Skyrocketing Autism Numbers a Call to Action for SLPs

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Last week the child-development community got a jolt from news of a jump in numbers of children diagnosed with autism spectrum disorder: an increase of 30 percent in just two years. One in 68 children had ASD in 2010, up from one in 88 children in 2008, according to data from the U.S. Centers for Disease Control and Prevention.

And that’s raised many questions among speech-language pathologists and other developmental experts. For one thing, what’s driving the increase? And what does it mean for ASD diagnosis and treatment? There are no clear answers or absolutes. But developmental expert Stephen Camarata is willing to speculate. We talked with the Vanderbilt University hearing and speech sciences professor about his take.

What is behind this increase? Is it really just an increase in identification?

There are three main factors. One is a real increase in incidence. Our technological ability to take preemies weighing less than a pound and have them survive has changed, and it’s not surprising that more of these kids might have challenges.
Second, there’s increased awareness, so more people are looking for ASD in kids. And third there’s the expansion of the definition of spectrum. The numbers of kids identified as high functioning and as having Asperger syndrome has skyrocketed.

What do the higher numbers mean for SLPs?

We’re the speaking profession, so we have a central role in assessing and treating these kids. Based on this, we’re obviously seeing a big increase in caseload, which as a field we need to develop ways to handle. But more basically than that, we need to figure out how to differentially diagnose these young kids, these 2-year-olds, distinguishing between ASD and the new DSM-5 [Diagnostic and Statistical Manual of Mental Disorders] category of social communication disorder.

We are the main profession driving identification and treatment of SCD, and we need to develop assessments and interventions in this area. It’s a huge opportunity and a huge challenge—and we need to be prepared to handle this demand.

The study suggests that there is a lag in identification, with most kids diagnosed at 4 and older when they could be diagnosed as early as age 2. What can SLPs do to help get these kids diagnosed earlier?

First I should point out that when the kids in this study were toddlers, in 2004 and 2005, we weren’t yet able to accurately diagnose autism at those young ages. Now, with the toddler module of the Autism Diagnostic Observation Schedule, we can. And given that with ASD comes late onset of speaking, SLPs are often doing the earliest assessments. Right now, we may be less inclined to put a late-speaker in the SCD category because we want to get these kids services but don’t yet have appropriate assessments, treatments or reimbursement for SCD. Our charge is to develop these. And it’s also to it’s also to continue to develop continuing education for our practitioners to diagnose autism, which we can do, typically as part of a team.

The study suggests that kids who are African American and Hispanic are being underdiagnosed relative to white kids—again, what can SLPs be doing to help close this gap?

It should be noted that, if you look at the report, there actually has been a dramatic increase in diagnosis in both those communities. But yes, the rates still lag behind those in white children a great deal, so there’s a need to close this gap. Part of this is an issue of cultural difference, but it’s also the well-known health-disparities story of lack of access to services. So we need to do more outreach and education in the African American and Hispanic communities about early intervention and their entitlement to public services.

What are the implications of these findings for the services SLPs provide to children on the spectrum?

This is my sense: Some SLPs feel like they’re not necessarily the primary interventionists in cases of autism but if a kid’s primary weakness is in the speech and language domain—which is the case in ASD, along with behavior—then they really have the role. Improved speech improves behavior. And parents want their kids to talk, so we are and should be primary clinicians involved in diagnosing and treating ASD.

As we go forward, we need to work on distinguishing SCD from autism. We need to own this, but to do that we need to provide data that make a difference and train others on what we know.

 Learn more about social communication disorders  and autism spectrum disorder on ASHA’s website. More information on both categories is available from ASHA—e-mail Diane Paul, ASHA director of clinical issues in speech-language pathology, at dpaul@asha.org.

Stephen Camarata, PhD, CCC-SLP, is a professor of hearing and speech sciences at the Bill Wilkerson Center at the Vanderbilt University School of Medicine. He is an affiliate of Special Interest Group 1, Language Learning and Education. Contact him at stephen.m.camarata@vanderbilt.edu.

Kid Confidential: The Latest on Treatment of Ear Infections

ear infection

For those of us speech-language pathologists who serve the birth-5 year old population (or have young children of our own), it is always important for us to know the most recent health and safety regulations that can affect our clients/students. Here are the newest regulations regarding the medical treatment of ear infections.

As otitis media affects three out of four children by the age of three, and there is a correlation between chornic otits media and communication delay, it is likely that we as SLPs will treat students with acute or chronic otitis media.  As a result we must understand the American Academy of Pediatrics (AAP) guidelines regarding the medical treatment of this condition.

Although, these regulations were initially released in 2004, it appears there is still much confusion among the medical community and, as a result, a second publication of the same AAP medical regulations for treating otitis media was released in 2013.

The regulations were written in response to antibiotic overuse and resistance in children.  Traditionally children are treated with antibiotics as the first line of defense for acute otitis media.  As there are a number of causes for ear pain, it is crucial that pediatricians firstly make an accurate diagnosis of otitis media prior to administration of antibiotics.  Doctors are urged to diagnose otitis media only when a moderate to severe bulging of the tympanic membrane (i.e. ear drum) is present.  Mild bulging and recent ear pain (i.e. meaning within 48 hours) exhibited along with other signs of ear infection (e.g. fever) also may be diagnosed appropriately.  Therefore, if the pediatrician is unsure of the diagnosis of otitis media he/she is discouraged t to prescribe antiobiotics.

