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Pragmatics and Social Communication: Treatment Strategies

Pragmatics and Social Communication: Treatment Strategies
Angie Neal, MS, CCC-SLP
August 15, 2018

Introduction and Overview

My disclosures include: I wrote The Pirate Who Could not Say Arrr, Simply Social at School, Spelling That Makes Sense.  I have some items on Teachers Pay Teachers as well. I am also receiving an honorarium for this course. There are no non-financial relationships to disclose.

In this course, I am going to clarify the difference between a social skill and social communication. We are also going to discuss evidence-based practices (EBP). We are going to talk about ways to get students to think about their own thinking in order to get to a deeper level of understanding about the social communication targets they are going to be working on. We will also review the four foundational areas that have a tremendous impact on the progress that our students are able to make in social communication therapy. Finally, we want to be sure to leave here with some good strategies that we can implement tomorrow because I know that is why I attend workshops.

This is Part Three of a three-part series. Congratulations if you have hung in there with me for Part One (Course 8528) and Part Two (Course 8569) as well. As I have stated before, there is no way I will ever be able to touch on everything in three hours. But if you are interested in a full-day workshop, just drop me an email, or try and catch me if I am ever in your part of the world.

Part Three will be about actual therapy which is my favorite part. I do hope you will go back and listen to Parts One and Two if you missed them because they provide a foundation for understanding the strategies I am going to talk about today. For our students, the “why” is as important, if not more important than, the “what” and the “how,” in order to help them generalize what they have learned. In Part One, we talked about why generalization is so tough for our students. In Part Two, we talked about the educational impact. While addressing conversational skills and nonverbal communication is important, we must also be aware of the pragmatic language areas that support academic success and non-academic skills in order to get our students college- and career-ready.

The Difference Between Social Skills and Social Communication

As we begin talking about therapy, I want to start by clarifying something that is going to frame our thinking about intervention for pragmatics. It is a change in the terminology we use, and it takes some practice, but once you understand why, it will become a habit. When you change the way you look at something, the things you look at change.

So what is the difference between social skills and social communication? A social skill is completing a social task that has a predetermined result.  The student, though, may not be able to understand why that skill is important or be able to use this knowledge outside of that predetermined or isolated context. Teaching a social skill simply means that the person has learned a skill that, if you look at it in isolation, may look okay. However, social communication refers to the ability to have a broader, deeper level of understanding, such that the person is able to understand why certain skills are important and how to demonstrate them across broader contexts. This is another reason for making sure we teach the “why.”

Let me give you a good real-life example of the difference between a social skill and social communication. Have you ever been to the restaurant Chipotle or Subway®? When I go there, I give my order; for example, say I want a turkey sandwich. But then I have to wait for them to ask me questions about the specific aspects of my order as they move down the line in front of the ingredients. When I go to a sit-down restaurant, I give my order all at once as well. So the skill of “ordering food” is the same in those two contexts. But the two different contexts have different expectations. Social communication means understanding that different places or contexts have different expectations. Even if it is the same skill, it is important for students to know that there are different expectations, and why there are these differences, in order to apply them. Otherwise, when working on pragmatics, we have only taught half of what they need to know. I hope that clarifies the difference.

The Five Whys

How do we accomplish this? Begin with “why.” If you have ever heard the talk I give on /r/, you may be familiar with “the Five Whys.” The gist is, you take a “why” question, answer it, take that answer, turn it into another “why” question, and you repeat this process until you have five “why” questions and five answers to those questions. The purpose is to transfer your answer into another question. Here is an example:

1. Why is it important to take turns?

            Because we are supposed to

2. Why are we ‘supposed to’ take turns?

            So that everyone gets a turn to play

3. Why is it important for everyone to get a turn?

            So no one gets left out

4. Why shouldn’t we leave anyone out?

            Because it’s more fun to play games with people

5. Why is it more fun to play games with people?

            Because it would be boring if you were the only person playing 

I can pretty much guarantee that for that first question, “Why is it important to take turns?” you are either going to get “Because you are supposed to” or “I don’t know.” The number one rule in my class is that we never say, “I don’t know.” You can say “I think…”, but “I don’t know” answers are banned. Why is that? Because “I don’t know” gives me no insight into what the student is thinking, and it is really just like giving up on the student’s part. So I do not let them off the hook with this. They have to tell me what they are thinking.

