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How I offer impairment therapy(1):

Re-animating intervention
Over the past two years Ravit Cohen-Mimran has developed and piloted a novel approach to intervention with older children with language impairment. Animation Therapy is a hybrid of skill based and naturalistic activities aimed at improving narrative. Here, she describes the stages of the intervention and the impact it had on 11 year old Ben.

developed Animation Therapy to enhance the narrative skills of children with language impairments. The important role of narrative abilities in the academic and social success of children has been affirmed by many researchers (see Boudreau, 2008 for a review). Narratives are stories about real or imagined events, constructed by putting together at least two utterances produced in a temporal order about situational contexts, characters, actions, motivations, emotions and effects (Gillam & Pearson, 2004). Effective oral narratives are essential for common activities, both in and out of the classroom, such as story telling or retelling, describing events, and sharing personal experiences with friends or teachers. Successful use of oral narratives is also connected to effective written expression and reading comprehension (Nathanson et al., 2007). Many studies have shown that school-aged children with language impairment have persistent story telling difficulties. Compared to children with no language impairment, they tend to compose stories that are poorer linguistically (eg. shorter utterances) as well as structurally (eg. fewer story grammar components) (Fey et al., 2004). Johnston stated, "literature has convinced me that narrative abilities should be included among the intervention goals for all school-aged children with language learning problems" (2008, p.93). She also wrote that, by focusing on narrative intervention, opportunities are created to decontextualise language, facilitate social relationships, provide practice in constructive listening, and identify language strengths and weaknesses. Some researchers have argued that schoolaged children with language impairment may need intervention focusing directly on their narrative abilities (Fey et al., 2004). Indeed, in the past few years, several studies have recommended use of narrative intervention programmes focusing on explicit teaching of story grammar structures (Stein & Glenn, 1979). Studies have demonstrated that such intervention has led to improved narrative skills not only in children with language impairment (Swanson et al., 2005), but also in children who have cochlear implants (Justice et al., 2008), learning disabilities (Nathanson

The setting for Bens animation movie

et al., 2007) and children coming from lowincome families (Zevenbergen et al., 2003). The intervention programmes used by investigators are diverse. However, all include the presentation of a story, either by means of a picture book or movie, followed by asking the children to tell the story they have just heard or seen (Nathanson et al., 2007). Animation Therapy is an activity-based intervention founded on the naturalistic approach. During the past 20 years, clinicians have tended to use more naturalistic intervention programmes to optimise social and verbal interaction, thus helping people with disabilities improve their communication and language skills. The aim of the naturalistic approach is to facilitate generalisation and maintenance, since it tends to rely more on language use and meaningful practice than on repetitious tasks (Vilaseca & Del Rio, 2004). It enables us to help children

improve their skills by setting up situations providing opportunities to learn through age-appropriate interactive processes in natural settings (Vilaseca & Del Rio, 2004). In this child-centered approach, the clinician uses activities in which they can incorporate modelling and reinforcement of therapy targets within contexts that are meaningful to the child. However, this leaves the therapist with less control over the focus of the session. Thus, to allow the clinician more control over specific pre-selected therapy targets, Animation Therapy also includes structured parts, which make it a hybrid language intervention combining skill-based and naturalistic activities. The Animation Therapy intervention programme consists of four one hour individual sessions over a four week period. The programme is also suitable for group interventions, where it would most



likely include additional opportunities for increasing functional communication skills and pragmatics.
Figure 1 Bens animated traffic jam story (translated from Hebrew) The story that Ben told Ravit in the beginning: There is a big traffic jam. There was a big traffic jam. There was this kid, a student. He decided to try and direct the traffic to get it going again. So he began to direct the cars. And in the end he makes a big mess. The story that was written with Ravit's help: Once upon a time, at an intersection in a regular neighbourhood, the traffic lights stopped working. Soon, all the cars stopped. No one could drive and all drivers were nervous. People heard loud sirens everywhere. Gal was on his way home from school. Gal, who had been chosen to be the classroom helper that day, heard the loud sirens. When he reached the intersection, he saw a huge traffic jam. Gal felt a responsibility to help. He raised the megaphone that the classroom teacher had given him that day, and started yelling "Stop the sirens! I'm coming to help!" He immediately walked into the middle of the intersection and starting directing traffic. Gal was turning around in all directions, and before he knew it, he had created a huge pile up of cars. Gal stood on the pavement, very satisfied with himself. "Way to go! I can direct traffic!"