Although pain is present, antibiotics are not necessarily to be considered the first course of action. In fact, in response to ear pain and/or low grade fevers, pain relievers are to be recommended initially as “about 70 percent of kids get better on their own within two or three days, and giving antibiotics when they aren’t necessary can lead to the development of superbugs over time” reports Dr. Richard M. Rosenfield, professor and chairman of otolaryngology at SUNY Downstate Medical Center, Brooklyn.

Antibiotics are only to be prescribed when the child is exhibiting several signs or symptoms of otitis media (e.g. pain, swelling for at least 48 hours, fever above 102.2 degrees Fahrenheit, etc.).  Immediate prescription of antibiotics should be recommended in the event a child’s tympanic membrane ruptures.

Although it is important to understand the medical treatment of otitis media, perhaps it is more important for us to understand the simple preventive measures a parent can take to help avoid the development of ear infections in the first place.  In addition to this medical treatment plan, the guidelines also stress avoidance of tobacco exposure, receiving the influenza vaccination, and breast feeding exclusively for the first 6 months (if possible) as additional ways to prevent infant ear infections.

Medial guidelines for “silent ear infections” (i.e. middle ear fluid without presence of other symptoms typically following acute otitis media or colds) consist of “watchful waiting.”  If a child is diagnosed with “silent ear infections” also known as otitis media with effusion the pediatrician should initially provide no medical treatment.  A follow up reexamination should take place three to six months later.  If fluid persists for more than three months, the pediatrician should recommend a speech/language and hearing assessment.  If middle ear fluid persists more than four months and signs of hearing loss are evident, a pediatrician may recommend placement of PE tubes or refer their patient to an ENT for further assessment.

I very much appreciate the AAP for adding in the guideline of further assessment in the areas of speech/language and hearing if fluid persists longer than three months.  This demonstrates the AAP’s understanding of the important of communication development and the need for a quick resolution to such delays rather than the typical “wait and see” attitude that parents often report to encounter particularly in instances of “late talkers.”  Now we, as SLPs, have guidance and support from the AAP for our clients/students with long-term persistent middle ear fluid.

Please refer to the resources below for further information.

Resources:

Jaslow, R. (2013, February 25). Antibiotics for ear infections: Pediatrician release new guidelinesCBS News.

New guidelines for treating ear infections. (2004). The Harvard Medical School Family Health Guide.

 

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.

Collaboration Corner: In Defense of the Whole Child

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I treat children with autism. I’ve been doing it for a while now. As the numbers of children with autism peak a staggering 1:88 (Center for Disease Control, 2014), the demand for trained staff has gone through the roof. Many districts have specialized paraprofessionals whose primary job is to teach and support children with autism. In the Boston area, graduate and certificate programs related to ABA are cropping up everywhere, churning out new and enthusiastic graduates by the boatload.

Before I go on, there are three things you should know about me: 1) I have never been a diehard, one-shoe-fits-all clinician, 2) I embrace whole-heartedly the principals of ABA. It’s as an evidenced-based approach, and it works wonders for all sorts of kids, not just ones with autism, and, 3) If I couldn’t be silly with my students, I would just close up shop.

As an SLP, I know there are mountains of other kinds of research, and that child language and cognitive development that are important too. In this age of ABA, I find myself wanting to shout from the rooftops, “Wait! Stop! There’s more to this kid than just autism!”

Our role as SLPs and educators

Working with so many professionals “trained in autism” made me realize that, as SLPs, we bring to the table our knowledge of childhood language development, learning, motivation and context. Never before has this been more evident to me. We also bring the friendly reminder the importance of a playful approach and rapport building.

I’ve found myself shifting discussions to the whole child, and what we know about children and learning.

Here are some pointers I frequently share with staff:

  1. Appeal to the inner child first (yours and theirs). The individual comes before the label.
  2. Not every behavior can be attributed to one definitive cause. Environments, emotional state/regulation, personality, medical/biological components, all should be up for consideration.
  3. Assessment and intervention is a daily process, which is sometimes messy and dynamic (see #2). We won’t always get it right the first time. Or even the second time.
  4. It’s possible (and OK!)  to be structured and silly at the same time. Sometimes silliness increases engagement.
  5. Watch and learn from your kindergarten teachers (see #4). I’ve learned a lot from them about having fun while being structured, thoughtful and flexible.
  6. Use visuals even if the child is verbal or becoming verbal. We can model language through PECS, topic boards and Aided Language Stimulation techniques, within natural play activities.
  7. Strive to meet every child “where they are” in all aspects of learning: attention, behavior, communication and language development.
  8. We can’t make someone ready to learn or communicate; we simply lay the foundation.
  9. Learning can’t happen in a bubble. Context is just about everything. I know what a zoo is, because I’ve been in one, not because I’ve seen a flashcard of one.
  10. And finally, my favorite: Provide random acts of praise and compliments. Make daily deposits into that relationship bank. It’s a worthwhile investment.

