How Can You Tell if Childhood Stuttering is the Real Deal?

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One of the more challenging clinical decisions that confront speech-language pathologists is what to do with a young child who stutters. Do we recommend intervention? Do we wait and see if the child recovers without formal therapy? A recent study published in Pediatrics by Reilly and colleagues has generated a significant amount of press, with headlines declaring that preschool children who stutter will “do just fine.”

Even though this message does not appear to be the intent of the authors (as per their more detailed podcast on StutterTalk), it is the message the media chose to run with in their headlines. There are several key points about the Reilly article, preschool stuttering, and our current research base that need to be evaluated before we make claims such as those put forward by the media.

First, the Reilly et al. study used temperament and behavior scales, which were not designed to assess reactions to stuttering or communication. In fact, of the three scales used, only one had a question relating to communication, and it was not about stuttering. So, while it certainly may be true that young children who stutter may exhibit normal temperament and behavior (a finding we should not be surprised by), this study did not actually assess reactions to stuttering or communication, as the misleading media headlines have suggested.

This brings us to the second point of discussion, which is the difference between early stuttering and normal disfluencies. For a child with normal disfluencies, a “wait and see” approach is much more acceptable than for a child with early stuttering. We often use the term “emergent” to describe skills that are developing, but have not fully emerged. Children with normal disfluencies have emergent fluency. Their skills are developing in this area. Children who exhibit signs of early stuttering are much more at risk for continued stuttering, without proper intervention. As such, the question for parents, physicians, SLPs and others, is “How do we know the difference?”

The chart below describes some characteristics of “normal disfluency” and “stuttering.”
Normal Disfluency (less risk)                               Stuttering (higher risk)
Phrase Repetitions Sound                                                Syllable Repetitions
Interjections                                                                          Prolongations
Revisions                                                                                 Blocks
Multi-syllabic Whole Word Repetitions                     Tension/Struggle
No tension or struggle                                                       Changes in pitch/loudness
No secondary behaviors                                                   Secondary behaviors
No negative reaction or frustration                             Negative reaction/frustration
No family history of stuttering                                       Family History of stuttering

 

 

This can be a starting point to help determine risk. In addition, the child’s gender (boys are at a higher risk), time since onset (greater than 6 to 12 months is higher risk), age of onset (children who start stuttering at age 3 ½ or later are at higher risk), overall speech and language skills (it is important to assess all areas of speech and language), and level of parent concern also need to be considered.

Third, much of the problem that persists in our understanding the risk of early stuttering lies in the difference between population studies and clinical studies. Studies that have looked at recovery rate have been population studies, and thus likely captured many children who were experiencing “emergent fluency” rather than “stuttering.” The research does not translate well into clinical settings. While up to 80 percent of children in population studies may outgrow their “stuttering,” that number is far lower in a clinical setting.

Of the children seen in a clinical setting, many have several of the above risk factors that would put them at higher risk for continued stuttering without proper intervention. Children in a clinical setting are not a random sample of the population, but a specific subgroup with an identified concern (usually on the part of the parents) about stuttering. As such, speech-language pathologists need to be careful about discussing recovery rates with parents that may not apply to their child.

Finally, a “gold-standard” that allows us to predict with 100 percent accuracy which children need intervention does not currently exist. As such, we have to rely on current best practice: the integration of research evidence, clinical experience, and client values. Even if we assume that waiting to intervene will result in a similar outcome later, the reality is we do not know if waiting has a negative impact on social skills, self-confidence, and peer relationships.

Given the above information, what do we recommend to parents, physicians and SLPs? Parents are often the most reliable judge of their children. When they come to us with concern, it is warranted in most cases. Parents should trust their instincts. If they are concerned about their child’s stuttering, they should discuss those concerns with the child’s pediatrician and advocate for a consultation with a speech-language pathologist. Parents do not need a referral for an SLP. They can contact an SLP on their own (go to ASHA’s ProSearch directory of clinicians to find one in their area) or go through their public school or Child Find.

Pediatricians should refer to an SLP when any of the following are present in a child who is stuttering:

  • A family history of stuttering
  • Child has been stuttering for more than six months
  • Child exhibits any negative reactions toward stuttering
  • Child exhibits physical tension or secondary behaviors (e.g., eye blinking, head nodding, etc.) associated with stuttering
  • Other speech/language concerns are also present
  • Parents are concerned
  • Child is experiencing negative reactions from other family members or peers

Through a collaborative effort between the parents, physicians, SLPs and others in the child’s community, we can make a significant difference for children who stutter.

