As an SLP, parents and teachers are often concerned about middle school language development. They often ask me about a student who just doesn’t seem to “get it.” They’ll describe a child who takes everything literally, misses a joke, or seems to lack empathy. Since these kids are fluent speakers who sound like adults, it’s easy to assume these behaviors are a sign of a problem.

This is the middle school paradox. We assume that since their language sounds mature, their brains are fully equipped to handle complex social and communication skills. But what the lack or immaturity of these skills wasn’t a sign of a delay, but evidence of a developing brain? The truth is, while middle schoolers are great at sounding mature, their ability to handle the subtle, unspoken parts of communication is still a work in progress.

The Middle School Brain is Still Developing

It might seem they’ve suddenly grown up, but a middle schooler’s brain is still under construction. The prefrontal cortex, which handles complex thinking and self-control, won’t be fully developed until they are in their mid-twenties. This means many of the skills we adults take for granted are still being built. And honestly, don’t we all struggle with some of these things ourselves, no matter our age?

Understanding Abstract Language

Think about sarcasm, idioms, or metaphors. When a teacher says, “Oh, that’s just what I needed,” after a student drops papers everywhere, most adults get the joke. A middle schooler might not. Understanding this requires going beyond the literal words and reading the person’s tone and context.

This is also where inferencing comes in—it’s the ability to “read between the lines” and figure out what’s not explicitly stated. While a student might be able to define idioms on a school test, using and understanding them in a fast-paced, real-life conversation is much harder. Understanding colorful phrases is a still developing middle school language skill.

PSST: Read my last post Beyond “Spill the Beans”: Why Teaching Idioms Needs a Modern Glow-Up, for more information on this skill.

Navigating Social Cues

This is more than just empathy—it’s the ability to see things from another person’s point of view. Middle schoolers are so focused on figuring out their own identity that they can seem self-centered. It’s not a lack of caring; it’s a natural part of their social language development in middle school. A person has to understand their own self before they can truly understand others.

Part of this age’s awkwardness is that as they try to figure out their own identity, middle schoolers often “try on” different attitudes, styles, and interests. A student who is quiet one week might be outspoken the next. This isn’t being fake; it’s a natural form of social experimentation as they explore different versions of themselves.

Handling Big Emotions

Middle schoolers understand basic feelings like happy or sad, but they often struggle to name more complex emotions like frustration or anxiety. This can lead to them acting out because they lack the vocabulary to express what they’re truly feeling.

They might feel a physical response—a tight stomach, a pounding heart—without knowing what emotion is causing it. They’re also still developing the self-awareness and self-talk needed to pay attention to these body signals before they become too overwhelming.

For more information on social-emotional learning (SEL) and language, see this post: Beyond Happy or Sad: The Real Language of Emotions.

More Skills Developing in Middle School Brains

A few other language skills are still growing in middle schoolers, affecting their ability to learn and succeed.

Vocabulary and Word Knowledge

It’s not just about learning new words, but understanding all the different meanings and contexts for a single word. For example, a student might know that “trunk” refers to a suitcase, but they may not yet understand its use in phrases like “elephant trunk” or “tree trunk.”

Complex Language Comprehension

While they are using more sophisticated language, they can still struggle to fully understand long, grammatically intricate sentences in academic texts. The ability to break down and process this kind of intricate language is a skill that develops with exposure and explicit instruction.

Memory and Metacognitive Strategies

Middle schoolers are not only learning new things, but they are also beginning to learn how they learn. They’re developing metacognition—the ability to think about their own thinking. This includes learning and applying strategies for memory, such as using mnemonic devices or chunking information to make it easier to remember.

How You Can Help Middle School Language Development

Your support is the scaffolding they need to build these crucial skills. Here’s how you can help:

• Don’t Just Clarify, Explain. If you use sarcasm, follow up by saying, “I’m just being silly; I actually didn’t need that.” This helps them learn to spot a joke.
• Keep It Simple During High Emotion. When a middle schooler is upset, their thinking brain is offline. Use minimal words and direct instructions, like “Sit down. Breathe.”
• Talk It Through. Help them reflect on social situations. Ask, “Your friend looked sad. Why do you think that is?” This helps them practice perspective-taking and gives them the language to identify complex emotions.

