Exploring the Impact of Leading and Lagging Indicators in Therapy, Part 2 - Ep. 96

Do you ever wonder just what your data is telling you, and how to use your data to help your clients progress? If so, then this episode is tailor made for you! In part two of Leading and Lagging Indicators you’ll learn about some therapy ideas for measuring leading indicators. Leading indicators are so helpful, because they predict future success and help us chart the way forward with our clients.

--- Useful Links ---
Leading and Lagging Indicators, Part One 
Body Awareness Fun Deck 
Orange is a Carrot 
Simple Poem Six Ways 
Follow the Narrative Road 
Permission to Play 
Music: Simple Gifts performed by Ted Yoder, used with permission

Transcript

 Hello and welcome to the Speech Umbrella podcast. Today's episode is a continuation of the last podcast about leading and lagging indicators. In the last episode, I gave a general overview of what constitutes leading and lagging indicators and how to apply them to our field. Today, we're going to talk about specific therapy activities and whether we're measuring leading or lagging indicators, but first in case you're a new listener or didn't catch the last episode, here's a quick summary. A leading indicator measures the potential for future success and it's something you can influence and change, while a lagging indicator is something that has already happened and therefore can't be changed. The example of weight loss is a helpful way to think of it. A leading indicator would be diet and exercise while a lagging indicator would be the number on the scale. It doesn't help to focus too much on lagging indicators, although they have their place. It all sounds cut and dried, but when you get down to the brass tacks and try to figure out which one you're measuring, it can be confusing. That's why I thought today's topic would be valuable to you. I spent a long time thinking about leading and lagging indicators in regards to speech therapy. And I can't wait to share my best techniques with you. I'm not saying that lagging indicators are not worth our time or attention, I'm saying it's important to know what you're measuring. And if I spend more time on leading indicators, it's because lagging indicators are already pretty well covered in our world. Today, I'm talking about activities in the following areas: articulation, syntax, fluency, and narrative language. And we're just touching the tip of the iceberg. There are so, so many things I could talk about.

In articulation therapy, lagging indicators might be percentage of correct phonemes and syllables words, phrases and conversation. As I mentioned in the last episode, an example of a leading indicator is achieving a correct oral resting posture and maintaining that oral resting posture while doing something else. That's an absolute game changer when a client can do this. Several years ago, a fellow therapist told me about these cards called Yogarilla cards. They're basically pictures of a gorilla doing very basic yoga positions. And she said they helped with mindfulness and self-regulation. I got this idea as I was working with clients on achieving and maintaining optimal oral resting postures, to have them do these yoga poses with the oral resting posture. Did I already say it's a game changer? I was saying it again. The combination of the two skills is a huge predictor of progress in articulation.

Here's how I do it. First and foremost, they must be able to achieve the correct oral resting posture without doing anything else. And this can take a while for them to get there. I usually look for them being able to hold it for five seconds, five times in a row at the start of a session before I introduce any of these positions. The first five are done with their hands on the table. And the rest of the cards are in standing positions. And I found I only really need to use the first 10 cards, five at the table and the next five standing. That's all I need to get generalization of oral resting posture. That's provided there are no physical limitations such as neurologically based muscle weakness or tongue ties.

What is really fascinating to me is that the hand position pose with a crossing midline movement is the most challenging for these kids, but it makes a huge difference. And also one of the standing poses, it's one where they stand with their feet in sort of a mountain position and they put their hands on their hips. That one is also really challenging, but makes a huge difference when they master it.

 Here's a fun story about using the oral resting posture with one of these poses. I had a preschool articulation client with a huge bunch of motor involvement and really low intelligibility. And we worked on oral resting postures. And when we finally got to the point. where we were working on standing. And he was in the mountain pose, that's the body straight, the feet a little part in parallel, and with your hands on your hips. He put one foot behind him instead of putting them parallel. And so I helped him adjust his feet so they were parallel, and the minute I did that, his middle collapsed and he would have fallen over if I hadn't caught him. His core strength just wasn't there. This was so amazing to me. I told his mom I thought an OT eval was an order and sure enough, he did qualify for occupational therapy at the district preschool. In the meantime, I continued to work on that standing pose with his hands on his hips and his oral resting posture, and when he mastered that his speech cleared up amazingly. He went from mostly unintelligible to mostly intelligible in a matter of a few weeks with just a few things to clear up. This is simply amazing to me and I've seen it again and again, and here's one little tip. Make sure they are actually closing their teeth gently when their lips are closed. Because some kids keep popping their teeth apart, even when their lips are closed.

