Jehan Shehata-Aboubakr joins us this week. She is a speech and language pathologist at Clinical Communication Consultants in Thornhill, Ontario (just north of Toronto). She is an expert DIR provider and trainer with the Interdisciplinary Council on Development and Learning (ICDL) and faculty with Profectum. We did a podcast together last year on scripting and she’s back today to discuss what to expect from developmental, relationship-based speech and language therapy.

The idea for today’s podcast came from the online weekly parent support drop-in where a parent said that she thought that once her non speaking two-year-old started speech and language therapy, she expected her to begin speaking! I know that I wondered myself what to expect when my son stopped talking after his brain inflammation at age 2. Jehan says that it is a very crucial topic in the sense that it happens again and again as families wonder when their children will speak and converse with them.

As a field and profession, Speech and Language Pathology has grown and changed. She’s grateful to take this opportunity to extend the meaning of who is a Speech and Language Pathologist and what do they do?

What to Expect from a Developmentally-Based Speech and Language Pathologist

by Affect Autism | affectautism.com

The Roots of Speech and Language Pathology

Speech and Language Pathologists started focusing on receptive language as a bulk of words, and on expressive vocabulary. Next, they started to think of comprehension, Jehan says. Now there is a group of Speech and Language Pathologists who have come to perceive language in a bigger framework: that of content, form, and use. The developmental Speech and Language Pathologist, working from a relationship-based approach, knows there is language and there is speech.

Language is the capacity to articulate words, Jehan continues. It’s a bulk of content and word knowledge where there is structure such as grammar, rules, and pattern of the linguistics. Then there is the use, which is the social act. Caregivers nurture the capacity for language. It happens within the interaction to carry meaning to the structure form of the linguistics, she says, no matter what language (Spanish, Italian, Mandarin, English, etc.). It is picked up within the interaction. It’s a much bigger view of speech and language than earlier on.

Most importantly for the developmentally, relationship-based Speech and Language Pathologist is that we are born with the potential for language and this grows into a capacity. This happens in the context of interaction in a relationship with our caregivers.

Jehan Shehata-Aboubakr

The Foundational Capacities for Language

When we come to the question from the parents, “When will my child start speaking?“, yes, this is the ultimate goal. We want to help our clients develop the capacity–not a skill–for language. When we talk about a capacity in developmental, relationship-based speech and language therapy, we know it happens within an interaction. It also happens along with the development of other domains that all grow together including (1) the potential for logical thinking, (2) play, (3) language (4) social-emotional interaction, and (5) communication.

When Jehan meets a child for the first time she assesses the child’s level of functioning and the complexity of use of the tool we call language. If the child is verbal, she’ll also look at the child’s speech. She is looking at the pre-linguistics and the quality of the interaction. Jehan says that brings us to the foundational capacities that precede language which starts with emotional regulation, sensory-motor self-regulation and the ability to share and attend (FEDC 1). Jehan referenced the Foundation for Regulation podcast I did with Speech and Language Pathologist, Amanda Binns and I mentioned the Foundation Academics podcast I did with Dr. Gil Tippy.

Jehan then looks at the engagement (FEDC 2), asking herself, “How do I engage with him? Does the child engage with me? If he does, does he engage independently? And how much support does he need?” Next, reciprocation (FEDC 3 and into FEDC 4): “Is he able to build relationship? One that carries that engagement? How is the back-and-forth? How is his sense of self in this back-and-forth? Is he coming with ideas, thoughts, feelings or experiences. Is he sharing that independently with an intent and purpose to share, or does he require support? Do I have to elicit it? How much support does he need?

Those capacities that are developmentally acquired are capacities. They are not skills. They are also not attached to a specific age. It’s a capacity that is interdependent with five other domains and reflects at the level of sharing ideas: his logical thinking, his depth of ideas, his perception of feelings and the range of feelings, and the depth of his experience. And all of this happens not at the verbal level, but at the level of play. “Where is his level of play? Is it at the sensory level? Constructive? Symbolic?” (See the Floortime Manual post about these three levels of play). Jehan is looking at all of that in one moment as she looks at the child.