Their challenging behaviors are often a sign of a developing brain, not a lack of effort or intelligence. By viewing them as a work in progress, we can provide the guidance they need to become capable and confident adults.

A Final Thought: The Power of Perspective

Middle school is a time of immense change, and much of the behavior that adults find confusing or frustrating is simply a reflection of a brain that is in an incredible, albeit awkward, state of growth. By reframing our perspective, we can stop seeing challenging behaviors as defiance. We can start viewing them, not only as naturally developing middle school language skills, but also as opportunities for teaching and connection.

As an SLP, I’ve seen firsthand that a little understanding and a lot of patience can make all the difference. Your support today is the scaffolding they need to build the crucial skills that will help them succeed as capable, compassionate, and confident adults.

For a more intensive way to pinpoint where a middle schooler needs support, consider my Middle School Contextual Language Screener/Profile. It uses an intentionally written fable as context to naturally pull out academic skills such as figurative language, multiple meanings, inferencing and problem solving.

You’ve learned about all the different areas where the middle school brain is still developing. But how do you keep track of it all? To make it easy, I’ve created a comprehensive, one-page chart that summarizes all these skills in a simple, visual format. It’s a great tool to keep handy for a quick reminder—you could even hang it in the teacher’s lounge!

Download your free infographic: “The Middle School Brain: Your Quick Guide to Developing Skills” by subscribing to my newsletter!

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You’re not alone! While many therapists rely on a simple “yes” or “no,” this approach can lack objectivity and detailed feedback. Rubrics offer a powerful solution, providing a clear framework for defining goals, establishing evaluation criteria, and tracking student development.

This guide equips you, the SLP, with the knowledge and steps to create effective rubrics specifically tailored to complex communication goals.

But first, let’s explore the “why” behind rubrics:

Why Rubrics Shine for Complex Communication Goals

• Objectivity: Complex goals like summarizing or problem-solving can be subjective. Rubrics establish consistent criteria for different mastery levels, minimizing guesswork.
• Detailed Feedback: Go beyond a single score! Rubrics provide a framework for detailed feedback, pinpointing specific areas of strength and areas for targeted intervention.
• Motivation: Seeing progress on a rubric can be highly motivating for students working on challenging communication skills. It allows them to visualize their journey towards mastery.
• Data-Driven Decisions: Rubrics provide crucial data to track progress across various aspects of a complex goal. This data empowers you to make informed decisions about treatment strategies.

Building Your Rubric: A Step-by-Step Guide

Identify the Target Skill: 

Begin by defining the specific complex communication skill. This could be:

• Semantic Mapping: Identifying and organizing related vocabulary around a central topic.
• Summarizing: Restating the main points of a story or passage in a concise way.
• Problem-Solving: Identifying a problem, brainstorming solutions, and evaluating the best course of action.

Break Down the Skill: 

Once you have your target skill, identify the different sub-skills involved. For example, semantic mapping might involve identifying main ideas, brainstorming related vocabulary, and organizing them visually.

Define Performance Levels: 

Establish clear descriptions of what successful performance looks like at different stages. These levels might be labeled as “Needs Improvement,” “Approaching Mastery,” and “Mastery.”

Criteria and Descriptions: 

For each performance level, define specific criteria that will be used to evaluate the student’s performance. Be clear, concise, and observable. For example, under “Semantic Mapping – Mastery” level, a criterion might be: “Identifies at least 5 relevant vocabulary terms related to the main topic and organizes them in a clear and logical structure using a graphic organizer or chart.”

Optional Scoring System: 

You can choose to assign points to each performance level or criterion, allowing for a numerical representation of progress. However, focusing on descriptive feedback can be equally valuable, especially for complex skills.  Both are useful for demonstrating present levels and progress.

Want to take your rubrics to the next level?

Check out my downloadable Hard to Find Speech-Language Matrix/Rubric Growing Bundle, packed with pre-made rubrics for various complex communication goals, editable templates, and expert tips to get you started quickly!

Rubric Essentials: Tips for Success

• Tailored to the Individual: Adapt rubrics to each student’s specific needs and goals within the complex communication skill.
• Age-Appropriate Language: Use language that is understandable for the student’s age and developmental level.
• Visually Appealing: Consider using charts, tables, or color-coding to make the rubric visually engaging and easier for students to understand.
• Collaborative Effort: Involve parents or educators in rubric development to foster communication and understanding of the targeted skill.

