Have you ever wondered what “complex target selection” means in the world of articulation therapy? Kelly Vess breaks it down for us episode 40 of The Mindful SLP.  You won’t want to miss Kelly’s insights on a working with preschools to create maximal change, and set them on a path to life long learning. 

—– Useful Links —–

4-Step Process to Selecting Complex Targets

Speech Sound Disorders: Comprehensive Evaluation and Treatment  

Research Gate  https://www.researchgate.net/

Kelly’s Website. https://www.kellyvessslp.com/index.htm

Simple Tools: PROMPT Method and Complex Target Selection (or “Shoo Fly” Activity)

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Music: Simple Gifts performed by Ted Yoder, used with permission

Transcript

Kelly: Well, I love the questions you’re asking, because what we’re finding today, this is research that comes out in 2020, shows with childhood apraxia of speech, the more complex the target, the better the gains. Children with dysarthria, the more complex the target, the better the gains. Children with phonological disorders, the more complex the target, the better the gains. And children with articulation impairments, the children with R distortions, the better the gains.

And I’m going to tell you why I think, and I think that you would probably see the similarity coming from your prompt training, adding that to everything else, you know, is that now we have ultrasound research, and what we’re finding is these children that are so diverse in their etiologies, when you put an ultrasound on their tongue, it’s a motor movement and speech is like an instrument, it’s a highly complex motor movement.

Denise: Welcome to The Mindful SLP, the show that explores simple but powerful therapy techniques for optimal outcomes. I’m Denise Stratton, a pediatric speech language pathologist of thirty years. I’m closer to the end of my career than the beginning. And along the way, I’ve worked long and hard to become a better therapist.

Join me and I’ll do my best to make your journey smoother. I found the best therapy comes from employing simple techniques with a generous helping of mindfulness. Joining me today is Kelly Vess, an SLP and author of the book speech Sound Disorders, Comprehensive Evaluation and Treatment. Kelly presents best practice intervention seminars for Speech Pathology dot com, and the Bureau of Education and Research. You can find Kelly presenting research at ASHA’s annual conferences, all of which are freely available on Research Gate. Today, Kelly is going to share her expertise on how to select complex treatment targets to create maximum change in articulation therapy. Thank you so much for joining us Kelly. To start, tell us a little bit about yourself, your background, why you became a speech therapist and where you are now.

Kelly: Thank you so much for having me, Denise. I love your show and I love that your show showcases important strategies, and strategies that really, really make a difference. Uh, I’m so excited to be here because the strategy we’re going to talk about today makes a huge difference in speech outcomes.

So I’m so excited to share this strategy and the amount of change it’s going to create in the clients that we work with. Just a bit about myself. I have been working close to twenty years as a speech language pathologist, pediatric, uh, just as you have. And I do a lot of continuing education through speech pathology.com, the bureau of education and research, at state conferences, and also always at ASHA, you’re going to find me every year at ASHA. This year, I might have eight presentations. Well, so if you’re coming to ASHA, maybe we’ll bump into each other because I’m so passionate about it just as you are, is about the strategies and sharing the strategies that work. And what I love about your podcast is that you’re a creator, and you are not a follower. And you’re saying, you know, I’m going to take this and use this and make something better. So I liked that, I was listening to your interview with Douglas Peterson and I loved how you said, I create my own stories.

Denise: Theirs are great, but they don’t have enough of them. And some of them still too complex for really little kids.

Kelly: So, you’re saying, you know, what you’re doing is great. And I get what you’re doing, you’re doing the story grammar, and that makes a difference and you’re doing the multimodal queuing. And that makes a difference and the era of this learning makes a difference. And I can create stories that are really meaningful for my children that are three or for my children that are thirteen. I think as speech pathologists, so much more materials that come out today, take away the role of the speech pathologist being the creator.

Denise: Yes. Um, you can buy a lot of canned things, which…

Kelly: Yeah, and I really noticed that when I went to the teletherapy last season. And at first I thought, well, I’m just going to do what I do in person with pre-scorers(?), but we’re just going to do it through a screen.

