A humorous and educational look at speech pathology.

This was going to be a Facebook post, but it got very long for that, so forgive me if I ramble:

I’ve seen a lot of posts recently about pediatricians refusing to treat children whose parents choose not to vaccinate. The statements from the doctors have ranged from “sorry, but we need to look out for the well-being of all our patients, and we have many who cannot be vaccinated who we are trying to protect” to basically “eff you, you anti-science scum”.

At first, I was on board with the mentality that if you are unvaccinated by choice, your pediatrician is making a wise decision in excluding you from the practice (although I wasn’t really happy with the “eff you” presentation some doctors have – bedside manner is really important). After thinking about it for a while, I’m conflicted.

I agree that doctors have a responsibility to protect the unvaccinated-by-requirement from the unvaccinated-by-choice – I’d be super pissed if Dylan caught a disease she hadn’t yet been vaccinated against from an anti-vaxxer’s kid at her doctor’s office. But we also have to consider what we’re doing to the child whose parents choose not to vaccinate.

Everything that follows is based on the following beliefs/assumptions:
1. The goal of people who are pro-vaccine should be to get as many people as possible vaccinated rather than ostracize those who aren’t.
2. We should do everything we can to make sure a child doesn’t suffer from the sins of his or her parents.

Allowing pediatricians to bar unvaccinated-by-choice children from their practices does nothing to further either of these!
-If pro-vax pediatricians don’t see children of anti-vaxxers, they’re basically giving up on the possibility of the child being vaccinated. That may help at-risk children while they are sitting in their office at that moment in time, but the public health concern still remains – the unvaccinated children are still in the community and still likely to pass any vaccine-preventable diseases they have to at-risk children. Barring anti-vaxxers’ kids from the practice basically lets the doctor say, “not my circus, not my monkeys”. I don’t know if we should reward or accept that perspective.
-If pro-vax pediatricians refuse to see children of anti-vaxxers, these parents have two options for their children’s care – see an anti-vax pediatrician or seek no medical care at all. I don’t think either of these is desirable. An anti-vax pediatrician is likely to hold other views that conflict with medical/scientific research and put the child’s health in further danger, and no medical care is expensive to the child later in life *and* to us (because we’re likely to be subsidizing that care with either our health insurance premiums or our Medicaid taxes).

So if I’m saying that pro-vax doctors shouldn’t bar children of anti-vaxxers (and I hope I’m remembering well not to say “anti-vax children” because the children aren’t anti-vaxxers) from their practices, what are our alternatives?

First is persistence on the part of the pediatrician. Every time a parent brings an unvaccinated child into the practice (and I do mean every – this includes immunocompromised kids), the pediatrician should inquire as to why and do their best to get the kid vaccinated. For immunocompromised kids, this may not be possible. For kids who had a reaction to the vaccine, maybe there’s a new vaccine that the kid may not react to – but if you don’t ask the parent and just accept “unvaccinated kid”, you can’t know. For kids whose parents chose not to vaccinate, the pediatrician needs to engage that parent about the reasons they aren’t vaccinating (“I understand that you’re worried about the ingredients in vaccines – can we discuss which ingredients you’re concerned about?”) and educate and advocate with love and logic. And they need to do it at every appointment until that kid is vaccinated. If the pediatrician truly approaches the matter with compassion and parent gets still gets mad and leaves the practice, that’s unfortunate, but neither ignoring the elephant in the room nor banning the parent from the practice gets that child vaccinated. Persistent education and advocacy *might* get the kid vaccinated; telling the parent they aren’t welcome *never* will.

But what do we do about the presence of anti-vaxxers’ kids co-mingling with our unprotected kids in the waiting room? That’s one I don’t have a good answer for. Maybe pediatricians can have blocks of time where they only schedule anti-vaxxer kids and fully immunized kids (who, granted, don’t have guaranteed immunity, but have a much better chance than a 9-month-old infant or a third grader on chemo)? Separate waiting rooms for pro-vax and anti-vax families? It’s a tricky situation, I know. But I firmly believe that working it out to give these children access to quality medical care and their parents persistent reminders of accurate medical information regarding vaccines is both the practical way to peak vaccination rates and our responsibility as a moral and ethical society to make the most effective health care possible accessible to all children.