Week 1: Brainstorming

This session includes two goals. First, the child is encouraged to invent and talk about a story plot. According to the seven story grammar elements (Stein & Glenn, 1979), child and clinician try to answer the following questions: who the story is about (characters); where the story takes place (setting); what the goal or plan of the main character is; what the obstacle to achieving the main character's goal is; how the main character tries to resolve the problem (attempts); and finally, what the outcomes are (resolution and conclusion). After the plot has been generated, dialogues are considered as a means of discussing the main characters thoughts and feelings. Second, the child is encouraged to think and talk about the story setting. Child and clinician plan the set for the shoot. Should the characters be created from playdough or should real toys be used? How should the set be built, and what materials are needed? Together, a list of toys, objects and materials is composed, and by the end of this session it is decided who is responsible for bringing what.

problem-solving are provided within the context of very natural situations.

Week 4: The writing

Week 2: The set

After the child recalls the story plot, the setting needs to be created. Dcor is cut, glued and built as needed. After the set is ready, the child recalls what was done during this session in temporal order. To foster recall, the clinician might provide the child with a sequence of photos depicting what had been done, or encourage the child to answer the question: And what did we do next?

After the speech and language therapist has edited the animation movie, both child and clinician view it together. The child is then asked to tell the story. Based on what the child recounts, the clinician encourages them to expand upon the story by providing more details concerning the setting, the main character's looks, and thoughts and feelings. In addition, both work together to reshape and lengthen the sentences, adding or changing words to use more sophisticated vocabulary. At the end of this session, the child is given a copy of the story and is encouraged to read it to their relatives a couple of times.


Week 3: The shoot

After recalling the story and organising the set that was built in week 2, picture shooting begins using the "stop motion" technique to create an animation movie. In this process, objects change step by step, within 120-150 individually photographed frames. This technique helps to create the illusion of movement when the series of frames is played in a continuous sequence. During this session, the child and the clinician move the characters as well as the other objects in the set according to the story plot. After each move they take a picture. To create smooth movements of the characters in a realistic environment, two principles must be adhered to. First, the characters must move in very tiny steps; second, the set must stand still. This procedure demands patience from the child. However, from my experience, the clinician can encourage the child by switching between the two roles of moving characters and taking pictures and by helping solve problems that can occur during the shooting (such as when part of the setting suddenly collapses or the dough-character's hand disconnects from its body). Thus, opportunities to discuss

In all sessions the following principles apply: 1. Language treatment goals are integrated into all activities, so the child has opportunities to learn via the interactive process. 2. The intervention structure includes planning, experiencing and reconstructing. 3. All participants (child, parent and clinician) are initiators who take part in all activities. 4. The family plays an important role in the therapy as they are involved in all stages of the programme; in particular, in generating the story and decorating the set. 5. The animation story must be based on: narrative knowledge (story grammar structure, temporal order of events) textual knowledge (coherence and cohesion) and linguistic knowledge (semantics and syntax).

Bens therapy

Ben, aged 11;1 years, was a fifth grader in a regular class. Two years previously, in third grade, he had been given remedial reading lessons, but his assessment visit to me was his first experience of speech and language therapy. Ben met all the exclusionary criteria for specific language impairment as he had no hearing impairment, showed no evidence of neurological impairment and was of average IQ for his age. At the same time, he showed low performance in language and reading skills.

