of verbs are ‘love’, ‘run’, and ‘eat’. Verbs form the core of a sentence and they dictate what roles (see below) or positions need to be filled to finish that sentence so that it makes sense. For example ‘give’ is a verb. To use ‘give’ in a sentence we first need to have someone to do the giving but ‘Sue is giving’ isn’t a complete sentence. So give also needs something to be given but ‘Sue is giving the cake’ still isn’t a complete sentence. It turns out that ‘give’ also requires someone to receive whatever has been given so our complete sentence is ‘Sue is giving the cake to Bob’. By way of contrast, the verb ‘sleep’ needs only someone to do the sleeping to make a complete sentence ‘The dog is sleeping’ , you can add other things but these are optional. This is why it is so important for children to learn verbs as well as nouns as part of their early vocabulary. Without verbs, it is impossible to build grammatically correct sentences.

Roles – ‘Roles’ are the slots in a sentence that need to be filled to make the sentence complete. As described above, the verb you use dictates which roles need to be filled. The main roles to be aware of are ‘Subject‘, ‘Object‘ and ‘Indirect Object‘. There are others but you only need to know about those if you are studying in detail! The subject is the ‘doer’ of the action and in English, all verbs require at least a subject to make a complete sentence – The boy is drinking. The object is whatever the action is done to and many verbs require an object as well as a subject – The boy is drinking juice. You will also come across indirect objects which are typically the beneficiary of the action – The boy bought some juice for his brother. In English, the order of these roles in a sentence is usually subject, verb, object, (indirect object) or SVO(Oi).

Tenses – verbs in English have different endings and sometimes other words used with them to show when the action happens in time. Examples are:

  • James has tidied his room or James tidied his room – past
  • James is tidying his room or James tidies his room – present
  • James will tidy his room or James is going to tidy his room – future

There are many distinctions of different types of past, present and future tense but discussion of those in detail here will just get confusing! For the purposes of early language development, the most important thing is to ensure a child is able to express the basic 3-way past/present/future distinction.

Adverb – An adverb is a describing word much like an adjective but it describes a verb rather than a noun. Adverbs describe how something is done and very often end in ‘-ly’, examples are: gently, quickly, carefully. You can often turn an adjective into an adverb by adding ‘-ly’ to the end. For example in the sentence ‘Your dress is nice’, the word ‘nice’ is an adjective which describes the dress. On the other hand, in the sentence ‘Your dress is nicely made’, the word ‘nicely’ is an adverb which describes how the dress has been made, ‘made’ being the past tense of the verb ‘make’.

Preposition – a preposition is a word that tells you about a location or position. Examples are: in, on under, between, behind, in front. Many children who have language delays or disorders need some help to learn these. Prepositions are essential for daily understanding and are also fundamental building blocks for sentences.

Plural – a plural simply means ‘more than one’. Typically in English, we put a ‘s’ on the end of a word to show there is more than one, this is called a ‘regular plural’ because it is a regular pattern. Examples of regular plurals are ‘houses’, ‘socks’, ‘plants’. In English there are a subgroup of plurals which don’t follow this pattern and these are called ‘irregular plurals’. Examples of irregular plurals are ‘mice’, ‘geese’ and ‘sheep’.

That just about covers the main ‘parts of speech‘ that you are likely to come across if you are working with a speech and language therapist. Incidentally the term ‘part of speech‘ is a term that means a group of words which share the same characteristics in language. Basically, parts of speech are the building blocks you need to make sentences. Nouns, verbs, adjectives, pronouns, prepositions, adjectives and adverbs are all parts of speech. It’s important to keep parts of speech in mind when you are working with a child who has language problems, particularly if they do not speak in sentences. In order to build sentences, it’s essential for a child to have a variety of words from various parts of speech in their vocabulary. A mix of nouns, verbs, adjective, adverbs and prepositions makes many more combinations available than just nouns and adjectives.

I hope that this article is useful and please do leave me a comment if you’d like further explanation or you’d like me to add something which I haven’t included!

