Auditory-Verbal Therapy: Supporting Listening and Spoken Language in Young Children with Hearing Loss & Their Families

Deep conversation

Photo by juhansonin

Approximately 95% of parents of children with hearing loss are hearing themselves (Mitchell & Karchmer, 2004), and trends indicate that many parents are choosing spoken language as the primary mode of communication for their children with hearing loss. In fact, some states such as North Carolina, are reporting that parents are choosing spoken language options for their children with hearing loss more than 85% of the time (Alberg, Wilson & Roush, 2006), especially when they know spoken language is a viable outcome for their child. And, these parents are typically selecting approaches that support listening and spoken language, such as Auditory-Verbal Therapy, without initiating visual communication systems.

With early identification and the use of advanced hearing technology, children with even the most severe or profound hearing losses can access audition and follow an intervention approach focused on achieving typical developmental milestones in listening, speech, language, cognition, and conversational competence. Parents’ communication choices are based on their long-term desired outcomes for their child. Once those decisions are made, professionals providing early intervention and habilitative services should support the parents’ choices and provide the necessary support and intervention to ensure, to the greatest extent possible, that the child achieves those outcomes.

Definition of Auditory-Verbal Therapy

The Alexander Graham Bell (AG Bell) Academy for Listening and Spoken Language, which is based in Washington, DC, governs the certification of Listening and Spoken Language Specialists (LSLS), the practitioners qualified to provide Auditory-Verbal Therapy. The Academy defines the practice of Auditory-Verbal Therapy as:

“Auditory-Verbal Therapy facilitates optimal acquisition of spoken language through listening by newborns, infants, toddlers, and young children who are deaf or hard of hearing. Auditory-Verbal Therapy promotes early diagnosis, one-on-one therapy, and state-of-the-art audiologic management and technology. Parents and caregivers actively participate in therapy. Through guidance, coaching, and demonstration, parents become the primary facilitators of their child’s spoken language development. Ultimately, parents and caregivers gain confidence that their child can have access to a full range of academic, social, and occupational choices. Auditory-Verbal Therapy must be conducted in adherence to the Principles LSLS of Auditory-Verbal Therapy” (AG Bell Academy, 2012).

The Principles of Auditory-Verbal Therapy: Defining Practice

The Academy has endorsed a set of principles that delineate the practice of Auditory-Verbal Therapy:

  1. Promote early diagnosis of hearing loss in newborns, infants, toddlers, and young children, followed by immediate audiologic management and Auditory-Verbal Therapy;
  2. Recommend immediate assessment and use of appropriate, state-of-the-art hearing technology to obtain maximum benefits of auditory stimulation;
  3. Guide and coach parents to help their child use hearing as the primary sensory modality in developing spoken language;
  4. Guide and coach parents to become the primary facilitators of their child’s listening and spoken language development through active consistent participation in individualized Auditory-Verbal Therapy;
  5. Guide and coach parents to create environments that support listening for the acquisition of spoken language throughout the child’s daily activities;
  6. Guide and coach parents to help their child integrate listening and spoken language into all aspects of the child’s life;
  7. Guide and coach parents to use natural developmental patterns of audition, speech, language, cognition, and communication;
  8. Guide and coach parents to help their child self-monitor spoken language through listening;
  9. Administer ongoing formal and informal diagnostic assessments to develop individualized Auditory-Verbal treatment plans, to monitor progress, and to evaluate the effectiveness of the plans for the child and family; and
  10. Promote education in regular school with peers who have typical hearing and with appropriate services from early childhood onwards.

The Listening and Spoken Language Specialist (LSLS):

Two Paths to Certification

The AG Bell Academy has designated two paths to certification for Auditory-Verbal practitioners: LSLS Certified Auditory-Verbal Therapist (LSLS Cert. AVT) and the LSLS Certified Auditory-Verbal Educator (LSLS Cert. AVEd). The LSLS certification is awarded to qualified professionals who have met rigorous academic, professional, post-graduate education and mentoring requirements, and have passed a certification exam. Typically, LSLS certified practitioners are licensed audiologists, speech-language pathologists, or educators of the deaf who have the required background, training and experience in listening and spoken language theory and practice with children with hearing loss and their families. For additional information about certification as a Listening and Spoken Language Specialist (LSLS), speech-language pathologists and audiologists should contact the AG Bell Academy at, visit the website ate, or call (202) 204-4700.


Alberg, J., Wilson, K., & Roush, J. (2006). Statewide collaboration in the delivery of EHDI services. The Volta Review, 106, 3, 259-274.

AG Bell Academy for Listening and Spoken Language (2012). 2012 certification handbook. Available at

Mitchell, R.E. & Karchmer, M.A. (2004). Chasing the mythical ten percent: Parental hearing status of deaf and hard of hearing students in the United States. Sign Language Studies, 4, 2, 138-163.


Dr. K. Todd Houston, Ph.D., CCC-SLP, LSLS Cert. AVT, is an Associate Professor in the School of Speech-Language Pathology and Audiology at The University of Akron. His primary areas of research include spoken language acquisition in children with hearing loss, strategies for enhancing parent engagement in the intervention process, Auditory-Verbal Therapy, and telepractice. He directs the Telepractice and eLearning Laboratory (TeLL), an initiative to evaluate clinical practices in the area of distance service delivery in Speech-Language Pathology.


Knitting Multiple Modalities

Knitted owl hat

Photo by Burstyriffic

Before becoming a mom I taught K-12 classes, starting in second language classrooms. It felt like I was at home because I grew up as a simultaneous bilingual — a person who was presented with two languages from birth in an immigrant household. My parents met in an ESL classroom in the Mission district of San Francisco, so I grew up learning in ways that helped all of us which meant using all modalities — visual, tactile, auditory, kinesthetic. Hearing wasn’t enough — it’s so subjective. Are you saying ‘b’ de burro or ‘v’ de vaca? This image helps one to establish in the mind that very fast sounds are distinguished by so little when coarticulation is involved. It also seems so fast when learning a second language, so physically moving or tapping out the sounds really helps. And of course, there must be a reason why so much of the motor strip targets the hands — I feel therefore I learn. In my own studying, it is not enough for me to just hear. If I can touch it, feel it, sign it — I feel like I own it like the way a toddler mouths a book or a toy.