And yeah, you can imagine how that worked. “But can you go catch, catch him again? Okay. Take him out from under the chair. Look at Miss Lily play with the toys.”

Denise: Yeah. Um, and boom cards are a big thing, but honestly, um, boom cards sometimes don’t really get to the root of the problem. So you’re, you’re kind of surface.

Kelly: So I kind of did a and, um, and we’re going to talk about the targets, but this is an example of that, where, um, I did a 180, so I thought, okay. I, I knew this is observational learning. This is not, hands-on learning that you do in person. And it’s really, really hard for anyone to, to do. And so I went into the canned programs, like you said, the boom cards, the blank, blank, blank.com, not to mention any names, but I felt like a dealer at a casino. There’s the bells, there’s the whistles. And you’re addicted to this and you’re doing it, and I thought this, this is scary.

Denise: Well, it doesn’t have the clients stop and think and process, right. It’s kind of just rote.

Kelly: We are agents of change and I felt, what am I teaching the children to pay attention to the screen? To respond to bells and whistles? So this isn’t what I’m here for. So, um, I did have to change my ways and create my own way. And that’s what I love about your podcast is that it says let’s create our own way.

Let’s do, it’s kind of a mastermind and it’s just like, this is what I’ve got and you bring so much to the table and let’s combined our minds and create something better. So that is a bit about myself and we want to get into the complexity of this. So as far as the complexity approach is concerned, I’ve been researching for about ten years with graduate students from local university. And I run a summer program with Wayne State University students. And what we do is we look at the detail.

And what we did with the complexity we approach is we compared, well, let’s keep everything the same and let’s compare to eliminate clusters such as the word slide, and let’s compare it with three element plus clusters, such as the word scrape.

And we randomly assigned the children to either two element consonant clusters or three. And what we found is three element consonant clusters produced much greater results. When we looked at children from diverse etiology, they may have had dysarthrias, cognitive impairment, autism spectrum disorder, phonological permit or distortion sounds(?).

So if we’re working on R, let’s not work on an R as a singleton sound or an as an R by itself, and let’s not work on it in two clusters, let’s work on R in three clusters and the word scrape when R the only error, we kept everything the same and let’s make it more complex and that makes a huge difference.

And even the research has shown if you’re doing less than perfect practice and you’re a drill and kill flashcard person, which isn’t me at all, you’re still going to get better gains if you do three element clusters instead of two. So that I feel so passionately, the research supports it, that the more complex the cluster, the better the gain.

We’ll talk about that first. Three, it’s just like poker, three trumps two, trumps one higher beats lower, later developing sounds beat lower. And we’ll talk in a minute about the exception to that rule. Okay. But when we look at, we’re getting back to these clusters, what’s interesting to me and it’s kind of like what you saw with Story Champs. Story Champs, they took something that you do in elementary school. They taught story grammar to preschoolers, but as you said, not just preschoolers with language delay, children with cognitive impairments, children with culturally linguistic, socioeconomic challenges and children with autism spectrum disorder. And they said, well, when you give these children this challenging material that’s traditionally taught at the elementary level, they all make great gains.

So when I look at this, I, I just another piece of information about myself that does impact my practice is I’m also a certified fitness instructor and a certified yoga instructor. So when we want to change the body, the mind is very much like the body. We need to challenge it. Challenge creates change. And especially if you’re a speech language pathologist, because you have 30 to 60 minutes a week and that’s it. So you can’t go easy or you’re not going anywhere.

Denise: There needs to be a framework though, to make the challenge accessible. So that’s what Story Champs does, right? Because, before I did Story Champs, I had done a few other narrative programs which were too complex. One of them introduced the complication at the very beginning, was the way you taught.

With Story Champs, you don’t introduce a complication in a second attempt right away, because that’s too much. So with everything we do, yes, challenge, but you’ve got to look at how am I going to make this challenge accessible to you? Because some things might be too hard for some clients that are not too hard for others.

Kelly: And that’s why we love Story Champs so much, is because learning story grammar is where the that’s like the three element cluster that is complex and they know that’s what matters. And as you said, keep you at 80% accurate. So you don’t drop the baby. You are going to provide that level of cuing, and as you said, slowly, fade it out.

