Mommaknows

 ​​Speech Therapy Ideas
for Children and Adults

​​     Cognitively Based Approach to Functional Language Therapy- Working with Adults

       A cognitively based approach to language rehabilitation has been shown to improve communicative outcomes for those who have been impacted due to accident or disease, by developing communication strategies to facilitate functional communication. (Cognitive/Linguistic Strategies Across Aphasia Types,  Sonal Chitlis IFNR 2015,MET Mumbai India) These might include writing/drawing, gesturing, using an AAC, or a combination of these items.  Keeping in mind that the ultimate goal of therapy is to improve functionality of the client as much as possible, there are several parts to an effective therapy plan:

1. Fostering conversation using what ever means necessary, (writing, gesture, pictures)

2. Stimulating language via all modalities (visual/writing,drawing auditory/ phonemic/intonation; tactile/prompting/gesturing, cognitive memory/attention/experiential)

3. Improving oral motor range of motion, increase tactile feed back for  phonemic placement,  eating/swallowing while normalizing muscle tone and teaching relaxation techniques, (ba,be,bi,bo,bu or bat, bet, beet, boat, boot, I like to use real cv words with my aphasics to help them link the sounds to something cognitive..sometimes they are daunted by the cv’s alone)

4. Developing pragmatic skills to improve communication independently, practicing functional activities such as using a phone, ordering, making appointments, greetings, reading the newspaper, writing on a calendar, signing or filling out forms, using a cd player or any device they might use for music or books on tape.

Along with the goals we establish for our clients, we must always be evaluating their behavior and trying new materials while varying activities to facilitate language. Each client is unique, so we learn to be good observers of behavior and good listeners of the sounds our clients are making as approximations to their communication. During diagnostic therapy, which is often a part of the therapy plan, I look for the modality that can serve the client best. For clients with progressive disorders particularly, regular assessment of function is critical. Again, a good clinician is a good observer of both the client and the clinician’s behaviors.  At no time do I continue to frustrate the client.  Stress reduces the chances that they will succeed. We reinforce communication approximations by affirming their productions and confirming their utterances.
            
Even if you have been in practice for many years, it is good to reorient ourselves to these objectives. 

The concept of establishing a Cueing Hierarchy:  In order to organize the therapy objectives and cueing types for gradual independence, I developed a chart for as a “Cueing Hierarchy” with  stimuli and behaviors as if placed on an imaginary linear continuum, from easy to hard and from simple to complex.
        Check out the table in the Tips for New Clinicians Page .


As we converse with others, we derive cues from the environment and from our audience. That is part of the reason why conversation amongst the adult neurologically language impaired looks better than when we test them by looking for specific words and longer utterances. Our goal { to establish a starting point on a Cueing Hierarchy} is to outline the steps we may use to develop SELF-cues and elicit more independently generated functional language.

When the client leaves the therapy room, we want him/her to be able to use their own skills as much as possible, rather than rely on others. Since they may not be able to independently develop their own means of self-cueing, we include self-cue skill development as part of the therapy plan. The client may or may not have the ability to provide his or her own cues, yet. But throughout the therapy we work with the clients’ unique ways to use self-cuing strategies, such as writing, gesturing, drawing pictures, pointing to pictures on an AAC and talking about the item or activity with words that are available.

During our diagnostic phase, the clinician first guides the client to use the above means of self-cuing. If the client can write or figure out the word with categorization the clinician will cue the strategies the client can use "think about what you use it for” (categorization) Show me how you use it (gesture,) What letter does it start with or can you write the word?(writing). Most of the time, these “strategies” need to be taught and practiced with the client. They do not realize they're are actions they can do already!     Once the client is familiar with these strategies, they will begin to use them if practiced.   This  behavior begins to form new neural links even if the link and resulting response is slow at first, it is a link that the client is developing himself.

This is “Neuroplasticity” at work. (“Harnassing Neuroplacticity for Clinical Applications”, DOI: http://dx.doi.org/10.1093/brain
/awr039 1591-1609 First published online: 11 April 2011)

The more links / memories there are for any word, the more likely the client will be able to get to them because if the direct route isn’t working, they can learn to look for the other still intact “visceral” links.   Relinking  these words with experiences can cooperate with repetition for the word, depending on complexity and abstraction.  If you look at the graph, you can decide where on the continuum, the client falls and what would work to achieve more independent communication. However, people have unique language abilities after CVA,TBI, PPA and abilities may be scattered. 
The goal of therapy should be to find the functional key to unlocking and maximizing their functional language abilities.