As part of my efforts to start regularly blogging again, I’m branching out a little beyond what games I use in speech therapy sessions and spending some space discussing why I use games in speech therapy. This conversation is going to occur over a few months, one topic a month, and will be rooted in my study of communication theory as well as my experience as a speech pathologist. I’m starting out with the theory that is something of the background of my perspective in both communication theory and speech pathology – Walter Fisher’s model of the Narrative Paradigm.

Prior to Fisher’s development of the narrative paradigm, research in human communication focused on logic. It assumed that people used rational argument and discussion to develop their beliefs and perspectives. As a result, communication relied upon developing knowledge and understanding and reaching conclusions based on that understanding that the way the topic was discussed – scientifically, philosophically, legally, etc.

Fisher found purely logical constructs of human communication to be too limited and inconsistent with how people actually behaved. Recent examples of human communication and persuasion – one notable example being the Daisy ad from the 1964 US Presidential campaign – didn’t use appeals rooted in logical or philosophical thought, and were extremely effective in motivating action. What these acts of communication did, Fisher argued, was appeal to a more fundamental nature in human communication – our nature as storytellers. Instead of placing evidence into a structure of logical arguments, people instead experience and interpret their lives and others’ as a series of ongoing stories or narratives, each with their own characters, scenes, and plots with beginnings, middles, and ends. Using the example above, the Daisy ad didn’t appeal to any sort of evidence to construct a logical argument. It created a powerful narrative that began with an idyllic scene of a young girl picking flowers, transitioned to a sinister countdown, and ended with a literal end – of everything – followed by a statement that not “standing together” behind President Johnson would make this dreadful narrative become reality.

Core elements of the narrative paradigm include:

  • Values/Beliefs – The narratives we experience throughout our lives define our values and beliefs. Additionally, values and beliefs we’ve already formed tend to influence which of conflicting narratives we accept or reject in the future. If my father was a hardworking electrician whose union membership allowed him to gain access to better wages and benefits, I’ll develop a belief that unions are good. If your father was an independent contractor who couldn’t find work because local businesses use non-union labor, you’ll develop a belief that unions are bad. Those beliefs will greatly influence whether or not we believe the conservative politician who says that right-to-work laws protect workers from union bullying or the progressive politician who says they’ll hurt worker wages and benefits, regardless of whether the statistical evidence supports either narrative.
  • Good Reasons – We develop our own “good reasons” for accepting and interpreting information and evidence in the manner we do. In contrast to evidence and logic, which are objective and the same for all people, good reasons are based on our own history, culture, and perspectives about the character of the others involved – measures that are more subjective and less completely understood by a communication partner. When a new student enters your school from a neighboring school or district, your opinion of the quality of the students’ goals is influenced by your previous experience with that student’s school and the service providers at that school, even though those previous experiences provide no actual evidence regarding the quality of this student’s goals.
  • Test of narrative rationality – When we experience a new narrative, we assess, and then accept or reject, that narrative based on the narrative’s coherence, probability, and fidelity. Coherence refers to whether or not the characters in a narrative act reliably or consistently – someone who is kind to his neighbors will be deemed unlikely to rob them. Probability Fidelity refers to accepting a narrative that matches our own beliefs and experiences – if our experience and belief is that there is no God, we are unlikely to believe a story of miraculous healing and instead search for a scientific rationale.

Where does Fisher’s narrative paradigm become useful to speech pathologists?

1. The narrative paradigm does much to explain why it’s difficult for the field of speech pathology to move from treatment and assessment based on anecdote to evidence-based practice. As the more natural communicative form, it’s difficult to switch from the anecdote to something more structured.

2. The narrative paradigm suggests that our clients will respond better to treatment methods that present tasks in the form of a narrative or require responses in the form of a narrative. By using a natural communication form, we are asking clients to take fewer steps in developing their communication.

3. We must be mindful of cultural and social factors when developing treatment plans. If we present treatment activities or assessment items that are outside a client’s values, beliefs, or experiences, they’re not going to do as well on them. This is why students in low-income urban areas tend to do poorly on the Understanding Paragraphs section of the CELF – attending double features at movies and getting positive attention from emergency workers tends to be wildly inconsistent with their experiences.

4. We need to acknowledge that, even in the face of direct evidence to the contrary, our predisposition to use “good reasons” is likely to influence our therapy or assessment decisions – and the input of other professionals. Considering the influence of these narratives is critical (and the narratives may not necessarily be wrong – standardized assessments frequently do not present information in narrative form or ask students to respond that way).