Remember: Rubrics are a dynamic tool. They can be revised and adjusted as therapy progresses and goals evolve.

By incorporating rubrics into your speech therapy practice, you gain a powerful tool to effectively gauge progress and guide your students on their journey to mastering complex communication skills.  Let me know in the comments below what communication goals you use rubrics/matrices for!!

Happy Rubric Creating!!

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Less is More: Spacing Out Data Points

Data collection shouldn’t dominate every therapy session. Think of it as a progress report, not a live feed. Leave room for teaching and practicing new skills before measuring performance.

Consistency is Key: Setting the Stage for Meaningful Data

Data only tells a story if it’s collected under similar circumstances. Here’s how to ensure your data paints an accurate picture:

• Baseline Before Takeoff: Always collect data at the beginning of a session, before any specific training takes place. This establishes a baseline of the student’s current skills.
• Data Probes: Your Unsung Heroes: Develop consistent data probes for each goal. These probes should directly assess the specific skill you’re working on and be age-appropriate for the student.

Crafting Powerful Probes: What to Consider

Here are some key elements to consider when developing effective data probes:

• Target the Goal: Ensure your probe directly assesses the specific skill you’re working on
  increasing. Don’t phrase it in terms of decreasing a deficit.
  • For example, instead of saying “Decrease the phonological process of stopping,” a more positive phrasing would be “Increase the student’s ability to produce fricatives.”  I’ve gotten some worried phone calls from parents who see the graph rapidly decreasing!!
• Age Appropriateness: Consider the student’s age and developmental level. A picture card probe might be appropriate for younger children working on articulation of /b/. In contrast, older students practicing narrative skills might handle a written story prompt better.
• Multiple Forms: If possible, develop probes in multiple formats (pictures, written words, real-life scenarios). This approach assesses a skill from different angles and reduces the chance of memorization affecting results. For example, a student working on vocabulary might be shown a picture of a banana and asked to name it. Then later describe it using simple adjectives in a sentence.
• Error Analysis: Design probes that allow you to analyze the types of errors a student makes. This can provide valuable insights into their specific challenges and areas for intervention. For instance, a probe assessing a student’s ability to follow two-step directions might involve asking them to “Touch your elbow and then hop on one foot.” Observing if they complete both steps in the correct order or struggle with a specific part helps tailor future therapy sessions.

Examples of Goal-Probe Partnerships:

Let’s see how these principles translate into practice:

• Goal: Improve articulation of the /p/ sound in single words.
• Probe: A list of 10 words containing the /p/ sound at the beginning (e.g., “pan,” “pig”), middle (e.g., “apple,” “happy”), and end (e.g., “cup,” “hop”) of words. Note the number of correct productions and any specific errors made (e.g., substitutions, omissions).

• Goal: Increase expressive language skills by using synonyms in sentences.
• Probe: Provide the student with a sentence with a blank space (e.g., “The dog is very _____ today”). Offer a list of synonyms for the missing word (e.g., happy, joyful, excited) and see if they can choose and use the appropriate synonym in the sentence.

Embrace the Nuance: Moving Beyond Pass/Fail

Data shouldn’t be a simple yes or no. When possible, use rubrics or detailed observations to capture the nuances of a student’s progress. This provides a richer picture of their strengths and areas for development. For example, instead of just marking articulation attempts as correct or incorrect, note if the sound was produced accurately for the first time, required multiple tries, or needed specific prompting.

Feeling overwhelmed by creating rubrics? Don’t worry! In our next blog post, we’ll delve into the world of rubrics, providing step-by-step instructions and helpful examples to make crafting these powerful tools a breeze: Mastering the Art of Measurement: A Guide to Creating Rubrics in Speech Therapy (with Bonus Example!).

Let’s Chat!

Have questions or success stories about data collection in speech therapy? Share them in the comments below!

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Picture This: The Power of Visual Data

Once you’ve gathered all that valuable questionnaire data, how do you make sense of it and present it effectively? Enter the magic of graphs in questionnaire interpretation! Creating clear, color-coded graphs, like the example from Orion’s, can be a game-changer for your reports.