I conducted all sessions in a quiet work room in a university clinic, and over the four weeks of intervention we created a short animation movie. In the beginning, Ben was excited and eager to start, as he had watched a few animation movies I had done with other children and was motivated to make one of his own. In the first session, he created the plot, choosing a child as the main character. He decided that the story would take place at an intersection. The main events were: the child returned from school, he saw a traffic jam (the problem), and tried to fix it by taking charge and giving orders as to where the drivers were to go (attempts). In the end, the character caused the cars to pile up instead of fixing the problem (result). After the plot was determined, we discussed the set and its materials. Ben decided that the people would be made from LEGO and Playmobil that he had at home. In addition, he offered to bring many little cars, little trees and a few traffic lights. His mother volunteered to find a picture of a street that could be set up in the background. I offered to bring coloured paper. We described the set in detail and recorded a list of the materials. During the second session, after Ben had retold the story, we built the set together with his mother. In the third session, Ben retold the story again and we took photos of the set. While doing this, we talked about the music and sounds to be added to the movie (such as the beep of a car's horn, a child shouting, and samples from the music of "Mission Impossible", originally composed by Lalo Schifrin). Between the third and fourth sessions, I mailed the final movie to Ben, with photos, music and sounds already edited. Thus, during the fourth session Ben was able to view the movie. In this session, we wrote the story. First, Ben told the story, and I refrained from making any corrections. Then we retold the story together, writing it down on the computer and printing it out, thus making it easily accessible for reading at home. During this stage, I asked leading questions and rephrased Ben's sentences. After the story was complete, Ben read it and promised to read it at home as well. These two stories (figure 1) have been translated from Hebrew. To ensure the language level stayed the same including mistakes a Hebrew speaker who is also a



native English speaker translated the texts. It is important to note that the written story Ben received at the end of this session, intended for repeat reading at home, was a good story in terms of rich vocabulary, accurate grammar and an appropriate plot comprised of the seven story grammar elements. To test the outcomes of the intervention, I collected two spoken narratives from Ben before it, then again after it. I collected the pre-test stories as part of a large diagnostic battery which includes language, memory and reading tests. Immediately following the language evaluation I asked the family to participate in this study. This meant that Bens treatment would begin with Animation Therapy and focus only on this method for a few weeks. The family gave their consent and, four weeks after the pre-test, Ben received the four therapy sessions. A week later, the posttest took place. Thus, 2.5 months had passed between the pre- and the post-tests. To elicit the narratives, I used two sets of six sequence pictures, the campfire story and the painting story, from story cards published by Schubi. I didnt give any prompts. For both stories, I asked Ben to study the pictures and to think about the story that accompanied them. I then asked Ben to generate a story while still looking at the pictures. I wrote up and analysed the stories from digital audio recordings. Another speech and language therapist analysed them separately, with good agreement. We analysed the oral narrative performances at two levels: a. macrostructure - assessing the overall quality by addressing story grammar elements and overall coherence b. microstructure - testing linguistic structures. To examine the macrostructure level of oral narratives, we used the Index of Narrative Complexity. This index is differentially weighted in favour of episodic complexity and narrative cohesion (Petersen et al., 2008). The scoring system includes categories such as characters, setting, initiating events, internal responses, plans, action/attempts, complications, consequences, narrator evaluations, formulaic markers, temporal markers and causal adverbial clauses. The scores in each category range from 0 to 3 points. Based on the Index of Narrative Microstructure (Justice et al., 2006), we also included six indices reflecting both productivity and complexity. Productivity was measured by total number of words, total number of different words and total number of T-units. In linguistics, a T-unit consists of a single main clause and any dependent constituents, including clauses and phrases. Complexity was measured using mean length of T-units in words, total number of coordinating conjunctions and total number of subordinating conjunctions. These two indexes were designed for use as clinical tools in setting targets for therapy as well as evaluating the outcomes of the intervention. Figure 2 shows the macrostructure level analysis. Comparison between pre-test and post-test demonstrates a dramatic increase in
Figure 2 Intervention outcomes evaluation: macrostructure analysis (Petersen et al., 2008) Campfire story Pre Character Setting Initiating event Internal response Plan Action / attempt Complication Consequence Narrator evaluation Formulaic markers Temporal markers Causal adverbial clauses Knowledge of dialogue Total Score 1 0 0 2 1 1 1 0 0 0 1 0 0 7 Post 1 1 2 2 1 2 1 0 0 1 1 0 0 12 Painting story Pre 1 0 3 2 0 2 0 0 0 0 1 0 0 9 Post 1 2 3 2 0 2 0 2 1 2 1 0 0 16

