Talking Through the STRIVE Framework With Amy Graham

Full transcript

Amy: We're starting this live over again. We haven't been able to get Nicole Kolenda and Julie Case on here at the same time, so we're going to try our best. Thanks for laughing, you guys, I appreciate it. All you can do is laugh sometimes, right? Nicole and Julie, when you see it, just tap "request to join," and we'll see if we can make this happen.

While we're waiting: what we're doing here today is a live with Julie Case from the Case Speech Lab at Hofstra and Nicole Kolenda of the NYU Motor Speech Lab, because they're going to talk about the STRIVE framework, this lovely little two-sided piece of paper. They both presented it at... oh, I'm getting a request from Julie. Okay, here we go.

It says Julie is unable to join; neither of her accounts is working. I'm super bummed out. Should we just keep trying to chug along? What do you think, Nicole?

Nicole: I don't want to get into the weeds about it, because I really wanted to do this with Julie. This is coming from both of our labs, and, as you know, we did this presentation at ASHA, and we're still working through how we're sharing it. It's almost like a work in progress at this point, is the way I would describe it. Julie's saying, please go ahead.

Amy: How about this, I have an idea. Why don't we talk just in generalities about how this can help clinicians with target selection, and then direct everybody to the Case Speech Lab account? Julie, maybe you can take it from there, and even do a question box or some stories you can save as a highlight, so people can get that nitty-gritty information. Does that sound okay?

Nicole: I think this sounds good. Julie, you're there. Does that sound okay? She said yes.

Amy: All right. So if you're watching this, we're having connectivity issues with Dr. Julie Case, but we're going to go over, just in generalities, what this framework means for apraxia of speech, and then she's going to take it away on her account later, whenever she's available. So be sure you're following both the NYU Motor Speech Lab, which Nicole runs, and the Case Speech Lab.

What do we work on?

Amy: So tell us about it briefly. This is what I'm looking at right now, and it may not be ready for prime time yet, but it's a great framework to help SLPs figure out what in the heck we're supposed to be addressing in speech therapy. Because, as SLPs, I know a lot of us struggle with: well, what do I work on? This is not a disorder about sounds, the way phonological and articulation-based disorders are, where this is the sound the kid doesn't have, so that's what we're going to work on. That's not what we do with kids with apraxia and motor speech disorders. It's about movement and motion and improving the motor speech system. So I think that's the big confusion: well, then what do we work on?

Nicole: Right. Yes. We talk a lot about this. Our two labs collectively created this idea, "make the shift": how do you make the shift to pediatric motor speech therapy? And listen, you and I are in the same generational camp. This is uncomfortable for us. We weren't trained this way. It's a whole shift in the way we organize our sessions. I have been on this research, doing this therapy intensely, for... we're in our sixth year now, and it took me a little bit of time to even find myself in the treatment and have it feel comfortable. I've always worked with children with apraxia, and I've always done this type of therapy, but not in this way.

So what do we always get asked? How are you selecting your target words? We're constantly talking about this, and constantly thinking about what appropriate treatment words are. I want everyone to think about it differently from the way you think about traditional articulation therapy. These words are a vessel to work on the system. We want to work on the efficiency; we want to work on the planning system. So we're picking our words differently.

Start with a dynamic assessment

Nicole: First and foremost, what you want to be considering is doing a really thorough dynamic assessment. That's how you're able to really think about it. I like to think of the assessment as the very beginning of really successful treatment, right? Wouldn't you say?

Amy: Absolutely. For me, the biggest paradigm shift was: I'm not just going to focus on what sounds the child doesn't have and try to get that sound into their inventory. We actually have to switch and understand what sounds they're capable of producing, and, when we think of movement, what syllable shapes they're capable of producing. What amount of cueing do they need to produce the speech targets we're trying to get them to say? We need to know how we can help them be successful. And I think when you say dynamic assessment, that's what you're talking about. If they say "wabbit," we're not just going to mark W and move on. We're going to say, "Okay, now watch me. This is what I want you to try to do," and see: does that cueing help them? How beneficial are particular cueing strategies? Is that sound in their inventory at all without cueing? Then we can take that information and know: these are the sounds they have in their inventory; these are the syllable shapes they have in their inventory. Would you say that's the jumping-off point for how we then pick our targets?