And I think that Trina Spencer’s background, and I have some background in ABA and VBA, as a BCBA, really helped with that. And she’s bringing those principles of errorless learning as you talk about, I think it’s going to seep into other things we do in our field, which is, which is exciting.

Denise: A little bit about the research base. So you’ve done this research, but I’m sure other people have. Where did this complex target selection come from?

Kelly: Oh, yes. I’m so glad that you asked this question. This was from Judith Garrett out of, uh, University of Indiana. And what she did is she looked outside of our field just like Trina Spencer did. Trina Spencer looked at the field of learning and said, Hey, why don’t we take these principles and put them into speech pathology?

And what Judith Garrett did is she looked in the field of linguistics and she said there’s these universals in every language around the world in which children develop speech. And the first thing they develop is vowels and then stop consonants and then fricatives and then affricates and then two element clusters and then three element clusters.

So Judith Garrett said, let’s use this in speech therapy and why don’t we work higher on the staircase? And that will have a cascading effect in which those easier sounds, the stops, the fricatives, the affricates, will naturally develop because we’re working on clusters, we’re working at the stop, the top of the staircase, and that creates system-wide change.

And what she did is the problem was her numbers, her studies were, were big. She was saying the children that had these complex clusters, they made much better gains. Okay. But the problem is, is that she didn’t have hundreds of children, which is what you need for statistical support. And then there was another person, Susan Rvachew out of McGill University, she said the complexity approach is not empirically supported. And let me tell you why. And she gave one group of children an easy sound. and one group of children a late developing sound. And the children that had the easy sound made better gains, like a P, instead of the children that had the R.

Now that’s true. .My research shows the same thing. We are not nature. We do not change how sounds develop. We just make it go faster. So the problem was she was comparing a grape to a grapefruit. So the grape is P, P’s going to naturally evolve, that’s easy, right? You’re a speech pathologist. P, boom.

R, whoa. That takes time.

That research support, the research I do, is that earlier sounds will always develop before later sounds, always. So if I, when I do, if I have a vowelizer that’s going a a a a a, I typically start, I’m able to start with S W blend and what develops first? P B T D N M. What develops next? F B. Reliably, they go up. I’m not working on any of those sounds. I’m working on SW and they’re going up that staircase very quickly. And what takes a really long time? R. So explain that to parents, I’m like, this is like mountain biking and like go really fast. And then when you get to the top of the hill, I just braced parents for this. You got to get off the bike and walk up that hill.

Because it doesn’t come fast and easy because it’s so complex and it’s such a late developing sound. And so that, so that’s how it works. So it was false causation. What Susan Rvachew and her colleague Michele Nowak said, is they said, oh, look, look, look the P developed faster than the R. So the complexity approach doesn’t work.

And I’m saying, oh no, no, no, no, no, this, yeah. All you’re saying is the complexity of approach very much works. Uh, speech develops like teeth. The first thing that’s going to come in is, is, is the front teeth. And then after that, it, no matter what you do, dentists won’t change that. Then you’re going to have the lateral and then you’re going to have the canine stiletto incisors, then you’re going to have the molars. Speech is the same way. We are only nurture, a speech pathologist will not change how sounds develop. What my research has shown is the child that had the later developing target would have done way better on that speech than the child that had the earlier developing target.

And what I would find is I would say, well, the child they gave the R to, they can’t produce R after five sessions, but they can reduce P B T D N W. They can produce all of these sounds that I didn’t even touch. So that’s how it works. So there really is absolutely no research to against the complexity approach.

That is a case of, um, correlation is not causation.

Denise: And as a PROMPT therapist, which is a bit of a different approach. But I have to say, when we work on. vowel space and, um, rounding and retraction, jaw slide, all that, sounds emerged that we don’t even work on. So it’s a bit different, but with PROMPT I see the same thing.