Using the Narrative Paradigm in Therapy

Many games I’ve suggested in previous blog posts either present information in narrative form or require students to produce narratives in responses:

Games that present information in narrative: Dixit (a narrative in image form is still a narrative), Telestrations, Snake Oil, Storyteller Cards.

Games that require a narrative response: Apples to Apples (a great example of how values, beliefs, and “good reasons” influence choices), Rory’s Story Cubes, The Storybook Game, Who Would Win.

I hope this brief exploration of communication theory was useful. This kind of blog post is new for me, so I’d love to hear any feedback regarding what could use better explanation or what portions simply weren’t useful to you. At the end of next month, I’ll cover another communication theory, and you’ll see a couple more posts covering board games between now and then.

-John

And I’m back after a long hiatus (major interferences involved a very interesting year or so at work and a baby).

This week, I’ll be looking at a party game that was originally released by Gorilla Games and now published by Gamewright, Who Would Win?

Description: In this party game, two players are each given a fictional or historical character (Darth Vader, Albert Einstein, etc). Then, a moderator reveals a card from an event deck (figure skating, gardening, pie eating, etc). Each player has 20 seconds to explain why their character would win at that event. The moderator chooses a winner, and players switch roles.

Variants: There’s an iOS version of this game. It doesn’t appear to be made by either publisher of the card game, so you may encounter different figures and/or events, but it’s the same concept.

Skill Supports:
-Comparison: Comparing two people is a fundamental part of the game.
-Agent/Action Relationship: This game requires students to synthesize at least the “who” and “what” of a scene, likely adding in the “how” and “why” as well.
-Inference: The game requires students to take a person they know something about and apply it to a context that the person (probably) isn’t involved in. How would Michael Jordan’s basketball expertise help him in a sailing competition? Does Marie Curie’s remarkable scientific mind help her sing?

Strengths:
-Supports wide range of players: If the clinician acts as moderator, this game can support as few as two players or as many as eight.
-Narrative comparison: Who Would Win taps into a skill that many speech impaired students have a hard time with – comparison – and approaches it from perspectives that almost all kids are familiar with – competition and storytelling.
-Easily adapted – If you’ve got lesson plans in advance, it is not difficult to modify the event deck or the character deck to include events or characters from your students’ lessons. Class studying civil rights for Black History Month? Forcing kids to think outside the box and explain why Harriet Tubman would beat Malcolm X at a science fair could help improve understanding of both iconic figures in US History. (And now I want to see the poster presentation for Tubman’s project, “Can natural terrain features be used to fool scent-following hunting dogs?”)

Challenges:
-Background Knowledge Required: If you don’t know who Albert Einstein is, you won’t be able to argue why he’d be better than anyone at sheep herding.
-Limited Time: Students who process information slowly or stutter will have difficulty with the 20-second time limit.
-Favoritism in Voting: The rules of the game ask all players not involved in the debate to sit on a “jury” of voters. There’s a significant risk for students who are not popular to do poorly regardless of what they say.

Accommodations/Modifications:
-Throw Away The Timer – Untimed response is usually better in therapy anyway.
-Player-Chosen Characters – If you don’t mind getting an in-depth knowledge of Miley Cyrus or Kim Kardashian (and honestly, if you did, what were you thinking working with kids?), let students pick their own person to argue about before introducing the event. Just be careful of that kid who can make Batman work for anything.
-Adapt to Curriculum – We discussed above the possibility for a custom deck for Black History Month. The same would work for a deck of characters (or events) based on stories read in an ELA class and events/characters in a social studies class, and you could even stretch to make event decks based on things like health concepts (who’s better at CPR – Benjamin Franklin or Lassie?).

Alternate Uses:
-The character cards can be used to create a “person-only” game of Apples to Apples, or even as a text-only approach to Dixit.
-The game in general can be played in the style of Apples to Apples, with the judge holding a scenario and each player playing the character they think would win. This would keep a greater number of students consistently engaged in the session.

Overall, this game is one of the strongest games for high school students with language impairments that I’ve encountered (and they’re a hard group to shop for). It’s also especially adaptable to general education curriculum concepts, which is important as more states adopt Common Core and SLPs are encouraged to push into the classroom. It’s not the easiest game to find right now, but if you can locate a copy, I highly recommend it.

-John

Wait… I have a blog?