 

Craig Coleman, CCC-SLP, BRS-FD, is assistant professor at Marshall University and president of the Pennsylvania Speech-Language-Hearing Association. He is an affiliate of ASHA Special Interest Groups 4, Fluency and Fluency Disorders, and 18, Telepractice. 

Handling Verbally Disruptive Behavior in Patients With Dementia

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Verbal behavior that others consider disruptive is common in later-stage dementia. This behavior can range from a man who follows his nurse around asking repetitive questions, to the woman who sits in her chair and screams loudly for no apparent reason, to the man who lies curled up in bed, moaning softly through the night.

And there are many other variations on these themes. It has been estimated that 25 percent of those with dementia who still live in the community, and 50 percent of those who reside in long-term care facilities, exhibit this type of behavior at any given time. As many as 90 percent of those with dementia will demonstrate such behaviors at some point.

There are a number of different types of dementia-producing illnesses that can lead to screaming and other verbally disruptive behaviors. These include Alzheimer’s type dementias, vascular, Lewy Body, and frontotemporal, as well as the less common prion diseases, metabolic imbalances, and other degenerative conditions. Disinhibited behaviors are often associated with frontotemporal dementia, but they can be due to other diseases as well.

Often, sadly, the typical response to these disruptive individuals is to administer some medication intended to calm the person and make the behavior more manageable. However, in most cases there are non-pharmaceutical interventions that not only work much better, but also produce fewer side effects. I have heard it said that up to 95 percent of behaviors in people with dementia are actually a form of communication. When one considers the loss of verbal language production that inevitably occurs in dementia’s latter stages, it is no surprise that people with this disease resort to whatever means they can to communicate with the outside world.

The messages they seek to convey tend to fall into a few common categories: 1.) “I’m in pain,” 2.) “I’m lonely/frightened/bored,” 3.) “I don’t want to be here,” and 4.) “I need/want something.” At times, it is readily apparent what the person is trying to say. But, more often than not, the person’s caregivers need to do a little detective work to decipher the meaning behind the verbal outburst.

When I work with a nursing home resident with dementia and  consistently problematic behavior, I first attempt to define the behavior more clearly. What exactly does the resident do? What times of day does this occur? Are there any other events and circumstances associated with the behavior—occurring immediately before or after the behavior, for instance? What else is going on in the environment? It is also helpful to know what interventions have been attempted in the past for dealing with the behavior, and whether these interventions have proven at all beneficial. I try to learn as much as I can about the resident’s medical, family and occupational history. It is important to remember that this verbal agitation or disruption is a symptom and not a disease or condition in itself.

Pain, often related to conditions such as arthritis, compression fractures, limb contracture, and constipation, is responsible for perhaps as much as 50 percent of verbal disruptions. Because people with advanced dementia may lose the ability to ask for pain relief, administering a daily maintenance dose of Tylenol or a similar medication can be helpful.

In addition, I recommend doing the following to assess what might be causing discomfort:

  • Conduct a physical evaluation. Has the resident recently been placed on a new medication, or taken off one? Is there any sign of infection, injury or other medical issues? Is there pain related to arthritis, a toothache, constipation, etc.? Is the resident hungry or thirsty or in need of a change in bedding?
  • Survey the person’s environment to determine if any changes may have prompted the behavior. This could be a change in the routine, a new caregiver or a new roommate. Perhaps the hustle and bustle of getting the unit ready for Christmas is too much for the person to handle. Has there been an upsetting visit from a family member? (Also be aware that understimulation can be just as problematic.)
  • Assess the caregivers in this particular situation. Caregivers, both professionals in long-term care facilities, and family members in a home environment, are subject to a great deal of stress. This stress may not be directly related to the situation at hand. It could be that a nurse has had to place her own husband in the hospital, or has just learned that a son is having trouble in school. And if the caregiver is feeling stressed, it is likely that her charges will pick up on this as well.

Any form of intervention ultimately depends on the cause of the outburst.  Treating acute medical issues—and addressing dehydration or hunger—should take precedence over anything else.  Next,  consider environmental modifications, such as using softer lighting or music, establishing a routine that can provide a calming influence, and so on.