 

Kerry Davis Ed.D., CCC-SLP,is a speech-language pathologist in the Boston area, working with children who have significant communication challenges. She conducts trainings and workshops, and serves as a volunteer speech pathologist and consultant for Step by Step Guyana, a school for children with autism in South America. The opinions expressed in this blog are her own, and not those of her employer.

Apps with Elders

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I am a tech savvy person. Use of technology is integrated into my life, and I am always learning something new. Currently, I am learning basic coding and web design to help private practice owners with their websites. Your website should tell your story and technology can make that happen. Perhaps I was a little naive, but it never occurred to me that maybe I should not use an iPad in my work with my geriatric patients in the SNF setting.

In the SLP social media communities I saw many SLPs using iPads or other tablets with their school or pediatric clinic caseloads. I saw what they were doing and thought, “Hey, I could do that with my patients.” And so I did. A few years ago when I got my CCC’s I gifted an iPad to myself.

And then I started using my iPad in therapy. There were a few bumps along the way, but I am still using it today. The iPad will by no means do therapy for you, but it is an excellent tool.

Five Tips to make using an iPad in therapy easier

Be confident to reduce the intimidation of technology. I start by asking if a patient has used an iPad. Then I briefly explain that it is a “little computer”, and we are going to use it to have a little fun in therapy. I gloss over the technology aspect and go straight to the fun. And then I choose an easy but interesting game, so they will have success when they are learning to use the tablet.

Use a stylus. A stylus is a pen-like instrument that the tablet will recognize similar to a fingertip. I pick them up for super cheap at stores like Marshalls or Ross. Some of the ladies I work with have gorgeously lacquered long fingernails. This almost always causes a problem, since tablets respond to fingertip taps rather than fingernail taps. A stylus will solve this problem.

Make it fun. Some of the games and apps can be quite challenging (just as any other task). When frustration starts to rise, I remind my higher level patients that we are just experimenting. If the solution or answer is not correct, we just figure out why and try something else. This approach seems to ease frustration. With my lower level patients, I do not allow that point of frustration to be reached. I use errorless learning and vanishing cues to increase success rate.

Keep your client relaxed. Because it is an unfamiliar technology there can be some anxiety about using it. I watch my patient’s body language. Is their brow furrowing, are their shoulders creeping up, are they tapping the stylus with great force? Sometimes I use subtle cues to help them improve insight into how they are feeling. Other times overt. These are great moments to talk about the effect of emotions (including anxiety) on cognitive function. Then I teach the strategy of doing something less taxing during these moments and moving back to more challenging tasks when they are feeling calmer.

Get a case. Get a case that allows you to prop up the tablet at different angles. This is really helpful for reducing the glare caused by different patient positions as well as making the tablet more accessible to those with mobility impairments.

Favorite Adult SLP Apps

Memory Match: If you are looking for an app to exercise use of memory strategies (visualization, association, verbalization) then Memory Match might be an app to check out. It’s $0.99 and available for iPad and Android. This is only suitable for clients that are able to generalize memory strategies and need activities to learn strategies.

ThinkFun Apps: Rush Hour and Chocolate Fix are great problem solving brain teaser apps that require use of deductive reasoning and logic for visual tasks. First, we identify the problem. Then, we work backward to solve it.

Tactus Therapy: This company makes some great apps. I have several, but my favorite is Conversation TherAppy. It is so versatile. I seldom use the scoring function of the app. The app has picture stimuli and a variety of prompts to target specific skills. I love not having to carry around a deck of picture cards. Have you dumped a box of stimuli cards on the floor? I have, too many times to count.

Google: Access the Google search engine via Chrome or Safari for endless possibilities. Do you have a client working on word finding tasks and needs a visual cue? Google it. Need a restaurant menu or a prescription label as a stimulus for functional questions? Google it. And I’ve been known to use it as a task motivator. Do your dysphagia exercises, then we’ll look up information about moose. (True story.)

Dropbox: Scan those 3-inch binders full of worksheets, protocols, and other information. Create PDFs and put them into Dropbox and have them anywhere you go with your iPad.  If you buy digital versions of books or tests to use on your iPad you will resolve the problem of original documents getting raggedy.

If you have an iPad or another tablet at home and haven’t used it for therapy, I recommend checking out what it can do. You might be pleasantly surprised.

Rachel Wynn, MS CCC-SLP, is speech-language pathologist specializing in geriatric care. She blogs at Gray Matter Therapy, which strives to provide information about geriatric care including functional treatment ideas, recent research, and ethical care. Rachel’s projects include: Gray Matter Therapy newsletter, Research Tuesday, and Patient Education Handouts. Find her on FacebookTwitter, or hiking with her dog in Boulder, Colo.

Avoidance Reduction Therapy: A Success Story

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I was interviewing for assistant positions at our summer speech and language camp when I first met Ben Goldstein.  Ben is a graduate of the University of Maryland and was in the midst of taking his pre-requisite courses to apply for graduate school to become a speech-language pathologist.  Ben also happened to be a person who stutters (PWS).    As the interview continued he shared that he was introduced to avoidance reduction therapy by Vivian Sisskin at the College Park campus of UMD.  I had already been applying aspects of avoidance reduction therapy with my clients,  however Ben helped solidify my feelings on this approach.  Ben was kind enough to answer some questions and walk me through his experience with avoidance reduction therapy, which is included below.