Nicole: Yes. A dynamic assessment gives us a whole bunch of information. And remember, we've talked about this a lot: children with apraxia can also have phonological challenges. We don't shy away from that. We just think carefully about what they have and how we can capitalize on what they have.

We picked "STRIVE" purposefully, because what we're seeing, and I know what you all are seeing when you're working with these kids, is that they're getting there. We wanted it to be positive, because we're seeing results. So the idea is that we're picking targets and thinking about syllable structure, and prosody, and maybe what processes might be happening in their output. Maybe, like you're saying, that initial R is challenging for them. We're thinking about all of this, because we're working on the system as a whole, and this is not an easy thing to do. So with this framework, we've come up with a way to really capitalize on where the child is and where we're hopefully trying to get them to go.

A small set of targets

Amy: And if we think back to the principles of motor learning, we have a small set of targets in these sessions. I think that's really, really important to tell everybody, because when we think of targets for speech sound disorders, it's like: initial R words, pick any 50 R words. That's not what we're doing here, since we're working on improving the motor planning system. Like you said, this is a system improvement. We're choosing a small handful of targets, and we're going to work to improve the accuracy and consistency and prosody and everything about those specific targets. That's why choosing the right targets is so important: we're not going to work on a ton.

Nicole: Exactly. It's a really small set. And I know this might seem strange, but as somebody who works out a lot in the gym, I frequently connect motor training with teaching speech production. If you think about it, when you go to the gym and you want to train, are you doing the same exercise over and over again? No. You have maybe a half hour, 45 minutes, and you're trying to get a full-body workout. I hope this is translating, but these sessions are intense, and we're trying to get the biggest bang for our buck in the types of targets we pick. So we think very carefully about these targets, because, like you said, it's not a traditional session where you're working on 20, 30, 40 different targets. It just doesn't look like that. In practice, at most I have five targets going in a 45-minute session. In the research I've been on, it's been four times a week for 45 minutes, and sometimes it's really only been three or four targets in a session. So again, that's a big shift, right?

Amy: Mind blown. "I'm only working on three targets."

Nicole: And they're target words. Remember, we're working on the whole word; that's super important too. So that's one of the main variables in changing to this type of treatment, and then thinking very carefully about what your target words are.

Assessment tools: the DEMSS and the Goldman-Fristoe

Nicole: So when we talk about dynamic assessment, we use the DEMSS in our lab, the NYU Motor Speech Lab, and at the Case Speech Lab: the Dynamic Evaluation of Motor Speech Skill, developed by Dr. Edythe Strand. It's very systematized, in that it goes through different syllable shapes. It starts with CV, then VC, CVC, all the way up to more complicated words like "banana," "lemonade," "honeydew." I have it embedded in my head. It's really helpful to do this dynamic assessment, see how they respond to feedback, and then think about what my targets should be.

But I don't want to discount how awesome a good Goldman-Fristoe is as well. We need to do that too, because we need to understand their repertoire. This is where those processes will come out. And sometimes, if you're doing the Goldman-Fristoe, we have to be careful when we're scoring and all that, but you can take a word and go into a little bit of dynamic assessment with the Goldman-Fristoe as well. All that really means is: how are they responding to my input and my feedback? Am I able to get that target word?

I see a really good question coming in from a previous student of mine. We do do phrases also. We're starting to really look at that; more to come. I'm just going to put a pin in that, because I could talk a lot about it. Julie is saying it depends on the level of the child and their needs. Absolutely.

