SIM IMULTANEOUS PROCESSING OF IN INFORMATION TO ACHIEVE AN OUTCOME = WORKING MEMORY E.g.: a dictation exercise Can you get a quick snack for lun ch from the tuck shop with your cash ? Teacher’s aim: assess effective carryover of spelling rules. For the child with WM challenges: complex task (analysis, synthesis, LTM, WM, STM) • Child must hold the target phrase or key words in head. If the teacher repeats the key phrase a few times, may serve to confuse the child with WM challenges, either leaves out words or repeats words • Try and recall sound patterns or spelling rules (‘married couple’, is it a house word?) from their LTM • Must remember their diagraphs (sh, ch, th), blends, capital letter at beginning, question mark at end.
Working Memory is like A MENTAL WORKSTATION - a temporary storage for the active manipulation of information to complete a mental operation e.g.: asking directions at a petrol station (have to visualise where the petrol attendant is telling you to go, have to verbally rehearse what he is saying in order to HOLD onto the information accurately and to keep it in your WM. W.M. has… - small capacity (bet. 5 & 7 items). If overloaded, will collapse. - holds information for a short period (to increase the time period, has to verbally rehearse the key information). - Information cannot be delivered too quickly – auditory bombardment (system will collapse) - Hold and manipulate information - Successful WM – dependant upon one’s attention and requires MENTAL EFFORT (active processing)
• Children with WM deficits: WORKING MEMORY – KEY - Fewer strategies to assist them AREAS to hold onto the information in the WM for long enough for it to be useful. - • Temporary • Limited Capacity • Holds Information • Have to manipulate the information • Process (active effort)
So, where does it all go wrong…. LTM→ WM The information from the LTM can’t be kept in the STM → WM WM long enough for it to be organised or communicated effectively – an activity like speech, But the information decays too quickly, then writing, drawing… the child cannot recall specific details. e.g.: knife boat pen sack = night bone sack output can be jumbled (poorly sequenced) – animals → amimals Or lost from the WM (leaves child feeling ‘it is on the tip of tongue’ phenomenon). Child may be able to recall target information later because they can suddenly retrieve from their LTM. N.B. for storage and retrieval of information from LTM
How to recognise the AT RISK child in your classroom… • Inattentive (is this more APD or more of an attention deficit or a combination?) • Easily distractible (is it age- appropriate?) ‘You must be interesting to keep them interested!’ • Always looking blank? Asking ‘what’ or ‘huh’?? • Mishearing words (night vs. knife) • Misunderstanding instructions – poor comprehension in general. Is the child an ↓ OBSERVATIONAL learner? Language processing or APD? • Limited pragmatic communication skills – struggles to ‘read’ social cues (facial expressions, body language, reading between the lines, takes everything literally). Often have no friends –considered an ‘odd child’ • Performance ↓ cognitive potential • Struggle to work/focus/understanding within a NOISY environment • Present as GLOBALLY IMMATURE children • Poor CONCEPTUAL thinking – very literal children
Strategies to assist… - repeat the information (auditory rehearsal – silently or through subvocalization) – helps to keep the information in the WM for longer so it can be effectively transferred from the STM → LTM (like rehearsing a cell phone number until it has been effectively carried over into the LTM) WM deficits – these children present with a LIMITED CAPACITY in terms of their PHONOLOGICAL STORE i.e.: can recall short simple sentences effectively ‘Show Jimmy your picture’ Vs. ‘Remember chapters 5 and 6 in the History Book will be on Friday’s Quiz’ = ‘chapter 5 and 6 will be in the history quiz’ SO… BOTH the LENGTH & COMPLEXITY of the memory string can cause information to be lost.
FACT: children with APD’s have smaller than average sequential memory capacity (usually assess that using the digit span or the word span tests) – may only be able to recall 3 -4 items correctly. Learners in your class with limited WM capacities?? Need to alter MODE of delivery! HOW?? • Breaking instructions into shorter, more manageable chunks • Shorter more concise instructions (not too wordy) • Too much information too quickly → auditory overload → au auditory ry bom ombardment ** ** • Can an ass assist by y wri ritin ing key facts (p (page numbers or or exercis ise numbers) on on th the board
• Children with WM deficits are vulnerable to MEMORY IN INTERFERENCE - the information is interfered at the INPUT stage as the child CANNOT pay sufficient attention to the actual incoming stimuli - hence FAULTY information goes to… STM WM LTM
Why is Pace of Presentation so important? Information can be interfered with once it reaches the WM: • being crowded by more REMEMBER: incoming information - APD: many have a WM (AUDITORY BOMBARDMENT) capacity that is SMALLER than average and processing speed that is SLOWER.