Avoidance reduction therapy is an approach to stuttering therapy that can be used with both school-aged and adult clients.  This approach views stuttering as an approach-avoidance conflict; a theory that states that a PWS experiences the desire to speak and interact with others while simultaneously experiencing an urge to hide their stuttering.   The result of these competing desires culminates in the maladaptive secondary behaviors that interfere with communication (ex. eye blinking, leaning forward, use of fillers, etc.).  These competing desires also result in a feeling that one can not partake in certain activities and situations due to their speech.

Avoidance reduction therapy works toward reducing these maladaptive behaviors, leaving in its place a more comfortable, forward moving form of stuttering.  It also works toward reducing the handicap of stuttering, whereby increasing a person’s willingness to participate in various activities and situations, whether or not they show some stuttering.   Unlike other approaches that focus on fluency, this particular approach views a person’s strong desire to be fluent as perpetuating the problem and ultimately what contributes to their word and situational avoidances, as well as much of the struggle behaviors you see in their speech.  Avoidance reduction therapy does not put an emphasis on fluency, but rather on improving a person’s ability to successfully communicate in the “real” world.

How do you incorporate avoidance reduction therapy into your sessions?  Start by helping your client to identify their own stuttering patterns and assist them in recognizing how much of their pattern is “true” stuttering and how much of what we see is actually habits they formed in an attempt to mask stuttering.  Challenge clients to allow themselves to show true stuttering (or perhaps use voluntary stuttering), beginning in the safety of the therapy room and eventually branching out to different “real-life” situations.  As you work through these challenges, clients will often discover ways in which their stuttering was holding them back that they may not have realized before.   Read on to learn about Ben Goldstein’s first-hand experience with avoidance reduction therapy.

Before jumping into avoidance reduction therapy, how would you describe your speech intervention experience leading up to it?

Ben: Prior to avoidance reduction therapy, I saw two SLPs as a private client. Both focused primarily on common fluency shaping techniques (easy onset, breath control, continuous phonation). My parents felt that the therapy helped me sound better, but I don’t remember sounding better. I also don’t remember feeling better about myself or my stuttering through therapy.

Can you describe your stuttering pattern prior to beginning avoidance reduction therapy?  Do you feel like stuttering impacted your quality of life?   

Ben: When I showed my stuttering I usually blocked for long periods of time, contorted my lips and mouth, tapped my leg to release a block, used fillers such as “umm” and “you know,” and closed my eyes. There was little actual stuttering going on. It was mostly secondary behaviors.

In particularly scary situations, I would avoid talking altogether if I felt that I was going to stutter.  If somebody asked me a question and I felt a disfluency coming on, I would often pretend that I didn’t hear the person. I would constantly change words that I thought I was going to stutter on. I would not go to parties and avoid hanging out with friends sometimes.

All of that avoiding had a huge impact on my life. For one, I never showed my real personality. If I had a joke I wanted to tell or a comment I wanted to say, I usually wouldn’t say it. My mindset everyday was “Let’s get through today without showing stuttering. Say only what you absolutely have to say.” That kind of mindset suppresses one’s personality and it can lead to a lot of feelings of shame, guilt and feeling less than others.

How were you introduced to avoidance reduction therapy?  

Ben:  After my first semester freshman year at the University of Maryland, I found my way to the on-campus Hearing and Speech Clinic.  It was there that I was introduced to avoidance reduction therapy.

How would you define avoidance reduction therapy and the rationale behind this approach?  

Ben: I think the most basic definition of avoidance reduction therapy is to reduce one’s avoidances related to stuttering, speaking, and really, in life.  In other words, the goal is to reduce how often one actively avoids stuttering, avoids various speaking situations, and avoids different opportunities in life. The rationale behind the therapy is that stuttering is perpetuated by habit and fear.  If I have a fear of speaking in class, every time I keep silent in class, I reinforce that behavior and the fear of speaking in class grows. Avoidance reduction therapy is about reversing that process.  If you face your fear head on and with a different attitude of what is a success and what is a failure, the fear eventually dissipates, and once the fear of speaking weakens, you can start to make choices to stutter in a more comfortable and effective way.

Most clients seek therapy to try and reduce or eliminate stuttering and may be initially concerned with the premise of avoidance reduction therapy. How long did it take for you to “buy in” to this approach?  

Ben:  Great question. For me, I bought in pretty quickly. No one before in my life had explained to me the cycle of avoiding stuttering, the feelings and thoughts that I had, and how those feelings and thoughts perpetuated and worsened my speech.  Once these ideas were laid out for me it was almost like a lightbulb went off in my head. “Yes, finally what I’ve experienced my entire life makes a little sense.”

Can you explain what a typical therapy session would look like?

Ben:  A typical therapy session usually begins with the client talking a bit about how their week went. The client might talk about a speaking-related success they had the previous week (talking about my successes helped me feel good about myself as a communicator), a situation that is really bothering them (these always helped me relieve some anxiety and develop a plan), or a topic unrelated to speech altogether. While the client is speaking, the SLP is taking note of the client’s speaking pattern and assessing how successfully they are hitting their target from the previous week.

