Treatment at the Level of the Family System: The Role of Context in Speech Therapy

What are we, exactly? An individual with its own thoughts and goals? A mass of different cells and microorganisms each with their own intentions and agendas? Maybe just a subunit of a larger organism much like an ant in an ant colony? Depending on your perspective, all of these views hold some truth. Perhaps this waxes philosophical, but I believe that assuming these different perspectives can also help us to diagnose and treat issues in speech therapy.

We are familiar with seeing others as individuals and thinking of ourselves as separate from other people with our own thoughts, goals, aims, and decision-making abilities, but we are actually made up of 37 trillion cells, each of which also respond to environmental cues, make decisions, and even form sub-groups to solve novel puzzles (Levin, 2021). Not only do our own human cells exhibit agential properties, but non-human microorganisms (e.g., bacteria in our microbiome which are separate, individual living entities) outnumber our own human cells. In some ways, we are similar to ant colonies in which many individual ant behaviors (e.g., suicidally defending the colony, sharing food through trophallaxis, and complex nest construction) only make sense at the 'colony level.' Synthetic biologist Michael Levin notes that, in fact, "all intelligence is collective intelligence." Scaling up, we can see how individuals form social groups, such as friendships, families, sports teams, schools, societies, and countries. Each group exhibits certain properties not found in any single individual, but that emerge out of the relationships amongst the parties. This could be something as simple as the traditions and holidays of each different country, the eating behaviors of a family, or how different 'plays' become possible in a sport like football or basketball. Thinking at these 'different levels of a system' helps us to diagnose and solve a problem in the most effective way by helping us to get a bigger, more appropriate picture of a complicated matter.

Let us consider a simple sports example: in basketball, if one player on the team does not pass, it is usually not the case that there is something wrong with his muscle fibers. Thinking at the 'individual, physiological level' is not helpful here. However, if we consider the 'level of the team', other reasons become apparent, such as the plays the coach is calling (e.g., maybe the plays that are being called do not necessitate passing), or where other people are standing on the court (e.g., standing too far away or behind the opposing team), or even something about the team's psychology (e.g., no trust between players). This framing at the 'level of the team,' so to speak, helps us to see what might be preventing passing and ways to help increase passing. This allows us to clearly see the all-important role of context.

Why is context so important in speech and language therapy? Language is like 'passing', in this example, in that it requires the coordination of multiple parties. Rather than a private, individual practice (e.g., practicing dribbling a ball in your room), language is a dynamic, system-level property that emerges from the interactive, distributed processes between individuals, their social contexts, and their material contexts. It is shaped by, and dependent on, the collaborative interactions, cultural practices, and environmental affordances within which communication occurs. That is a mouthful, but, in simpler terms, language only exists and makes sense in the context of a social group and physical environment.

In Deb Roy's famous TED Talk, The Birth of a Word, he describes a study in which he amassed “roughly a quarter million hours of (home) audio and video” to examine how his son developed language. What emerged was a beautiful dance between caregivers, son, and their physical environment (i.e., home) in which the son, after hearing 17,529 productions of the word “water” in routine, but varied spatial contexts, was finally able to properly utter his first word — water. Roy repeatedly stresses that the temporal (i.e., time of day), spatial (i.e., where in the home), and linguistic (i.e., what other words were used around the target word) contexts were critical in the language development process (Roy, 2011). It is perhaps an obvious point to mention, but a child “needs to hear pieces of language before they can use it” (Tomasello, 2003). Language is “socially learned through cultural imitation in which the learner acquires the form of the symbol, but importantly its conventional use in the act of communication" (Tomasello, Kruger, and Ratner, 1993). Without a social context, there is no meaningful language input; consequently, there can be no language. In fact, in 1983, Schwartz and Terrell found that children between 12 and 18 months took, on average, “10-12 exposures to a novel word before being able to produce it appropriately.” Additionally, “92% of children's earliest utterances were all derived from the first 25 lexically based patterns they heard from their mother” (Lieven et al., 1997). It is clear that family plays an integral role in language development.