Figure 3 Intervention outcomes evaluation: microstructure analysis (Justice et al., 2006) Campfire story Pre Total number of words Total number of different words Total number of T-units Mean length of T-units in words Total number of T-units of two or more clauses Total number of coordinating conjunctions Total number of subordinating conjunctions 30 25 8 4.38 1 0 1 Post 64 45 9 7.11 4 3 2 Painting story Pre 29 20 6 4.14 1 1 0 Post 50 38 6 8.33 6 3 5

Figure 4 Resources needed for Animation Therapy A software tool for making animated films - I use "stop motion pro-action" (www. stopmotionpro.com), which is perfect for children and educators looking for an inexpensive and easy-to-use tool A digital camera that has a USB connection Tripod Playdough Small toys - small plastic people and objects Office supplies such as coloured papers, glue and scissors

Bens post-narrative score. Both stories show improvement in setting and formulaic markers. Improvement in initiating event and actions is seen in one story, and in consequence and narrator evaluation in the other. The four narratives - in Hebrew, parsed into T-units and translated into English are available in the members area of www.speechmag.com. They illustrate use of structures characteristic of mature narratives in post-narratives compared to pre-narratives. For instance, past tense verbs appear in the post-narratives, compared to present tense verbs more common in the pre-test stories ("are angry", "sees", "doesn't like"). In addition, the temporal marker in the post-narratives is "when", compared to "then" in the pre-narratives. The deictic maker "here", characteristic of narratives of younger children (Shen & Berman, 1997), was used in one of the pre-narratives.

Figure 3 demonstrates the microstructure level analysis. Pre- and post-test comparisons reveal a dramatic score increase in both parameters: productivity and grammatical complexity. Ben used more words and more words per T-unit in the post-narratives. The increase in grammatical complexity in the postnarratives was expressed through the presence of more subordinating and coordinating conjunctions, revealing more complex T-units. Results indicated a reliable change in Ben's narratives following one block of intervention. In particular, his narratives were longer, containing a greater number of different words and more complex structures. The plot was extended by adding setting, consequences, formulaic markers and even evolution remarks. Furthermore, it is important to mention that this was achieved within the time allotted.




Editors choice

Editor Avril Nicoll gives a brief flavour of articles that have got her thinking.
Nouns are generally easier to learn and teach than verbs. Japan has a standardised system of Pictogram Symbols for use by people with communication difficulties and the general public, which Fujisawa, Inoue, Yamana & Hayashi used to investigate The Effect of Animation on Learning Action Symbols by Individuals with Intellectual Disabilities. Results were positive, particularly for the participants at a lower level of linguistic development. As an alternative to arrows, the researchers offer a number of ideas to indicate motion in static pictures. These include blurring, vibration marks, and a visual wake (p.59), as well as capturing a state of disequilibrium which cannot be maintained. Augmentative and Alternative Communication (2011) 27(1), pp.53-60 Work and study can make it difficult for people to attend regular clinic appointments. In The use of email as a component of adult stammering therapy: a preliminary report, Carolyn Allen draws on a range of literature and experience with 16 clients. Email can offer easier access at a convenient time and place. It gives client and therapist opportunities for immediate expression or detailed reflection, and may support maintenance and transfer. Although I would quibble with the use of clients...are not permitted to receive therapy exclusively via email (rather than we have chosen not to offer therapy exclusively via email), Carolyn successfully sets the scene for efficacy studies with a comprehensive overview of benefits and risks. Journal of Telemedicine and Telecare (2011) 17, pp.163-167 Carole Pound is one of the great thinkers of our profession. Her influence on practice and research with people with aphasia, particularly through work at Connect, has been profound. With Reciprocity, resources and relationships: New discourses in healthcare, personal and social relationships she raises the bar yet again, pulling together findings from a wide range of disciplines and two successful projects. We are challenged to address the power and inequality rooted in healthcare practice, and to be more creative in co-creating opportunities for friendship, participation, contribution and personal development which make a difference to health, identity, resilience and happiness. International Journal of Speech-Language Pathology (2011) 13(3), pp.197-206