Anyway, turn that  “you are supposed to” answer into another “why” question. “Why are we supposed to take turns?” “So that everyone gets to play.” Turn that into the next “why” question. “Why is it important for everyone to get a turn?” “So no one gets left out.” That turns into, “Why shouldn’t we leave anyone out?” “Because it is more fun to play games with people.” That finally turns into, “Why is it more fun to play games with people?” The deeper answer is, “because it would be boring if you were the only one playing.”

We are using the “Five Whys” to dig deeper into why the skill is important and to go from a superficial answer to something more meaningful. I cannot stress enough how important it is to make sure that what we do is meaningful, because what we are asking our students to do is something that does not come naturally or easily for them.

I want you to do something, wherever you are sitting, unless you are driving. Cross your arms across your chest. Now look down. Which arm is on the top? Now put your arms down to your side again. Now cross them again, but this time, put the other arm on top. That is a little harder and requires a little bit more thinking. It feels a little unnatural and awkward. Remember this feeling, because this is what our students probably sometimes feel when we are asking them to do something that is new and difficult, and awkward at first. This goes along with what we are going to talk about next: cognitive behavioral intervention. Cognitive behavioral intervention is based on the belief that behavior is mediated by cognitive processes. In other words, we will teach students to think metacognitively -- to think about their own thinking, and to recognize when they are in a social situation that requires a specific response, or in a similar social situation but different context that requires a different response.

Evidence-Based Practice

Cognitive behavioral intervention is an evidence-based practice. Let's start by talking about that term. When I went to graduate school years ago, I cannot recall if I ever heard the term “evidence-based practice.” I may have; I just do not remember it. If you do a keyword search on the ASHA site for convention topics in 2002 using the term “evidence-based practice,” there are only three results that appear. But it has increased every year since then. And actually, the theme of the 2005 convention was “Using evidence to support clinical practice;” not that research was a new thing by any stretch. Science, medicine in particular, has used evidence and research as the basis for what they have done for years.

Part of the need for evidence-based practices emerged in the 1990s with access to the internet and what is referred to as the Information Age. At no time in history, since the invention of the printing press in the 1400s, has access to information taken such a huge leap. But is all of this information good information? No, not at all. Evidence-based practice is imperative in order to improve the quality of care that we provide, and to ensure that it is effective, and that it is not just time well-spent, but money well-spent as well.

Let's be clear on what evidence-based practices are so that we can apply that knowledge to the strategies we are going to talk about later. ASHA uses the following definition of evidence-based practice: “The integration of research evidence with practitioner expertise and client preferences and values into the process of making clinical decisions.” Note that although this is referred to as “evidence-based practice,” the roles of clinician expertise and client preferences and values are equally important. The notion that external research evidence somehow trumps all other considerations is one of the big myths surrounding evidence-based practice. The definition of evidence-based practice includes three factors, not one; it is not just the research alone. It is an integrated definition that includes the clinical expertise and your expert opinion, external scientific evidence, and client/patient/caregiver/student perspectives in order to provide high-quality services reflecting the values, interests, needs, and choices of those that we serve. That is all straight from ASHA.

When we are looking specifically at the evidence, keep in mind that the research can be somewhat subjective as it relates to pragmatics. It depends on the views of the people reviewing the data and how the data might be applied to their practice. What I mean by that is that a behavior analyst looks at a set of research data through a different lens than an SLP might. If you want more information about what has been found to be evidence-based, do a Google search for either the National Standards Project or the National Professional Development Center. Go ahead and do that, knowing that even those two documents vary a bit.

