How To Work Towards Speech and Language Therapy Goals: A Practical Case Study
This blog post is aimed at teachers, nursery staff, parents, carers and anyone else involved with a child who is working towards speech and language therapy goals.
Setting Goals That Are Meaningful To Everyone
Goals are obviously important for any therapeutic work so that you have a baseline and a way to measure progress. However, it can be very hard to set goals which are meaningful not just to the therapist but for everyone involved with a child. Therapists often set goals for others to work on, e.g. nursery practitioners, teaching assistants, parents and carers. The goals might be completely transparent for a therapist, but not to others. For example:
- X will be able to make subject + verb + object sentences in structured activities with minimal support by the end of Term Six.
Even with resources, others might be unsure of how to work on goals. With on-going cuts to speech and language therapy and strict criteria for service delivery in the NHS, there are fewer and fewer opportunities for therapists to model working on goals, and for them to provide training, yet we ask others to do more and more of what was once part of our role. Services argue that it does not matter who works on goals, that outcomes are the same regardless of who supports the child. However:
- You can find evidence for and against everything. There are always two sides; for example with lateral lisps, some research states you should work on them before the child is four-and-a-half and other research says you should not work on them until after the age of seven.
- The Hanen Centre found that if carers had sufficient training, there was no difference in the outcomes of therapy. However, if they did not have sufficient training this was not the case.
- Everyone is different. Some people find it easier to support children with speech, language and communication difficulties than others. Confidence is often involved, and some people need more support to take over working on SLT goals. In the current climate, it is hard to personalise a service so that it is based on need, and this can impact on the outcomes for a child.
What do we know helps children achieve speech and language therapy goals?
- Working on them little and often, in different settings, e.g. at school, at home, in one to one sessions
- Integrating them into the child’s routine, rather than keeping them separate to other areas of the child’s daily life
- Enabling the child to take responsibility for their goals, e.g. making sure they know what their goals are, teaching them to evaluate their progress.
How can we do this?
Working Towards Speech and Language Therapy Goals: A Case Study
The child’s name in this case study has been changed for reasons of confidentiality
Felix has learning difficulties; attention and listening difficulties; rigid thinking – he often gets stuck on things and it can be hard to move him on (perseveration). Rigid thinking impacts on his understanding of visual and auditory information and he has a literal interpretation of what he sees and hears. His cognitive difficulties affect his executive function skills. He has poor monitoring skills and difficulties holding information in his short-term memory. He also has social difficulties and his rigidities impact on this area, too. He has severely delayed understanding and use of language and some speech sound difficulties. He is lovely to work with.
The school and his carer said that listening and attention difficulties impact on everything. He has one to one support during the school day and is not able to access tasks and activities without adult support.
The school said that he finds it hard to learn by rote and has not learned the days of the week. He has a severely reduced understanding of time, e.g. yesterday, tomorrow, last week/this week, week, weekend, before, after.
His carer said that she would love to know something about what he does at school, but he is not able to tell her anything about his school day.
The school and his carer said that it can be hard when he gets stuck on things, e.g. when I first met him, he told me repeatedly that he was going to have tea with the head teacher. His teacher said that he says this all the time to everyone.
I could write pages about his difficulties, but these are the main things that the school and his carer flagged up. Underlying these concerns are severe speech, language and communication difficulties. My contract with this child is one full assessment each academic year and one therapy session every six weeks carried out with his Individual Needs Assistant, so they are going to do the bulk of the work on the goals. We set them together and this is what we set:
1) Goals for Felix, his Individual Needs Assistant (INA), Teacher, and Carer
Felix gets stuck on things and finds it hard to move on from, e.g. when the therapist first met Felix, he told her that he was having tea with the head teacher repeatedly. His teacher said that he told everyone this all the time.
Felix finds sequencing hard and does not yet know the days of the week. Assessment shows he has severely reduced understanding of concepts, e.g. first, next, last, before, after.