Using multiple modalities also made me think of a fairly recent experience. Two summers ago I wanted to knit a playmat for my kids, so I took a beginning knitting class co-taught by two women in my area. One woman relied on auditory teaching skills — I was so lost. Knit one pearl two — what!?! She went regular speed, thinking that’s what she needed to model so that we could learn to knit correctly. There were a group of us (20 total in the class) who were just not getting it. She kept coming to our group to retell us what she had already told the larger group. Repeating didn’t help. Still lost. She showed us again at her regular speed. Stressed. So contrary to what knitting addicts profess. “Way over-rated,” I thought of knitting, as my shoulders elevated toward my ears from the stress.

Then the other teacher came to us and gently placed her hands on ours to physically guide us in the pattern. She also made the pattern slower, much more exaggerated and larger in movement than the other teacher. BINGO!!!! Our eyes and minds that had previously felt as if they were on a fast spinning merry-go-round that didn’t give us a chance to hop on finally were able to catch up and get on. We got it! And not only did this small group of auditory strugglers get it, we outlasted the larger group and stayed with the project while many others dropped out. Ahhh…knitting wasn’t over-rated after all, but much more like a catnip invoked endeavor…

This experience reinforced something I intuitively knew from growing up in a household of second language learners, from teaching second language learners, and teaching my son who has special needs including severe dysarthria, severe CAS and ASD: all modalities help. I saw this espoused at ASHA’s 2011 conference in sessions regarding ASD. Also, it’s not just the modality but the speed and the size of the movement of these modalities which also help to get those neural networks firing and wiring for a meaningful experience.

So when I think of multiple modalities for our client population — I can’t help but think knitting….


Liz Guerrini has been a K-12 and college teacher for the past 18 years and is entering her final graduate year in Communicative Disorders at CSUN. She’s an Olympian who finds many applications of her sport world to the teaching and therapy worlds. She home-schools her bright and beautiful son who lives with trisomy 2, severe dysarthria, severe CAS, hearing loss, ASD and hypotonia. She is a member of ASHA’s Minority Student Leadership Program. Liz blogs at  Christopher Days, SLP to-Be and the Signing Time Academy.

Using Your iPad in Dysphagia Therapy

iPad fascination

Photo by rahego

So many people are using iPads, iPhones and iPods in therapy. While there are many other devices out there, I’m focusing on the “iDevices” because those are the devices that I know the best. It is very easy to find apps for pediatric speech therapy, even apps for adult language therapy. There are apps for language, articulation, AAC, voice, fluency, and a few for dysphagia, but not many. It seems that few therapists are using their devices for dysphagia therapy. In lieu of the small number of apps available for those of us specializing in dysphagia therapy, we can very effectively use our iDevices for treatment.

One feature that comes with any of the iDevices is the notepad. This looks like the yellow legal pads that I’m sure we’ve all used. You can use the keyboard or dock your device to a keyboard to type notes. Once these notes are done you can then choose the option to print or you can email it to yourself to print. You can also use Evernote (which is free) to create documents and access everything from any of your smart devices or from the computer.

I use Dropbox quite often. Dropbox is a cloud storage app. I have it installed on my computer, iPad, iPod and Android phone. I save files from my computer including journal articles, forms, documents, etc and can access them through any of my mobile devices or can access them via the internet on any computer. In addition to Dropbox (which is free for 2 gb), I use Carbonite. Carbonite is a yearly subscription (around $60 a year) that is a backup system for your computer, it backs up all of your documents, plus you can log onto your account from any computer via the internet to access all of your backed-up items and there is an iOs and Android app to access your files from your mobile device.

Dysphagia2Go is the new Dysphagia evaluation app that lets you use your iPad during your Clinical Dysphagia Evaluation to write a report with all of your findings. If you already have a computerized version of your report, you can email the results to yourself and copy and paste your findings. This app is available through SmartyEars and will have some exciting new updates soon!

iSwallow is available for Apple devices. iSwallow is a free app that allows you to show videos of each exercise for your patient and allows your patient to track their exercises and lets the therapist see how many times each exercise was completed at home. This hasn’t been a very functional app for me; fortunately it was free. You have to email the company to get a password to unlock the app and I tried many times, unsuccessfully, to get the password from them. Fortunately, I ended up finding another therapist that had the password to get it. Also, it would be helpful if you had patients that owned iDevices so that they could utilize it. At this time, I’m not willing to loan out my devices to allow patients to track. Most of my patients are 70 or older and don’t own iDevices.

Lingraphica offers 2 apps for dysphagia. One is a communication aid for the iPhone/iPod Touch that can also be used on the iPad. It allows a patient with dysphagia to communicate regarding their dysphagia, for example, “I need my dentures” or “I need to be sitting up to eat”. This would be helpful if you have an aphasic patient with dysphagia that would be able and/or willing to communicate these items with others. Lingraphica also has an oral motor app which has videos of each exercise being completed.

There are also several apps which show the structures, from a scope view. You can use iLarynx, LUMA ENT and URVL to look at the structures, or to use for patient education. They are also fun to play and see if you can “insert” the scope appropriately.

Lab Tests is a relatively inexpensive app, I think it’s $1.99 that describes the lab values and has normative data for lab values. This is nice if you work in an acute care hospital, where they typically draw daily labs to interpret what the lab values indicate.