Think about it: a well-designed graph can instantly highlight patterns and differences in responses across different raters, as well as across skills. When creating your graphs, aim for enough detail so that someone else looking at it could draw similar conclusions to yours. And don’t forget the most crucial part. Always include a written explanation of the data in your report to provide context and your interpretation.

The Value of Multiple Reporters

When you have responses from multiple people, graphing individual skill ratings and calculating averages by respondent and setting can reveal fascinating patterns. For example, in the area of Peer Skills, we might see that while the overall average suggests mild concerns, specific skills like offering and accepting criticism are rated as areas of moderate concern. Furthermore, comparing the average ratings from home versus school might show discrepancies. This could potentially highlight the impact of environmental demands.

For those using the Orion’s Pragmatic Language Skills Questionnaire, this process can be significantly streamlined. A companion Google Drive report and charting tool is now available. It automates the report writing process and generates visual comparisons of scores. This tool transforms raw data into comprehensive, insightful reports with illustrative charts in as little as 15 minutes. It saves you valuable time and effort.  See my FREE fillable Orion’s form.

Examples

• Overall, respondents had mild to moderate concerns for {FirstName}’s use of pragmatic language skills.
• {FirstName} appears to have an easier time with pragmatic language at home. The home rating was an average of 1.5, and XX and YY rated an average of 1.8 and 2.6, respectively. This is likely due to the lower demands of the home environment versus the school environment.
• Furthermore, her performance with YY might be impacted due to her low preference for the subject.
• However, most of the areas that were of the most concern are higher level social language skills. These skills are still developing at 6 years of age and involve maturing concepts such as understanding perspectives, conversational nuances, multiple or non-literal interpretations, and abstract thought. These higher level skills typically show a wide range of development at this age, and are highly dependent on context-rich exposure, practice, and reinforcement. Situational based discussions, targeted skill playgroups and review of challenging situations to problem-solve them are recommended to continue development in these areas.

Decoding the Differences

One of the coolest things about using questionnaires with multiple respondents (like parents and teachers) is that you might see some differences in their ratings. Instead of viewing this as a problem, see it as an opportunity for deeper understanding! These discrepancies can reflect the different demands and expectations of various settings, which can be uncovered with effective questionnaire interpretation.

Don’t hesitate to reach out to respondents to discuss their ratings. You could ask for specific examples of why they rated a skill a certain way. Or explore the reasons behind differing opinions. Maybe the child’s communication skills fluctuate depending on the time of day, the specific setting, or the people they’re interacting with. These conversations can provide invaluable qualitative data to complement your quantitative findings. They offer deeper insights into the ‘why’ behind the ratings.

Don’t forget that things like culture, time of day, medications, and comfort level in setting can play a huge role in the ratings, as well!

Conclusion

By thoughtfully presenting the data you’ve gathered from questionnaires, especially through clear visuals and detailed explanations, you can paint a much richer picture of your students’ communication abilities across various settings. Understanding and interpreting the nuances in responses from different individuals, through effective questionnaire reporting, provides invaluable insights. These insights can directly inform your goals and recommendations. Embracing the power of questionnaires in this way truly elevates your evaluations and ultimately benefits the students we serve.

Update! 

I‘ve created Reporting Tools for my popular Student-Centered Fluency & Articulation Scales!  Designed to save you time and really demonstrate student perceptions and holistic impact of their speech. Find them on TPT!

What are your experiences with reporting questionnaire data? Any other tips you’d add? Let’s continue the conversation in the comments below!

Don’t forget to check out Part 1: Value and Use!

Happy rating!

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They can offer invaluable perspectives from parents, teachers, and even the students themselves, giving you a much richer and more comprehensive understanding of their communication skills across different environments. Let’s dive into why these tools are so powerful and how you can effectively use them!

Why Rating Scales are Your Secret Weapon

Think about it: we often see our students in a specific setting, be it a quiet therapy room or a structured testing environment. We have those crucial standard scores. But how do they communicate in the classroom? At home? With their friends?

Rating Scales bridge this gap, providing insights into real-world communication in various contexts. They’re especially golden for those communication skills (or deficits) that might not always shine through during formal testing – and you get it without overwhelming the student with lengthy testing. This is where your experience as an SLP moves beyond giving a rote test.