Music is associated with reduced agitated behavior, especially during bathing or meals. Light physical exercise can prove to be a pleasant distraction for the person. Other possible interventions can include pet therapy, massage, white noise, photographs of family or familiar people and places, and attention to any personal needs the person may have.

If you’ve tried all these strategies, and the person with dementia continues to be disruptive, possibly posing a risk of self harm or harm to others, then antidepressants, mood stabilizers and antipsychotic agents may provide some benefit. But, given that the side effects can be severe, opt for such agents only after careful consultation with the person’s physician and family.

Jami L. Hede, MS, CCC-SLP, is a private practitioner and affiliate of  ASHA Special Interest Group 15, Gerontology. This post was adapted from her blog, “Exploring Dementia.” 

The Signs Of The Times

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Announcing the launch of ASHA’s Identify the Signs, a public education campaign broader in reach, scope, and array of ASHA member-oriented tools than anything we have done in the recent past.

Identify the Signs spotlights the importance of early detection of communication disorders and the ability of certified speech, language and hearing professionals to provide quality treatment and help. Altogether, it is a unique and promising opportunity for everyone in the ASHA community to be involved at every level, working in concert to raise the profile of our professions and most importantly, the needs of those we serve.

Nationally, the campaign features English and Spanish television, radio and print public service announcements that highlight the importance of early detection and encourage the public to learn the early warning signs. We also will engage broadcast, print and digital media outlets to bolster the campaign and direct the public to our new campaign website, IdentifyTheSigns.org. The website has helpful, easy to understand information about the early warning signs of communication disorders that will enable the public identify potential communication issues and seek treatment.

But here is a truly exciting part: Identify the Signs is designed to be equally active and effective at the grassroots. In the coming months, outreach to local media markets will be conducted, and we anticipate that it will result in opportunities to feature ASHA members. In recent years, numerous members have been very effective media sources and our new campaign represents a golden opportunity to increase the number who serve in that role, spreading the word about our discipline and the important work we do. Interested ASHA members are invited to indicate their interest by sending in a brief email to pr@asha.org. They will then be contacted as appropriate media opportunities arise.

Apart from that, there are a variety of campaign assets for ASHA members to use to raise awareness in their practices, their schools and their wider communities. Along with the public-focused website, ASHA has developed a member toolkit that includes print and digital posters, social media badges and more to educate people about the early warning signs of communication disorders and highlight speech-language and hearing professionals as the best sources for treatment. Also, products and brochures that complement the campaign are now available in the ASHA store.

We encourage ASHA members to visit the campaign site and use the outreach tools there in their communities. They are also invited to send feedback about the campaign, its resources, and their involvement to pr@asha.org. The Identify the Signs effort will extend over the next year, and such input will be helpful guidance for the future.

Patty Prelock, PhD, CCC-SLP, is the current president of ASHA and the dean of the College of Nursing and Health Sciences and professor of communication sciences and disorders at the University of Vermont. patricia.prelock@uv.edu.

Why Suspected Childhood Apraxia of Speech Requires Careful Assessment

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Recently I got one of those phone calls that speech-language pathologists often dread. It went something like this:

Parent: Hi. I am looking for a speech therapist who uses PROMPT [Prompts for Restructuring Oral Muscular Phonetic Targets] to treat my son’s childhood apraxia of speech. Are you PROMPT-certified?

Me: I am PROMPT-trained and I do treat motor speech disorders but perhaps you can first tell me a little bit about your child? What is his age? What type of speech difficulties does he have? Who diagnosed him and recommended the treatment?

Parent: He is turning 3. He was diagnosed by a neurodevelopmental pediatrician a few weeks ago. She recommended speech therapy four times a week for 30 minutes, using PROMPT.

Me: And what did the speech therapy evaluation reveal?

Parent: We did not do a speech therapy evaluation yet.

Sadly, I get these types of phone calls at least once a month. Frantic parents of toddlers ages 18 months to 3+ years call to inquire about PROMPT therapy based on a neurodevelopmental pediatrician’s diagnosis. The speech-language diagnosis, method of treatment and treatment were typically specified by the physician in the absence of a comprehensive speech language evaluation and/or past speech-language therapy treatments.

The conversation that follows is often uncomfortable. I listen to the parent’s description of the symptoms and explain that the child needs a comprehensive speech language assessment by a certified SLP before being treated. I explain to the parent that, depending on the child’s age and the findings, the assessment may or may not substantiate CAS because symptoms are similar in a number of other speech and communication disorders.