After the client has spoken for a bit, he or she usually receives feedback from the SLP. This feedback can be related to the thoughts and feelings of the client (dependent on what the client was saying) and/or his /her motor pattern (dependent on how the client was saying it.) Following feedback, the client and SLP engage in some specific practice where the client has the opportunity to put the SLP’s suggestions into action in a safe speaking environment. This allows the client to play around with the new assignment (whether motor-based or cognitive-based) and allows the client to begin to reinforce the new behavior.

Following target practice, the client and SLP finalize the client’s assignment or plan for the week. The client is told what the rationale behind the assignment is, and how that target or goal fits into the client’s longer-term plan.

What aspects of avoidance reduction therapy do you think are most beneficial to you and to the individuals in your group? 

Ben:  I can’t speak for everyone in my group, but to me, the lessons I’ve taken from avoidance reduction therapy are that it’s OK to stutter, it’s OK to be vulnerable and it’s OK to not be perfect everyday. Contrary to what I used to think, stuttering is not some giant, evil monster that I need to run away from for the rest of my life. It’s a part of me and not a negative thing. Perhaps most importantly, my goals have changed since starting avoidance reduction therapy. In the past, my priority was to avoid stuttering at all costs regardless of how it affected the way I connected with others and how I felt about myself. Today, my goal is to be true to myself, connect with other people, say what I want to say, and enjoy life as much as I can. If stuttering wants to come along for the ride, that’s OK.

How do you think your stuttering has changed?  Does stuttering affect your life in the same way it did prior to receiving avoidance reduction therapy?

Ben:  A lot has changed since starting avoidance reduction therapy. For one, my stuttering pattern has definitely changed. Now, I keep eye contact during disfluencies. The habit of tapping my knee is gone. I no longer use interjections with the same degree of frequency. I still contort my lips and mouth sometimes, but hey, it’s my next goal to tackle.

In terms of life impact, it’s night and day. Now, I say most of what I want to say. I show my personality. I also have a completely different perspective of what constitutes a success for me at this point and time and what is a failure. I recently gave a short talk in front of 600 people and stuttered a great deal. Four years ago, I wouldn’t have even thought of doing it, and if I had been forced to, I would have viewed my immense amount of stuttering as a failure. Today, I recognize what an accomplishment it is for me to voluntarily speak in front of that many people. I’m slowly chipping away at avoidances and those are my successes.

Do you think that there are individuals who would not benefit from this approach?  

Ben:  I think one really has to be motivated to change to undertake avoidance reduction therapy. It’s not easy work. Doing things that petrify us is so counterintuitive. If one has never talked in class before, talking in class that first time is going to be really scary. But talking the second time is going to be a little easier.

My experience of diving right into the therapy isn’t the common one. (And my initial experiences with avoidance reduction therapy probably weren’t as smooth as I’m remembering them). It takes time to truly change one’s attitudes and beliefs. This isn’t an intensive, short-term kind of therapy. But in my experience, and the experience of many of my peers, it’s a therapy that leads to real, meaningful, long-term change.  The motto “short-term pain, long-term gain” really applies here. I do think everyone is capable of receiving meaningful benefits from it, but they’ve got to put a lot in as well.

If you want to learn more about Avoidance Reduction therapy, I highly suggest Vivian Sisskin’s video Avoidance Reduction Therapy in a Group Setting, available through the Stuttering Foundation of America.

Brooke Leiman, MA, CCC-SLPis the fluency clinic supervisor at the National Speech Language Therapy Center in Bethesda, Md. She is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency     Disorders. This blog post is adapted from a post on her blog, www.stutteringsource.com, which focuses on      fluency disorders and their treatment

 

Ben Goldstein is a graduate of the University of Maryland. He will begin work toward a master’s degree in Speech Pathology in the Fall of 2014.  Ben is a member of the Rockville Chapter of the National Stuttering Association and formerly served as it’s co-chapter leader.  He can be reached at bagoldstein@gmail.com.

On Becoming an Interprofessional

teamwork

According the authors of “The Interprofessional Healthcare Team: Leadership and Development,” interprofessionalism refers to the active participation of different professionals, which may include persons with professional licensure or certification in nursing, occupational therapy, physical therapy, speech-language pathology, social work, and other health-related professions who are collaborating to provide quality services to the patients they serve. Through a steadfast commitment to collaboration, interprofessional practice among healthcare professionals seeks to enhance the quality of health and medical services, which lead to improved patient outcomes. Developing synergy between through shared knowledge and decision-making promotes positive change in work settings and builds meaningful relationships with patients and their families. But, say the authors, shaping efficacious teams depends upon fundamental knowledge of the represented field, the use of evidence-based practice, interprofessional leadership, and members who are prepared to collaborate effectively in a team, which we believe can be accomplished through interprofessional education (IPE).

 
The Institute of Medicine Committee on Health Professions Education provides recommendations for developing a strong team: “health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.” Because of ongoing changes to the U.S. healthcare system, including insurance policy initiatives, technological advances, and innovative service delivery models, it is imperative for all professionals, including speech-language pathologists and audiologists, to embrace a new spirit of interprofessional collaboration and cooperation. Leading health organizations, such as the Pew Health Professions Commission, the Institutes of Medicine, and the World Health Organization, support the concept that health professionals have received adequate education to work in healthcare settings only if it includes experience participating in interdisciplinary teams to collaboratively solve complex problems.