Pill Identifier lets you search medications by shape, color or score. Telling you what the pill is, what the indications are, how it is available OTC or prescription. You can view images of the pill or look at information of each pill via

3D Brain is a wonderful view of the brain to educate patients on lesions and where their lesions are located. It’s also a fun app to play with giving you views of the brain and descriptions of the areas of the brain.

I’m sure this is not a comprehensive list of the apps however, hopefully it’s a start to help you utilize your iDevice in your dysphagia therapy. Also, keep watching SmartyEars for possible new dysphagia apps.


Tiffani Wallace, MA, CCC-SLP, currently works in an acute care hospital in Indiana.  Tiffani is working to specialize in dysphagia and is working to achieve the BRS-S.  She is also a member of the Smarty Ears Advisory Board and co-author of Dysphagia2Go, and has a website about dysphagia, Disphagia Ramblings.

Eliciting the /r/ Sound- Taking the Pain Out of Therapy!

R Graffiti

Photo by CarbonNYC

The /r/ sound is one of the most difficult to teach in therapy. Several of my children struggle to produce the /r/ sound appropriately. Because of this, I wanted to see what other speech-language pathologists were doing during their treatment. I found out some new and interesting techniques that I am definitely going to try with my clients!

  • Auditory Bombardment- One technique, called auditory bombardment, involves the child listening to a repetitive and intense list of words including the targeted sound (in this case, the /r/). This evidence based procedure is supposed to assist children in their rate of sound development.
  • Imitation- This technique may seem obvious (“I keep modeling a good /r/ but they just aren’t appropriately imitating). Another option would be to have the child imitate certain animal sounds that are fun to make and may ease the child’s pressure of trying to model the sound appropriately. Some good animals to imitate are tigers (roarrrrrr), dogs (ruff, ruff), or birds (chirp, chirp).
  • Incorporate mirrors- Although the /r/ sound is hard to see with a mirror, I always like to incorporate them into my therapy sessions to increase awareness of mouth, tongue and lip movements.
  • Jaw movement- I often ask my clients to produce the /L/ sound. While they are doing this, I then model how to gently pull their jaws down until the /r/ sound is eventually reached.

There are plenty of other techniques to produce the /r/ sound, but these are the three that I find the most useful. Have any other techniques you want to share?

(This post originally appeared on Speechbop)


Erica Gosling, MA CCC-SLP is a full time SLP working in both Stamford, CT and New York City. She received her M.A. from New York University. She has worked in a variety of settings including schools, private practices and home based therapy. She has experience with a variety of communication disorders. For more information about Erica and speech therapy, please visit her blog at

The Best Speech-Language Pathologist Blogs from ‘A to Z’

Editor’s Note: In her daily work at PediaStaff, Heidi is Editor in Chief of the popular PediaStaff Blog for pediatric and school based therapist, and also created the PediaStaff’s Pinterest Site  for therapists and parents of special needs children.  The company’s continuing work to educate, share resources with, and support the special needs community has been featured on, and Love That Max, (an award-winning special needs blog).   In addition, PediaStaff has been recently profiled by the well-regarded social media blog, The Realtime Report, for their innovative work on the Pinterest social media site.


Author’s Note:   I would like to thank the following speech-language bloggers for contributing to this article:  Activity Tailor, All 4 My Child, Future SLPs, Play on Words, Speech Lady Liz, and Speech Room News.


The number of Speech-Language Pathologists blogging and engaging in social media grew steadily in 2011. Those of us who are active on Twitter (we call ourselves the #SLPeeps), have been sharing articles and resources on blogs, Twitter, Facebook and LinkedIn. Recently though, the new social media kid on the block, Pinterest, has made it easier than ever for SLPs to engage each other and share ideas. And with all the sharing going on, it has given bloggers a new place to network their ideas and find inspiration for new ones. While I am not sure exactly if there is causality, it seems that Pinterest is inspiring SLPs to jump into the blogging world. We have counted at least nine brand new SLP bloggers since the first of the year and all of them are also on Pinterest.

I was recently speaking with Maggie McGary, ASHA’s Social Media guru, and we started talking about how great it would be to survey Speech-Language bloggers and compile a short-list of ‘must follow blogs’ for both SLPs and their clients.   Sean Sweeney has compiled a great list of blogs in the SLP Blog Bundle, but he doesn’t have a list of exactly who is in there, nor does he describe them anywhere one by one. So, since we have relationships with a great many of the regular speech and language bloggers already through our blog at PediaStaff, I mistakenly thought that I was well-suited for the job of compiling a ‘Best Blogs’ list. I emailed our contributors with a straw poll of sorts to get their votes for the best speech and language blogs in each of several areas. I waited patiently for results, and planned how I would deliver the findings to you in this column.

The results? Well…. The moral of this story is that there isn’t a short list! There are now a dizzying number of blogs to follow and most of them are definitely worth reading. What’s more, our respondents found it impossible to rank as “better” or “best” because they all have their own flavors and angles.

After the ‘best laid plans,’ fell through, what emerged was a list of the active blogs that were submitted as favorites, ordered from A to Z , plus some that are brand new that deserve notice.   In order to make this list, the blogs needed to meet the following criteria:

  • written by a speech-language pathologist or current graduate student
  • currently active
  • writes about (or shares resources on) speech language topics at least once a week (preferably more)
  • directed to either clinicians, parents and caregivers
  • has good ongoing continuity without multiple periods of inactivity in the past
  • professional and well edited for spelling, grammar, etc
  • shares more general resources and news than it does information on their own products or services

It is important to note that note that neither PediaStaff nor any of the contributors to this list specifically endorse any of these bloggers, nor make any claims to the clinical competence of the authors. In fact, a few of these bloggers keep their full names to themselves to protect their privacy, so we have no way of verifying if they are who they say they are. Please make your own informed decision as to the effectiveness/appropriateness of what these clinicians are sharing.   I know this is by all means not a conclusive list (especially since new great new blogs seem to be popping up like daisies!) but as of  March 2012, the following are the speech and language blogs that PediaStaff and our colleagues recommend that also meet the above criteria:

Activity Tailor – Kim Lewis, M.Ed, is a private practitioner working in school settings.  Her lovely blog includes easy, creative treatment activities and private practice tips. I especially like her clever seasonal ideas and occasional commentary pieces.

