Thursday, August 23, 2012

The RBI and Speech-Only Children




Why should we do a Routines-Based Interview for children whose only need is related to a speech or language delay? After all, the RBI is lengthy and addresses much more than the presenting problem. More efficient methods exist for identifying speech or language goals.

Four reasons explain why the RBI is a good practice to use with “speech-only” children. (This colloquial label violates the person-first rule and is used to acknowledge my familiarity with early-intervention team vernacular!)

1. Early intervention is supposed to be more than a rehabilitation or remediation service. The purposes of early intervention are to support the family and other natural caregivers in promoting the child’s development just to provide a service to tackle those things that have gone wrong. It is supposed to address all areas of child development and family functioning, including and especially parenting.
Speech-only children are developing in other areas beyond those identified as deficient or delayed. They are learning to play, to solve problems, to move, to handle increasingly small and complicated objects, to get along with others, and so on. The ticket into early intervention is admittedly an established condition or a delay, but, once in, the program has an obligation not to put on blinders and address only the deficits.
Whether the early intervention system should pay for services addressing typically developing areas of development is a matter of public policy. From child development and family systems perspectives, addressing nondeficit areas is appropriate even for single-deficit children. In child development, to promote children’s language, we know it is helpful to promote their overall engagement. In family systems, we know that family members have many opportunities to work on children’s speech and language throughout every day. Therefore, it is not inappropriate for public funds to be used for promoting skills other than the deficient ones.

Another developmental reason for taking a broader view to needs assessment (i.e., conducting an RBI) is that children with speech or language delays might have behavior problems. Research has documented these areas are associated with each other more often than would be expected by chance. Therefore, we should conduct needs assessments for speech-only children that assess engagement (i.e., appropriate behavior) across the day.

The last issue related to the purposes of early intervention is that speech-only children have parents and other family members who might need support. An effective way of finding out what kind of support they might need is to conduct an RBI. This procedure helps identify whether they need emotional support, material support, or informational support, whereas traditional speech or language assessments do not identify support needs adequately.

2. What’s the best way of addressing a child’s speech-language goals? The most effective and efficient method for providing interventions to young children is to embed interventions into everyday interactions, activities, and routines. To do this, the team of people designing the interventions (i.e., the family and professionals) need to know what happens currently in routines and what the desired behaviors are (even if they are primarily about speech or language). Understanding the concept of goodness of fit, when children have speech or language deficits that means that the demands for communication and social interaction in different routines and the abilities or interests of the child do not match well. In other words, meaningful participation in a routine might require the child to speak clearly and, if the child doesn’t yet have the ability to speak clearly, a functional problem ensues. Now we have three options: (a) change (i.e., teach) the child, (b) change the routine, or (c) change your expectations. This goodness-of-fit approach requires us to assess routines in a way best accomplished by the RBI.

3. Do we really want to discriminate against speech-only children and their families? The RBI is heartily endorsed by families, has been shown to be effective, and is valued by many early intervention programs around the world. To deny families with children with speech or language delays the opportunity to participate in an RBI is discriminating against them, therefore, on the basis of the child’s specific disability.

4. The RBI helps determine the functional needs that arise because of the child’s speech-language deficits. Often the existence of a delay is determined, appropriately, by a norm-referenced measure, so that a person can say with some confidence that the child’s reported or observed speech or language is behind what would be expected for a child of that age. What it does not tell us is how this impairment affects functioning. If it did not affect functioning—if the child lived on a desert island, being raised by friendly animals who did not have conventionalized communication (so we might have to rule out chimpanzees), the deficits might not be important. Who cares? So-called normal communication isn’t needed. But usually there is some functional impact of a speech or language impairment. In fact, often the functional impact is what precipitates a referral to early intervention. To obtain an environmental scan of the current and potential impact of the impairment, an RBI is ideal. It addresses the everyday contexts of the child’s life, which are more varied and challenging than life on a desert island.

Without everyday context, the documented deficits could become “speech” goals that have no relevance to specific times, people, places, or activities. Therefore, children can be working on their final-th sound (e.g., both, bath, Beth, cloth) completely devoid of a reason to be using this sound. Although decontextualized instruction can be used with older children, it is usually very difficult to use effectively with young children. But many therapists and teachers try.

The final issue about functionality is that speech goals, as distinct from language goals, are actually about speaking so as to be understood. People familiar with my model will recognize these as the controversial “artic” goals—where we wonder why so much attention goes into articulation therapy when articulation is not resolved until children are in elementary school. But of course I do recognize that families want to be able to understand children and that children want to be understood when they speak. All children go through artic training by their natural caregivers, but some children still have great difficulty making themselves understood. So understandability goals are very relevant. The RBI can help figure out who needs to understand the child, when, where, and about what. Further assessment, usually by a speech-language pathologist, can help identify what specific problems the child might have, such as a structural or tone problem, which might guide what the intervention options are.

So, when you wonder why you’re going to all the trouble of doing an RBI with the family of a speech-only child, remember it’s because early intervention is supposed to address the whole child, it’s the best way of identifying speech-language goals, it’s discriminatory to deny an RBI to any specific group of families, and it helps determine functional needs.

2 comments:

Maureen said...

I would add one more reason. Many families of so-called "speech-only" children have other concerns with their child's development that are too often missed with a traditional speech-focused evaluation. As a family leader and trainer I am no longer surprised when during a training on functional outcomes the families of children with a speech-only diagnosis identify scores of other concerns--oftentimes in the adaptive domain--which are not being adequately addressed. However, I have found that having families use the RBI to think through their day they identify many other areas of concern. And if we only address the speech concerns and leave these other concerns we leave children and their families without the supports that they need and deserve from early intervention.

Mary said...

Shouldn't there be a "not" in the first sentence following the bold in #1?! :)