 
Due to changes in service delivery models that have resulted in an increase of members within healthcare teams, interprofessional practice is rapidly becoming an expectation in most healthcare settings. Universities and training programs in speech-language pathology and audiology are only recently beginning to embrace models of IPE. In some universities, students from several disciplines are enrolled in the same courses, teamed for practicum experiences, participate in field-based experiences, and ultimately learn to work as effective, interprofessional teams. A unique way for IPE to be learned has recently occurred though simulation-based education in the College of Health Professions at The University of Akron.

 
Simulation-based education is an innovative process for creating authentic situations in which groups of IPE students learn to collaborate. Specifically, this technique can assist in overcoming some of the challenges that exist in healthcare: inadequate communication among professionals, focusing on specific needs rather than the whole patient, lack of knowledge of other professionals’ roles, the inability to work as an effective team member, and a lack of conflict-resolution skills. IPE conducted as a simulation activity may supplement traditional classroom strategies to enhance the performance of healthcare providers, ultimately resulting in reduction of errors in the workplace and an increase in the quality of care provided to patients. Although this strategy has been recognized by various international professional societies, including the World Health Organization and Institute of Medicine, as foundational to achieving safe, high-quality, accessible patient-centered care, not many healthcare training programs are on board.

Fortunately, as graduate students in speech-language pathology at The University of Akron, we were given the opportunity to participate in an IPE simulation activity. It included more than 90 students studying in the fields of nursing, nutrition/dietetics, social work, medicine, and pharmacy. Groups of five or six students from each discipline worked together to treat a specific, simulated patient. This particular simulation portrayed a young female combat veteran primarily diagnosed with a traumatic brain injury, with secondary diagnoses of depression, binge eating, insomnia, post-traumatic stress-syndrome, and cognitive deficits. Working as a team, our goal was to assess, diagnose and create a treatment plan for this patient to help alleviate her daily struggles, such as her inability to maintain a healthy diet, pay attention during class, and communicate effectively with loved ones. To develop an effective treatment plan, these challenges needed the knowledge and skills of each of the disciplines that participated in the simulation activity.

As the simulation began, we quickly recognized the need for strong interpersonal skills. It was a challenge figuring out when to speak, when to listen, and how to deliver opinions appropriately. Common observations of group dynamics included students promptly stating their opinions on how the patient should be treated before discussing a rationale or their role; students aggressively prioritizing needs of the patient without consultation; and many students reported they were unaware or had misconceived ideas about the roles of other professionals, especially speech-language pathologists. From these experiences, the need for this type of training was even more apparent. We learned that professional roles, especially speech-language pathologists, may be unclear to others, and we found ourselves advocating for our field and its importance in making treatment decisions. We also found that many students were very knowledgeable about their discipline but lacked good communication skills. This challenge resulted in a struggle to connect constructively with other students in other courses of study. We now recognize how vital  interpersonal skills are to delivering optimum patient-centered care.

 
From this exercise we now believe an IPE approach to teaching and training can have a tremendous impact on the preparation of speech-language pathologists and audiologists. With this training, students will enter the workforce with experience collaborating with other professionals and will understand the power of teamwork to accomplish a task. When students practice interprofessionalism and see the power in collaborating with other professionals, greater progress can be achieved in the workplace. Participating in the IPE simulation has boosted our confidence by showing us how to apply our clinical knowledge and skills in a safe but functional learning environment, but most importantly, it has given us a sense of how to work as a team to improve the life of our patient, which is the essence of patient-centered care. We have definitely taken our first critical steps toward becoming truly interprofessional!

Crystal Sirl, BA, is a graduate student in the School of Speech-Language Pathology and Audiology at The University of Akron.
Grace Bosze, BA, is a graduate student in the School of Speech-Language Pathology and Audiology at The University of Akron.

 

 

Pragmatics with Elephant and Piggie

piggie

Are you working on social skills and building appropriate conversation with children ages 4 and older? Are you looking for more playful and fun ways to teach pragmatic skills and engage a child’s attention during therapy sessions?

Mo Willems is one of my favorite children’s book authors. Some favorite titles of mine are Knuffle Bunny and That is Not A Good Idea, and of course the infamous Elephant and Piggie books, which include A Big Guy Took My Ball, Should I Share My Ice Cream? My Friend Is Sad and many more. Mo Willem’s collection of Elephant and Piggie’s books expand to more than 20 books.

The Elephant and Piggie books are witty, silly and excellent for teaching some important social skills to children with delays or deficits with their pragmatic language skills.  These books are also ideal to read in a classroom or with a small social skills group because they are naturally engaging and can facilitate language.