Questionnaires/Rating Scales can be used to:

• Guide an evaluation or demonstrate the need for an evaluation
• Generate a discussion about speech/language skills
• Develop child-centered, functional goals
• Track progress over time
• Identify areas of most need
• Provide insight on communication in different environments

Important Note: Rating Scales should NOT be used as the sole diagnostic tool for speech or language disorders. However, they can easily demonstrate the need for related services as well as change over time.

Choosing Wisely (or Creating Your Own Magic!)

Selecting the right questionnaire is key, and of course, age-appropriateness is the name of the game. While finding that perfect age-specific tool can sometimes feel like searching for a unicorn, don’t despair! Even broader questionnaires can be helpful in painting a picture of the “end goal” and where our students currently stand in relation to it.  “Questionnaire” is an umbrella term that usually signifies open-ended questions, but rating scales are super useful because the response forms are limited, and therefore easier to compare.

Speaking of unicorns, I’ve found my own ‘Student-Centered Articulation & Fluency Scales’ to be incredibly insightful for student-centered evaluations. Giving students a voice in their evaluation can be so empowering and provide a unique perspective on their own communication experiences.  A time-saving Reporting Tool is now available for both scales!

For example, with stuttering, a student’s feelings about their speech can be the crucial factor that differentiates a mild presentation from one perceived as moderate or even severe. It can also highlight students who, despite ongoing stuttering, feel they’ve gained the necessary tools from therapy versus those whose negative attitudes indicate a need for more intensive intervention. 

I even have specific versions for articulation and fluency to tap into these nuanced self-perceptions in different areas of communication. This self-awareness piece is so vital and can significantly inform your clinical decision-making.  I’ve also thrown in a short, 10 question check-in scale for both articulation and fluency, for more frequent use.

Make your own rating scale!

And don’t underestimate the power of adapting existing rating scales, or turning a questionnaire with open-ended questions into a rating scale! Take something like Orion’s Pragmatic Language Skills Questionnaire – a simple tweak of adding “as compared to peers” to the questions can make it even more relevant and help raters focus on those crucial peer comparisons.

If you’re feeling creative, designing your own informal questionnaires can be incredibly rewarding. When doing this, consider these tips:

• Look at existing questionnaires, developmental milestones, or curriculum standards to get a feel for the skills and areas typically covered.
• Keep your rating scales concise – no more than four levels is usually best.
• Frame your rating scale in terms of ‘level of concern’ (rather than ‘always/never’) to encourage direct peer comparison.
• Ensure your top ratings reflect typical peer performance, not perfection.
• Maintain consistency in your chosen scale (e.g., 0 = no concern, 4 = high concern).
• Ensure all questions are easily understood by parents and teachers.

Finally, a quick but crucial note on published questionnaires: always double-check if they are free to reproduce, or make sure you purchase the rights to use them. We want to be ethical SLPs!

Handling the “Not Applicable” Headscratcher

We’ve all been there – a question on a questionnaire that just doesn’t fit the context. If you allow for a “Not Applicable” response (which I highly recommend!), here’s my simple approach: if a respondent marks a question as not applicable, I simply adjust the total number of rated items. For example, if there are ten questions and one is marked “N/A,” I calculate the overall score based on the remaining nine. Easy peasy!

Keeping It Peer-Focused

Finally, when you’re asking respondents to rate a child’s skills, it’s so important to emphasize the “compared to peers” perspective. Make sure your instructions clearly state that they should be thinking about how the child’s communication skills stack up against those of their same-age peers. This helps to provide a more meaningful and relevant comparison.

In Part Two, we dive into how to effectively present and interpret the valuable data you gather from questionnaires in your reports!