The innovation inherent in Animation Therapy is that it was developed to suit older children (8-16 years old). As speech and language therapists, we are constantly seeking new intervention tools to enable children to learn and communicate effectively; in particular, therapies which address older children with language impairment. These children generally receive treatment from an early age and sometimes are quite familiar with various intervention tools. Reactions such as: "Not this again", "Can we do something else?" or "It's boring" are often heard. Thus, I have tried to arouse students curiosity by choosing a method that is more playful than usual. Moreover, today's children are growing up in a high technology world and it is incumbent upon us to offer them something more suitable to their areas of interest. This particular treatment requires the clinician to devote out-of-therapy time, especially for editing the movie. However, I use very friendly software (figure 4, p.27) and the entire editing process takes me approximately half an hour. My experience with Ben, as well as with other children who have participated in Animation Therapy, reveals that they seem to enjoy the materials and activities, and also cooperate readily in all tasks. Children learn they have "good ideas", and that their ideas are valued. As a result, there is an increase in self-confidence regarding narrative production skills. It is important to note that, although most of the children improve their narrative skills after Animation Therapy, the level of the change varies. Usually I use Animation Therapy together with other traditional tools, such as re-telling stories and looking at picture books, so it is hard to define the effect of the Animation Therapy itself. The case study I have described in this article was the only time I have asked a family to participate in it immediately following the language evaluation, thus the treatment began with the Animation Therapy and focused for several weeks on this method only. In future, this approach must be tested in a larger study with more participants. Another important issue is the role of the child's family in Animation Therapy, being involved in all stages of the programme. In actuality, the clinician, rather than being the "instructor", shares her role with the parent. The parent becomes a full partner, with responsibilities in the process. The atmosphere is such that all work as a team to achieve a mutual goal the creation of the movie. These relationships motivate the child to take responsibility for the success of the movie, as well as the success of the SLTP treatment. Dr Ravit Cohen-Mimran is a speech and language therapist and Head of the Clinical Education Unit at the Department of Communication Sciences and Disorders, University of Haifa, email rmimran@univ.haifa.ac.il. See two videos at www.speechmag.typepad.com and the four narratives at www.speechmag.com/members.

References Boudreau, D. (2008) Narrative abilities: Advances in research and implications for clinical practice, Topics in language disorders 28(2), pp.99-114. Fey, M.E., Catts, H.W., Proctor-Williams, K., Tomblin, J.B. & Zhang, X. (2004) Oral and written story composition skills of children with language impairment, Journal of Speech, Language and Hearing Research 47, pp.1301-1318. Gillam, R. B., & Pearson, N.A. (2004) Test of Narrative Language. Austin, TX: PRO-ED. Johnston, J.R. (2008) Narratives: twenty-five years later, Topics in Language Disorders 28(2), pp.93-98. Justice, L.M., Bowles, R.P., Kaderavek, J.N., Ukrainetz, T.A., Eisenberg, S.L., & Gillam, R.B. (2006) The Index of Narrative Microstructure: A Clinical Tool for Analyzing School-Age Childrens Narrative Performances, American Journal of Speech-Language Pathology 15 pp.177191. Justice, E.C., Swanson, L.A., Buehler, V. (2008) Use of narrative-based language intervention with children who have cochlear implants, Topics in Language Disorders 28(2), pp.149-161. Nathanson, R., Crank, J.N., Saywitz, K.J. & Ruegg, E. (2007) Enhancing the Oral Narratives of Children with Learning Disabilities, Reading & Writing Quarterly 23(4), pp.315-331. Petersen, D.B., Gillam, S.L. & Gillam, R.B. (2008) Emerging procedures in narrative assessment: The Index of Narrative Complexity, Topics in Language Disorders 28(2), pp.115-130. Shen, Y. & Berman, R.A. (1997) From single event to action-structure: stages in narrative development, in J. Shimron (Ed.) Psychological Studies of the Language in Israel. Hebrew University, Jerusalem, Israel: Magnes. (In Hebrew.) Stein, N. & Glenn, C. (1979) An analysis of story comprehension in elementary school children, in R.D. Freedle (Ed.) Advances in discourse processes: Vol. 2. New directions in discourse processing (pp. 53-119). Norwood, NJ: Albex. Swanson, L.A., Fey, M.E., Mills, C.E. & Hood, L.S. (2005) Use of narrative-based language intervention with children who have specific language impairment, American Journal of Speech-Language Pathology 14, pp.131-143. Vilaseca, R.M & Del Rio, M-J. (2004) Language acquisition by children with Down syndrome: A naturalistic approach to assisting language acquisition, Child Language Teaching and Therapy 20(2), pp.163-180. Zevenbergen, A.A., Whitehurst, G.J., & Zevenbergen, J.A. (2003) Effects of a shared-reading intervention on the inclusion of evaluative devices in narratives of children from low-income families, Journal of Applied Developmental Psychology 24, pp.1-15.