I’ve had K and G I’ve had R emerge without even working on them. Usually the blends come in by themselves. But we choose movement targets not so much, but we’re looking at the movement to choose the targets, but it’s, uh, there’s a bit of connection there because when we address the thing that helps all sounds emerge, then sounds emerge that we don’t have to work on. So it’s really cool.

Kelly: Yes, that’s exactly. We’re talking about that cascading effect. I love Deborah Hayden. I’m such a fan of hers because all these children that don’t naturally develop speech, she came in and said, Hey, we can do something about. We, these are children that are going to need to feel it. And you’re going to need to use multimodal healing. The two researchers that I think changed the field of speech sound disorders the most would be Judith Garrett, but the other one would be Deborah Hayden with the multimodal.

Denise: We love Deborah Hayden.

Kelly: Yeah, we would, without Deborah Hayden, people would just be doing auditory bombardment and say, I’m just going to say the sound a hundred times and you do it, and then you’re going to learn that way, right? Uh, and so these are, these are people I really have a great deal of respect for that change speech sound disorders, where we can help anyone and everyone thanks to these ladies.

Denise: So what types of clients is this best suited for? I mean, is it to defer all articulation clients or is there a certain section that’s suited for?

Kelly: Yes, I like, I love, I love the questions you’re asking, because what we’re finding today, this is research that comes out in 2020, shows that with childhood apraxia of speech, the more complex the target, the better the gains. Children with dysarthria, the more complex the target, the better the gains. Children with phonological disorders, the more complex the target, the better the gains. In children with articulation impairments, the children with R distortions, the better the gains.

And I’m going to tell you why I think, and I think that you would probably see the similarly coming from your PROMPT training, adding that to everything else you know, is that now we have ultrasound research. And what we’re finding is these children that are so diverse in their etiologies, when you put an ultrasound on their tongue it’s a motor movement, and speech is like an instrument. It’s a highly complex motor movement.

Denise: Speech is motor. Yeah. That’s the, kind of the PROMPT tagline, speech is motor.

Kelly: You know, deborah, Hayden’s been saying this for about twenty years. It’s a complex motor movement. I think speech pathologists just like to simplify things, they like things in boxes and saying my phonological disorder, that’s a linguist issue. And this is a execution issue, dysarthria. And this childhood apraxic speech is just planning programming and they require different approaches.

Denise: It’s like this, my hands are interlaced. Listeners can’t see. But it is exactly like this, right? It’s all intertwined. Yes. You can look at someone who was largely motor, but once you get that well in hand, you’re going to have phonological issues.

So we got to find the best approach because they are, they are depressed in so many ways. Yeah. The best, the best, the fastest, the most effective approach, because it has affected so many areas. Every once in a while, have a client who is almost purely motor. Yeah, but not very often, not with it, not with the severe clients, who we want to get them reading and speaking and understanding and being intelligible.

Kelly: And that’s the thing. And that’s just like, Hey, if you can’t produce it correctly, it’s going to affect your perception. The neatest thing is, is now the ultrasound research is giving these children a voice because they’re finding in the children that have the distortion problems, the problem is they’re not complexly moving their tongue.

And when they look at children with phonological problems, they’re not complexly moving their tongue. If they’re looking at you on the childhood bricks of speech(?) are decidedly they’re all doing the same thing. They lack complexity in their tongue movement. And another thing that’s very important. It’s not about age.

So when they look at older, it’s the same story, I love that you’re getting this message out there because I think that people like simple and they’d like to categorize. And like say, well, you do this approach, minimal pairs. If it’s phonological. No. You do this and it’s articulated, you did this and it’s yeah. The, the maxims for best practice are for all children’s. So, and that’s what you find with PROMPT, PROMPT is something that is effective with all populations.

Denise: Yeah. Yes it is. When choosing complex targets, do you look at the client’s stimuability for later developing sounds? We might’ve already kind of answered this because you said, you said R takes a long time, so you’re not working on R if they can’t say R, but you’ve chosen another complex target they can meet. Am I correct in that, like an SW or?

Kelly: That’s a great question because the answer is, it depends. So suppose you have a child with autism spectrum disorder. That is the attention is about yea small, right? In, in the end, it is.