One big question to ask when looking at the research is, can we quantitatively study and determine what makes a person more or less socially appropriate? It is hard to define proficiency, because what is appropriate for a 5-year-old is different than the standard of appropriate social behavior for a 12-year-old, or an 18-year-old, or a 21-year-old. In addition, some of the students we are working with maybe 10 years old, but they are functioning at a lower level. So, when the study was done on whatever program it might be, did it include those kinds of considerations? What about students who may have diagnoses or classifications of autism, but also have a seizure disorder or attention deficit/hyperactivity disorder (ADHD)? Do the data include the impact of those conditions on the outcome? The research is usually looking for evidence that supports a certain program or a certain methodology. Social communication is a living, breathing, ever-changing, dynamic ability that has sub-skills upon sub-skills and related skills that overlap. It is very difficult to pin it down to one thing, one product or one program that meets the needs of even a certain age group. So, instead of focusing on whether a certain program is evidence-based or not, you may want to pay attention to the underlying principles and procedures.

I would venture to guess that most of us have probably seen firsthand interventions that are not evidence-based, but that have worked for certain students. This might include things such as a sensory diet or a gluten-free diet. I once had a little girl who came to therapy one day and was a completely different child. She was all over the place. I walked out and asked the mom, “Is something different today?” She said, “Yes, she had been on a gluten-free diet, but today at school, they gave her crackers.” That is not evidence-based treatment, but I saw that it made a difference in that particular child. I have also done therapy immediately after an occupational therapist (OT) has given the student sensory input. Suddenly, the child was processing; his attention and eye contact and verbal output were all significantly increased as a result of that sensory input. Again, sensory intervention is not evidence-based, but it made a difference for that specific child.

Am I advocating for non-evidence-based practices? No, absolutely not. There are a lot of snake oil peddlers out there that are more than happy to take mom and dad's money while promising a cure. What I am saying is, “Buyer beware.” Remember that there are three prongs of evidence-based practice, not one, and look at the research critically. Some studies are done by the developer of the product or program, and are not reliable. In some studies, the comparison groups are carefully selected so as to improve the outcome of the study program. It is very confusing.

So what can we study? We can study the results of our efforts; for example, when it comes to social communication, is the student or the child more independent? Is she navigating the social world effectively enough to get her needs met, or to agree and disagree appropriately, or to share space with other people without making them feel uncomfortable? Is the child more successful in school, or able to work better with others?

Examples of EBP

Here are a few practices that are considered evidence-based, just to get you thinking. This is certainly not a comprehensive list:

  • Cognitive Behavioral Interventions - have to do with teaching students to think about their own thinking, and that different social situations have different social expectations. It is also teaching them to recognize when things do not make sense and to use learned strategies, or learned social skills, in order to change their thinking or behavior.
  • Natural Teaching Strategies - using what motivates the student, and structuring interactions and teaching around those things.
  • Social Skills Packages - target specific skills or behaviors, such as facial expression, turn-taking in conversation, initiating interactions, drawing attention, problem-solving, etc. Just remember, though, that when you train the understanding piece - the thinking, the feeling, the context, and the interpretation behind whatever that skill is - you are adding that cognitive behavioral part.

angie neal

Angie Neal, MS, CCC-SLP

Angie Neal is a school-based speech-lanuage pathologist from Greenville, SC. She earned her Certificate of Clinical Competence after obtaining her Master's Degree from San Francisco State University. Mrs. Neal has worked in inpatient and outpatient rehabilitation settings with both children and adults. She completed ASHA's Leadership Development Program for School-based SLPs in 2013 and presented at ASHA on the topic of social communication in the school setting at the national convention held in Philadelphia, PA in 2016.  She presents throughout the United States on topics related to social communication, language and literacy and effective school-based therapy.  Mrs. Neal is the author of The Pirate Who Couldn't Say Arrr (Tate Publishing), Spelling that Makes Sense (TPT) and Simply Social at School (Super Duper Publications).  

Related Courses

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/r/ Therapy - Part 2
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This is Part 2 of a two-part series that will provide SLPs with a solid understanding of why /r/ is a complex phoneme to master, and how to achieve successful remediation. This session will describe metalinguistic cues and elicitation strategies for teaching /r/. Therapy activities that promote generalization will also be discussed.

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