Elephant and Piggie are best friends and treat each other with love and respect, which is an excellent friendship model for any child. I’ve used Elephant and Piggie books to help teach the following pragmatic skills:

  1. Turn Taking in Conversation: Elephant and Piggie have simple and animated conversation with each other and in certain stories, other characters. The conversation flows naturally between the characters and is related to a specific topic (great for practicing maintaining conversation). Role play after reading the book! A role playing activity can be a fun activity in a social skills group.
  2. Interpreting Body Language: Elephant and Piggie are extremely animated and express themselves well through body language. When reading an Elephant and Piggie book, discuss how the character’s body language shows how he is feeling (e.g. Elephant is jumping up a down, he must be excited!, Piggie is crying, he must be sad)  This is an ideal opportunity to ask questions and model language.
  3. When and why to use intonation in conversation: Mo Willems uses many explanation points, bold and italic wording to express the emotions and feelings of Elephant and Piggie. For example, in the book, “We Are In A Book,” Elephant jumps up and down and says “THAT IS SO COOL!” Ask your client, “Is Elephant whispering or shouting? How do you know?” Discuss when and where it is appropriate to use a soft or loud voice. When you are reading the book, make sure to use appropriate intonation as related to the text. I recently wrote an article about using intonation when reading to a child. Another great carryover book to teach punctuation and facilitate language would be with the picture book, “Exclamation Mark” by Amy Rosenthal and Tom Lichtenheld.
  4. Discussing Emotions:  Elephant and Piggie have intensive feelings and emotions in this series which makes it really conducive to discussion within a group. Ask your client how the characters are feeling and why. In Should I Share My Ice Cream? Elephant is confused about whether he wants to share his ice cream with Piggie. Discuss what “confusion” means and relate to an experience you or your client has had recently.
  5. Expanding and maintaining a topic within a conversation: Elephant and Piggie have extensive conversation in each of their books. Discuss how the characters extend conversation, maintain a topic and keep the dialog going. Determine if it’s by question, comment, etc. This can be a great exercise that can easily be carried over to other conversations with peers.

Other goals can include answering “wh” questions, building literacy skills, expanding vocabulary, describing, commenting, improving narrative skills and recalling information. This series of Elephant and Piggie books are also available at most libraries, which make them accessible.

More information about the Elephant and Piggie series is available online. If you have any comments, please comment below!

Rebecca Eisenberg, MS, CCC-SLP, is a speech-language pathologist, author, instructor, and parent of two young children, who began her website www.gravitybread.com to create a resource for parents to help make mealtime an enriched learning experience . She discusses the benefits of reading to young children during mealtime, shares recipes with language tips and carryover activities, reviews children’s books for typical children and those with special needs as well as educational apps. She has worked for many years with both children and adults with developmental disabilities in a variety of settings including schools, day habilitation programs, home care and clinics. She can be reached at becca@gravitybread.com, or you can follow her on Facebook; on Twitter; or on Pinterest.

Aural Rehab: Are We Getting the Job Done?

tin can 2Aural rehabilitation was once the root of our profession. ASHA defines it as “an ecological interactive process that facilitates one’s ability to minimize or prevent the limitations and restrictions that auditory dysfunctions can impose on well-being and communication, including interpersonal, psycho-social, educational and vocational functioning.” Audiologists know the importance of providing our patients with education, counseling, and training to overcome the challenges presented by hearing loss. However, the most recent MarkeTrak survey results indicate that very few of us are actually providing these services to our patients. This is an unsettling finding to say the least.

I truly believe that most audiologists attempt to provide their patients with adequate education and counseling. However, these MarkeTrak survey results prove that our attempts are not being received by our patients. I believe there are two factors at play: technological overwhelm, and unrealistic expectations. Patients are often so overwhelmed by the vast array of technology at their fingertips that their sole focus is on the technical workings of the hearing aids and wireless accessories. In addition, the vast improvements in technology lead our patients to believe that the hearing aids alone should address all their communication problems. What we are missing is a standardized, effective, and efficient aural rehab protocol that helps our patients to retain what they have learned, and use the strategies we teach them.

As a practicing audiologist, I face these challenges on a daily basis. As technology progresses, I find myself spending more clinic time educating my patients on the technical aspects of their new hearing aids. In a busy ENT clinic, time is of the essence, and this leaves very little time for counseling about realistic expectations, communication strategies, and auditory training. I tried various educational handouts as well as group AR classes, but struggled with patient compliance. I also found it difficult to engage family members in the rehabilitation process. When I read the MarkeTrak survey results, I realized I wasn’t the only audiologist facing these challenges. So in 2013 I set out to develop a fun and effective approach to aural rehab that would be easy for patients to comply with, and efficient for professionals to implement. I call it Cut to the Chase Counseling. There are three simple steps to this aural rehab approach:

1. Education: Patients need to be educated in a fun, easy, and efficient way. While there are many great educational materials on the market, I chose to create my own patient guidebook that organizes communication strategies into five simple keys (see below) that are easy for patients to remember. It is also important that our education addresses realistic hearing aid expectations as well as the importance of family member involvement. Our aural rehab approach defines the following components as the “5 Keys to Communication Success.” I will discuss these further in future blog posts.

2. Action: Patients need to immediately act on what they’ve learned to begin creating new communication habits early in their rehab process. We start this action with personalized Successful Communication Plans that guide the patient and their communication partners as they apply the five keys to their most challenging communication situations.