STM (information overload – exceeds child’s capacity) WM (information transferred to WM either inaccurate or incomplete. But BEFORE information can be transferred to the LTM, MORE information is incoming – EXCEEDS WM CAPACITY-vital information is lost) LTM (what is transferred to the LTM is faulty, bitty, complete or the system shuts down – child gives up in exasperation or tears)
Well-explained in GATHERCOLE & PACKRAM-ALLOWAY (2008) in what they refer to as the PRIMACY EFFECT vs. the RECENCY EFFECT. E.G.: if I present a 7 item list to a So…. child and ask them to recall them Theoretically, best items recalled (the average WM for an adult is 7, were the first few as they were give or take 2) and we can usually successfully transferred to your hold into the information between LTM (so PRIMARY EFFECT) 15-30 seconds. and … the last few items as they were Let’s test the theory! technically still in your WM (hence RECENCY EFFECT)
Why is faulty information arriving? Auditory Bombardment ….yes And….NOISY CLASSROOMS WHY DOES A NOISY CLASSROOM AFFECT THESE CHILDREN MORE? • Weaker auditory figure-ground (so struggle to filter/discriminate between relevant from irrelevant information) → FAULTY in information arr arrives at t th the STM • To o ach achieve better filt filterin ing, g, ch child ild needs to o FOCUS more OPTIMALLY upon th the tas ask (an (an im impossib ible tas ask for many of of th these ch child ildren as as th they of often have a a concomit itant ATTENTION ch challe lenges • SO…..
F.M. SYSTEM (Frequency Modulation) • Allows for a direct, intense auditory signal free from competing This is is is sp specific icall lly for ch child ildren who background noise (ideal signal to str trugg ggle le wit ithin a a nois oisy envir ironment with ith noise ratio). poor fig figure-ground an and poor au auditory ry dis iscrimin ination. • Long term studies have shown- a year after using such a device that even when not using the device, that Teacher wears a a Micr icrophone an and a a speech perception improved even tr transmit itter → signal sent directly to a when device was not being used. wir irele less receiv iver worn by y th the ch child ild. • BUT… • Isolating – a microphone must be passed around the class during class discussions or switched off • Teacher must remember to switch off during 1-1 with other children
Multisensory Approach…Dr. Erica Warren TACTILE KINESTHETIC VISUAL AUDITORY There are two types of Kinaesthetic learners Visual learners learn Auditory learners tactile learners: need to move their optimally through understand 1. Some touch objects bodies. Activities and observation. They like information best or manipulate movement help them to see visual stimuli through listening objects to engage in such as tables, graphs, 2. Others find that information. and pictures. Some taking notes or drawing helps to also have a strong encode information capacity to visualize. TOUCH SEE MOVE LISTEN
SEQUENTIAL SIMULTANEOUS REFLECTIVE LOGICAL VERBAL Sequential learners like The simultaneous The reflective learner Verbal learners like to informational to be learner wants to see needs to think about think aloud. They need presented in a series of “the BIG picture.” it’s and analyse material to talk about their steps or specific order. important for that they encounter. thoughts and academic information to be They like to think things material to themselves related and connected. through and create and others. concepts or models. THINK ORDER CATEGORIZE SPEAK
INTERACTIVE INDIRECT EXPERIENCE DIRECT EXPERIENCE RHYTHMIC MELODIC The interactive learner The indirect experience The direct experience The rhythmic learner is needs to work with learner enjoys vicarious learner wants to inclined to think in others. They like the experiences. They acquire encounter or practice rhythms or patterns. They company of others while knowledge from the what they are learning. respond to music – either learning and processing shared experiences of They prefer hands-on appreciating or criticizing information. others. experiences that allow what they hear. They may them to interact with the walk to a beat and some material. find that music blocks distractions. DEMONSTRATE COLLABORATE DO TEMPO
The theory suggests that when information is received through several senses at the same time, the CENTRAL EXECUTIVE organises and then stores this information in several places in the brain. To facilitate the transfer of information from STM →LTM involves the use of many different senses (simultaneously)
USER FRIENDLY TIPS… Be Dynamic – VARY intonation patterns, facial expression, annedotes … “you must be interesting to keep them interested” Provide a brief summary of your expectations “firstly, you must complete…, and then ….” PRE-TEACH CONCEPTS -introduce new concepts (more/less/top right/centre vs. middle/half/double/equal…
Over learning… e.g.: if doing minus sums, do many BUT use a different language, etc. - Mrs. Jones has 15 brownies. Her children eat 6. - How many does she have left? - Sally has 26 balloons. 6 pop. How many does she have now? - What is 5 less than 21? - Lindiwe has 13 goldfish.4 died. How many goldfish does he have? - 23 minus 7 ? - 20 take away 3? - What is the difference between 5 and 17?
Children with APD challenges do NOT have global learning challenges. Traditionally, in subjects that have fewer language demands, like IT or Maths or Maths Literacy, they tend to cope a lot better. I.e.: they can present with an uneven academic profile.
A number of Models of Memory have been proposed and refined over the years which provide some insight into MEMORY, and where the breakdowns occur and how these breakdowns impact upon the learning process in general… INPUT/ OUTPUT MODEL OF MEMORY LTM INPUT WM OUTPUT STM INPUT OUTPUT MODEL OF MEMORY (Kelly & Phillip, 2011)
Information comes into the STM (presented either visually or verbally) – learner holds onto to for a few seconds (repeat the sequence) to use in WM (like performing mental calculation (BUT, if you have a deficit in WM PLUS no strategy to keep information ‘alive’ in WM for long enough, information decays too quickly before the information can be transferred to LTM for permanent storage or what is transferred is faulty information.