All 4 My Child – This Edublog finalist for best new blog offers book reviews, searchable by goal or theme with activities for use to meet therapeutic goals. This site also shares uniquely collaborative therapy ideas, experiences and musings related to social interaction written by co-treating SLPs and OTs.

ASHASphere – You are reading it now.   Definitely a “greatest hits” blog with tremendous articles for speech and language clinicians daily!

Becoming Olivia SLP – Olivia is a graduate student in Canada chronicling her experiences as an SLP student in video log (vlog) format. She is full of energy and creating quite a bit of chatter for herself amongst the ‘SLPeeps.’

Chapel Hill Snippets  – Ruth Morgan is a school-based clinician who highlights her “assorted observations both in work and play.” Her blog is insightful and well-written. Ruth’s free therapy shares (often downloadable books) are especially popular and well done.

Child Talk – Becca Jarzynski, who specializes in autism, writes a wonderful speech and language therapy blog for parents/caregivers that should not be missed. Her articles offer concrete ideas for parents to help their child communicate during “everyday life.”

Cindy L. Meester’s Blog – An oldie but a goodie, Cindy Meester’s blog has been extremely popular with SLPs since before blogging (and reading blogs) was trendy. While she blogs about all sorts of topics, she was recognized by the Edublog Awards as a finalist in the Ed Tech category.

Early Intervention Speech Therapy – Stephanie Bruno Dowling has a well-known blog on Advance for SLPs and Audiologists. It is unique among the blogs on this list in that it is only one of a few that specialize in Early Intervention.

Eric Sailers’ Blog – Eric is a former school-based clinician who blogs about technical applications for SLPs. He is also the creator of several apps including ArticPix.

Erik X. Raj, Speech Language Pathologist – Erik is a creative SLP, best known for former blog ‘ArticBrain’ which shared how to really engage kids in speech with humor and talk of ‘boogers’ and bugs! He is also blogging on Pocket SLP.   His current blog is a video blog.

Hanna B. gradstudentSLP – is a brand new blogger who has come onto the SLP blogging scene just in the past eight weeks. So far, she has made some very nice (and quite frequent) posts on a variety of school-based topics.

In Spontaneous Speech – This blog was recommended to us recently by several bloggers that speak highly of Cindy. We have started following her and suggest that you check her out as well.

If I Only Had Super Powers  – This blog is another “oldie but goodie” that has been around since long before blogging was popular. Although we have not gotten to know this blogger personally, she is on our ‘must read list.’

Jill Kuzma’s SLP Social & Emotional Skill Sharing Site – Jill works with students with Asperger’ Syndrome and other high functioning students with social and emotional needs. This blogger is well-respected among her peers in the industry and her blog has much to offer.

Let’s Talk Speech-Language Pathology – Brand new in February of 2012, this is a student blog with some nice potential. We are looking forward to reading her thoughts and ideas.

Little Stories – Kim Rowe’s parent oriented blog is new to us, but was recommended to be in this list by our colleagues at All4MyChild. Based on what we have read so far, it seems to have some great resources and insights for caregivers of young children with speech and language delay.

LiveSpeakLove – Another brand new school-based SLP blogger, Lisa at LiveSpeakLove, is an SLP in the Baltimore County Public Schools. She has creative activities and offers up a bunch of great Boardmaker shares, often with a seasonal bent.

The PediaStaff Blog  – I feel a bit awkward including our own blog in this list, but the contributors to this article insisted that I mention it. With posts up to five times a day, the PediaStaff blog aggregates and presents a collection of the clinical articles, treatment ideas, and news. Our staff combs over 100 therapy blogs, websites, and news wire feeds daily,  to ensure that PediaStaff readers receive the best information available as it is happens and is written.

Play on Words – This unique, ‘must-read’ blog focuses on toys, games and books that facilitate language development. Sherry Artemenko writes excellent book and product reviews, and also offers up specific ways parents can sneak speech language therapy practice into family fun time at home.

Playing with Words 365 – We discovered this blog through Pinterest. SLP blogger Katie is also certified in ABA. She has a well developed blog that, although written for parents and caregivers, is quite popular among her peers in the profession.

Say What Y’all – Here is yet another brand new school-based SLP blog with great promise. Clean and fresh, Haley Villines’ blog has a modern and creative feel that is echoed by her excellent articles, so far.

Speech Gadget – ‘Deb T., SLP’s’ blog features a variety of articles on books to use in speech language therapy, tools, websites, apps and other online resources. On hiatus for a bit, she seems to be back in action with regular (and excellent) posts and tips.

The Speech Guy – Quite active in the #SLPeeps community on Twitter and Facebook, Jeremy Legaspi, SLP, writes primarily about technology. His articles on worthwhile apps, interactive websites, and technology are definitely worth reading.

The Speech Ladies – This mother and daughter team has an excellent school-based blog full of colorful posts, creative ideas and free downloads. Highly recommended!

Speech Lady Liz – Liz Gretz is a second generation SLP with a great deal of energy and creativity. Her blog is oriented to parents and professionals alike and features tons of colorful, culturally relevant activities that the kiddos can get excited about. She is also very active on Pinterest.

Speech Room News – Young and full of energy, school-based SLP Jenna Rayburn posts fresh, fun activities to promote speech and language goals. New last year, the site was awarded First Runner-Up among in the Edublog 2011 awards in the ‘Best New Blog Category.’ PediaStaff is proud to have made the initial nomination of Speech Room News for this award.