Hey all,
It’s been a really long time since I made an update with actual content. Part of the reason for this is that I’m a lazy bum, but a bigger part of it is that I’m not doing much speech therapy at work anymore – I’ve taken on compliance and monitoring responsibilities at one of the districts my employer contracts with. While I totally plan to get back into the blogging habit – soon – right now my focus is on getting some new data systems up, which is really interesting only if you like spreadsheets and database management. I hope to have some speech stuff up soon (like within a couple weeks).

-John

As some readers may already know, I’m one of the co-authors of the Dysphagia2Go app by Smarty Ears. The app is a tool to assist SLPs in writing diagnostic reports for dysphagia.

I’ve just learned that the app is in the process of being translated into Portugese, and Smarty Ears is interested in translating the app into as many languages as possible. To do so, they need translators. Translators need to be practicing SLPs and will be compensated with a free copy of the app. Interested parties should send an e-mail to contact AT smartyearsapps DOT com.

-John

Today, rather than writing a post about a single board game, I’m going to write about a tool for creating games and therapy activities: Storyteller Cards by Jason Tagmire. The project is currently raising funds on Kickstarter (for people unfamiliar with Kickstarter, it’s a site where creators of small-scale projects can raise funds for their creative endeavors using a “crowdfunding” model instead of a traditional investment model – patrons pledge funds toward the project in exchange for a reward from the project creator, usually a physical product).

Storyteller Cards

General Overview: From the tool’s Kickstarter page: “Storyteller Cards is a deck of 54 playing cards that each feature 4 unique elements. There is a CHARACTER, holding an ITEM, completing an ACTION, in a LOCATION. Each of these elements can be used to create something new, get you out of a mid-project slump, or just to have some creative fun with family and friends. The cards also feature additional icons in the corners to help you dig a little deeper into storytelling, creating, and gaming. The icons represent a RANKSUITMOOD,SEASONLETTER, and COLOR.”

The cards themselves come with a Storyteller Manual that contains a number of games that are being revealed as the Kickstarter campaign progresses. Games described so far include Once Upon A Time (not the card game I discussed in an earlier post, but a Mad Libs-style story completion game), the Comic Challenge (a collaborative story-drawing game), To Be Continued (a story-building game in the spirit of the Storybook Game), Possibilities (a free-form card game where the players write the rules as they play), ChromaCards (a strategic crayon coloring game), and Short Stories (a game of my own design in which players use the elements of the cards to tell a story that resolves a storyteller-created conflict). There are still other games yet to be revealed, including  Director’s Cut (a game where the players create their own film using 8 cards from the deck). Some of the games work best with notepads that can be purchased with the cards, but they all work with only the deck of cards and the PDF manual that comes with the kit (some printing of worksheets may be required or desired).

Skill Support:

  • Vocabulary – There are very few games included with this kit that do not involve identifying at least one property of the cards, whether the character, action, setting, item, or something else.
  • Problem Solving – Most of the games (especially Short Stories) require the student to provide some sort of solution to a problem.
  • Narrative Sequencing – As the name implies, Storyteller Cards are primarily about storytelling, and whether you’re building a story with each card as a piece like in To Be Continued or Director’s Cut or using a single card to build an entire story like in Comic Challenge, building a cohesive narrative is a useful skill.

Strengths:

  • Flexible – Because Storyteller Cards were designed as a tool rather than a specific game, an enterprising and creative SLP can find ways to integrate them into most therapy contexts.
  • Low Literacy Friendly – Each Storyteller Card has two letters on it, and those letters are in a corner of the card. Having literacy skills is not a requirement for most activities that use Storyteller Cards.
  • Fun For All Ages – The activities in the Storyteller Manual are designed for students of all ages and ability levels. The project creator has used Storyteller Cards with his five-year-old daughter, and some of the games in the Storyteller Manual can be made complex enough for high school students.

Challenges:

  • Clinician-facing – As a tool rather than a game (although there are games included), Storyteller cards are exactly as useful as the clinician using them can make them. A creative clinician can make Storyteller Cards an indispensible asset, but one who is used to using prescribed activities may have difficulty.
  • Distractions – By design, there is a lot going on in each picture and on each card. A student that has difficulty focusing may have a hard time focusing on the card element that the activity is focused on.

Accommodations/Modifications/Alternate Uses: Because Storyteller Cards are a tool rather than a game, describing accommodations, modifications, or alternate uses isn’t really a thing here; the tool is designed to fit a wide variety of activities (especially in the context of language treatment). The Kickstarter campaign does have some add-ons designed to enhance the Storyteller Card experience (notepads to supplement games, interactive pencils, a deck of blank cards for Possibilities, and a print copy of the Storyteller Manual), but with PDFs included in the base pledge level, the add-ons aren’t necessary if you have access to card stock and a printer.