Parents react in a number of ways. Some hurriedly thank me for my time and resoundingly hang up. Some stay on the line and ask me detailed questions. Some request an evaluation and become clients. A number of them find that their child never had CAS! Past misdiagnoses have ranged from autism spectrum disorder (CAS was suspected because of imprecise speech and excessive jargon) to severe phonological disorder to dysarthria secondary to cerebral palsy.

CAS is a disorder that disrupts speech motor control and creates difficulty with volitional, intelligible speech production. Research indicates that while children with CAS have difficulty forming words and sentences at the speech level, they also struggle with areas of receptive and expressive language. In other words, “pure” apraxia of speech is rare.

This condition needs to be diagnosed by an SLP. In fact, due to the disorder’s complexity, it is strongly recommended that parents seek an assessment by an SLP specializing in assessment and treatment of motor speech disorders. Here’s why.

  • CAS has a number of overlapping symptoms with other speech sound disorders, such as severe phonological disorder and dysarthria.
  • Symptoms that may initially appear as CAS may change during the course of intervention, which is why diagnosing toddlers under 3 years of age is problematic. Instead, a “suspected” or “working” diagnosis is recommended in order to avoid misdiagnosis.
  • Diagnosis of CAS is nuanced, complex and challenging, though a new instrument—Dynamic Evaluation of Motor Speech Skill (DEMSS)—shows promise with respect to differential diagnosis of severe speech impairments in children.

When children with less severe impairments, SLPs need to determine where the breakdown is taking place by designing tasks assessing:

  • Automatic versus volitional control.
  • Simple versus complex speech productions.
  • Consistency of productions on repetitions of same word.
  • Vowel productions.
  • Imitation abilities.
  • Prosody.
  • Phonetic inventory before and after intervention.
  • Types and levels of cuing required for response.

Given the complexity of CAS assessment and treatment described here, you can see that the PROMPT approach may not even be applicable to some children. Thus, I strongly urge developmental clinicians to first refer a child for a speech language assessment—and refrain from making recommendations for specific types and frequencies of treatment—when difficulty with speech production is observed.

For more information on childhood apraxia of speech, please visit the Childhood Apraxia of Speech Association of North America website or visit the ASHA website to find a professional specializing in the diagnosis and treatment of CAS near you.

 

Tatyana Elleseff, MA, CCC-SLP, is a bilingual speech-language pathologist with Rutgers University Behavioral Healthcare and runs a private practice, Smart Speech Therapy LLC, in Central New Jersey. This post is adapted from a post that originally appeared on her blog, Smart Speech Therapy LLC. She specializes in working with multicultural, internationally and domestically adopted children and at-risk children with complex communication disorders. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education, 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, and 16, School-Based Issues.

Kid Confidential: Typical Aggression in Toddlers

 

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As an SLP who works with very young children a common question I am asked by parents is about their toddler’s aggression toward other children.  “Susie just started taking toys from other children–is this normal?”  “What do I do when Bobby hits other kids because he wants their toy?”  I hear the pain, fear, and frustration in their voice with each question.  Parents wonder if there is something wrong with their child because the aggression is new and unexpected.

So let’s talk about what is typical aggressive behavior.  According to National Center for Infants, Toddlers, and Families’, Zero to Three website, aggressive behavior is part of typical development.  Here is a brief overview.  Feel free to refer to the websites mentioned here or other material on infant and toddler aggression for further information.

From birth to 12 months of age, aggression can come in the form of babies pulling on parents hair, biting during breastfeeding, swatting at a parent’s hand when the parent has a toy child wants.  Your infant does not want to hurt you, but is rather exploring the world around them through their senses.  They are learning about biting, hitting, scratching, yanking, and pulling from your reactions to their behaviors.

Aggressive behavior from 12-24 months of age occurs as toddlers tend to be impulsive and cannot yet effectively express their feelings and wants.  Hitting, kicking, biting are all typical aggressive behaviors during this time.  Aggression tends to peak around the age of two as they have not yet mastered empathy at this time.

Aggression during 24-36 months of age tends to be exhibited when a child feels overwhelmed, angry or jealous.  Aggressive behavior tends to be targeted toward parents, which can cause feelings of hurtfulness and frustration.  Parents tend to believe that as verbal skills improve, behavior also should improve.  However, children at this age are still very impulsive and although they may be able to verbally express a rule, they cannot control their own bodies sufficiently to follow the rule.  Emotion will rule behavior every time.