Speech Techie – Sean Sweeney is no stranger to technically savvy (and wanna-be technically savvy) SLPs. He is a regular presenter at both ASHA and Boston University on using technology for Speech and Language therapy. This blog is a must read and is a past EduBlog first place winner in the ‘New Blog’ cateogory.

Speech Time Fun – “Miss Speechie” is also a brand-new and already prolific young blogger. Her posts are full of colorful, creative and fun ideas for the classroom.  She is active on Pinterest and often modifies ideas she finds there through a speech/language lens.

Sublime Speech – The explosion of creative new speech blogs continues with Sublime Speech. Lots of ‘Do It Yourself’ activities with free downloadable versions of her creative and ‘hip’ creations! Another one to watch!

Talk It Up Speech Therapy – Ashley Dyer McGeehon’s ‘Talk it Up’ is another brand new one to watch online. A school-based SLP, her ideas are current, interesting, and engaging.

Therapy App411 – This new group blog, also an Edublog nominee, is a collaborative effort of several of our favorite therapy bloggers. The aim is to review smartphone and tablet apps through a therapy lens. Is a must follow for SLPs interested in using smartphones, tablets and technology in the clinic and classroom.

There are several other blogs that I would like to offer honorable mention to that didn’t meet all our criteria.  For the most part they are just not posting often enough  (how dare those student bloggers pay more attention to their classwork than their blog!) or have taken too many extended breaks from blogging.   Please be sure to check out:  2 Gals Talk About Speech Therapy, Cree-zy, Crazy Speechie, Easy Speech and Language Ideas, Future SLPs, Geek SLP, Heather’s Speech Therapy, Landria Seals’ Blog, The Learning Curve, Lexical Linguist, Mommy Speech Therapy, Pathologically Speaking, and The Speech House


Heidi Kay is one of the founding partners of PediaStaff and is the editor-in-chief of the PediaStaff Blog, which delivers the latest news, articles, research updates, therapy ideas, and resources from the world of pediatric and school-based therapy. PediaStaff is a nationwide, niche oriented company focused on the placement and staffing of pediatric therapists including speech-language pathologists.


Turning Pinterest Boards Into A Therapy Activity!

If you follow me on Pinterest, you might notice I use it A LOT. A few weeks ago PediaStaff started creating boards with pictures to be used in therapy. They made boards with action pictures, pronouns, problem solving, inferencing and concepts. As soon as Heidi emailed me and told me about them, I knew I could adapt them for speech therapy on the iPad. I figured it would be way more entertaining than printing them all out! About the same time, I won an app called TapikeoHD. After playing with it for a while I realized it was perfect for the PediaStaff Pinterest boards. Let me show you what I came up with!

The app I used is called Tapikeo and available at this time for $2.99 in the app store. Tapikeo allows you create your own audio-enabled picture books, storyboards, audio flashcards, and more using a versatile grid style layout. Check it out for yourself in the itunes store here.

First I opened Pinterest on my iPad and decided I would make an activity working on labeling verbs. I opened their board for actions words.

Then I saved the pictures to my ipad by holding down on them to save.

Next you will head on over to the app and start a new grid. When you click on the empty grid square you will get a screen like this. If you want text to accompany your photo/audio (and I did because I want to support literacy skills!)  you can type that in at the top. I type ” The boy is ___.” Then select ‘browse’ to add the photos you just saved to the iPad. Then select record. For my grid I saved my voice reading “The boy is.” When I use it with younger students, all they need to do is name the verb. For older students working on full sentence generation – I can turn the sound off and they are responsible for developing the whole sentence.

Once I finished adding all my cards (it took me about 5 or 10 minutes) the board looks like this.

When the student clicks on one of the pictures, it expands to fill the screen and the audio/visual joins the picture. This is when my students identified the verb or created a new sentence!

There is also an ‘e-book’ setting where the app transfers your pictures into more of a slideshow like setting. I kept mine on the grid formation so I could work on receptive language skills at the same time. I had the students pick their picture a few different ways: by following directions with spatial concepts, by answering WH questions, or by listening to clues and making basic inferences.

These boards are easy to make in the app and PediaStaff has done most of the work finding all these great images. What other topic boards would you like to see PediaStaff create?

(This post originally appeared on Speech Room News)


Jenna Rayburn, M.A., CCC-SLP is a school based speech language pathologist from central Ohio. She is a graduate of The Ohio State University. Jenna is the blogger at, sharing fun treatment ideas and technology tips. Visit SpeechRoomNews on Facebook.

Figuring Out Speech

Do you ever feel like you’re slogging through another therapy session?  Especially if you are working with a long-term child who has been with you awhile and is likely to stay with you a good deal longer?  Sometimes adding a new person to your group with the identical deficits can be just what the party needs.

And what if this new client required no paperwork?  Does it sound too good to be true or have you figured it out? What I’m suggesting is the inclusion of an action figure to the circle.  I have one kiddo that really improves his articulation productions when he’s speaking for the action figure.  The fact that he slows his speech rate certainly helps, but the authoritative tone that superheroes apparently require is a big part of it too.

I’m kind of partial to Thor myself, but you could have a variety of action figures for the kids to choose from or have them bring one from home (or have them check their pockets, the male version of Mary Poppin’s bag).  Using action figures is also a great way to break the ice with a quiet child who might be more willing to speak for someone other than himself.  And while eye contact is ideal, the honest truth is that eye contact can be sensory overload for some kids.  Providing an object for joint attention, can be a happy compromise.

(This post originally appeared on Activity Tailor)


Kim Lewis M.Ed, CCC-SLP has a private practice for pediatrics in Greensboro, NC. She is the blogger at, providing creative ideas for speech therapy, and the author of the Artic Attack workbook series.