Freely Available Questionnaires and Rating Scales

1. Orion’s Pragmatic Language Skills Questionnaire (PDF): This is a widely shared questionnaire for screening pragmatic language abilities. I’ve made it into a fillable form for free on my TeachersPayTeachers store.
2. Early Childhood Speech and Language Assessment – Speech and Language Assessment Scale (PhenX Toolkit): Find it at https://www.phenxtoolkit.org/protocols/view/200302. The PhenX Toolkit offers various measurement protocols, including this one for early language.
3. Intelligibility in Context Scale (ICS) (PDF): Accessible via https://cdn.csu.edu.au/__data/assets/pdf_file/0010/399970/ICS-English.pdf. This parent-report scale helps understand a child’s speech clarity in different situations.
4. Speech Assessment and Analysis in Conversation (SPAAC): Located at https://www.csu.edu.au/research/multilingual-speech/speech-assessments/spaa-c. This tool focuses on analyzing speech within conversational contexts.
5. NESC Resources – SLP Tools: Visit https://nesc.k12.sd.us/resources.html#slp for a broader list. Be sure to check out the sections dedicated to Autism and Social Skills for more relevant questionnaires.

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I made a previous post on Making Data Meaningful in Speech Therapy: How Often, When & Why. But what happens when the session’s focus didn’t lend itself to easily counted data? How do we articulate progress (or lack thereof) in a meaningful and defensible way, beyond quantifiable data?

Whether you’re in a school, clinic, or home-based setting, this post explores documenting nuanced therapy sessions where formal data points are limited, offering strategies for crafting compelling statements of progress that paint a clear picture for reviewers and contribute to a comprehensive client record. 

In this context, ‘difficult data collection’ refers to therapy activities yielding primarily observational or qualitative information, rather than easily quantifiable metrics. While I firmly believe in structured quantitative data (as discussed in my previous post), qualitative notes are essential for sessions where such data is challenging to obtain.

The Importance of Session-Specific Documentation

Before we delve into the data dilemma, let’s reiterate why detailed session notes are crucial:

• Continuity of Care: Notes inform future sessions, ensuring a logical flow and building upon previous work.
• Communication: They provide valuable insights for other professionals involved in the client’s care, as well as for parents and caregivers.
• Accountability: They justify the services provided and support reimbursement processes.
• Progress Monitoring: Even without formal data, observations contribute to the overall understanding of the client’s trajectory.

Navigating the “Difficult Data” Session

Sometimes, the nature of our therapy doesn’t easily translate into percentages or frequency counts. Consider sessions focused on:

• Instruction &/or Practice: Documenting formal data concurrently with direct instruction and support can be challenging.
• Functional Communication Activities: Engaging in naturalistic conversations, role-playing social scenarios.
• Caregiver Training: Educating and coaching parents on implementing strategies at home.
• Exploratory Play: Facilitating language development through child-led activities.
• Problem-Solving Tasks: Working on higher-level cognitive-communication skills.
• Initial Interactions: Building rapport and assessing the client’s current abilities informally.

In these instances, attempting to quantify performance for progress statements may not accurately reflect the client’s engagement and learning, potentially leading to less impactful documentation. Descriptive language becomes essential.

Crafting Meaningful Progress Statements Without Formal Data

Here are some strategies to articulate progress effectively when formal data isn’t the primary focus:

Qualitative Observations

• Focus on Observable Behaviors: Instead of numerical data, describe observed actions and verbalizations.
  • Instead of: “Participated in a social skills activity.”
  • Try: “Client initiated greetings with the therapist and one peer during the structured play activity, demonstrating appropriate eye contact in 2 out of 3 observed instances.”
• Highlight Qualitative Improvements: Describe changes in the quality of the client’s responses or interactions.
  • Instead of: “Practiced answering wh-questions.”
  • Try: “Client demonstrated increased detail and complexity in their responses to ‘what’ and ‘where’ inquiries compared to the previous session, now including relevant contextual information.”
• Note Changes in Independence and Cueing: Document any shifts in the level of support the client required.
  • Instead of: “Worked on following directions.”
  • Try: “Client followed two-step unrelated directions with minimal verbal cues, a reduction from moderate cues noted in the previous session.”
• Describe Engagement and Participation: Comment on the client’s level of involvement and motivation.
  • Instead of: “Engaged in play.”
  • Try: “Client actively participated in the pretend play scenario for 15 minutes, demonstrating sustained attention and initiating several communicative turns.”
• Connect Back to Goals (Even Qualitatively): Explicitly link session activities and client performance to overarching goals.
  • Example: “During the caregiver training session focused on Goal #3 (increase use of descriptive language at home), the caregiver verbalized understanding of three new strategies and demonstrated appropriate implementation during role-playing.”
• Document Caregiver/Client Feedback: If the session involved training or discussion, note pertinent feedback received.
  • Example: “Caregiver reported successful implementation of the visual schedule at home this week and observed increased independence during morning routines.”
• Acknowledge Challenges or Lack of Progress: Be honest if the client struggled or if progress wasn’t evident. Describe observed barriers.
  • Example: “Client continued to demonstrate difficulty initiating communication during unstructured play, requiring frequent prompts to engage with peers.”