When I say yea small, their invidium(?) is not an inch wide where they like (makes unintelligible noises)

Denise: Oh yeah, yes, yes, yes. We all know that. We all know that child.

Kelly: We know that child. Well, I’m going to have that child. I don’t care if they’re speaking the Queen’s English. I care that they’re saying a paragraph. So I’m going to have that child say a paragraph of speech. Maybe it involves the word scrape sprays, and they’re saying it like (makes more unintelligible noises), I want to increase their attention. So there’s some children, I don’t

care about your speech clarity, but I care about the foundational skill of attention. Yes.

And what do you think happens when the attention improves?

Denise: They’re able to listen. And so as Helen Keller said, hearing children catch speech on the fly and they learn it and deaf children have to work so hard. Well, I was thinking as I was reading that, yeah, but not our, not our children with impairments and not our children with speech impairments in the phonological impairments, they do not catch speech on the fly, right? They do not catch those words, they don’t, they don’t catch the order of syntax. They just miss it.

Kelly: Yeah. Yeah. And I listened to another podcast of yours that you did with these sticky notes. Not to get off the topic, you got to move the sticky note. Like this is real, I like that. And so, uh, but yeah, getting back to the topic and that’s a whole nother ball of worms, but I work on the paragraph and they’re saying, scrape it to me, spray it to me straight up to me.

And they say it clearly, no, but guess what happens? Their speech improves, their language improves, their socialization improves, their executive function improves, and their vocabulary.

Denise: Because you were getting attention. So what I like what I like to call mindfulness. Yeah. You’re improving their ability to be mindful.

Kelly: Actually, to be honest with you, I wonder how much of the lack of joint attention is the underlying problem of attention.

And when you improve attention.

Denise: A bunch of, a whole bunch of stuff can happen when you improve attention. I love talking because if that comes off, you said it depends on the client, whether they can say those later developing sounds. So you’re targeting things just to get them, their attention going sometimes.

Kelly: Yes. You’ve asked, you’ve asked a very important question because, okay, now we’re talking about those children, but let’s talk about children have problems with R. Children that have problems with Rs, so we’re going to go through a three and I’m going to do the S Q U blends. So can you squeeze it to me please? I will shelf the R if with maximum prompts, I do not want to reinforce that. I do not want the child to say, you know, scwape and I’m like, yay.

Denise: Oh yeah, you don’t want to reinforce an incorrect production. Yes, I’m totally there. .

Kelly: Yes. Thank you for asking that questions, yes. Because practice makes perfect and practice makes an…

Denise: An errorless learning, so, oh yeah.

Kelly: Yes. And the keys(?). And then there’s another sound that I want to talk about, cause you, you brought it up, which I think has been important. I used to spend a lot of time on the K and G fronting when the children were three and I’ve learned if I work on L and R instead and let the, the maturation occur that K and G actually will develop on-

Denise: Their own. For the most part, for the most part.

Kelly: Yeah. For the most part, there is those exceptions that come along every few years. Uh, but yes, and that, and that has been a no more tears moment because yeah.

Denise: That’s great.

We’ll just let that sound happen. If you come to the point where you’ve done all this and a client is not stimuable for a sound, do you do motor things? What do you do? I mean, I guess PROMPT, I’m going to be looking at it from that perspective. But, um, I do a lot of stuff with R, because if I get an older client who I haven’t had from the beginning, and lots of times if I do PROMPT the R just comes, but I get so many older clients. Here we go, now we’re working on R and S. Does this, do you use this approach with them?

Kelly: I like what you’re saying, because I work on R when they’re three, uh, which has been really fabulous because I can, there, it’s not habituated yet, but I have worked with children. I noticed the difference when I when I, they weren’t mine and they came to me when they’re five and they haven’t worked on R yet. So it’s really habituated, and at that time I have found I have to maximum prompt it, but if I had them do angry dog teeth, like rrr, and they really stay with it, angry dog teeth and we say it slowly with our body to, and our fingers to and limbs like rrr, can angry dog I can get it, and I can keep it, and I don’t drop the baby. I will do maximum prompt the whole time they’re with me. And I’m going to ask if this is what you find happens, what happens is it’s not going to show on testing. On when I do the testing, I explained to the parents and that’s why I do do gradiations. You talk about that in other episodes to have a distorted R cause a W for an R is very different than a rotic R.