Jehan continues that if the child is able to share ideas (FEDC 5), she wonders if the child is able to bridge the ideas (FEDC 6) between the child’s own ideas and feelings. Is the child able to bridge between their experience and her experience in the back-and-forth? Once she understands the capacity along these pre-linguistic capacities for language, she’ll look at his verbal and non-verbal language (his eye gaze, his referencing, and if the child approaches her–and is the child coming for help or to show her something? And if they need help, are they asking for help or just looking at her? Do they project their range of emotion? Then Jehan will look at how much language the child has (verbal and non-verbal). And all of this is in the moment.

The Plan of Action

When Jehan meets a family for the first time, she likes to ask for a short clip–even 3 minutes–to gauge where the child’s developmental level is. Sometimes this can’t be determined right away. Sometimes it happens within the child’s comfort zone with one of the parents instead of with her. There is a basal level and a ceiling level of the developmental level that she sees. Jehan will then meet the child where he is at, or just below, then harnasses their internal drive to get in that interaction in that context to let the child experience, perceive, feel and learn the next step.

It could be in terms of regulation, or engaging with intent and purpose, reciprocating and maintaining a certain sense of self, and sharing. At that point, if these foundational capcities are not yet there, working for the child, Jehan won’t go for speech even if the child uses words. There might be articulation errors and phonological patterns. She’s not going to address speech and grammar or use of language. She’s going to make sure that the pre-social, pre-linguistic capacities are working for the child so they will be open to share.

There’s the road map in her head but she’s focused on what the child’s bringing to the table and she is supporting them. She needs to focus on the child’s internal drive to help them acquire those foundational capacities, and then when they have a good back-and-forth, she can address the linguistic, associate it with meaning, and then address how they’re making their words. She needs to keep the child’s sense of self solid so they will take risks with others.

Parent Mediation

Jehan’s goal is to bring the caregiver on board so this is happening consistently at home, not just in her sessions. She doesn’t stand a chance versus the parents if they are in synch with their own child, supporting, co-regulating, enabling from a place of strength, and not addressing the weaknesses. You help those areas of need, but you are holding the child where their strengths are. That is the developmental, relationship-based perspective where the developmental, relationship-based speech & language pathologist is working.

Language is about meaning. Jehan says if she’s not addressing that capacity within a meaningful context–for the child, not for her–it’s not going to trigger anything in the child’s own experience. Jehan says this is not the fault of the parent (the initial question), but the fault of how the Speech and Language Pathologist has defined themselves why parents assume the therapy is about speaking. So when some of the parents come with quite young children trying to do Floortime: using that prosodic voice, co-regulating, joining in with the child and are not feeling like they’re getting that interaction back, Jehan has to coach the parent.

It’s About the Child, Not Us

Jehan says that as she has the privilege to try to connect with a child, she sees if the child is approaching her or the parent and has an object of interest. She is still determining how the child’s sensory motor system is coming together for the child to be able to multi-task. That is, can the child focus on what he’s doing and focus on the incoming stimulation? Jehan doesn’t know whether he feels emotionally stressed, being in a new place, with the parents and therapist talking, with it being noisy, and the child perhaps being scared based on a prior experience. 

Jehan needs to get in there and try to engage with the child instead of getting the child to engage with her. If she’s successful, she needs to engage with the child and what (s)he is busy with. She’s not going to ask the child what colour it is, what it’s called, or if she can see it. All of this is putting demands on the child. The fact of just approaching a child in this context and in this moment, makes Jehan feel that she needs to understand first what’s going on with the child. She’ll sit close by, watching and reading his cues and signs, watching what he’s doing, and approaching him where he is and enjoy it with him.

It’s about the child. This moment is not about the child peforming for me, but about me getting to know the child. It’s not about putting the child under stress. It’s about joining the child so he’s calm, focused, and willing to open up–even a small crack in the door–for her to exist with them.

Jehan Shehata-Aboubakr

With the parents, she’ll recognize, appreciate and respect their parental concern about their own child who is not coming to them, so to speak, but she’s going to explain with much appreciation and respect, that we need to put our fear on the side and look at the child. It is about the child. It is about being with the child. It’s about building the trusting Relationship for the child to be able to feel secure. And if the child looks at Jehan the way they look at their mother, they don’t have to have the words. We talk with our eyes, body language, gestures, etc. We feel the vibe of someone’s body as they enter the room. Let’s give ourselves the chance to know where the child is at.