STRIVE: S is for structure

Amy: And I think that's the perfect segue to the framework, because STRIVE is an acronym to help us think through what aspects of a particular target we should consider. Do you want to start going through those a little bit? So this is STRIVE right here. S: word structure is something we need to consider. So what is structure?

Nicole: We want to think about the syllables, how many syllables are in the word. And I just want to honor what Julie is saying right now. Julie is talking about phrases: conceptualize them by syllable number. A short phrase is essentially a sequence of syllables, like "get out." It's really a two-syllable phrase. I think that's what you mean, Julie, right? So we're thinking about the flow of that word. Is it an open or closed syllable shape? Are there sequential consonants in the word?

And we see this a lot, and it's well intended by the therapist: we don't want a list of five words that all have the same syllable shape. The idea is that you're generalizing. So if a target word in my session is "bye," CV with that beautiful diphthong, what starts to happen? I can tell you what starts to happen. I'm working on "bye" in therapy, doing blocks of training with this word, 10 to 20 repetitions per block, really focused, conscious practice. Two weeks into therapy, Mom says to me, "You're not going to believe this, but he just said 'hi' to one of his classmates, and he's never used that word before." That's the hope and the dream.

Amy: Yeah, exactly. That's what I see with my kids, too. I think sometimes parents and even clinicians are like, "Really? We're just going to work on that one word? Then that's the only word they'll ever generalize." And no, because it improves the entire motor speech system. What we tend to see is that the particular structures we're working on begin to emerge in other, non-practice words in their system. That's exactly what you're saying.

And I want to say, too: this STRIVE framework isn't just for picking a particular word. It's for looking at all of your targets and asking, in terms of the S, the structure of the word: are we varying the structure? Because you don't want all CVC words; then we get overgeneralization of that particular structure. So the point of STRIVE is to look at your whole handful of words and ask: are they varied, based on structure? So the S in STRIVE is word structure.

Nicole: Yeah. And a point you're bringing up, something that was super important to me in this framework: when I'm creating the word set for each participant, I need to be looking at all of the words at one time. Because, just like you're saying, sometimes you think you have good words, and then you look at the set and you're like, "Wait a minute, I'm using this phoneme too much," or "I have this syllable structure too much." You're really on it, and you still don't see it all. So what's really important in my personal process is being able to see all of the words, or phrases, or targets, and think about how they're interacting with each other for the individual child.

STRIVE: T is for transitions

Amy: Exactly. So the first thing, S, is structure: you're thinking of consonant-vowel combinations. Am I varying those in my target set? And the next letter in STRIVE is T, and that refers to transitions, articulatory transitions. So what are we looking for in our target set in terms of transitions?

Nicole: With transitions, we're thinking about what the target is starting with, maybe what was a hard start for this child, and what it looks like going into the word, how the word starts and ends. I don't even want to say "word." I want to say: what is the movement position?

Amy: Got it.

Nicole: Right. How is this starting and ending, and how is this looking? Sometimes we have kids for whom that initial H is a challenge, and we want to work on that transition from, I'm just giving an example, let's say "hi," from the initial H, which is that unvoiced continuant, into that voiced diphthong. Sometimes we're thinking about kids who have a hard time with a certain ending in a word. Maybe they have a preference for open syllable shapes, so we'll purposely pick a word that ends in an M, like "home," or something like that.

Amy: Right. So it goes beyond just syllable shape. Now we're looking at specific phonemes within that syllable shape: how we transition with our movement from those particular sounds, and how we end or begin with movement. That's kind of what that means.

Nicole: Yep. It's okay, Julie, we love you.

Amy: Bye, Julie.

Watch for the intrusive schwa

Nicole: Something else to consider here, something we talk about, is the intrusive schwa. You might hear it in a word like "eat": it becomes "eat-uh." We really want to think about what we're going to do to facilitate not having that challenge. Julie has coined this as vocal inertia.

Amy: Ooh.

Nicole: She talks about it that way. Have you heard that before?

Amy: I love that. I haven't heard that.