Obviously, I’m a fan of Storyteller Cards, since I contributed to the manual. I think that the toolkit does a lot to improve on and synthesize other games that I’ve talked about in previous posts, like the Storybook Game and Once Upon a Time (and one of the games that may end up in the manual was originally named “Dixit Done Right”). Once this game arrives (estimated ship date is November if the Kickstarter is fully funded), it will be a staple of my traveling therapy kit.

CONTEST! For the first time, I’m offering a contest through this blog. To compete in the contest, you must post in the comments section of this blog post a speech therapy activity using Storyteller Cards. To be eligible, the activity must include its target skill/goal/objective and a brief description of the activity – I’ll try to comment if I need more description. On June 8 (to give non-winners a day to pledge to the Kickstarter campaign), I’ll review all the eligible entries, and the best entry (totally subjective) will get a free copy of Storyteller cards once pledge rewards are fulfilled (estimated delivery November 2013).

-John

Disclosure: The author of this blog post is a contributor to the Storyteller Manual.

This week, I have a (relatively) brief post reviewing another Out of the Box game, Word On The Street.

Word on the Street (regular version)

Word on the Street

Variants/Expansions: There is a Junior version of the game, which includes simpler categories and tiles for the entire alphabet (rather than only 17 letters).

General Overview: Word on the Street is a word-based party game designed for 2-8 players of ages 12+ (8+ for the Junior version of the game). Players are presented with a category, name an item in that category, and move the letters used to spell that item toward them in a “tug of war” fashion. Once a letter is moved off one side of the board, that player (or team, if there are more than two players) claims the letter and it cannot be moved again. Once a player or team claims eight letters, that player or team wins.

Skill Support:

  • Category Identification – Players need to name items in categories to determine what words they’re spelling.
  • Spelling – Word on the Street requires students to spell the words out in order to know what letters to move.
  • Phonemic Awareness – As the students work to spell the words, they need to demonstrate or practice phonemic awareness skills.

Strengths:

  • Playable “Out of the Box”: This is a game that can be explained and demonstrated with less than five minutes of setup. Modeling game play is easy.
  • Variable Challenge Level: Younger students who have a hard time with spelling and/or vocabulary will only be able to create smaller words, but if everyone in the group is at that level, the game’s challenge level, by its nature, adjusts to meet the students’ ability level.
  • Multisensory: By physically move the pieces and saying the letter’s name out loud while doing so, a student who has difficulty with spelling or single-modality learning can participate in the activity using visual, kinesthetic, and auditory methods, helping to reinforce concepts.
  • Variable Participation: Because this is a game that uses teams, it’s possible to pair two younger or weaker students together against an older or stronger student (or the therapist), allowing the teams to collaborate to give everyone a chance to remain engaged.

Challenges:

  • Literacy is required: All the cards have words, and none of the cards (even in the younger versions of the game) have pictures. In addition, spelling the answers is a part of the game, so if spelling is hard for your students, modifications will need to be made.
  • Narrow scope: This game is rooted in naming and spelling items in categories. Unlike many Out of the Box games, there isn’t much variability in skills using the components in the box.
  • Team game: Because this is a team game, it isn’t as useful for individual therapy unless you participate at the child’s level, which can sometimes make note-taking difficult.

Accommodations/Modifications:

  • Therapist participation: The biggest area in which a therapist may need to participate or interfere with the game is to help with spelling. This can be done as a treatment activity by itself to work with phonemic awareness, or done entirely by the therapist to reduce frustration.
  • Heavy example use: Using one or two examples of an item that fits into a particular category can really help to jog a student’s memory if he or she is having difficulty.

Alternate Uses:

  • The board and letters can be used to add kinesthetic engagement for other tasks with single-word answers.
  • The category cards can be combined with a number of other activities to create an entirely different game that reinforces a wide variety of skills.

This game is narrow, but the inherent multisensory and multimodal use of the game’s components make it ideal for the skills it addresses. It’s more popular with my younger students than any other game that requires literacy, and the strategy of trying to think of words that use particular letters keeps older, more capable students engaged.

Has anyone else had experience using this game in therapy? How useful has it been? What other uses and modifications have you used?

-John

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