So I make sure to show the progress and I find that, and I don’t know if you find that it’s like a year later they have an ET moment. The ET moment is really just like, like they kind of own it. There’s an internal locus of control. And they’re thinking about it themselves and showing you I got it, I’m doing the angry dog teeth without any.

And like in the paragraph I work with children. I tell the parent like, look in the mirror when you see this paragraph and look at your mouth and how it changes when you say the word R. So you said, can you scurry? And they see their mouth looks like this. Or can you spray, or can you, so you’re saying jerr up and every time angry your mouth is doing something totally different when you’re producing the R.

Denise: Yes. For our listeners who can’t see, cause I can see Kelly, so, um, she’s got a big retraction, you know, when she’s going scrape her lips or pulling back and retracting. From my perspective, lots of rounding and retracting. And in some jaw grading of moving from different vowels is what builds complexity. That is what builds a child’s complexity to move their tongue in a complex manner is to a certain degree, learn how to move their jaw freely up and down and how to move their labial facial muscles backward and forward. So that’s kind of my little take on, well, why this works so well, these different words, is because I see a lot of rounding and retracting going on. It’s just like building the core muscles. If you’re going to do sit-ups and you don’t have good core strength, you’re just pulling on your neck, right?

Then you get a neckache and this is how I explain it to parents, well you build the core muscles, the sit-ups work like they’re supposed to, so I am building good vertical movement. vowels, good horizontal boot with rounding and retracting, and then the tongue can just do what it needs to do. Then the tongue starts making those complex movements. So that’s the way I see this complex target selection interfacing with PROMPT, if you will.

Kelly: Yes. I love that. And that’s exactly how I explain to parents. It’s funny that you do the same thing. How would you explain something so complex simply because it is complex to parents. And you’re saying we need to work from all angles.

Denise: Yeah, cause, cause we’re three dimensional, three dimensional beings. So our, our speech is three-dimensional, we’ve got horizontal, which is your jaw grading. And we’ve got vertical, which is rounding and retracting. And then we’ve got front to back anterior posterior, which is the tongue. And that’s the most complex of all the movements.

So, if you get the, if you get the other two movements going, then the anterior, posterior complex movements are gonna come in so much better.

Kelly: You’re making me drool because just like what happens in the body happens in the mouth.

Denise: So I have some preschool clients, they come in with like a lateral S or something, we get that fixed until it’s just a tiny little lisp, the tongue’s barely out. And I’m like, well, motor wise, I mean, I know you can do that perfect S, yeah, but should I care about this? Because they’re like, I don’t care. I don’t care about this. And it’s like, it’s too much for them to do that degree of self-monitoring. I don’t know if you’ve ever run across anything like that.

Kelly: And I think you bring up a very important point because what works for preschool is not the same as what works for elementary school. And a lot of my graduate students come in and they’re like, well, now it’s time for these preschoolers to self-monitor. So I’m not going to give feedback, you know? And I say, no, no, no, no, no. And I showed them, well, here’s the research. At elementary age they do that metacognitive stuff. But you see what the research says, at preschool age, the more feedback you give them the better if it’s objective. So I hear exactly what you’re saying.

Like, some people are like, well, now we’re supposed to fade it out. And we’re supposed to focus on knowledge of performance because I’ve been reading, you know, about motor principles and it’s like, and whether it’s right or wrong and they need to figure out why. And I’m saying no, and they’re preschoolers.

Right now all you need to tell them is nice big smile. I see your sparkly teeth. When you talk about that high level concept of self-correcting and self-monitoring, I really do see that as something that is elementary and (ahem), I don’t need to worry about. There is something I want to make sure to cover. We did research on all of the blends, and you can guess which blend is the most powerful and influencing other sounds, the S blends. S blends are in a hot spot in the mouth, neovilar(?) region in the mouth. They’re highly complex and they’re highly influential. So we have complete paired F blends, vilar blends, S blends, the Th blend, and how much gains are you going to get if you, if you choose these targets? Yeah, the essence, the life of the party, you’re going to get huge gains. If you focus on the S blends and the total dud is the Th blends. And I think that’s when we apply the principles of motor, the motor principles is the principles of specificity.

