Richie is an engaging 9-year-old boy who is in treatment to improve his language skills. He is compliant and cooperative in sessions and is eager to learn new information. There’s only one problem: Richie is unable to spontaneously ask questions and request clarification when he doesn’t understand what he is told.
He’ll just sit quietly, making nice eye contact with the clinician. His entire body posture says, “I am listening to you!” But when it comes to answering questions about what he’s learned, Richie clearly doesn’t get. He might attempt to answer the questions and stumble halfway through before giving up. He might also provide an answer completely unrelated to the question. But most of the time, much to our frustration, Richie will simply shrug his shoulders and reply, “I don’t know.” This is typically when some might ask him with barely disguised frustration: “Why didn’t you tell me before that you didn’t understand?” Richie will shrug his shoulders again.
But here’s what’s important: He is not trying to be oppositional. He really doesn’t know.
Richie has impaired executive function, and this causes difficulties with initiation—asking questions, getting help, beginning to work on tasks and so forth—and pursuing clarification when he needs it.
Executive function is a set of mental processes regulated by the frontal lobe of the brain that help with optimal life functioning. Intact executive function allows us to manage, plan, organize, strategize, attend to, and remember things appropriately. However, if EF is underdeveloped or impaired (damaged) as a result of an injury or disorder, such as attention-deficit hyperactivity disorder or fetal alcohol spectrum disorder, then the child will present with significant difficulties in various areas of functioning. This will make it difficult to appropriately meet school requirements or engage in successful social interactions.
While it is important that children with EF impairment receive remediation in all affected areas, I typically start by targeting initiation, specifically improving the child’s ability to ask for help when needed. Why is that skill more important than the rest? For starters, it lets you know when something is wrong, or in some extreme cases, very wrong.
Imagine working with a 10-year-old verbal child who all of the sudden shuts down and cries while clutching her stomach. You spend valuable time questioning, prodding and cajoling until, about 10 minutes later, you find out that the child had an acute stomach ache. She was simply unable to initiate and tell you, “I need help. My stomach hurts.”
This is why it is important to use charts and other such strategies to help these children navigate treatment. To illustrate, I’ve created a “Strategies of Asking for Help” chart for my clients who are verbal but have mild cognitive impairment (IQ 70+) or have average cognition. I keep this chart in the child’s line of vision and remind him or her to choose a relevant strategy from the chart to alert me when in need of help. For example, under the category, “if confused,” the chart advises saying, “I don’t know where to find the answer.”
Of course, prior to using the chart, I pre-teach the child the strategies on the chart. I also explain when to use each strategy (during what type of tasks/questions/situations), as well as why it is so important to ask for help. Depending on the severity of the child’s impairment, I may need to spend several sessions pre-teaching these concepts to optimize the child’s success.
I also don’t limit use of the chart to language treatment sessions. What would be the point if the child only learns to ask for help during treatment, but is unable to do so when working on assignments in class or homework at home? Consequently, I provide a copy to both teachers and parents to attach to the child’s desk in class and at home.
Thus, the chart serves as a continuing visual reminder to ask help, along with strategies for how to do it. For your own free copy of the chart, download a copy here from my blog, Smart Therapy LLC.
Tatyana Elleseff, MA, CCC-SLP, is a bilingual speech-language pathologist with Rutgers University Behavioral Healthcare and runs a private practice, Smart Speech Therapy LLC, in Central New Jersey. This post is adapted from a post that originally appeared on her blog, Smart Speech Therapy LLC. She specializes in working with multicultural, internationally and domestically adopted children and at-risk children with complex communication disorders. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education, 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, and 16, School-Based Issues.