SIMILARLY… If information is retrieved from the LTM but cannot be kept in the WM for a long enough time period (again, poor or ineffective strategies) so it is not optimally ORGANISED OR COMMUNICATED EFFECTIVELY • Jumbled, poorly sequenced work – creative writing ( Target word = taxi : ‘ I went Ana and David sleep ’ – did not even use the word taxi in his sentence – grade 1 child) (Target word = quick : ‘I went to the shop quick then I need good lunch’ (grade 1 child) (Target word = tuckshop : ‘I spent my money on the bank all day at tuck shop’ (grade 1) (Target word = wind : ‘The wind got my car and dad and the wind went off’.( grade1) • Information lost from WM (‘tip of tongue phenomenon’) • Writing a test or recalling specifics in a recipe (you know it… just can’t recall in the moment… a couple of hours later, you remember it!)
WORKING MEMORY MODEL OF Gathercole & Packiam-Alloway, (2008) CENTRAL EXECUTIVE VISUO-SPATIAL VERBAL STM STM
This WORKING MEMORY MODEL (GATHERCOLE & PACKIAM-ALLOWAY) demonstrates how information flows in TWO directions from the CENTRAL EXECUTIVE to both the – VISUO-SPATIAL STM & the VERBAL (ARTICULATORY/PHONOLOGICAL LOOP) STM, but there is no direct link between the V-S STM and the Verbal STM. • CENTRAL EXECUTIVE – controls your attention & is involved in higher order mental processes. E.g.: Child experiences challenges processing rapidly presented visual information, so inaccurate information is taken into the V-S STM so faulty information is sent onto the Central Executive.
In Gathercole & Packiam- Alloway’s model (2008), they propose the following breakdown occurs… Rapidly presented visual information So, how does this present itself… • Letters in words are stored in the incorrect sequence or sequence deleted Over bombardment – system fails Said → siad; does→dose ; friend→fend ; went →wet • Confusion with letter orientation – Inaccurate information →V -S STM p/b/d = bed →deb or jug →tug • Confusion with words of similar shapes Faulty information sent onto CE→LTM for Shop vs. stop, was vs. saw, on vs. no, storage growled vs. ground (effects whole word recognition)
Essentially the same model applies to AUDITORY PATHWAY (temporal processing challenges) if the child is experiencing problems processing information accurately from the VERBAL STM. Temporal processing challenges – So…how does this present… inaccurate information from the • Sounds are mis-sequenced (swim → VERBAL STM ‘ siwm ’) • Child relies upon phonetic spelling for sight words (after → ‘ arefter ’; what → ‘wot’) Faulty information → CE • Difficulties discriminating between similar sounding words or between the short vowel sounds or long vs. short vowel sounds: Thus faulty information stored in LTM with → ‘ wath ’; will → ‘wall’; make → ‘ mack ’
CENTRAL Baddeley’s Three Component Model of WORKING MEMORY EXECUTIVE (2003) VERBAL EPISODIC VISUO-SPATIAL articulatory/ BUFFER SKETCHPAD phonological loop VISUAL SEMANTICS EPISODIC LANGUAGE LTM
With different types of learning experiences, children can draw upon different types of memories to assist them. • EPISODIC MEMORIES - memory for something we have actually experienced (beach sand on a hot summer’s day or the chill of the air when snow skiing) – learning through personal experiences • SEMANTIC MEMORIES - this is the automatic recall of information – stuff we know rather than we have to rely upon our memory banks (colours, shapes, fruits, date of birth…) • AUTOBIOGRAPHICAL MEMORIES - memories from a special event or an experience that has a particular emotion attached to it or reference (the birth of your first child or the first time you scored a goal in a soccer match) – specific milestones These types of memories assist the learner in actively engaging in the learning processing – these types of memories are often a strength in children with both Dyslexia and APD.
Baddeley then revised the earlier model of WM (initially the CE controlled both the VISUAL STM & the articulatory/phonological loop (VERBAL STM). Baddeley then added a third component – the EPISODIC BUFFER (which explains how our memory for experiences to stored) This EPISODIC BUFFER then integrates VISUAL, SPATIAL & VERBAL INFORMATION within TIME SEQUENCE (like a memory for a story) This EPISODIC BUFFER allows to REMEMBER events that we have experienced because it is assumed to have links between the LTM & SEMANTIC MEANING. The EPISODIC BUFFER is thought to hold MORE information that can be held in the PHONOLOGICAL LOOP (almost like temporary long term store). So, we can remember what we wore 3 days ago or what we had for dinner on Monday night (but after a while we forget those details).