Nicole: Yeah. It's almost like, I got the system going, and I get the word out, and then I can't stop. Or sometimes we see that intrusive schwa before a target word. Maybe the target word is "bye," and it's "uh-bye." I like to think of it again this way, and I wish Julie were here to talk about it a little bit: I'm getting my system going, I can't start right away, so I start with that intrusive schwa to help me get going. And here's the thing: if we're hearing the intrusive schwa, we want to target it, right?

Amy: Absolutely.

Nicole: So we purposefully go in at that. And the other thing, just on a side note, and then we can move on: I've gotten caught with this. You don't want a lot of targets that end in those stop plosives, because they facilitate it, like the example I gave before, "eat" becoming "eat-uh." It's easier with "home," because it's a continuant, right?

Amy: Right. I think that's a great way to put it, because a lot of this is going to depend on how your child presents.

STRIVE: R is for responsiveness

Amy: So in STRIVE: S is word structure, T is transitions, and R is responsiveness.

Nicole: It's your cueing.

Amy: So what does that mean in terms of choosing your handful of words, when we're considering responsiveness? Do we want some words they're really responsive to, and some that are more difficult, that require more cueing? Is that what that refers to?

Nicole: Yes. Well, we want to be thinking about two things with this. And this is one of the things, when we talk about making the shift, that I had a really hard time with in the very beginning: giving this type of feedback. This is not feedback based on phonemes. It's not "What a great T sound that was." We're not thinking like that at all. We're thinking about movement. So in that particular example, you want to be saying something like, "I love the way you moved your tongue up in your mouth. Did you feel that? Did you feel how you got your tongue up?" We want them to start becoming aware of the movement associated with these productions. And honestly, that was really hard for me in the beginning.

So what we're thinking about is: during our dynamic assessment, what was this child responsive to? And again, like you said, Amy, this is very individual. Some kids really love it when you touch them, and other kids are like, "Get it off me." You all know that. So you're making little notes, like, okay, they don't like me to touch them. Some of them really respond to tactile cues.

One of the things that sticks with me, that I talked about at ASHA, was a CVC target. Let's go back to "home" as a target: the child has a preference for that CV syllable shape, so we're purposely putting in a CVC with a beautiful, visible continuant at the end. And something I might also be doing, and it's one of my favorite things, I know it's silly: I start here for the H, then I go down the arm, "home," and I end it at the wrist. They can really feel the final sound. And then I'm saying to them, "Do you feel the way your lips came together at the end? Did you feel how they tingle a little bit when you bring them together?" And I'm having them really look at me. This is so important in this type of treatment. So, back to your earlier question, we're thinking about what cues they're responsive to and what they need to get the actual target. And then we're refining that and pulling it back.

Mixing hard and easier targets

Amy: I love that. I tend to think of it, too, before even looking at this: do I want all of my target words to be so incredibly difficult that they just break down in therapy? No. Or do I want some, maybe frequently used ones, where they're highly responsive to the amount of cueing I'm giving, so that's a much easier target? Because I think we need to think about the emotional aspect of all of this. I want to help that child feel successful. So do we want everything to be really challenging, or everything really easy or really responsive? No, we want to mix both. So I think the responsiveness in STRIVE is really important to think through, in addition to what syllable shapes and what transitions I'm working on.

Nicole: I think you bring up a really good point, too, in terms of emotional saliency and why we're picking these targets. Sometimes a really hard target is also a really good target. I'm thinking about a former participant who I adored, and her target was her cat, Mugsy. That's a really challenging articulatory transition: "Mugsy." But she was so motivated to work on this target, and it was so appropriate for where she was and what she needed to be doing. And we got it. But it was definitely hard.

Amy: But how do you come to that conclusion? You ask what's important, and you try. I have parents who tell me, "Oh, she really wants to say this word. Do you think she can do it?" And I'll say, "I don't know, but we're going to give it a shot." If they shut down and it's not working, then okay, maybe not this week. But if it's highly motivating, functional, and personally meaningful, we're going to give it a shot, whereas some random syllable shape that was in a book somewhere, on some flashcards, isn't meaningful. That's probably not where I would go with that child.