Underlying attention and listening difficulties impact on learning and retaining information. Given Felix’s difficulties, it will help him if speech and language therapy support can be integrated into his daily routine as much as possible.
Felix will be able to understand, and use, the following concepts:
- Last week
- Next week
- Using a calendar, or the days of the week (see attached symbols) to talk about his routine with support in the classroom at least once a day by the end of term, 6, 2016.
- Order the days of the week with Felix. Start by asking him what today is and putting the symbol for this in front of him. Then ask him what day it was yesterday and what day it will be tomorrow. If he does not know, offer him a choice of the correct day and the wrong day, e.g. “Is it Tuesday or Friday?”
- Arrange the days of the week with Felix. Then turn them over except the day today, e.g. Tuesday. Tell Felix you are going to have a quiz. Ask him if he can remember what day is after Tuesday – if he does not know offer him a choice, e.g. Sunday or Wednesday. Then he can turn over the day and see if he is right. You can do all of these with another child too so that Felix is taking turns with a peer. Keep it short and fun.
- Extend this by arranging the days of the week and making a mistake, e.g. “today is Monday; the day after Monday is Wednesday, then it is Thursday….” to see if Felix can correct you. If he can’t, you can say, “Wait a minute! I don’t think that is right! Let me try again, will you help me?” and then try making a mistake the next time you do this and see if he can correct you.
- Order the days of the week in front of Felix with spaces, e.g. Monday Tuesday _______ Thursday Friday __________ Sunday, and see if he can tell you which days are missing. “Monday, Tuesday. Oh, what day is after Tuesday?” etc.
- You can use the visual timetable to work on before and after, too. For example, when you go through it with Felix, you can use these concepts so he can hear them in context, e.g. “First, we have got assembly. After that, we have got literacy. Then, we have got ….” etc. Give Felix a quiz on this, e.g. “Can you remember what are we doing after assembly?”
- Can he order the days of the week and tell you which day is today, yesterday and tomorrow?
- Can he tell you what day is before another day and what day is after a given day, e.g. what day comes after Friday?
- Can he answer questions about the visual timetable that contain before and after, e.g. what did we do after break?
- Can he tell you one thing he did last week?
Felix needs support to tell others what he did at school and what he did at home.
Felix will be able to tell his carer one thing that he did at school at least three days a week with visual support, e.g. a photo of him doing an activity at school, and he will be able to tell his teacher and INA about one thing he did each weekend with visual support, e.g. a photo or picture of somewhere he went, every week with adult support by the end of term 6, 2016.
His teacher has made a large calendar page and is putting pictures on each day to remind Felix what he did and to help him talk about it. Felix’s carers are going to do the same.
Talking about what he did at home and school gives Felix opportunities to:
- Learn vocabulary in context
- Use vocabulary in context
- Develop his social communication and interaction skills
- Develop memory skills
- Can he use the visual to talk about one thing he did at school / home?
- Can he rehearse what he is going to say with an adult, e.g. with his INA, and then tell another adult, e.g. his carer?
Using Visual Supports
The school were not using any visuals with Felix, so we set up using a now and next board – see below. This resource shows the child what they are going to do. It helps them remember what they have to do, it makes their routine predictable and it makes it concrete for them – this has made a huge difference and the calendar that the teacher made is great, too. This helps Felix to understand his routine and it makes it predictable. He is no longer getting so stuck on things. These strategies have also had an impact on his attention and listening skills and ability to follow the class routine, as you would expect. But the point is, while speech and language therapists expect this and know this is a likely impact, others do not.
We are used to these strategies but this can be very hard to take on board for others. Schools have so many demands on their shoulders that this can feel like a lot of extra work. A friend of mine, who is a SENCO, recently said to me, “We were understanding with you when the cuts started affecting speech and language therapy input to schools, now you have to be understanding with us. We cannot work jointly so easily with other services any more. We have too many demands to meet in our own role.”
The goals above involve the INA, the class teacher and Felix’s carer. The ones below are mainly for the INA to work on with Felix. I have modelled working on all of these with the school and I am in regular email contact with them. When I saw Felix last, he was doing brilliantly.