BUT, if the event had some emotional relevance (like what you wore to your Graduation Ball) – that is stored more permanently in your LTM (known as AUTOBIOGRAPHICAL MEMORIES). Essentially PERSONAL EXPERIENCES (like traveling or physically doing something) Acquire a wide range of FACTUAL KNOWLEDGE about the world Information is stored in the SEMANTIC MEMORY (more permanent)
Baddeley depicts the LTM as a more CRYSTALLISED system (more stable, unchanging) but the STM as a more FLUID system which can be altered in terms of capacity and the length of time material is held. MULTISENSORY teaching is a KEY strategy to assist with the retention of information in the STM WM LTM
When information is received through several senses simultaneously , the CENTRAL EXECUTIVE organises and then stores the information in several places in the brain at once. TACTILE MEMORY VISUAL MEMORY Somata-sensory cortex of the Stored in different places within the right hemisphere (for objects, Parietal lobe faces, spatial positions) AUDITORY MEMORY Left parietal lobe
Children with WM challenges and with APD’s in general have a few COMMON TRAITS… • POORLY ORGANISED • INCOMPLETE TASKS - ensure that homework is written down - a combination of their slower pace, forgetting part of the instructions, - show them how to plan ahead for difficulties with the actual processing of projects/tests/assignments – use a the instructions → these children are month planner on their desks – a visual easily overwhelmed. depiction of what is happening in the month ahead - easily side-tracked (colouring in or the drawing of a picture thus forgetting - parents can assist by writing up a key task) daily programme and placing on child’s work board (what to pack for each day, - task avoidance (put off doing tasks etc.) that they perceive as being too challenging) - leave books at in the classroom or at aftercare…
Reading can become very effortful – ‘barking at the print’ – laboured and thus limited reading for meaning. Word for word reading… miss out on the pleasure of reading. Games to develop memory skills – improve knowledge of sight words. Play MATCHING PAIRS – sight words are written in pairs onto identical pieces of cardboard and placed up side down in rows between the child and therapist/parent…each person has a turn to pick up 2 cards, must read what is on the card – aim is to find the matching pair. Winner has the most matching pairs.
Make and play an adapted ‘SNAKES & LADDERS’ game. Make a HUGE snake and divide the body into various segments. Into the segments, write the key reading words (house, horse, purple, people, who, what, how, now, no, know, where, were…). Add a few ladders & snakes, a dice and a couple of counters and you are ready to go… AIM: to improve the child’s visual store of sight vocabulary → better fluency on the high frequency words→ improved fluency → better overall reading for meaning.
YES/NO reading game. This assesses: - reading for meaning - word attack skills - effective carryover of knowledge of the sight reading words - plus a few phonetically spelt words that they have to visually decode and auditorily encode - all in a ‘game’ format TARGET WORDS ARE SELECTED FROM THEIR LIST OF READING WORDS… - Can you park a bus in the street? Y/N - Is a caterpillar a good pet to keep in a box? Y/N - Can a squirrel run up and down a tree? Y/N - Can a duck swim in a pond with a fish? Y/N - Can you push your gran in a pram? Y/N - Can you rest at the tuck shop on a bench? Y/N - Can you have a quick dip in the fish pond? Y/N - Does your teacher shout a lot? Y/N
GAMES TO DEVELOP AUDITORY SEQUENTIAL MEMORY… Play ‘I went to the market’ but make it ‘silly’ (children love humour, especially when we as adults are being silly). I went to market and I bought seven slithery snakes. I went to market and I bought seven slithery snakes & four fat frogs. I went to market and I bought seven slithery snakes, four fat frogs & eight angry antelope….. This games can be played within specific semantic themes to effectively carryover vocabulary (sea creatures, farm animals, fresh produce….)
The letters of the alphabet and their associated sounds (phoneme/grapheme matching) are one of the key foundation phonological skills that children need to learn in order to be able to read and/or spell successfully. Many struggle…. AUTOMATICITY OF SKILLS IS VITAL! Make flash cards with the upper and lower case of the letter on one side, and then pictures that begin with the target sound on the other or something similar.
• AUTOMATICITY DEFICIT THEORY (Nicolason & Fawcett, 2008) suggest we need numerous exposures to a stimulus (printed word, auditory input, tracing in shaving cream or sand or in sandpaper…) before it can be stored in our LTM and then quickly retrieved. • Foundation PHONOLOGICAL skills taught in the reception year (Grade 0) are vital and should be established prior to the child commencing the more formal stages of learning. Again… OVERLEARNING principle. Aim to improve the SPEED OF RETRIEVAL.
When reading a passage (reading comprehension) or writing a sentence or a paragraph, get the child to actively engage with the text, by asking WHO, WHAT, WHERE, WHY types of questions. e.g.: he is sitting and crying So…. Get the child to VISUALISE what they are trying to describe. • The chubby boy sat on the Who is sad? A boy? A fat boy? rickety park bench sobbing Better word … plump or porky or quietly as he missed taking his chubby boy… dog for a walk. • The porky boy sat on the gravel Where is he sitting? Park bench? Outside the garage? Outside his outside the garage crying classroom? because his mom had yelled at him for breaking her vase. Why is he crying? He lost his tuck money. His dog passed away. His mom is angry with him…
Testing spelling in the small group or within the therapy setting… • Get child to repeat word verbally prior to spelling it (rules out any auditory • If the child is really hesitant, get them discrimination challenges) to repeat a few times , keeping the • Get the child to sound out the word word ‘alive’ in the WM, long enough orally, saying the letter names or to write the word down accurately, sounds, so the therapist/teacher can check the child has correctly analysed but child must name the letters as he the word BEFORE putting pen to is doing so… p -l-u-m-p or s-n-a-k-e. paper, SO AVOIDING incorrect MEMORY TRACES being built up. • This verbalisation whilst writing helps to strengthen the association between the LETTER names and the SHAPES, AGAIN…. VERBALISATION IS making for a more AUTOMATIC AN IMPORTANT STRATEGY & representation in the brain and KEY ELEMENT OF ALL enabling STORAGE and RETRIEVAL of MULTISENSORY ROUTINES . information to become more automatic.