 Okay, let's move on to syntax. Some examples of lagging syntax indicators would be percentage of correct pronoun use. Percentage of complex sentences formed, type of frequency of grammatical morphemes used, and on and on, you get the drift. Leading indicators would be memory and ability and phonological awareness. Some of our measures seem to straddle both leading and lagging indicators. And when I was a younger clinician, I used to wonder why sentence repetition was part of so many standardized tests. I reasoned that unless we had to memorize lines for a performance, when did we ever actually use sentence repetition? Eventually I learned that the ability to memorize and repeat sentences is a key indicator of syntax performance and attention to detail. And I learned that kids can get better at memory tasks and they can get better at sentence repetition. Getting better at auditory memory tasks also predicts success in phonological awareness. So while a client's accuracy on a sentence repetition task is a lagging indicator, you can predict that improving memory will help their grammar and phonological awareness, which in turn helps with both receptive and expressive language and reading comprehension. So it all just builds on itself. And that light it's a leading indicator.

One thing I love to do is work on memorizing a short poem. And I particularly like the poem, Orange is a Carrot, because of the great rhyme scheme and the relative ease of memorization. I have a simple tools video on Orange is a Carrot and a PDF you can download at thespeechumbrella.com or on TPT, if you want to work on that sentence, repetition.

 Let's talk about fluency, an area where it can be difficult to get long-term results. Lagging indicators would be types of frequencies of disfluencies or a client able to identify their own past disfluencies, a reduction in disfluencies. While a leading indicator would be a client's feeling about their locus of control, about their ability to have control in their life and in their speech. Earned fluency is also a leading indicator. Um, by earned fluency, I mean when a client takes measures to be deliberately fluent at the moment they expect a disfluency to occur. It is awesome to witness that kind of change in a client who was stuttering. I've got an interesting story here, about a young elementary client. He was in first or second grade and he had an unexpected reaction to his earned fluency. We were both sitting in front of a long mirror so we could see each other's faces, and I told him I was going to hold up a finger every time I heard a disfluency just to help them with identification. He didn't want to do it, but I told him he could do hard things. And as we went through this activity, he was so fluent. I could tell it was intentional fluency, by the way he was speaking mindfully. He was in fact completely fluent And while we only did this for five minutes, he remained fluent throughout the session and was only mildly disfluent for the rest of the time I saw him. And what was interesting to me was his reaction. He didn't cheer or look amazed or proud of himself or comment on his fluency. His reaction was that he didn't care much for that mirror thing. And so that might have been saying something about his future outcome, because I did hear later from his mother after he had quit coming here, that he began stuttering again. And I will say this. He was a child whose mind was everywhere and where his mind went, his language went. And maybe he felt it was too much effort to keep his mind organized enough for fluency, even though he understood, at least for a time, how to use earned fluency. So for that client, I think it was a leading indicator, his reaction to his earned fluency that he wasn't really thrilled with that. And perhaps he was missing a little bit of that feeling of locus of control.

Now on to narrative language, one of the best interventions we SLPs have for receptive and expressive language and pragmatics. I love, love, love working on narrative language. Lagging indicators would be their inclusion of the story grammar parts, vocabulary use, sentence structure, all of which I do measure regularly. Mastery of basic stories in and of itself is a great leading indicator for mastery of more complex stories. And this is one of those areas where it gets a little hard to tell what you're measuring. Am I measuring leading, or am I measuring lagging. One of the ways I look at leading indicators for narratives is when I'm considering whether a client is ready to begin narrative intervention.

 I have a podcast on preparedness and that's episode 46, Follow the Narrative Road. To summarize that podcast success in telling stories can be predicted by their ability to one understand sequences, two compose basic sentences and three, remember and describe something that they just did. I go into how to do that all in episode 46. I also want to add that following the Story Champ model for narrative instruction is really key to success. It helps them work on memory and internalizing story structure. In the Story Champ method, they tell the story three times with diminishing cues, first with the pictures and the icons for the story grammar, then just the story grammar icons, and then the third time they're independent of pictures or icons.

And once you do begin working on narratives, every narrative milestone they meet becomes a leading indicator for more narrative success. And that's what I love about narratives. And here's one tip when you're considering beginning working on narratives. Sometimes a child meets all the above criteria, but it is so hard for them to come up with words to tell the narrative. In these cases, I have found that unstructured play and more play and more play can really unlock the fountain of words inside of them. Sometimes they just haven't had a lot of experience with talking while playing.

Episode 12, Permission to Play, is about one client who needed play to unlock her words. In her case, talking freely during play was the leading indicator for success with narratives. So take a look at your data. Are you measuring both leading and lagging indicators and using that data to chart your course? If not, there's no better time to start than today because when you measure leading indicators, the lagging indicators take care of themselves.

 Thank you for joining me today on the Speech Umbrella podcast. Transcripts and links for this episode are located at thespeechumbrella.com slash blog. While there be sure to sign up for the free resource library where you have access to over 25 therapy and clinic resources for free. Those are at thespeechumbrella.com slash free. I'm on social media now. I look forward to discussing speech therapy with you. Find me on Instagram at dstrattonslp and Facebook and YouTube at the Speech Umbrella. Please tell a colleague about what you've learned today on the podcast and invite them to join us under the Speech Umbrella. Bye for now.