2) Goals for Felix and his Individual Needs Assistant (INA)
Felix needs some support to remember two-part instructions (instructions to do two things), e.g. put the sink in the kitchen and the sofa in the bathroom (Elklan Silly House resource)
Felix will be able to follow two-part instructions in the following, without support at least three times a day by the middle of end of Term Six, 2016:
- Games and activities, e.g. the farm activity, dressing the bear, Mr Silly’s house
- Daily, routine instructions at home and school, e.g. Get your Batman watch from the kitchen (1) and give it to X (2)
When you do the paper activities (farm, bear, house), make sure that there is a choice of items that he has to discriminate between when you give the instructions so you are testing his understanding. For example, Put the pig on the tractor and the cow in the field (choice of big and cow, choice of tractor and field). To make these harder, add more words, e.g. Put the little pig (you need a choice of big pig and little pig) and the big cow (choice of big cow and little cow) in the field (choice of field and barn).
- Use your fingers when you give an instruction to show Felix what he has to do first and second
- Ask him to repeat the instruction, or say it with you, e.g. “Put the sink in the ____________” leave a pause for him to fill.
- If Felix can’t follow an instruction, make it easier so he can do it (make it shorter)
Felix has a reduced vocabulary and difficulty finding words, he has a weakness around the sounds in words and this area needs support.
Felix will be able to use a descriptor card * to tell you the following, with minimal support, by the middle of June, 2016:
- What something can do, e.g. bird: it can fly
- Where you find it, e.g. in a tree
- What parts it has got (what it looks like), e.g. wings, a tail, a beak, claws, feathers
- What group it belongs to, e.g. animals or food
- The first and last sound (not letter)
- How many syllables it has (clap them as we did in the session and count them)
- Use the pictures on the cards, or use objects rather than pictures or use topic words (see attached pictures for growing)
- Take it in turns to think of ideas
- If he can’t tell you the first/last speech sound, offer a choice, e.g. bird, is the first sound b or s?
- Clap the syllables with Felix and count them with him.
- If Felix can’t find a word, says thing instead of a word, or says the wrong word (e.g. he said tap for teapot):
- Talk to him about what the word means, where you find it, what you can do with it, etc. to see if this helps him find it
- Give him some information about how to say the word, e.g. bird – it starts with b, if this does not help, give more information, e.g. bir, if that does not help you know he does not know the word and you can tell him what it is.
- Give him opportunities to hear words, e.g. when we did the house, he said taps for sink, but was able to say sink when the therapist told him it started with ssss. He had lots of chances to hear and say the word in the activity.
This might seem like a lot to work on, but Felix’s INA often works one to one with him, so she asked for things to do with him to support his speech, language and communication difficulties. We are using *descriptor cards by Language Link – you can see an example of this resource in one of my previous blog posts, under Programme To Develop Listening and Attention Skills. If you do not know this resource it is great! It is basically a word web, but a great one and easy to use and easy to extend. We are using topic vocabulary with this so now that Felix is familiar with it; we use it as a class resource. His INA is now able to work on targets in the classroom and she is able to include another child. It is going very well and she is just fabulous and it is a joy to see her confidence and skills grow.
I try to make my goal sheets are practical as I can, to put in strategies that we have discussed and that have seen modelled. I try to make them as user friendly as I can, and to avoid all jargon, because only speech and language therapists understand this, so it is pointless using it when your goals are for others to work on, in my opinion.
When I was last in the school, Felix had been able to talk about what he did at the weekend, and everyone was very excited about this! He was able to order three days without help and the others with a choice. He was great at using the descriptor card and his teacher and INA said he is now sitting on the carpet in many lessons with his peers; he couldn’t do this before. Things are reported to be easier at home as his attention and listening improves and his carer is using visual support, which is making a big difference. In this situation, they could cope with this number of goals, but how many I set is dictated by the child, by those working with the child and by the setting. These are variables that are not constant and one size does not fit all.