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Accompanies Cohen-Mimran, R. (2011) 'Re-animating intervention', Speech & Language Therapy in Practice Winter, pp.25-28.

Bens four narratives. All narratives parsed into T-units and translated to English
Pre-intervention 1: Campfire story haya shney yeladim ve-tuki (There was* two kids and a parrot) Character tiylu (Went walking*) Action hem lakcho etsim (They collected some woods) Action ve-gam po (and here too) ve-hem hemshicho le'esof (And they continued to collect) Action ve-po hem ratsu la'asot medura im ma she-hem hevi'u (And here they wanted to make campfire with the stuff they brought) Plan ve-hatuki shachach lehavi gafrur (And the parrot forgot to bring some matches) Complication ve-az hem ko'asim alav (And then they get angry at him) Internal response Post-intervention 2: Campfire story pa'am hayu yalda ve-yeled ve-chaver shelahem tuki (Once there were* a girl and a boy and their friend a parrot) Formulaic marker, character ve-hem tiylu ba-ya'ar (And they went walking in the forest) Setting ve-hatuki he'ela ra'ayon lehachin medura (And the parrot had an idea to make a campfire) Initiating event ve-hayeladim hiskimu (And the children agreed) Action ve-hatuki her'a la'hem me'eyfo lakachat krashim vekama tsarich (And the parrot showed them where they could find some wood and how much they needed) Action ve-hem hitchilu lechaber et ha'etsim ve-la'asot medura (And they stared to build the campfire) Action k-she-kulam kvar hayu muchanim, ha-yeladim hayu muchanim litslot basar, hem natnu latuki lehadlik et ha-medura (When they all were ready, the children wanted to grill the meat, so they let the parrot start the fire) Action ve-la-tuki lo hayu gafrurim (And the parrot didn't have any matches) Complication ha-yeladim hayu atsuvim ve-me'od ko'asim al ha-tuki she-ratsa la'asot medura ve-shachach lehavi gafrurim (The children were sad and very angry at the parrot that wanted to make a campfire and forgot to bring matches) Internal response, Plan Pre-intervention 1: The painting story tuki yatsa (A parrot went out) character hu ra'a ez ve-ala lo ra'ayon (He saw a goat and had an idea) Initiating event ve-az hu metsayer ota (And then he is drawing* her) Action ve-az hu ro'e (And then he* saw) ha-ez ro'a et ha-tsiyur (The goat sees* the painting) Initiating event ve-az hi lo ohevet oto (And then the goat doesn't* like it ) Internal response az hi ke'ilu me'ifa oto (So she 'kind of' throw him Action Post-intervention 2: The painting story pa'am achat haya tuki she-me'od hishta'amem be-beyto (Once upon a time there was parrot that was very bored in his own house) Formulaic markers, character, setting, Narrator evaluation ve-ala lo ra'ayon letsayer et ha-ez she-mistovevet bechatsero ( And he got an idea to paint the goat that was hanging around in his yard) Initiating event ha-tuki lakach et erkat ha-tsva'im she-kibel misavato leyom-huledet ve-irgen ota be-ginato ve-hitchil letsayer et ha-ez (The parrot took his painting kit that he had received from his grandmother for his birthday, moved it into his garden and started to draw the goat) Action ha-ez samcha she-metsayrim ota (The goat was happy that she was being drawn) Internal response ve-levasof k-she-hatuki er'a la ech hu tsiyer ota, Ha-ez hit'atsbena ve-ba'ata bo (Finally when the parrot showed her the drawing, the goat got angry and Kicked him). Formulaic markers, consequence ve-hu af la-avir (And the parrot was thrown high into the air) Consequence

* The Grammar mistakes were originally in the child's stories