3. Follow-up: Patients simply cannot absorb and retain all of the education and counseling during their hearing aid trial period. They are often so overwhelmed by their hearing aids, that they may actually remember precious little from what we have been teaching them. For this reason, they must receive some kind of regular follow-up education. Studies show that consistent long-term follow-up drastically increases patient compliance and satisfaction. We provide this follow-up in the form of weekly emails that patients receive for an entire year following their hearing aid fitting. These emails reinforce effective communication strategies and encourage the patients to return to their hearing care professional with any questions or concerns.

We know that our job as rehabilitative audiologists goes far beyond fitting hearing aids. I hope this simple three-step approach will provide an efficient way for professionals to ensure that education and counseling are an integral part of every hearing aid fitting. In the following five blogs, I will dig deeper into the five keys to communication success and give you strategies for integrating them into your practice.

Dr. Dusty Ann Jessen, AuD, is a practicing audiologist in a busy ENT clinic in Littleton, Colo. She is the founder of Cut to the Chase Communication, LLC, a company dedicated to providing “fun, easy, and effective” counseling tools for busy hearing care professionals. She is also the author of Frustrated by Hearing Loss? 5 Keys to Communication Success. Dr. Jessen can be contacted at info@CutToTheChaseCommunication.com. 

Our Perception of Taste: What’s Sound Got to Do with It?

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My first love as a speech-language pathologist is pediatric feeding.  I spend lots of time talking to little kids about “carrot crunchies” and “pea-pops” and various silly names for the sounds that different foods make in our mouths as we explore all of the sensory components of food in weekly treatment sessions.

Is it possible that sound is a larger component of our eating experience than many of us realize? What’s sound got to do with eating, or more specifically, with taste? Discovering how the sound of a crunching potato chip affects flavor is more than just curiosity.  Prof. Charles Spence, who leads Oxford’s Crossmodal Research Laboratory, studied how the sound that food makes in our mouths influences our perception of freshness.  It’s an important point for potato chip manufacturers, who strive to create the “crunchiest crisp possible.”

Background sounds in the environment also influence our interpretation of taste.  Spence conducted an experiment where individuals were presented with 4 pieces of identical toffee.  Two pieces were eaten while the subjects listened to the lower pitch of brass instruments.  Two other pieces were eaten while listening to the higher pitch of a piano.  The pieces eaten during the higher pitched piano music were rated “sweet” by the subjects and the pieces eaten during the lower pitched music were rated “bitter.”

Chef Blumenthal, owner of The Fat Duck near London, has taken Spence’s research findings to the next level.  Order the “Sound of the Sea” and you’ll enjoy more than seafood delicacies  presented on “a sand of tapioca and fried panko, then topped with seafood foam.” The dish is accompanied by an iPod nestled in a seashell, “so that diners can listen to the sound of crashing waves as they eat.” Spence reports that diners experience stronger, saltier flavors with the sound of the ocean in the background.  Another London restaurant, the House of Wolf, serves a cake pop along with instructions to dial a phone number and then, before tasting,  press 1 for sweet and 2 for bitter.  Diners who listened to the first prompt heard a high pitched melody and those who pressed “two” heard a low brassy tones.   In an article for the Telegraph, Spence said,  “We have also looked at the crispiness of crisps and biscuits and found that by boosting certain high frequency sounds when volunteers bit into them we could make them taste crunchier, and they became softer if we dampened those frequencies.”  It’s not just diners across the pond who are experiencing the marriage of sound and taste. Major food companies in the United States also have consulted with Spence, who developed a soundtrack to “complement”  the coffee at Starbucks®.  Speaking of coffee, in a recent study, Spence found that humans can detect whether a liquid is hot or cold, just from listening to the sound of it being poured into a glass, porcelain, paper and/or plastic cup.  I’ll consider this the next time I’m waiting for my drink at the local coffee shop.  Perhaps, from now on,  I can just listen to the sound of the pour, grab my drink and avoid the barista announcing “Lite Iced Triple Venti Half-Pump Americano Skinny for High Maintenance Melanie” with that smirk on his face.  But, I digress…

When I consider my little clients in feeding therapy, I wonder how this research might be expanded to detect possible differences in taste perception in children with sensory processing challenges, including kids with autism. Certainly, respecting the differences in a child’s sensory system is an integral part of feeding therapy for most clinicians.  Could it be that this hiccup in auditory, visual, gustatory or other sensory systems communicating efficiently with one another makes eating a variety of foods especially difficult for some children, more than we know at this time?  A recent article in The Journal of Neuroscience reported that kids with “autism spectrum disorders (ASD) have trouble integrating simultaneous information from their eyes and their ears” and discussed how this might affect their language skills. Wendy Chung, MD, PhD at Columbia University Medical Center explained in a recent video for parents how a poorly functioning pathway for simultaneous auditory and visual information (and the secondary problems of processing and responding to sensory signals) causes a child with ASD to be overwhelmed in environments that we find quite comfortable.  Perhaps future research may include Spence’s work and how it might apply to children in feeding therapy. Would certain tones be more soothing while eating?  Would certain music in the school cafeteria help children eat faster or even choose more nutritious foods? The common phrase “a feast for the eyes” may one day turn out to be “a feast for the eyes and ears” as we consider all the possibilities.

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is  offered for ASHA CEUs and includes both her book and CD for each attendee.  She can be reached at Melanie@mymunchbug.com.