Multicultural Considerations in Assessment of Play

Disdyakis dodecahedron

Photo by nfdecomite

As speech language pathologist part of my job is to play! Since play assessment is a routine part of speech language evaluations for preschool and early school-aged children, I often find myself on the carpet in my office racing cars, making sure that all the “Little People” get their turn on the toy Ferris Wheel, and “cooking” elaborate  meals in complete absence of electrical appliances.  In fact, I’ve heard the phrase “I want toy” so many times that I actually began to worry that I might accidentally use it in polite company myself.

The benefits of play are well known and cataloged. Play allows children to use creativity and develop imagination. It facilitates cognition, physical and emotional development, language, and literacy.  Play is great!  However, not every culture values play as much as the Westerners do.

Cultural values affect how children play. Thus play interactions vary significantly across cultures. For instance, many Asian cultures prize education over play, so in these cultures children may engage in educational play activities vs. pretend play activities. To illustrate, Farver and colleagues have found that Korean preschool children engaged in greater parallel play (vs. pretend play), initiated play less frequently, as well as had less frequent social play episodes in contrast to Anglo-American peers. (Farver, Kim & Lee, 1995; Farver and Shinn 1997)

To continue, cultures focused on individualism stress independence and self-reliance.  In such cultures, babies and toddlers are taught to be self sufficient when it comes to sleeping, feeding, dressing, grooming and playing from a very early age. (Schulze, Harwood, and Schoelmerich, 2001) Consequently, in these cultures parents would generally support and encourage child initiated and directed play. However, in many Latin American cultures, parents expect their children to master self-care abilities and function independently at later ages.  Play in these cultures may be more parent directed vs. child directed.   These children may receive more explicit directives from their caregivers with respect to how to act and speak and be more physically positioned or restrained during play. (Harwood, Schoelmerich, & Schulze, 2000)

In Western culture, early choice making is praised and encouraged.  In contrast, traditional collective cultures encourage child obedience and respect over independence (Johnston & Wong, 2002).  Choice making may not be as encouraged since it might seem like it’s giving the child too much power.  It would not be uncommon for a child to be given a toy to play with which is deemed suitable for him/her, instead of being asked to choose.   The children in these cultures may not be encouraged to narrate on their actions during play but expected to play quietly with their toy.  Furthermore, if the parents do not consider play as an activity beneficial to their child’s cognitive and emotional development, but treat it as a leisure activity that helps pass the time, they may not ask the child questions regarding what he/she are doing and will not expect the child to narrate on their actions during play.

Consequently, in our assessments, it is very important to keep in mind that children’s play is affected by a number of variables including: cultural values, family relationships, child rearing practices, toy familiarity as well as developmental expectations (Hwa-Froelich, 2004).  As such, in order to conduct balanced and objective play assessments, we as clinicians need to find a few moments in our busy schedules to interview the caregivers regarding their views on child rearing practices and play interactions, so we could objectively interpret our assessment findings (e.g.,  is it delay/disorder or lack of  exposure and task unfamiliarity).


  •  Farver, J. M., Kim, Y. K., & Lee, Y. (1995). Cultural differences in Korean- and Anglo-American preschoolers’ social interaction and play behaviors. Child Development, 66, 1088- 1099.
  • Farver, J. M., & Shinn, Y. L. (1997). Social pretend play in Korean- and Anglo- American pre-schoolers. Child Development,68 (3), 544-556.
  • Johnston, J.R., & Wong, M.-Y. A. (2002). Cultural differences in beliefs and practices concerning talk to children . Journal of Speech, Language, and Hearing Research, 45 (5), 916-926
  • Harwood, R. L., & Schoelmerich, A and Schulze, P. A. (2000) Homogeneity and heterogeneity in cultural belief systems. New Directions for Child and Adolescent Development 87,  41-57
  • Hwa-Froelich, D. A. (2004). Play Assessment for Children from Culturally and Linguistically Diverse Backgrounds. Perspectives on Language, Learning and Education and on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, 11(2), 6-10.
  • Hwa-Froelich, D. A., & Vigil, D. C. (2004). Three aspects of cultural influence on communication: A literature review. Communication Disorders Quarterly, 25(3),110-118.
  • Schulze, P. A., Harwood, R. L., & Schoelmerich, A. (2001). Feeding practices and expectations among middle-class Anglo and Puerto Rican mothers of 12-month-old infants. Journal of Cross-Cultural Psychology, 32(4), 397–406.

This post originally appeared on


Tatyana Elleseff MA CCC-SLP, is a bilingual speech language pathologist with a full-time hospital affiliation (UMDNJ) and a private practice (Smart Speech Therapy LLC) in Central, NJ. She received her MA from NYU and her Bilingual Extension Certification from Columbia University. She specializes in working with bilingual, multicultural, internationally and domestically adopted at risk children with complex medical, developmental, neurogenic, psychogenic, and acquired communication disorders.

Telehealth Regulatory and Legal Considerations: Frequently Asked Questions

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Photo by narcosislabs

Telehealth, the use of electronic communications and information technology to deliver health-related services at a distance, is a promising service delivery model for occupational therapy, physical therapy, speech-language pathology, and audiology. However, prior to engaging in telehealth, practitioners in the United States should be aware of the most current policies and practices related to telehealth and licensure, reimbursement, HIPAA compliance, and malpractice insurance coverage. The questions and responses below are designed to serve as a catalyst for further inquiry into the federal and state regulatory requirements associated with the use of telehealth technologies to deliver occupational therapy, physical therapy, speech-language pathology, and audiology services at a distance.

1. Is there a need to secure licenses in two states (i.e., where the practitioner resides, and where the client is located), before engaging in telehealth?