Thinking at the 'level of the family' could help us see context more clearly and establish more effective interventions that take this context-based learning process into account. However, well-meaning therapists tend to focus on the child at the expense of the family. Many therapists diagnose a child as having an articulation disorder or apraxia or simply something wrong 'with the mouth' without checking to see what communication is like in the home. This is the 'muscle-fiber passing problem' in the basketball example, in which we disregard essential factors that might contribute to the presence or absence of a skill by examining the wrong 'level of the system'. Of course, it is possible that there may be an issue with motor planning or with the child's physiology, but what if nothing in the environment is necessitating language (i.e. the child can get all of their wants/needs met by grabbing, eloping, etc.)? This would be like saying I have apraxia of speech after hearing me speak Chinese (which I do not speak) without checking to see if anything in my environment requires me to speak Chinese regularly. I have been guilty of this, naïvely imagining that language is a property of the individual rather than the family unit or social context, neglecting to bring parents into the session (some clinics even discourage parents from joining), or writing speech and language reports that mention family background as a passing thought rather than the central point of analysis.

This can be bitter medicine because this idea puts extra responsibility into the hands of busy parents. However, it offers a hopeful pathway forward. If we assume it is simply up to the child whether or not they want to start talking, then we are faced with a 'gravity problem' (i.e., an unsolvable, inevitable problem like gravity). However, reframing language disorders at the level of the social and material environment (i.e., the family unit in the home) can empower parents and therapists because it offers ways to increase the probability that the child will talk.

What can be done to ensure that context is considered? The first step is simple: Interaction. Families are increasingly replacing rich interpersonal interactions with screens and digital spaces (often filled with overstimulating and decontextualized noise). This is not saying that digital tools have no utility, but without a communication partner such as a parent present to create a 'joint attentional frame' (Tomasello, 2003), the development of important prelinguistic skills such as intention reading and pattern recognition may become stunted, and the child may not develop a proper understanding of the context in which language is used (i.e., the language from iPad becomes 'noise' rather than 'signal'). Importantly, language directed at the child predicts language development more effectively than simply hearing more speech (e.g., from devices or TVs) (Roy et al. 2015). This trend towards digital environments carries dangers for language development, and, in fact, researchers have shown that screen time during development is associated with 'communication and problem-solving developmental delay' (Takahashi et al., 2023). The ubiquity of devices in our daily lives may make this shift towards real-world interaction challenging, but choosing to appease your child with language input from devices is like choosing to give your child fast food at the expense of healthy, natural, home-cooked meals. Similar to nutrition, "when you are attending to the same thing, interacting, and providing rich language input, your child is learning and growing their language body" (Kuhl, 2010).

Second, these interactions can be nested in language routines (e.g., 'shower routine') which take advantage of temporal (e.g., 'after dinner'), spatial (e.g., 'in bathroom'), and linguistic (e.g., 'first, turn on water') contexts. Expanding on the nutrition analogy, it is important to feed a child healthy food at regular times, which helps the body with metabolism. If you feed a child twenty-one McDonalds hamburgers once a week, it will likely result in health problems and lawsuits. Language input works similarly. Researchers found that children learned words significantly better across distributed exposures (i.e., much better to try to learn a particular word once a day over four days than four times in one day) (Schwartz and Terrell, 1983). In addition, just like having meals at particular places in the house (i.e., the kitchen table), words are best learned when tied to specific places in the environment. Roy et al., 2015, found that “words used in distinctive spatial … contexts are produced earlier, suggesting they are easier to learn”. Finally, it is important to keep your language fairly regular (i.e., using the same words in the routine). This will help the child identify patterns in language and match speech forms to objects and actions in the real world. As a child starts learning more language, variation in context also becomes important for recognizing linguistic patterns and flexibly using new words across environments. Researchers found, for example, that hearing words in varied speaker (e.g., different family members or friends) and spatial contexts (e.g., diff. places in the home) are predictive of word production (Goldberg et al., 2022).