I’m saying it’s so different, sticking your tongue out. And we know that Europeans are like, I can’t, from Germany or like, I can’t do the T H sound. I’ve lived here 30 years. This is crazy. It’s so different from the other sounds in the mouth that it just doesn’t it’s doesn’t have influence. That’s the exception to the complexity rule has been the Th blends.

I just do not have the influence on other sounds.

Denise: So you did mention a form that our listeners could access for how to choose complex targets. How can we get to that or…

Kelly: I’ll make sure to give you the Google links for your show notes. I think you’re going to like that because the complexity approach is so simple. It’s just a simple four step process, from the book.

Denise: And so we’ll have links to your book, links to that form. And also for our listeners out there, um, Kelly’s provided a link to a video illustrating a graduate clinician working on complex target selection. So I’ll put that link in the show notes, but for our listeners there, can you just tell us what is that clinician’s goal? What are her goals for that session?

Kelly: I’m not here to, to help children speak the Queen’s English. That’s, that’s not why I’m here at the end of the day. I’m very crystal clear as a speech pathologist with every child I work with, it’s to develop an internal locus of control. I mean, you and I know the children we work with, they do not have a yellow brick road ahead of them. They are going to have to work harder than their neurotypical peers, we can’t take that away. Yes. And also by nature, if you’ve worked with Special Ed populations, a lot of your they’re more likely to have other cultural socioeconomic challenges on top of that. So the children that we work with are going to have to work harder, I can’t take that away. And what the research shows unfortunately, is that children with communication impairments, when they researched them and found them up longitudinally at 32 years of age, they believe that they do not have control over whether they’re successful in life.

So they ask them questions, what about your personal relationships? That’s out of my control. What about your professional relationships? That’s out of my control. What about raising your children? That’s out of my control. So if we want to really change lives, it’s about developing an internal locus of control in which the child, not you, the child, is the teacher. So when you see this video clip, you see that the child is prompting the child’s self, and this is very important using the fingers and using the limbs, but she’s doing the cues with the fingers in thems. And the reason it’s so important is because in the back of your head or head, we have the cerebellum, which is the little brain that is 99% of the neuronal activity in the brain. And it’s the CEO. It calls all the shots. That is going to make all the decisions. And in that cerebellum we have in the front of the cerebellum, you have your fingers. In the back area of the anterior cerebellum you have the limb movement, the arms, the legs, the gross motor movement in between that you had the tongue.

So if we can, what I found working with children who are pre-verbal with autism and the clip is a girl with autism, who I taught to talk to start with, if I can have her one thing that she’s cuing the K if she has her arm up, that’s one thing, I need the finger pointing, or the voice is not going to come. Because I needed to light that cerebellum up like a light ball, right. So the girl’s holding her arm up, pointing her finger and outcomes the voice. Huh? Huh. And in the beginning, as you were saying, it’s just, uh huh, I’ll go for that.

Denise: Yeah.

Kelly: So I’ll take that. So what you’re seeing in there is she is the teacher, the girl, the most important the quip with your(???) is you’re the teacher. And what, as you said, we’re gonna fade out, and at first we’re going to stop talking and she is the teacher. You’re saying there’s no, we’re going to put our hands together and you’re doing it on your own. Uh, not when you’re in trouble, but you’re also going to see in the video, she’s saying, what is the goal? The goal is that she put ins(?) SKR blends at the paragraph level, provided dynamic tapper from her(?) doing. What is she working on in there? She’s working on language. She’s saying a paragraph. She’s working on tier two vocabulary first then lastly, because those words that are bold. To, to make change. She’s working on improving her attention for longer periods of time. She’s working on executive function and dithering(?) was a problem, which I’m seeing more of. I don’t know about you, more executive function issues. And I think it’s electronically related. Yes.