What goes into a speech therapy session?

As with so many things in life, the key to a really good speech therapy session is good planning and preparation so I thought I would write a post about how I plan and prepare for each session that I do.

The first thing any speech therapist will do when they see a child for the first time is assess them to figure out what the underlying difficulty is.  Assessments come in the form of standardised assessment and informal assessment. A standardised assessment is a published ‘test’ which compares a child to other children of the same age using standarised scores. Informal assessment is used either where a standardised test does not exist or will not work well for the client in question. It takes the form of activities planned by the speech therapist to elicit certain language structures or simply consists of observation of the child during play or other day to day activities. Once the initial assessment is done,  I will analyse the results and use these to guide what we will work on in subsequent therapy sessions.

Next, I come to the planning stages when I decide on our overall targets to work on over the block of sessions as well as what to work on in each individual session.  This is always based on the assessment of the specific difficulty in question and my first aim is to form a rough ‘road map’ for a block of therapy sessions.  At this initial planning stage you never know how quickly a child will pick up on different topics or strategies. Having a  good understanding of the underlying problem and a clear idea of which areas to work on and in what order it makes it easy to move on as needed to keep the client engaged.

Simple speech therapy S game

A simple speech therapy game working on S

Once I have my over all therapy road map I move onto the planning of individual sessions and this is where I use all my skills and experience as a speech therapist to tailor each activity to the specific needs of the child. Even though I may sometimes see children with exactly the same speech difficulty and consequently quite similar therapy road maps, each individual requires quite different activities as their personalities, interests and ages may be quite different.  For example, one child may work well with a board game where another would work much better with an interactive game like crocodile dentist.

In all sessions, making it relevant, fun, enjoyable and interesting is the most important challenge. This often involves making materials of some sort and modifying the rules of toys, games  and activities so that they are relevant to the session. It is important to make sure that the difficulty of the game and the rewards of the game are tailored for each different client so that they stay engaged with the task, finding it neither too easy or too hard. I know I’ve got it right if they are looking forward to the next session!  For older children toys and games are often less suitable and this is where the interests and hobbies of the child or young adult are used to guide activities.

After the planning and making materials, the next thing I do is assemble all the materials into different boxes for each therapy session.  These fit neatly into my speech therapy cupboard so that I have all I need for the day whilst I am out and about in East Lothian and Edinburgh. In each of the boxes I always have to pack a back up plan just in case a session isn’t going as planned and I need to make the activity easier or harder to keep a child engaged.

Just before each session I also have to think about the work environment in the mobile therapy room.  Sometimes it needs to be very interactive, making full use of Velcro and magnets and sometimes it needs to be quite plain if a child is easily over stimulated or has a lack of focus.  The layout of the therapy room is important to make sure that you get the most out of the session.  Sometimes this involves working on the floor and sometimes working at tables. In addition I have to remember the obvious but easily forgotten things like making sure that the therapy room is warm enough and light enough for a good therapy session.

Once it gets to the actual session, hopefully everything will go like clock work and look to a casual observer like little more than structured play or an informal conversation. The more relaxed and natural the interaction in the session, the better as it gives me the best insight into the problem, what is being taken in and what needs to be done to move forwards.  It is really important for me to stay relaxed and playful on the outside but really focus my mind on observing the child so that I can pick up on all the subtle non verbal clues that give insight into the progress that is being made.  It’s always important to remember that sometimes activities do not work as well as you had hoped and if this happens there really is no point in flogging a dead horse! At this stage the most important thing is observation, thinking on your feet and reflection afterwards to see if there is anything else you can do differently next time.

Once the speech therapy session is over, it is essential for me to write up my notes promptly. My notes detail my observations (subjective as well as objective) from the session and are a continuous informal assessment.  The observations I make of the child’s response to the activities in the session are then used to guide the planning of the next session. My observations allow me to provide guidance and activities for parents to use at home and to other professionals such as teachers, other therapists or nursery staff.  Working outside of the session is the most important part of any child’s speech therapy support as this is where practise and the the generalisation of skills happens! After all, you wouldn’t expect to become a guitar virtuoso if you only practised for thirty minutes or an hour each week with your teacher!