Ideas for dictation routine… Ideal vs. real classroom setting… • Bear in mind the average STM capacity of the age group you are working with… • If the average child can only hold 4-5 units in their WM accurately – then present that. If working in the smaller group, get child/children to repeat the target phrase (to ensure correct) and then they must say each word (not sound out each word as that overload the WM) as they write it down. • Ideally incorrect spelling should be immediately corrected to avoid incorrect memory traces being formed.
More ideas to assist children with APD… • MIND MAPS (linking to the Visuo-sketchpad) - multisensory
• Learning nursery rhymes… - Explain the nursery rhyme – what • BUDDY SYSTEM (which has it is about. Once the child both pros and cons) understands, they cope a lot - Major disadvantage - the child better… ‘ blaa blaa back see who struggles to comprehend nenyneny woo’ - they just recall the and execute instructions intonation pattern. becomes too dependant - does not develop strategies for • OLDER CHILD- could provide them independent learning. with a TEMPLATE or RUBRIC to - Major advantage – supplies assist with ORGANISATIONAL skills. confidence to a child whose self- esteem may otherwise be very - What is expected of them poor. - Mark allocation
What about the poor reader… Or the child with poor AUDITORY MEMORY for a story… • Listen to the story on headphones – LISTENER’S LIBRARY - (ideal signal to noise ratio) – perfect for the child that is easily distracted. • Older child who struggles with reading, can visually follow in the book (taxing two modalities – visual & auditory – see written word and hear fluent output. Avoids ‘barking at print’ & assist with overall comprehension and enjoyment of the book.
AUDITORY SEQUENTIAL MEMORY… Chunking of information – 082 8511 205 Adding a rhyme so, eight = ‘a fatty and a thinny and ght ’ Take into account the ‘forgetting curve’ (the primary and recency effect) – So, shorter chunks and more repetition better. VERBAL REHEARSAL – keeping information alive in the WM Using your different senses (tracing, saying out aloud, trace in sand, shaving cream, make in modelling clay… more challenges…more therapy) Always try and have a quick summary of the previous lessons key pointers before moving on… Make sure that you the teacher/therapist are giving CLEAR ACCURATE information to avoid an incorrect memory trace
1 8 12 4 7 19 10 2 13 3 14 5 9 6 11 0 MORE COMPLEX WORKING MEMORY TASK (Grade 0 level) - Number of foundation concepts MUST be in place (prepositions/linguistic concepts/knowledge of numbers 1-20 plus is the effective carryover of vocabulary) Instructions can include something like… (ideally repeated ONCE, SAID SLOWLY & CLEARLY) • Draw a blue square around the number of legs a snake has. • Draw two red lines below the number of nostrils you have • Draw a yellow triangle above the number that comes before twenty. • Draw a green cross on the number of school days there are in a week. • Before you touch your nose, draw a red circle around the number of tentacles an octopus has.
AUDITORY PROCESSING OR ????? • There are a number of disorders that impact upon the child’s ability to understand AUDITORY INFORMATION… • ATTENTION DEFICITS – these children are poor listeners and have challenges understanding and remembering verbal information BUT the actual neural processing of the AUDITORY INPUT in the CNS is INTACT. Primary issue = FOCUS • AUTISTIC SPECTRUM – very broad range of challenges and children. They have challenges with the SPOKEN LANGUAGE COMPREHENSION. Their cause of difficulty is not a specific AUDITORY DYSFUNCTION.
Can APD coexist with an ATTENTION DEFICIT or LANGUAGE PROCESSING deficit or LANGUAGE/VOCABULARY DELAYS or DEPRESSION??? YES!! WHAT ABOUT APD & DYSLEXIA? Dyslexic children experience difficulties reading single words, sound/letter confusions (phoneme/grapheme confusion) and a poorer ability to map letters onto words. BUT, many of these disorders are INTERRELATED. So, children with Dyslexia often have APD’s, as well as language processing deficits making it challenging for the mainstream teacher to accommodate these children in her classroom. Children with APD’s – their ability to respond to rapid sound changes is poor.
How do these children present and how do we make a differential diagnosis? YOUNGER CHILD OLDER CHILD - Difficulties understanding speech - Difficulties with spelling, reading and with information presented verbally in - Struggles in noisy classroom class - Observational learner (can’t follow - Sometimes discrepancy between instructions effectively) performances between classes that - Can they hear optimally?? do/don’t rely heavily on listening - Behave at times like they have a - Once understood task requirement – hearing loss? they can then work more independently - Either they seek regular clarification or appear very ‘switched off’ CONFUSING FOR THE TEACHER!