When a target is too hard right now

Nicole: Absolutely. And the other thing I just want to say on that: we organize our sessions with a modified block schedule, meaning sometimes we're going to work intensely for 10 to 20 repetitions, and we're in a good flow. Again, I'm referencing Dynamic Temporal and Tactile Cueing, developed by Dr. Edythe Strand. But there are times with, let's say, a target word they're motivated to say, but it's harder and they're getting frustrated more easily, where that block of practice is going to be short and sweet. Because we don't want to engage in what we call negative practice: saying the target word over and over again incorrectly. We do not want them to build a motor plan for an incorrect production. So we stop.

One of the things I really like to do in that situation, if they're having a really hard time and they're saying it wildly incorrectly: I break it down and say, "Okay, why don't we just take the voicing off?" That takes off some of the cognitive load. Maybe we say it in a whisper. Still too hard? Let's just do it in a mime. And this is what I do: "Okay, I'm going to do it in a mime." That's from Dr. Strand, but it's brilliant. And then, if even that is too hard, I'll say, "You know what? Just watch me. Watch my mouth. Take a look at how I'm doing it. Great job. Let's move on."

Amy: Yep, exactly. I love that. It's about flexibility and being dynamic, not only in our assessments but in our therapy. I want to be mindful of people's time. Sorry, everybody, we've got three more left. So we've covered S, T, and R.

STRIVE: I is for inventory, V is for vowels

Amy: I is next: inventory, phonetic inventory. So what does that mean? We need to understand what sounds the child is able to produce, and use those sounds to make our target words?

Nicole: Yep, it's exactly how it sounds. You're doing the Goldman-Fristoe, and you realize they don't have N at the end of a word, but they have it at the beginning. You realize they have these phonemes but not those phonemes. So that's just what it is: you're taking phonetic inventory into consideration. You're also looking at age, you're looking at what's meaningful, and then you're bridging all of that together and putting it into the target. We can say more, and I'll have Julie talk more about that too, but in the interest of time, so we can go on...

Amy: So V is for those vowel errors.

Nicole: Which we really, really love working on. It's super important.

Amy: I think sometimes we forget about the vowels. I know I can be hypersensitive, just tuned into all of those consonant clusters; now I'm thinking very phonological in nature. But vowels have a tremendous impact on intelligibility, for one thing. So when we're thinking of vowels and that small handful of targets, we want to choose different vowels, vary those up? Is that what that is?

Nicole: Yep. And we like to think about using a really good diphthong; that goes a long way. And the one thing I do want to say here: I have the luxury of listening to and looking at my dynamic assessment again, because there are a lot of moving parts. I'm sweating, it's hard to get the kid focused. I have a trained ear; I'd say I'm pretty good at hearing errors. But I miss vowel errors sometimes, and I go back and listen, and I'm like, "Oh my goodness, I didn't notice they weren't saying that correctly." So it's worth recording yourself sometimes.

Amy: Same thing. I'll go back and re-listen: how did I miss that?

Nicole: I know. Sometimes in therapy you want so badly for them to get it right, and they had it right yesterday, or in the block you did seven minutes ago, so you're assuming they're going to get it now, and that almost overrides what you're actually hearing, and then you miss it.

Amy: Right. I can so relate to that.

STRIVE: E is for emphasis

Amy: Okay, so the last letter in STRIVE is E, and that refers to emphasis. This one, I thought, I have not been paying attention to nearly as much as I should have. Because again, it's a movement-based disorder, we have to think about movement, and with movement we have to think about stress and emphasis, and maybe pick different targets that have different stress patterns.