Jehan reminds us again that at every moment there are the aforementioned five domains of his thinking, emotion, sensory motor, and that language is his own perception of what’s going on in that moment that is threatened by his emotion, and disorganized by his emotion–the fear. As Barry Prizant said in his book, Jehan says, we have to be the other in a mindul, humanly-based understanding. Jehan says she needs to help the parent to slow down, get out of their own head, and get into the child’s head because they are still growing, building that relationship, and they need to take their child’s hand in a nurturing moment to help them feel secure.

Ask Why

Jehan continues that she’ll get the parent who will say, “But he’s being rambunctious, going all over the place.” Let’s ask “Why? Why is the child doing that, or why is he sitting in the corner by himself?” Instead of judging, let’s get more educated, aware, mindful and insightful of another person, Jehan suggests. Afterall, she also has her five domains working at the same time but has to put this aside to focus on the child and focus on the dynamic. She says there is not a list of things that the parents need to do. 

We need to get in touch with ourselves and tell ourselves that there is light at the end of the tunnel in that moment. Get busy paying attention to what’s going on with the child, to break through, but not with questions, and definitely not with testing questions. That will just shut down the child. They don’t have the words to say, “Stop it!” or even the non-verbal capacity to put up their hand in a stop motion or look at us with angry eyes. The child is vulnerable. Do we know what it feels like to be vulnerable? Then we can be compassionate and empathetic and get in there and connect. And it all depends on the child’s developmental level.

You cannot work the speech or language without understanding the function in the five domains, Jehan explains. This is what she appreciates about DIR/Floortime. It gives her the words and understanding of how those domains work together and she has to consider them. She can refer the child to an Occupational Therapist (O.T.) to help determine the child’s sensory motor capacities because she wants to understand where the child is in terms of ideas. Is he just taking an object and fiddling with it? Is he taking it and building something? Or is he pretending? 

Jehan says to get in there where he’s at, build that relationship, harness his interest to be in that moment with meaning. Then Jehan can work on content, form and use, all while the child’s regulated, interested in engaging, reciprocating and coming with intent. 

Therapy Example

I described to Jehan the difference in Speech and Language therapies that my son had from the early behaviourally-based sessions where they expected him to sit strapped in at a table and expected him to comply with their instructions versus his Floortime sessions a couple years later. They would bounce these bouncy rubber balls he loved to play with and watch the ball go behind, under, over or it was so fast. It gave him the context for the language and the emotional experience. He might not have been able to say those words yet but he now heard them in an enjoyable context that was emotionally meaningful. It is not memory-based, but it is meaning-based. 

They respected his sensory processing profile knowing that he needed vestibular input, moving the whole time, running, and throwing the ball which kept him regulated enough to share the interactions with the therapist. The therapist knew what he needed to be able to get him to engage in that back-and-forth and the ideation of the rubber ball and his interest in it, Jehan explained, while giving him the sensorimotor and visual-spatial and temporal and central auditory processing with the, “Is it under, behind? No! In between!

Development is a Process

Each of the domains Jehan described have their developmental scale. The child needs to be at the same level of functioning across domains. She cannot teach the child, “I want cookie” for the child to recognize the personal pronoun, the action and the object, when the child is not perceiving a 3-element situation. First children say single words, then 2-word combinations, then 3. It has to be perceived, seen, touched in play. They have to work together along with the social-emotional and the sensory motor domains, etc. 

She is looking not for the scripted language or language a child has memorized, but the language that the child generates that reflects the level of thinking, the range and complexity of emotion, and the level of play the child is at. Each domain is a window to where the child is at developmentally and this is where we want to give the just right challenge rather than coming in too high, or the child will be stressed. You don’t just work on regulation or reciprocity. If the child comes with an idea, you need to see if the child is solid with all the others before you jump forward. You can’t go forward if the ground is not solid or the building will collapse.

Thank you to Jehan for taking the time to share this wonderfully rich description of the developmentally-based, relationship-based Speech and Language therapy. If you found this informative and helpful, please consider sharing this post on Facebook or Twitter and feel free to comment below. Next week will be a back to school topic. Stay tuned!

Until next time, here’s to affecting autism through playful interactions!

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