Often, the SPEECH/LANGUAGE therapist is the first professional the child is referred to… • Not listening optimally, peripheral hearing test recommended (pure tone audiogram with tympanograms) • Comprehensive language/vocabulary assessment • Auditory sequential memory assessment (idea of child’s STM capacity) • Language Working Memory subtests conducted within the IDEAL SETTING (quiet, one-to- one & child’s focus redirect post each subtest) • Auditory Discrimination • Auditory Analysis and Synthesis (word building/blending) • Phoneme/grapheme associations • IDEALLY assessment in broken into ‘bite size chunks’ – 30 to 45minute sessions – ensure you are assessing ability and not fatigue or boredom • Assess over a few days – get a better understanding of the child • TIMING of the assessment is KEY – mornings are usually the best
Often not possible to address ATTENTION directly BUT we can offer SUGGESTIONS FOR BETTER EFFECTIVE LISTENING. Why is SLEEP so important? What are the LONG TERM effects of SLEEP DEPRIVATION? • An Australian Paediatrician and Adolescent Sleep Physician, Dr. Chris Seton at Sydney’s Woolcock Institute of Medical Research, reports that the average 14yr old with an average of 30 mins of missed sleep daily records a measurable IQ difference of up to 10 points. • This drop in academic results recorded by tired students can be explained by how sleep loss effects both the STM and the LTM. “in the one ear and out the other ear…” literally • Learning is only transferred to the LTM if the child has a consolidated night’s sleep after a successful day of learning. • Hence REM (RAPID EYE MOVEMENT) SLEEP consolidates learning. • There are a number of studies linking insufficient sleep to depression and anxiety.
HOW MUCH SLEEP IS ENOUGH? • Pre-schoolers should be getting 11 hrs of uninterrupted sleep per night • Prep school children about 9-10 hrs while our Teens should be getting about 9hrs of sleep. Average adult copes optimally with 7-8hrs of sleep per night. • It has been noted in the literature that the ‘teen clock’ is set later than the adult clock – ideally between 11pm and 8am.
Why do more and more children/teens struggle to fall asleep? • No set bed- time routine…45 mins BEFORE bed all technology should be switched off. • Play some relaxing music, maybe have a warm bath, listen to a story…train the brain to get ready for bed. WHY IS TECHOLOGY SO BAD before bedtime? • The negative effects BLUE LIGHT has on sleep is well- documented (cell phones, iPads, computer screens…) The short-wave length light emitted suppresses the sleep hormone (Melatonin) thus delaying the onset of sleep. The blue light tells our brain to ‘wake - up’. • How many of us quickly check our phones in the middle of the night??
HEALTHY DIET EFFECTIVE LISTENING?? COMMON SENSE? • We live in a busy, fast- paced world… a world of convenience…quickly packaged…hurry, hurry… • Are parents aware of how a highly refined, sugary diet is impacting upon their child’s ability to focus and remain focused within the classroom? • Breakfast? Do they even eat it? Bowl of Coco-Pops or Chocolate Pillows vs. a bowl of Jungle Oats or scrambled eggs?? • What is in that lunch box? Quick release carbohydrates? Save those for the weekend!
Effective listening is a HABIT that starts at home…. Need to train our parents… YOU choose not to listen, then YOU are choosing for me to …. Switch off the television….(time out for 10minutes…) – a consequence for poor listening NOT a punishment. Must be employed CONSISTENTLY and by ALL in the household. BUT… must reward the positive behaviours… excellent listening today… star chart… so many stars → time and a specific chosen activity WITH a parent (not a monetary gift) Working on the POSITIVE helps build a positive self-esteem DON’T do things for the child – to encourage better organisational skills, show them how to do it.
COMMON MYTHS REGARDING APD’S… 1. Are hard of hearing – so speak louder! NO, they cannot always process what is said accurately? 2. It is very rare. No! About 2- 7% of the population has APD’s and of that, twice as many boys relative to girls. 3. Children with APD’s are less intelligent than their peers. APD is NOT linked to intelligence. Yes, most of them score LOWER on the VERBAL IQ rating and most take longer to respond to questions and pick up new concepts. 4. There is a high comorbidity rate with ADHD – but ADHD children struggle with attention in all settings, APD children struggle in the auditory realm (background noise, following instructions, poor listening skills…) 5. These children are rude? They appear as if they are ignoring you…but they struggle to process auditory input, struggle to think of responses quickly, may mishear the question and give an unrelated answer ….ODD!