Current medical and legal practices dictate that it is the location of the client that determines the state in which the practitioner must be licensed. At the present time, if that location is in a different state from the one the practitioner is licensed to practice, then the practitioner would need to secure a license from the state where the client is located unless the state has exemption provisions within its licensure laws. Although not all states have laws, regulations, or policy pertaining to the use of telehealth, it is possible that a regulatory board receiving a complaint on a practitioner delivering services through telehealth who does not hold a license in the state where the client is located would fall back on the “operating without a license” penalty provision that exists in every state.

There are consultation and licensure exemption provisions in various states. For speech-language pathology and audiology, some states allow individuals to work in another state without a license for up to 30 days in a calendar year. In this situation, the practitioner must hold a license from another state that has equivalent licensure requirements and must provide services in cooperation with a speech-language pathologist or audiologist who is licensed within the state where the temporary practice will occur. Although this exemption exists in some states, it remains untested for use with services provided via a telehealth service delivery model.

Similarly, a few states permit an occupational therapist licensed in another state to practice temporarily by notifying the state’s licensure board for occupational therapy of the intent to practice within the state on a temporary basis, paying a fee, and submitting required documentation and credential verification.

Additionally, the Department of Defense (DOD) and the Veterans Health Administration (VHA) have their own licensing requirements and credentialing and privileging process because they operate on federal property (military installations, VA hospitals, etc.). Practitioners must hold a license in one of the US states, District of Columbia, or US territories, and be credentialed (i.e., authentication process to validate qualifications) through the DOD or VHA system in order to practice. Once the credentialing and privileging process is complete, a practitioner using telehealth can engage in inter-state practice if the client is located on federal property at the time of service delivery. This provision is not extended to services provided off federal property.

The Service Members Telemedicine & E-Health Portability Act (STEP) (H.R. 1832), proposed on May 11, 2011 by Representative Glenn Thompson may provide a solution to health disparities among military personnel who are eligible for federally funded health care services. If passed by Congress, the STEP Act will enable health care professionals (DOD civilian employees and personal services contractors) to use telemedicine and e-health applications to treat service members where they are located, including in their homes. Currently, health care professionals must obtain licenses in states where their clients are located if services are provided off federal property (i.e., in the clients’ homes or communities). Under the STEP Act, health care professionals providing therapy/treatment to service members through telehealth and e-health technologies will not be required to obtain additional licenses in the states where their clients are located (Thompson, 2011).

2. Do state laws differ concerning if and how telehealth can occur?

Yes, states have different laws concerning if and how telehealth can occur. The American Speech-Language-Hearing Association (ASHA) and the Federation of State Boards of Physical Therapy (FSBPT) have written model practice act language for states to consider when crafting laws and policies related to telehealth. States may use the model practice act language verbatim; apply part(s) of a model practice act, or create their own language to meet state-specific needs. The legislative and regulatory language and policies vary by state for occupational therapy, speech-language pathology, audiology, and physical therapy. Currently, among the state boards overseeing speech-language pathologists and audiologists, 14 states and the District of Columbia have some provision, statutes, regulations, or policy, regarding the use of telehealth/telepractice (American Speech-Language-Hearing Association, 2011). Similar to provisions for speech-language pathologists and audiologists, several states have statutes, regulations, or policy related to the use of telehealth by occupational therapists and physical therapists.

With inconsistent adoption and non-uniformity of language regarding the use of telehealth, it is extremely important to check a state’s statutes, regulations and policies before beginning to practice; such information can be found through a number of mechanisms. The state licensure board within the state where a practitioner plans to practice should be regarded as the leading authority on the use of telehealth as a service delivery model within the state. Most state licensure boards have websites that can be easily accessed through a search engine. Generally state laws, regulations, and policies governing practice within the state can be found on these sites. It is always incumbent upon practitioners to know their scope of practice laws and regulations for the states in which they render services. Professional associations may also be a resource for preliminary information gathering.

3. Do any states expressly disallow telehealth?

There are a wide variety of regulatory mechanisms that may disallow the practice of telehealth or create barriers for its use within various professions. Problems can arise when the interpretation of the language of a statute, regulation, or rule creates barriers for the use of telehealth. One such example of restrictive language would be a requirement that the clinician conduct an in-person physical exam of the client before providing telehealth. Moreover, such restrictions are not universally applicable across all professions and their areas of practice. For example, a client seeking assistance from an occupational therapist to identify and implement ergonomic principles and work space modifications to promote health and prevent injury may not require an in-person evaluation prior to a remote consultation. Instead of an arbitrary requirement, clinical reasoning should dictate which clients are appropriate for services delivered through telehealth.

For speech-language pathology and audiology, Delaware has a regulation that states: “Licensees shall not evaluate or treat a client with speech, language or hearing disorders solely by correspondence. Correspondence includes telecommunications (Delaware General Assembly Title 24 Professional Regulation, 2006, Section” Thus the Delaware Board, through an unfortunate choice of wording, significantly limits the use of telehealth within their state for speech-language pathologists and audiologists by defining telecommunication in this way. Because amendments and revisions of statutory and regulatory language take time and money, careful consideration of practice language and its interpretation is warranted. It is important for practitioners to review the state practice act, board regulations, and any relevant board opinions/interpretations in the state in which they reside, to determine what restrictions or requirements may come into play as they relate to the use of telehealth. Before embarking on inter-state telepractice, practitioners will also need to check the state practice act for the client’s state of residence. If a state’s practice act does not mention telehealth or have any published opinions or positions, practitioners should contact the state board for further clarification to ensure that they do not violate any aspect of their license.