Denise: Yeah. So for our listeners here, Kelly is showing us, and you’ll see when you watch the video, but the clinician has, a tactile, a symbol for problem, and talking about the problem. And she’s also working on balance, I thought.

Yes. So, so the sensory motor is getting engaged, which I love because yes, kids need to move their bodies. Yeah, and also as part of the executive function, which yeah, I think it is she’s um, visually recalling what she just did. So she’s got this checklist, the clinician has her mark off the item she retrieved.

You know, she’s a way to remember and to improve memory that this is what I just did. I’d love that. Absolutely love that approach. And I do a little bit of that in a different way to help kids remember what they did, because if they can’t go out into the waiting room and they have no clue what they just did, or they have a clue, but they can’t communicate to their parents. You know, uh, I like them to be able to a way to build that memory and start to be able to say, this is what I did.

Kelly: Yes. And I love what you’re talking about with the body, because children with autism, 80% of them have movement disorders in their body. And what is really totally unacceptable is they’re no more likely to receive physical therapy, physiotherapy, movement therapy, then their typically developing peers and to me, that’s totally unacceptable because these are the children that can’t talk. If I look at the children I’ve worked with, and I’m sure it’s the same case with you, who have not developed speech, these are also the children that are lying on the ground, unable to get off the floor. These are children that can’t take three steps independently from point A to point B .Their motor, their foundational skills are so poor in their body…

Denise: Like core strength. They don’t have core strength.

Kelly: The core develops first. Then the gross motor, you become prompt. Lastly comes the speech. These kids don’t have wings. These kids can’t fly.

And what do some professionals say? If the child has a cognitive impairment, no, the approach has a cognitive impairment. This child does aim at core strength, and we’re going to teach this child to talk. This is, and, and we do know the children, these children benefit immensely from physical therapy. Why are they not receiving this therapy? It’s just, it’s, it’s unethical, it’s inexplicable, it’s illogical. Um, it’s I, you think that a lot of people think because the autism advocacy is so strong that these children are being served, they are being so underserved.

Denise: Yeah. So with people not realizing the sequence of development and what they need, it’s really important. Let’s look at the sequence of development. We can build in a lot of, um, motor movement into our sessions, you know, if we think about it and just realize that there’s a reason for that, and there’s a benefit for that. So thank you so much for joining us on The Mindful SLP, Kelly. So besides Research Gate, where can our listeners find you?

Kelly: Oh, I’m at Kelly Vess slp.com. And there’s a lot of free materials there that I just put up. And, and like I said, I think that the book is pretty amazing. Uh, what I like about the book, I, it reminds me of your podcasts and that is a mastermind format. It says here in the book, it’ll say this is an evidence-based activity in video.

And then the reader watches the video, they critique it and then they’re guided through to do it better. So it’s just, it’s, it’s kind of reminds me of your podcasts and why I like it so much as you put their minds together and you create a third mind that is even better than what you bring to the table, what I bring to the table, there’s something bigger than us.

Denise: Well, that about wraps it up for today. I want to thank Kelly for joining us. This has been an awesome discussion on how to choose articulation targets while boosting foundational learning skills in our clients. Be sure to check out Kelly’s book, Speech Sound Disorders, Comprehensive Evaluation and Treatment.

I’ll put the links in the show notes fore her book and her website. This discussion has motivated me to make a Simple Tools video that shows how I use complex targets while I’m using the PROMPT method. A link is in the show notes at SLP proadvisor.com/blog/40. Once again, that’s SLP proadvisor.com/blog/40.

We’ve got a lot of great topics coming up this fall on The mindful SLP. We’ll be talking about fluency and about getting young clients ready for narratives to name just a few. Thanks for listening and join us next time.

Dan: Thanks for listening to The Mindful SLP. We invite you to sign up for our free resource library at slpproadvisor.com slash free. You’ll get access to some of Denise’s best tracking tools, mindfulness activities, and other great resources to take your therapy to the next level. All this is for free at SLP proadvisor.com/free.

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