Any at risk factors…. Alarm bells in a case history…. These are alarm bells for many developmental delays… But, can also contribute to APD’s LOW BIRTH WEIGHT PREMATURE BIRTH HEAD TRAUMA CHRONIC MIDDLE EAR INFECTIONS LEAD POSISONING
CASE STUDY 1 Boy, 5yrs – referred post a very poor School Readiness assessment for Grade 0. Healthy full term pregnancy, no pre, peri or post natal complications. 2.9kgs birth weight. Motor milestones achieved within average range and first words at 9mnths. Sentence development was reportedly slow and vocabulary development reportedly limited. Significant history – febrile convulsions at 1/12 (was hospitalised for a week but a brain scan proved normal) and again at 18/12 when he was hospitalised again. Had a lumbar puncture at a month and had 2 sets of grommets inserted at 12 & 24mnths. Good eater, chews well, no pacifier or bottle beyond 2yrs. No parental concerns. Play school concerned re: comprehension and that he struggles on occasions to follow instructions. NO REAL ALARM BELLS! Assessment (broken down into 3 shorter sessions) revealed the following: - Chatty +++ (mostly unrelated, irrelevant information) - Poor pragmatics (eye contact adequate but no conversational turn-taking or topic maintenance. Lots of tangential thinking) - Limited perseverance - Limited attention span (fidgeted and fiddled ++)
Articulation - developmentally appropriate (th/f) RECEPTIVE LANGUAGE - Could not follow instructions (with auditory and visual modalities) (Concepts and Following of Directions subtest <3yrs. E.g.: point to the elephant that is next to the giraffe = he pointed out both) - BPVS 3.0yrs - BASIC CONCEPTS (Celf Pre-School Battery) - <3.0yrs - TACL – Grammatical Morphemes 3.9yrs (Prepositions & pronouns flagged) - REYNELL (tactile, auditory & visual): 3.1yrs (again to specifics of instructions really poor). “Take 2 buttons out of the cup” = all the buttons or ‘put one small pig next to the black pig’ = one small pig behind the farmer’ EXPRESSIVE LANGUAGE - Renfrew W/F: 3.2yrs; CELF Expressive Vocab : <3.0yrs (fireman = the sprayer water; wheelchair = sit like this; footprint = leg, no a toes; mermaid = swimming)
Word definitions : Cow : ‘Eating the grass, eating the trees, you know the cow’s tongue is cutting the cow’s tongue’ (P) ‘the cow’s getting upset – he can’t find food’ (muddled) Brown : ‘The child goes to bed and you sleep in it and the monster can open the door and scare the child’ Ice : ‘Eating food and eating supper for breakfast’ Apple : ‘Eating apple like this’ (P) ‘a monster’ (P) ‘eating apples’’ Ocean : ‘Sixty, we have sixteen and we have seventeen’
STRUCTURED EXPRESSIVE OUTUT : • A picture of a cat having caught two mice = ‘ the cat stop the mouse and he stopped it’ (repetitive) ‘but he’s stopped it and cat will throw all the mouse away’ (immature language). • ‘ he’s putting up the cat out’ (P) ‘he was climbing up the kitty and the kitty doesn’t fall ’ (referring to a man climbing up a ladder to rescue his cat from the roof of his house). • ‘ she fall down and she break her glasses she was crying – shame – she was crying and she fall down ’ (referring to a woman who fell down the stairs
AUDITORY COMPREHENSION subtest revealed the following: e.g.: Chip lived in a town by the sea, but he had never been to the beach. Qu.: Who lived by the sea? ‘The boy one’ Qu.: Where had he never been? ‘He’s swimming like this and to the palace’ e.g.: Jan likes to go to the airport. She likes to watch the planes take off. Qu.: Where does Jan like to go? ‘ He is going to go to the green plane’ Qu.: Why does she like to go there? ‘ The plane is moving and its going to fly up to the sky’ e.g.: Mark made a tuna sandwich for lunch. Qu.: What kind of sandwich did Mark make? ‘Chicken’ Qu.: For which meal did he make the sandwich? ‘Chicken curry’ (related to the previous evening’s dinner) e.g.: Jenny went to get her bike. She wants to go and ride in the park. Qu.: What did Jenny go and get? ‘Going to get chicken for supper’ (perseveration) Qu.: Where was she going? ‘She was going to eat her food and then go outside and play with her bicycle’
AUDITORY COHESION (altogether a far too complex task for him) e.g.: Susan’s mother told her not to touch the hot pan on the stove? Why did Susan’s mother tell her not to touch the pan? An.: ‘She close her eyes and go swimming’ e.g.: The street lights are not on during the day on Jackson Street. Qu.: Why are the street lights not on during the day? An .: ‘I was swimming. We went to the palace and I was swimming’ (the family has been to SUN CITY two weekends prior to this assessment occurring, hence his perseverance upon the swimming) e.g.: Sophie watched the rain make big puddles in the garden; then she put on her boots and went outside. Qu.: Why did Sophie put her boots on? An.: ‘ She’s putting on the hat and she’s putting on her sunblock and she’s putting on her costume and she swim like this ’ (rambling, unrelated response)
IMPORTANT: All splinter skills were in place and NO articulation errors and he makes sentences (no content … but he talks). These type of children slip through the cracks. He could: count to 39 Knew all his shapes and all his colours Could recognise the digits 1-20 SO, many areas of concern. Behaviour was a real challenge – oppositional, tantrum, he liked a particular routine to be followed each therapy session prior to entering the therapy room (which we had to stop) Language: vocabulary/concepts/prepositions/pronouns Working memory!!
WHERE TO START??
Started with twice weekly language therapy (July 2017)… • Modified the diet particularly breakfast and the lunch box • Modified behaviour (you choose… then you choose…) • Started chatting about concentration and impact it has upon learning (a process…) • Commenced with SI OT in January • Diagnosed with ADHD in January and placed onto appropriate meds • Pyscho-educational assessment June – WORKING MEMORY still a real concern • Entire team feels smaller class environment optimal • Will commence at a Remedial School in January 2018
CASE STUDY 2 Boy, aged 4.10yrs, commenced at present Pre-School January 2018. Had received speech therapy previously at last pre-school (was not really talking and presented with many artic/phonological challenges). Now was verbal – hence parents were relaxed. REASON FOR REFERRAL: Grade 00 concerned – child cannot comprehend and execute instructions, complete observational learner, difficult to understand without a visual referent, limited attention span. History: Normal pregnancy, delivered at 36 weeks, caesarean section. No pre, peri or post natal complications, birth weight 2.44kgs. APGAR’s reportedly fine. All early milestones reportedly fine: sat 6/12, first steps 14/12. Hearing fine bilaterally (has been assessed formally). Goes to bed late each evening as wants to sleep with mom, so waits up until she goes to bed. ? Sleep deprived.