4. Can services delivered through telehealth be billed the same way as services provided in-person?

Practitioners are encouraged to contact the reimbursement entity prior to engaging in telehealth to determine if and how services delivered through telehealth are reimbursed. Medicare does not currently recognize occupational therapists, speech-language pathologists, audiologists, or physical therapists as telehealth providers. Some state Medicaid programs do reimburse for services delivered through telehealth by rehabilitation professionals, though qualifying circumstances vary by state. Private insurance reimbursement for services delivered through telehealth varies by state. Some states have legislation that requires insurance companies to reimburse for a service delivered through telehealth if that same service delivered in-person would be reimbursed. If a practitioner does bill for services delivered through telehealth, the modifier “GT” is generally used along with the appropriate CPT/HCPCS code. The use of this modifier identifies the service delivery model as telehealth and enables the collection of data on the frequency and types of services delivered using a telehealth service delivery model.

5. If practitioners fulfill the requirements to maintain licensure (e.g., continuing education obligations) in their state of residence, do they also need to fulfill the requirements to maintain licensure for the state in which the client resides?

Provided a practitioner holds a license in his/her home state and the state where the client resides, the practitioner is required to comply with the laws, regulations, rules and policies where the licenses are held, including continuing education requirements, which vary between states. For example, in occupational therapy, continuing education (CE) hours required for licensure renewal range from 0-24 hours per year; some states calculate hourly requirements annually while others calculate hours biannually. An activity that is defined as continuing education for which hourly credit is allocated also varies by state. Some states require that the CE hours are earned from state-approved continuing education providers. Other states may also accept activities for which the practitioner has engaged in over the course of the renewal period, including scholarly activities such as presenting at a conference, engaging in research, or contributing to articles, chapters or books. This is not an exhaustive list and many other variations on CE requirements between states and the rehabilitation professions do exist and require careful review before embarking on multi-state telehealth practice.

6. Will professional malpractice insurance cover services delivered through telehealth?

Malpractice policies for services delivered through telehealth vary by carrier. Practitioners should therefore consult with their malpractice insurance carrier prior to engaging in telehealth. Consideration of the insurer’s licensed coverage area is also warranted if a practitioner intends to practice in multiple states using a telehealth service delivery model.

7. Does a sole practitioner need to abide by HIPAA regulations?

Telehealth is a service delivery model. Services rendered through telehealth must comply with the same rules, regulations (federal, state, institutional) and practice stipulations that apply to services delivered in-person. Two major areas to consider when reviewing HIPAA compliance are security and privacy. Practitioners should become familiar with the HIPAA Breach Notification Rules and technology encryption requirements. Excellent resources are available for practitioners to complete a risk analysis for privacy, security, and HIPAA compliance when using Voice over the Internet Protocol (VoIP) (Watzlaf, Moeini, & Firouzan, 2010; Watzlaf, Moeini, Matusow, & Firouzan, 2011). When states have differing requirements for privacy, security, and informed consent, practitioners are encouraged to follow the most restrictive laws and regulations (particularly when the greatest restrictions occur where the client is located).


In conclusion, practitioners and their clients are poised to benefit from the use of emerging technologies to deliver health care services. Practitioners interested in using telehealth should become familiar with all pertinent legislation, regulation, and policies related to licensure, reimbursement, and malpractice coverage for services rendered through telehealth. Additionally, practitioners’ respective professional associations, the American Telemedicine Association and its Telerehabilitation Special Interest Group, the Center for Telehealth and e-Health Law (CTel), and regional telehealth resource centers may be able to provide additional information for professionals interested in using telehealth as delivery model.


1. American Speech-Language-Hearing Association. (2011). State licensure telepractice provisions. Retrieved from
2. Delaware General Assembly Title 24 Professional Regulation. (2006). 3700 Board of Examiners of Speech/Language Pathologists, Audiologists & Hearing Aid Dispensers, Section Retrieved from
3. Thompson, G. (2011). Thompson STEP Act passes U.S. House of Representatives. Retrieved from
4. Watzlaf, V., Fahima, R., Moeini, S., & Firouzan, P. (2010). VoIP for telerehabilitation: A risk analysis for privacy, security, and HIPPA compliance. International Journal of Telerehabilitation, 2(2), 3-14. doi:10.5195/IJT.2010.6056
5. Watzlaf, V., Fahima, R., Moeini, S., Matusow, L. & Firouzan, P. (2011). VoIP for telerehabilitation: A risk analysis for privacy, security, and HIPPA compliance – Part II. International Journal of Telerehabilitation, 3(1), 3-10. doi: 10.5195/IJT.2011.6070

(This post originally was published in International Journal of Telerehabilitation;; Vol. 3, No. 2, Fall 2011; doi: 10.5195/ijt.2011.6077)

Interested in Telepractice? ASHA’s Special Interest Group on Telepractice (SIG 18) was formed in 2010 in response to the growing interest and in telespeech and teleaudiology. SIG 18 sponsors continuing education via Perspectives  and short course and panel presentations at the ASHA convention, and SIG members have access to a private group in the ASHA Community for professional discussion and resource sharing. Consider joining SIG 18 today!


Jana Cason, DHS, OTR/L, is an Associate Professor in the Auerbach School of Occupational Therapy at Spalding University in Louisville, Kentucky. Dr. Cason is a national and international presenter and author on topics related to telehealth and telerehabilitation. Dr. Cason serves as chair of a Telehealth Ad Hoc Committee with the AOTA, is a member of the American Telemedicine Association (ATA) Telerehabilitation Special Interest Group (SIG) Executive Committee, and is co-chair of the ATA Telerehabilitation SIG’s Licensure Portability Sub-Committee.   

Janice Brannon, MA is the Director of State Special Initiatives in the Government Relations and Public Policy Division at the American Speech-Language Hearing Association (ASHA). She provides lead support on ASHA’s government relations response to telehealth and state licensure issues. Ms. Brannon’s experience in government relations has led her from the halls of Capitol Hill to her own consulting firm. Ms. Brannon has been a participant in the White House Working Group on Telemedicine, contributed to the discussion on the Nurse Licensure Compact while at ANA and recently was appointed co-chair of the ATA Inter-professional Work Group on Licensure Portability, Telerehabilitation SIG.