Scholastic.com’s article titled “Preschool Struggles” discusses how typical aggressive behavior will continue through the preschool years.  This article explains how aggressive behavior on the playground or in the classroom, temper tantrums and fighting over objects (toys usually) are typical behaviors for children during this age.  In fact, Dr. Susan Campbell, author of Behavior Problems in Preschool, goes so far as to say that “probably 95 percent of aggressive behavior in toddlers and preschoolers is nothing to be concerned about.”  She explains that parents should only become concerned if the aggressive behavior “escalates, goes on for a long time, or occurs with other problems.”

In both articles, how parents handle aggressive behavior is addressed.  The Zero to Three website suggests parents do the following:

  • Observe and learn when and why your child is exhibiting aggressive behaviors.  Do behaviors occur in certain environments or with particular people?  Is the aggressive behavior in response to change in the child’s life?  Is the child tired or hungry?
  • Note how you as an adult are responding to the situation.  Is your response escalating or de-escalating the behavior?  Are you able to remain calm when responding to your child?  Do you feel effective in your response during these situations?
  • Respond to your child based on your best understanding of the situation.  Here are a few suggestions:
    • Give your child advanced notice of change or transitions.
    • Help your child understand his/her feelings during these situations.  Use emotional language and explain what and why the child is feeling.
    • Prevent aggression if possible.  Avoid going places or doing things when your child is tired.  Pack snacks if you know your child will get hungry.  Ask family members to wait until the child has warmed up before they expect a hug.
    • Stay calm.  Take a few deep breaths and give yourself a “time out” before you respond to the situation.  When you stay in control you are teaching your children to do the same in the future.
    • Recognize and acknowledge your child’s feelings and/or goal.  Show some sympathy and understanding with true feelings of compassion.
    • Use words and gestures to communicate.  It is helpful to use both words and gestures to aid your child in understanding what it is you want them to do.
    • Tell them what they CAN do.  Positive statements of what behaviors a child can do will sometimes ward off a temper tantrum.  Ex. “Oh I see, you spilled your water on the floor because you want to play in the water.  Let’s goes play at the water table.  We can have much more fun there.”
    • Try distracting your child.  Sometimes a simple distraction will change your child’s attention to something more positive and he/she will forget all about feeling agitated.
    • Suggest ways to manage emotions.  Teach your child to take a few breaths or use other methods of relaxing.  It is important to teach your child healthy ways to deal with strong emotions.
    • Have your child take a break.  Sometimes the best thing to do is have your child remove him/herself from the situation, and take a break.  Giving your child time to get his/her emotions under control in a “cozy corner” or “safe zone”, etc. can be very helpful.
    • Debriefing.  After your child is calm you can discuss the situation and explain consequences of his/her behavior, brainstorm better choices for the next time, and always remind your child that he/she can come to you for help if needed.

The article also addresses ways to minimize misbehavior by doing the following:

  • Be consistent with consequences.
  • Avoid negotiation.
  • Allow your child some time to problem-solve before you step in.
  • Provide lots of positive feedback when your child is showing self-control.

So that is what typical aggression looks like in children birth to 5 years of age according to these sources.  Please understand that all children develop at different rates and the ages mentioned in this post are general ages of development.  With that said, every child should be viewed as an individual.  The bottom line is that all children have aggressive behaviors as they are typically developing and learning how to negotiate this world we live in.  However, if you or parents you are working with have concerns about a child’s behavior, I encourage you to continue your own research and request help as you feel is appropriate.

Maria Del Duca, M.S. CCC-SLP, is a pediatric speech-language pathologist in southern, Arizona.  She owns a private practice, Communication Station: Speech Therapy, PLLC, and has a speech and language blog under the same name.  Maria received her master’s degree from Bloomsburg University of Pennsylvania.  She has been practicing as an ASHA certified member since 2003 and is an affiliate of Special Interest Group 16, School-Based Issues.  She has experience in various settings such as private practice, hospital and school environments and has practiced speech pathology in NJ, MD, KS and now AZ.  Maria has a passion for early childhood, autism spectrum disorders, rare syndromes, and childhood Apraxia of speech.  For more information, visit her blog or find her on Facebook.