Working With a Speech & Language Therapist

Speech and language therapy sessions work best if parents and speech and language therapists work collaboratively. Therapy has to be a 2-way relationship after all, while the speech & language therapist is an expert in communication, parents are THE experts on their child!

Speech and language therapy is different form some medical treatments where a doctor can ‘fix it’ by giving you a specific medicine that will make your condition go away. It is more like physiotherapy where the therapist guides you but carrying out the recommended exercises between sessions is what really fixes the problem.

Working with a Speech and Language Therapist is an advice sheet for parents. It gives you some handy tips and ideas about how to work well with your child’s speech and language therapist to get the most out of your child’s treatment programme. Click on the link below to download it:

10 Top Tips for Working with a Speech & Language Therapist

 

How do speech & language therapists help people with autism?

The short answer is that the possibilities are endless! A speech & language therapist can help someone who has autism with any aspect of communication as well as play skills and self-organisation. How a speech & language therapist helps a person on the autistic spectrum depends very much on what their specific needs are. For this reason, the first step for any speech & language therapist working with someone on the spectrum is to complete a comprehensive assessment of their communication skills.

Once the therapist has gained a clear understanding of where their client is up to with their communication skills development, the necessary support can be put in place. Support is offered in many ways, not just in the form of face to face therapy sessions (for example, it may be more effective for the therapist to train key people in their client’s life). The nature of support depends very much on the individual and their specific needs.

What follows will give you a flavour of the massive range of things a speech & language therapist might provide support with for someone who is on the autistic spectrum.

Before spoken language develops…

  • Understanding the value of communication – For more severely autistic clients, the first thing a speech & language therapist will often do is to help their client to start to see the value of communication. This is important both from the point of view of asking for (and getting) what you need and forming positive, enjoyable social relationships with other people.
  • Developing the fundamentals of communication – things like using and understanding facial expression, eye contact and gesture, taking turns with others, enjoying being with another person are all fundamental communication skills. Babies start learning these skills from a very early age in face to face interaction with their parents and other adults. Speech and language therapists will use the principles from this early parent child interaction to help people with complex needs and autism (or other conditions) learn these skills through approaches like Intensive Interaction.
  • Developing play skills – Play is were children learn to share experiences and objects with others which is an essential learning skill. Imaginative play is also strongly linked to the development of something called ‘symbolic understanding’. Symbolic understanding is what ultimately allows us to realise that a collection of funny sounds (a word) relates to a real life object or action. Speech & language therapists help clients to develop interactive and imaginative play skills.
  • Alternatives to speech – Often, a speech and language therapist will recommend using a picture, symbol or object-based communication system for people who are not developing useful spoken language. For many people the Picture Exchange Communication System (PECS) is very effective but this does not suit everyone. A speech & language therapist will work with their client (and family) to establish a system that works for them.

Once spoken language starts to develop…

Autism brings with it idiosyncratic learning patterns and unusual language processing. As a result, children who are on the spectrum often have problems developing spoken language. Many young people with autism learn spoken language in chunks without breaking what they hear down into individual words and sounds. That means they can often repeat long chunks of favourite stories or TV programmes without really understanding what they’re saying or being able to use any of the words in the chunk independently. A speech and language therapist will help with all aspects of spoken language development including:

  • Speech errors – pronouncing words so that others can understand.
  • Learning and recalling vocabulary.
  • Putting words together to make phrases and sentences.
  • Putting sentences together into stories (narrative) to express experiences to others.
  • Understanding spoken words and sentences.
  • Understanding specific vocabulary groups. Many children with autism have great difficulty with time concepts, abstract language and vocabulary that depends on context for meaning.
  • Understanding language associated with reasoning skills.
  • Understanding non literal language like idioms, hints and indirect instructions.