Complementary Data & Tool Utilization

• Collect Supporting Data: Even if you’re not taking data on the primary goal, consider collecting quantitative data on related skills or behaviors. This combination of qualitative descriptions and quantitative data on supporting skills offers a more comprehensive view of the client’s evolving abilities.
  • For example, in a session focused on improving inferencing skills, you could track:
    • The number of clues the client identified correctly (e.g., 8/10 clues).
    • The frequency with which the client accurately stated relevant prior knowledge (e.g., 4/5 opportunities).
    • The number of times the client requested clarification.
• Utilize Data Collection Tools: For complex or multi-faceted skills, consider using data matrices to track progress across different components. (Refer to your previous post on matrices for more details.)

Document Deviations from Planned Data Collection

• Explain Changes in Approach: Note if planned therapy activities intended for quantifiable data collection were modified. Clearly explain the rationale for the change in approach and the session’s ultimate focus.
  • This could be due to client factors (e.g., unexpected behavior, fatigue), instructional needs (e.g., requiring more basic instruction), or the need to address supporting skills.

Example in Action:

To further illustrate how to document a session focused on instruction without formal data collection, consider the following SOAP note example for an inferencing activity:

• Subjective:
  • The student presented as attentive and cooperative throughout the session. The student appeared motivated to participate in the inferencing activities but required frequent verbal encouragement to maintain focus on the task.
• Objective:
  • IEP Goal #3, focused on improving the ability to make inferences from short stories and passages, was addressed. Instruction involved identifying textual clues and integrating them with prior knowledge to formulate inferences. The SLP read aloud short mystery scenarios, pausing to model the inferencing process. The student was guided to identify clues and articulate prior knowledge through verbal and occasional visual prompts (highlighting key words). Formal data on inference accuracy was not collected due to the instructional nature of the session. However, data were collected on the number of clues the student correctly identified (7/9).
• Assessment:
  • The student demonstrated improved understanding of the inferencing process with direct instruction and modeling. The student could identify some textual clues with verbal and visual prompting but continued to struggle with consistently articulating relevant prior knowledge to support inferences. The session effectively introduced and practiced inferencing strategies, establishing a foundation for future data collection on independent inferencing skills.
• Plan:
  • Instruction on inferencing strategies will continue, emphasizing common inference types (e.g., cause-effect, prediction). Graphic organizers will be introduced to facilitate the visual representation of clues and prior knowledge. Data collection on the accuracy of the student’s inferences in structured tasks will commence. The caregiver will be contacted to discuss strategies for reinforcing inferencing skills during reading activities at home.

Key Takeaways:

• Descriptive language is essential for capturing the nuances of therapy sessions.
• Focus on observable changes in behavior, quality of responses, and level of independence, as well as the scaffolding required.
• Always link observations back to the client’s individualized goals.
• Maintain honesty and specificity in documentation, even when progress is gradual or not immediately apparent.
• Remember that appropriate qualitative data should be an integral part of every session note, providing crucial context and a comprehensive understanding of the client’s performance, even in sessions with a strong quantitative focus.

Documenting progress without relying solely on quantifiable data necessitates thoughtful observation and clear articulation. By emphasizing the qualitative aspects of our sessions, supplemented by quantitative data on supporting skills when appropriate, we can create comprehensive and meaningful records that accurately reflect the valuable work we do. Prioritizing detailed and insightful observations, strategically supported by direct data collected at meaningful intervals, allows us to effectively communicate our clients’ progress.

See my next post on Medicaid documentation, with a free resource!

**Important Note: SLPs should always verify the specific documentation requirements of their organization and payers. While these observational note-taking strategies can supplement data collection and provide valuable descriptive information, they do not replace the necessity of collecting and documenting quantitative data when possible and at regular intervals. In fact, observational notes can help to keep data collection focused and aid in the interpretation of data trends over time.

Happy Documenting!

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