ASSESSMENT RESULTS Observations: short attention, fidgeted & fiddled +++, ++ tangential thinking, attention short (benefited from being frequently redirected to the task at hand) SPEECH: rapid speech production (almost cluttering); swallowed ends of words; developmental sound substitutions (th/f, th/v, r/w), swallowed ends of words (jus/just), weak syllable deletion ( te’bear ) and sequencing challenges (skele scope/telescope or amamils/animals). Vowel distortions: bee-bee/baby, cutterpillar/caterpillar; mun/man RECEPTIVE LANGUAGE Concepts & Directions: <3yrs (limited concepts) – no attention to specifics ‘when I point to the tiger, you point to the giraffe’ (did not wait for therapist and pointed out both) ‘point big dog then the little monkey’ (pointed to all the animals)
AUDITORY COMPREHENSION - ach chie ieved <3 <3.6yr age e eq equiv ivalency subtest revealed the following: e.g.: Ch Chip liv lived ed in in a town by th the e sea ea, but t he e had never bee een to o th the e bea each ch. Qu.: Who lived by the sea? ‘Your mom and your dad and your sister and you dad’ Qu.: Where had he never been? ‘He been for two weeks’ e.g.: Ja Jan lik likes es to o go o to o th the e airp irport. Sh She e lik likes es to o watch th the e pla lanes take e of off. Qu.: Where does Jan like to go? ‘ To the playground’ Qu.: Why does she like to go there? ‘ Because his friend is there – his friend is there’ e.g.: Mark made e a tu tuna sandwic ich for lu lunch ch. Qu.: What kind of sandwich did Mark make? ‘Sandwich – it is called cheese’ Qu.: For which meal did he make the sandwich? ‘Everyone’ e.g.: Je Jenny wen ent t to o get t her er bik ike. e. Sh She e wants to o go o and ride ride in in th the e park rk. Qu.: What did Jenny go and get? ‘His bike’ Qu.: Where was she going? ‘He was going to the park ’
Lo Logical l reas asonin ing: Not formally scored due to all the prompting why is a chicken different to a horse: ‘cos it is black and white’ (P) ‘cos it is black an and a a ban anana lik like a a ch chicken – monkeys eat bananas’ why does a knife cut: ‘for papers and pages’ (P) ‘cut for papers’ why does a rock sink? ‘cos when you blast off you can get some air’ what is the shape of a starfish? ‘when you eat food for everything’ (P) ‘a square’ RECEPTIVE VOCABULARY BPVS: 3.4yrs BASIC CONCEPTS: 3.7YRS TACL: Vocabulary: 4.0yrs; Grammatical Morphemes: 3.0yrs (prepositional phrases/pronouns flagged); REYNELL Receptive Language (multi-modal – 3.5yrs)
EXPRESSIVE LANGUAGE VOCABULARY: Renfrew W/F: 3.3yrs; CELF Pre-School Battery: 3.8yrs Word definitions: BIRD: ‘can live in a nest’ (P) ‘a bird can live in a cave or a nest or anudder cave or two caves’ APPLE: ‘for eating childrens ’ (P) ‘you have an apple’ ICE: ‘for looking’ (muddled with ‘eyes’) (P) ‘when blows airs… what’s why… you know Blaze, can save him from..’ (tangential thinking) COW: ‘A cow called a ‘ splam ’ ( splam ??) ‘yes, he drink in da splam ’ (P) ‘I know cows when mommy said she mouse’ BED: ‘for sleeping night time’ FACE: ‘face called - be a ears, be a eyes…you have a clock (spotted a clock on the wall) ‘the clock say play time when the clock say playtime’ SAD: ‘when you get … when your mommy scream – not my mommy – why you have watch?’ (++ tangential thinking)
EXPRESSIVE LANGUAGE STRUCTURED EXPRESSIVE OUTUT : • A picture of a cat having caught two mice = ‘ he do catch da food where to da want to eat’ (P) ‘beetle’ (P) (mouse) ‘oh, a mouse, two mouse, a bwudder and a sister – dat’s where he gonna get food • ‘ he jus want to catch his cat’ (P) ‘need big one to climb on ladder cos he need to catch a cat’ (P) ‘da cat in da blocks dere ’ (referring to a man climbing up a ladder to rescue his cat from the roof of his house). • ‘ da girl – he fall on da steps and den his glass bwoke ’ (referring to a woman who fell down the stairs COMMENT: no use of complex syntax; output muddled at times, pronouns and verb tenses muddled (remains developmentally appropriate). No visual referent = difficult to comprehend (esp. for uninformed listener)
THOUGHTS??? What do we tackle first? Further assessments – if so, what??
To conclude… • ‘Every student can learn, just not on the same day or in the same way’. GEORGE EVANS • ‘EDUCATION IS THE MOST POWERFUL WEAPON • ‘The more that you read, the WHICH YOU CAN USE TO more things you will know. The CHANGE THE WORLD’. more that you learn, the more places you will go’. DR SEUSS Nelson Mandela
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