Using language socially…

For many young people on the autistic spectrum, social communication presents a massive challenge. Speech and language therapists can provide help and support to help negotiate the social minefield under the following headings:

  • Self awareness – what are my hobbies, what am I like, what are my strengths and weaknesses…
  • Awareness of others – what do others like/dislike, what are their strengths and weaknesses, what are their interests…
  • Friendship skills – developing and maintaining friendships
  • Feelings and emotions – understanding the vocabulary of emotion, reading and using facial expression, reading and using body language.
  • Conversation skills – starting conversations, taking turns in conversation, staying on topic, how to change topics, active listening, ending conversations…
  • Assertiveness in communication – saying ‘no’, asking for help…
  • Developing self esteem.
  • Understanding and making sense of real social situations – SLTs can ‘coach’ young people through problematic situations using a variety of approaches like Social Stories or Comic Strip Conversations to break the situation down, see what goes wrong and provide corrective strategies.

Other bits and bobs…

Speech & language therapists can provide advice and support to help clients use visual supports like visual timetables or organisers to help them with organisation and planning of daily life.

Speech & language therapists who are autism specialists are often a helpful resource when a client is becoming aware of and learning about their diagnosis and what it means.

So, as you can see, there is a huge range of support that SLTs can offer clients who have a diagnosis of autism. There will be some things I’ve missed out but hopefully this post will give you a flavour of what an SLT can do for you or your child.

Why do you need to contact my child’s NHS therapist?

Before we start working together, I will ask for your permission to contact any other speech & language therapist that your child sees. Apart from being simple good practice, contacting other SLTs involved with a child is necessary for a number of reasons. Your child will gain a lot more from their speech & language therapy support if the therapists they see work together. A close working relationship avoids unnecessary repetition and allows (with your permission) information to be shared so that the most effective care plan for your child can be agreed.

It is also necessary from the point of view of assessment. Speech and language therapists often use standardised assessments to compare a child’s skills to the normal range of ability for their age group. These assessments and their results become invalid if they are repeated too often so it is important to know what has been done already and for me to let your child’s other therapist know what I have done.

What’s the difference between a delay and a disorder?

When children are learning language, they all make mistakes and these mistakes follow a typical or usual pattern. For example, almost all children try to make the past tense of ‘go’ regular by saying ‘goed’ instead of ‘went’. The usual pattern of mistakes is well documented and a speech and language therapist will tell you if your child’s language is within the normal pattern of variation or not.

  • A delay means that the child is making mistakes that are a usual part of development but at a later age than might be expected. For example, a 5 year old who says ‘tat’ instead of ‘cat’ would be using a pattern called ‘fronting’ which most children go through. Usually, fronting disappears by the time children are about age 3 1/2 so this child has a speech delay.
  • A disorder would mean that the child’s pattern of mistakes is not part of usual development. A child who misses out all consonants and only speaks in vowels (this does happen!!) would be experiencing a speech disorder because this is very unusual and not part of the typical pattern of development.

If your child’s pattern of mistakes is not within the normal pattern of variation, seeing a speech and language therapist for some support is important.

How often should my child have a speech therapy session?

There is no set number or length of speech & language therapy session that can be ‘prescribed’. The number and length of sessions your child requires will vary depending on a variety of factors such as the type of communication problem, how long the child can pay attention successfully, age, how quickly they learn, and so on… Speech & language therapists will therefore tailor a programme of sessions specifically to your child or the group of children they are working with.

The most important thing is following the advice of your SLT and doing any suggested activities regularly with your child. Individual therapy sessions are very important for learning new skills but new skills will only be remembered of they are practised often. After all, no-one expects to lose weight on a diet that you only stick to for an hour a week or to become a piano virtuoso by practising for 45 minutes once a week! Remember that you are essentially trying to break a ‘habit’ that your child has gotten into so it is better if you can make your speech & language therapy work part of your child’s daily routine so you replace the old habit with a new one. Your speech & language therapist will advise you on how regularly you need to do any recommended activities.