Nicole: Yes, yes. When we think about lexical stress, we're really talking about two-syllable words, or phrasal targets that have that interaction of different types of stress. We know we have the trochaic, or strong-weak, and the iambic, or weak-strong. Something I think about frequently: when I first started working, I had this really cute kid on my caseload, and how did he say "happy"? No one knew what he was saying. We don't realize how important it is. The syllable shape was there; the emphasis was off.

Amy: The syllable shape was there. Even if you think about it, the consonants were right, and even the vowels, somewhat.

Nicole: Yeah, but the stress is off, right? And that affects meaning. So we definitely want to be thinking about lexical stress when we're picking our target words, and having different types of lexical stress in the words. Because ultimately, this small set we're working on in our therapy sessions, we want to push out and generalize to so much more output for this child. So we want that variability in our targets.

Amy: Absolutely. I think that is the whole goal. We have to touch on a little bit of a lot of different things in our targets, so that it generalizes, instead of overgeneralizing one particular thing we're working on. Even if you were only working on two-syllable words, which we don't want to do, if you choose a word with emphasis on the first syllable and another word with emphasis on the last syllable, even that in and of itself helps add flexibility to the speech system.

A viewer question: revisiting earlier targets

Amy: I see a really good question coming in: do you revisit past easy target words periodically, or do you do it every session?

Nicole: I can tell you what our process has been in research, once we're able to get to spontaneous production of the words. What I start doing with a target, at the very beginning, is using a sort of cloze procedure, so that once I get to spontaneous production, they know what I'm going for. Let me back up and give you an example. Say the target word is "bye," and the child can't say "bye" yet. He comes into my room, and I'll say, "Okay, what did we just say to Mommy? We said 'bye.'" And I'll work through it with them. What am I doing there? I'm laying down the groundwork, so that whenever I say, "What did we just say to Mom," or Dad, or whoever is bringing them, a sister, whoever, they know the response is "bye."

So by the time I've gone through the hierarchy and I'm at spontaneous production, I want to make sure I can get that target 10 times across the session. I'm not working on it in a block. I'm like, "Tell me again, what did we say to Mommy?" "Bye." Beautiful, they got it perfectly. And I'll do it again. We call this sprinkling. And I want to make sure that across three sessions, without targeting the word explicitly, I've set it up so they say it spontaneously, 10 times in each session. And then I feel so good about not having to target it.

Amy: Right, where it's like a maintenance level. We're just maintaining that they've still got it. I love it.

Where to find STRIVE

Amy: Nicole, tell us, and I'm not sure if this is ready yet for public consumption: where can everybody go to get more information about the STRIVE framework?

Nicole: Okay, so please... and I say "we" because we are in collaboration with the Case Speech Lab, C-A-S-E, Dr. Julie Case over at Hofstra, and I am with the NYU Motor Speech Lab, which is under the direction of Dr. Maria Grigos. We will be sharing it on our respective pages, and we're super excited to share it. I do want to point out that we're sharing what we talked about at ASHA, but we like to think of it as a work in progress, and we're happy to hear any input you may have about it as well.

Amy: So if you're not already following those accounts, you definitely should be, if you're an SLP who works with any children who have motor speech impairments. When I save this to my profile, I'll tag both of those accounts below, so please go follow. I know Julie wasn't able to join us today, but she's definitely going to be posting more information. I think this information is going to be so helpful, to give us SLPs a guideline for what we need to be thinking through to choose the right targets. Because choosing the right targets is what will help kids improve faster. That's my whole mission: choose the right targets, choose the right approaches, help your kids improve quicker. So I think this will help everybody. Nicole, thank you so much for joining. Any parting words before we go?

Nicole: Thank you so much for having us, and for supporting our work all this time. And if anyone has any questions, I run our NYU Motor Speech Lab Instagram, and I'm so happy to connect. I try to do helpful videos for clinicians, so if there's anything you want me to share, we love hearing from clinicians.

Amy: I love that. Thank you. Thanks for all your work.

Nicole: Take care, everybody. Bye-bye.