Third, steps can be taken to modify the physical environment in the home to create optimal conditions for language to emerge and continue to be used -- language 'feng shui,' if you will. I like the example of strong, healthy centenarians living in Okinawa (this came from a Netflix documentary on 'Blue Zones'). The documentary noted that the houses of these 100 year old individuals had no chairs and often had stairs that required the seniors to retain the ability to get up off of the ground and walk up and down. The daily necessity of these movements, due to the simple features of the house, prevented muscle atrophy and degeneration associated with aging. This is the reason for the senior care injunction, “never do for [seniors] what they can do themselves” (Riggs, 1988). A similar rule applies to language development as well. The daily necessity of language will increase its use, and subsequently, its growth. Simple examples of this might be putting favorite toys out of reach, such that the child will need to request them. It could also mean determining the activities that motivate your child to engage in play, so that opportunities for intention reading and linguistic pattern recognition increase. Once you recognize how the environment affords language opportunities, it is simply a matter of creative problem-solving. This puts the power back in the hands of the family, and it offers hope for successful communication with the child.

American educational philosopher, John Dewey, thought that neglect of context was “the greatest single disaster which thinking can incur” (Dewey, 1931). I believe this also applies to speech therapy. Neglecting context leads to multiple errors in diagnosis and intervention. My grandmother (a lover of rich foods) recently got gout in her foot, but was convinced it was simple 'foot pain' and was applying pain-relieving foot creams in vain. If you do not understand that the parts of your body are all connected in a larger context, you might miss the idea that a buildup of uric acid crystals from diet or lifestyle factors can cause pain in a peripheral part of the body. You can certainly ice your foot and take pain medications, but what is most helpful here is a change in diet. Similarly, speech and language diagnosis must take into account what is happening at the family level, and intervention should involve careful analysis and restructuring of, you guessed it, context. Understanding and embracing the role of context in speech and language development through examining the problem at the ‘level of the family’ vs. the ‘level of the individual’ allows us to address the root causes of speech issues, design more comprehensive interventions, and foster environments where language can thrive.

Garrett is a speech language pathologist, musician, and research coordinator based between California and Tokyo with a multidisciplinary background in music, language, and cognitive science. Graduating from Emerson College in 2014, he has given presentations in a wide variety of language topics at school districts along with the American Speech Language and Hearing Association Conference in 2018. He is also an internationally touring music professional and an avid surfer. Given his multidisciplinary background, he is passionate about how concepts and technologies from other fields can be re-purposed for the use of treatments for communication disorders. To this end, he was a co-creator of a beatboxing for speech therapy curriculum and part of ongoing research into how current machine learning technology can be applied to speech assessment and intervention. 

References

1. Dewey, J. (1931). The Development of American Pragmatism. In J. Dewey (Ed.), Philosophy and Civilization. New York: Minton, Balch & Company.

2. Goldenberg, E. R., Repetti, R. L., & Sandhofer, C. M. (2022). Contextual Variation in Language Input to Children: A Naturalistic Approach. Developmental Psychology, 58(6), 1051-1065.

3. Kuhl, P. K. (2010). Brain Mechanisms in Early Language Acquisition. Neuron, 67(5), 713-727.

4. Levin, M. (2021). Synthetic Bioelectric Computation [Video]. YouTube. Retrieved from YouTube.

5. Lieven, E. V. M., Pine, J. M., & Baldwin, G. (1997). Lexically-Based Learning and Early Grammatical Development. Journal of Child Language, 24(1), 187-219.

6. Riggs, C. M. (1988). Understanding the Needs of the Elderly. Journal of Gerontological Nursing, 14(5), 34-40.

7. Roy, D. (2011). The Birth of a Word [Video]. TED Conferences. Retrieved from TED

8. Roy, D., Frank, M. C., & Roy, B. C. (2015). Relating Activity Contexts to Early Word Learning in Dense Longitudinal Data. Cognitive Science, 39(8), 1985-2008.

9. Schwartz, R. G., & Terrell, B. Y. (1983). The role of input frequency in lexical acquisition. Journal of Child Language, 10(1), 57-64.

10. Takahashi, T., Watanabe, K., & Yorifuji, T. (2023). Screen Time and Developmental Delays in Young Children. JAMA Pediatrics, 177(2), 134-142. Retrieved from JAMA Pediatrics

11. Tomasello, M. (2003). Constructing a Language: A Usage-Based Theory of Language Acquisition. Harvard University Press.