Tricks to Take the Pain Out of Writing Treatment Goals

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Supervising has taught me a great deal about what trips up SLPs. And one of the most challenging things for new SLPs seems to writing treatment goals. One reason is, of course, that we know these goals will drive the treatment and that they are important; but it is more than that. We want goals to organize our treatment and make it more linear, more hierarchical. We want our goals to be read as a path to development, or recovery: first do this, then move to this and then go on to that. This is, after all, the essence of task analysis.

Speech and language development, or recovery, is not however, linear or even, in many instances, hierarchal. It is so much more, but that is for another post.  We also want our goals to address the clients’ most important needs and in some cases we are hard pressed to figure out just what is most important. We also need to have our goals fit in with the guidelines that our employer sets and that just keeps changing on us. So goals become a challenge.

When writing goals keep in mind that goals are supposed to be SMART: specific, measureable, attainable, relevant and timely. A pet peeve of mine are goals that say “the client will improve his receptive/expressive skills.” These are not SMART: First of all they are not specific, but more, importantly, there is no measurable component in them.  In a report you can head the respective goals with, “In order to improve his receptive/expressive skills the client will…..” But those sentences are not goals and are certainly not SMART goals.

There are numerous data banks of goals on the Web, but I have never found the goals in any database to be just quite right; they all need to be tweaked for the client. You can certainly look up goals in those databanks, but you have the skills to write goals on your own. They are not that difficult when you think them through. You can use a template such as ___ will ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­___ by ___ to ___ percent above baseline or ___ percent of the time as measured by ___ or some such formula but you still have to fill in everything from your own mental data bank. You can do this easily by using the answers to some simple questions you must ask yourself.

Let’s look more closely at SMART.

Specific
Part of the problem is thinking about goals as a separate entity. Goals are just a way to put what you want to do in therapy in writing. Most SLPs are not uncomfortable about doing therapy so why should goals be a problem? Ask the following questions for a start for your specific goals.

  • What are the client’s communicative strengths?
  • What are the client’s communicative weaknesses?
  • What are the skills contributing to the strengths?
  • What skills are deficient and therefore contributing to the weaknesses?
  • Which of client’s skills can be used to compensate for deficiencies?
  • Which skills that are lacking can I actually help the client attain?
  • What do I want to work on first? And now answer: Why do you want to work on that first?  That answer will help you determine if you have made a viable choice.
  • What are the tasks you will have the client complete or engage in to work on the skill?
  • What supports will you provide for the client?

When you have the answers to those questions you have the “specific” for the goals.

Measureable
Can you define the skill that will determine if the client is doing what you want him to do and can you measure progress in that skill?  How will you measure progress? When will you consider the goal accomplished? If you can answer all these questions move on; if not, go back and adjust the goal to something you know you can see or hear and therefore measure.

Attainable
Do you think the client can actually accomplish this in a year? If the answer is yes, move on. If the answer is no, go back and choose something you think the client can accomplish within a reasonable timeframe.

Relevant
Will the attainment of this goal serve a communicative function for the client or will it just be something you can do with the client?  Will it serve a purpose in the client’s life considering the limits and ramifications of the diagnosis and his cultural and social needs?  In the case of an IEP does this goal serve to move the child along to fulfill the common core standards?  If the answer is yes, move on if not… yes, you get the picture go back and start again.

Timely
Does the goal contain a time frame or a date for accomplishing the goal? And can the goal be attained in that time frame? If yes….

Short-term objectives need to follow the same criteria but they should not just be separate pieces of the overall task but rather steps to getting to the long-term goal. The timeframe for accomplishing each part of the short term objective is, obviously a portion of the long term goal and the objective should actually contain that time frame.

As I stated in my last post, what best facilitates treatment is knowing what you want the client to do and knowing that your treatment is actually addressing this. Well, such knowledge also facilitates goal-writing. Use it to write your goals. You have the skills. You need to convince yourself that you can use them. When you keep that in mind, goal writing can be simple.


Irene Gilbert Torres, MS, CCC-SLP
, chair of ASHA’s Multicultural Issues Board, is a clinician in New York City who contributes this ASHAsphere series for beginning SLPs and welcomes treatment questions to address in future posts. She concentrates primarily on infant and preschool evaluations and supervision of graduate students. She is an affiliate of ASHA Special Interest Groups 11, Administration and Supervision; 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations; 16, School-Based Issues; and 17, Global Issues in Communication Sciences and Related Disorders.

A New Twist on Vocational Training

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In April, 2013 I wrote an article challenging SLPs  who work with students with autism spectrum disorder to use our creativity to help our students identify their strengths, interests and even fixations and parlay them into career possibilities (“Gearing Up for Reality,” ASHA Leader Magazine April 2013).

As a result I decided to create a six-week pre-vocational summer camp counselor experience for eight  high school aged male students, many of whom I hadn’t seen for several years. I wanted to offer them the same summer intern experience that typical students are exposed to minus the stresses and fear of failure.  Staff and I wanted this to be a safe and nurturing environment with structures in place to help them navigate the world of work.

The criterion was quite simple; the students needed to commit to work in our summer camp at least three days per week and attend weekly job club meetings where I would address daily living, social, and pre-vocational skills.  Additionally, each student would receive a stipend of $200.00 in exchange for their participation but more importantly to make our discussions on money management real and tangible.  Our program would culminate in a trip to Clear Lake, Calif., for a weekend work experience.

Sadly, our  six weeks have come and gone. I vividly remember how I felt on that first day seeing the boys. I stayed on the verge of tears as they each filed into my office with their parents in tow. Despite their height, good looks, and deep voices I could still see in each of them the little boys who I once knew. As I extended my hand to greet them, each gave me a warm hug. My heart melted!

It was interesting to watch the boys interact with each other on that first day. Some were more socially adept than others but they had all come a long way. In many ways, they were like typical teens sizing each other up and looking for a common ground while seeking acceptance.

During the first week I began to see their personalities unfold.  We had an antagonist, a peacemaker, a social “dude,” a wanna-be grouch with a beautiful smile, a cool diplomat, an “honest Abe,” an easy rider, and the sleeper with a big heart who never ceased to amaze us.  As different as they all were, the thread that bound them all was ASD. I was curious to see how they would adjust to working with the staff who were their bosses, the children who were the clients or consumers and the other assistants who were their colleagues.

During our first club meeting, as I laid out the employee rules, the antagonist challenged me on the “no cell phone” rule.  He wanted to remind me that the phone could be used for more than talking or texting.  After all, what if he wanted to check the time?  I calmly repeated the rule and reminded him that this was a company policy and referred him to the clocks on the walls.  This was nonnegotiable.

Meanwhile, “honest Abe” complained of total exhaustion and became stuck on how challenging the little children were. Interestingly, my sleeper who appeared to not be paying attention, when asked for an opinion said.  “I was like that when I was four and couldn’t talk, but once I learned how,  I didn’t cry as much.” Our diplomat closed it out and reminded everyone that they should “want” to help the kids in the same way “we” had  helped all of them. My heart skipped a beat as I thought how amazing are my boys!

Staff and I marveled as we watched them grow and mature in just six short weeks.  Several of them had worked with the boys in their early years.  We remembered the “social dude” when he had a fixation with fans. He told us that he has turned his fixations into hobbies and then began to tell of his hobby.  We also reminisced about the peacemaker who as a child was extremely shy.  We watched in disbelief as he  reprimanded the group and pleaded for them to allow the antagonist to finish his statement.

On July 19th we boarded our flight to Sacramento, drove two hours to Clear Lake and settled into an unbelievable weekend at the Full Circle Sheep Farm with sisters Eva and Marty who embraced us as if we were family.

Our workday started at 7 am on Saturday and we painted barns, tended the sheep and their lambs, and played with pets Blaze and Malcolm X . We then returned to our Travel Lodge to swim and relax before returning to the farm to paint drawings of sheep on the barns.  The remainder of the evening was spent discussing TrayVon Martin and lessons we could learn from this and similar situations.  Their concerns were valid and we collectively developed strategies to deal with the unexpected.

On Sunday morning we returned to say our goodbyes. The boys surprised all of us as they spontaneously spoke from their hearts about what the experience meant to them and even what they meant to each other. The social dude suggested they should all return not for a weekend but an entire week.  The grouch flashed his beautiful smile and agreed unconditionally.  Honest Abe said, “Lets do it again but somewhere that’s not so hot!”   Our smooth  diplomat said “We are like brothers and I love all of you.”  The sleeper had the last word and said “  I feel so blessed. I want to bring my family here.”  All of the adults fought to fight back our tears of joy.

On the flight home all I could think was “mission accomplished.” My pilot pre-vocational program was a success. The boys have committed to staying in touch and having quarterly activities. They have gotten a taste of the world of work and more importantly, they have learned the importance of giving back. We all agreed autism is a label and it doesn’t define how far we can go in life.  The sky’s the limit.  In the words of my sleeper, I feel so blessed!

Pre-vocational training video

From the blog of Los Angeles Speech and Language Therapy Center, Inc.

 

Pamela Wiley, PhD, CCC-SLP, is the president and founder of Los Angeles Speech and Language Therapy Center, Inc. She can be reached at pswiley@speakla.com.

Planning a Play-Based Therapy Session

momanddoll

The big laminate-top kidney tables that many of us have in our school-based “speech rooms” are a great place to run through flashcards, worksheets, read and map stories, answer questions, and teach brand new skills. However, unlike infant–toddler SLPs, for whom playing on the floor is standard, school-based SLPs often overlook opportunities for such play-based therapy.

With play-based therapy, you can really capture a child’s attention and make memories that will extend beyond the therapy session. These memorable moments support learning and retention, and are essential when treatment sessions are infrequent.

Play is flexible, non-literal, episodic and process-oriented. During play, the child is actively engaged and intrinsically motivated. True play has no extrinsic goals, but we sacrifice some of that to ensure that target skills are practiced. When designing play-based lessons, the less you deviate from true play, the better. Here’s how:

Required targets

The first step of planning a play-based therapy session is to select targets to teach. Next, you’ll identify a way to require those targets during play. Start with the lesson, not with the toy or game! You may think in terms of how to give access to something the child wants following skill demonstration. This “something” can be toys, food, parts of a whole (for example, puzzle piece, song phrase, portion of a motor sequence), social interaction, or a funny or amusing consequence. You’ll also have suggested targets that are encouraged but not required. This is because requiring target demonstration at too high a frequency quickly turns the play session into drill-based “work” and begins to peel away the benefits of playful learning.

Example: “Sleepy Sue,” target = /s/-initial words. Let the student choose dolls for each of you. Make your doll’s name “Sue.” Explain that Sue has a pesky tendency to fall asleep (*insert snoring*). When she dozes off, the child’s job is to wake her up by saying, “Sue! …Sue!” You assist with correct articulation, then commence with doll play until Sue falls asleep again. In a short period of play, the word “Sue” will be required many times, but you may also model things Sue and her dolly friends like to do, like sew, sing, or sit—targets that will be suggested but not required.

Memorable episode

The more episodic and story-like your play-based session is, the better. This is because associated events scaffold memories. Later that day, if a child can’t tell mom “what I did in speech today,” you aren’t reaping the benefit of repeated recall. Consider the “Sleepy Sue” example above—the more related the activities that Sue and her doll friends do, the better. It’s too easy to *think* you’re using playful learning, when in reality you’ve set up a nonassociative work–reward–work–reward structure (as with many games).

Memorable targets

In addition to the play episode being memorable, it’s perhaps even more important that the targets be memorable. I’ve used “Sleepy Sue” with a five-year-old who called me out the next session because I accidentally called Sue, “Sam.”And that was great! But a lot of kids wouldn’t remember that target, just like they won’t likely remember many of the target words in a series of flashcards. So I’ve also had “Sleepy Sue” do a cooking episode.

Example: “Sue Makes Soup,”target = /s/-initial words. Sue loves to cook, and the student can help Sue by choosing the ingredients for her soup. The child can add salsa, sausage, seeds, soy sauce, syrup, sour cream, and such. Of these targets, some can be the real thing! And how much fun is it to put real salt or real seeds in the soup bowl? “Salt” and “seeds” can be your required targets, and you hold the shakers until the student needs them. The student may even take some of the “targets” home to show dad. The other words may be required or suggested targets, depending on the student.

Play-based learning can be done with children of any age. What would play-based learning look like for a fifth grader? Start by considering how fifth graders play with one another (for example, talking about their favorite TV show), and design from there. Play-based learning is also excellent for students with autism—check out this article and this one. Whatever the child’s age or skills, always ask yourself—“Could we be playing with this?”


Meredith Poore Harold, PhD, CCC-SLP,
is a speech–language pathologist and independent scholar in Kansas City, Missouri. She works primarily with infant-toddler and elementary-aged children, and provides resources for parents and clinicians at www.meredithharold.com.