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.

Kid Confidential: Data Collection Using Thematic Therapy

data collection

In December’s Kid Confidential column, I discussed the advantage to using thematic lessons in speech therapy.  Last month, I explained how I write goals when using thematic lessons in therapy and the need for additional sources of data throughout the academic environment.  Today, I’m going to discuss how I record data during thematic therapy sessions as well as how I have gotten other school staff members on board to collect data.  Please note that the below information is based solely on my clinical experience.

Data Collection of SLP in Thematic Therapy Sessions

There are three main ways I can think of to collect data using thematic therapy.  The first of which is to do so throughout the entire therapy session.  The second way is to collect data for certain activities during each session.  The third option is to use periodic data collection among several therapy sessions.

Target goals throughout the entire session

Once you know exactly what skills you are targeting with each student you can determine how you will do this in thematic lessons.  One way to do this is to simply target at least one skill for each student in every thematic therapy activity.  I tend to use this technique most often when working with small groups of students who demonstrate emerging skills.  I will choose language rich thematic activities and incorporate ways to target at least one goal/objective for each student during each activity.  For example, if I have a student who is struggling with pronouns, I will be sure to ask questions during every activity that would require that student to label or expressively use pronouns in order to answer my questions.  This way I am targeting that one specific goal for the entire session for that student. This technique allows me to continue to take data throughout the session for each student and performance in this way tends to demonstrate generalization of skills to other activities as well.

Multiple Short Activities Targeting Different Goals

Now there are times when it is necessary to “drill and kill” a skill for students who have yet to demonstrate emergence of skills and who seem to require multiple trials in one session to facilitate learning.  When this is needed, I will choose to have my students participate in several different short thematic activities where each student is given time to repeatedly target an individual skill within an activity I created just for them centered on the theme and interest of their choosing.  In that manner, all students participate in each activity however data may not necessarily be collected for each student during every activity.  Time for each activity should be flexible depending on your goals, the time it takes to complete the activity and students’ interest.

For example, let’s use the recent holiday season as a possible theme for therapy.  In a small group of 5 students, I may have one that is working on understanding and using prepositions, another student working on increasing overall vocabulary skills, two students working on auditory comprehension skills and recalling details of a story and one student working on articulation skills.  What can I do?  Well I can have a quick craft in which my student working on articulation skills can read directions with different prepositional phrases.  This activity will allow me to collect data on the student who requires assistance in learning prepositions, the students who are working on improving auditory comprehension skills, as well as allowing me to tackle articulation skills of my fourth student.  The next activity could be a thematic book in which my students take turns reading the pages (or if I want to save some time, I may read the book).  Of course this allows me to ask WH questions about the book, possibly ask for synonyms, antonyms or even definitions of words within the book and finally have the students attempt to use a graphic organizer to “map the story” thus requiring them to recall details in sequential order.  Now I have targeted at least one goal for each of my students.  As the book activity would most likely take longer than the craft, this is an instance where my second thematic activity may have a longer duration as compared to my first activity.  By the end of the session, I should have data on at least one goal/objective for each student from at least one activity.

Periodic Data Collection Across Therapy Sessions

The third main option, I believe we have as SLPs is to periodically record data.  This may mean, as an SLP, data is not collected every session but periodically among a number of sessions.  Some colleagues prefer this method of data collection for a number of reasons explained to me previously such as periodic data collection allows for a therapist to focus on the therapy itself without the additional distraction of data collection.  Periodic data can aid in time-management skills particularly for those with extremely high caseloads.  Some therapists feel this is a better indicator of a student’s skills over time without needing to filter out the variability of performance on a daily basis.  Additionally, some therapists believe using the “pre- and post-teach/testing” method of collecting data reflects the academic environment more accurately than daily data.  With all that said, I do want to share a word of caution to those thinking about using periodic data.  The most important thing to remember is to be consistent in taking that data.  Know ahead of time when you are planning on data collection and ensure that you have enough data collection days within each marking period to target goals effectively.  Meaning, if you write your goals for a skill to be performed with a certain amount of accuracy across three data collections days, then you must at least have three data collection days to determine if the skills has been achieved.  Also be diligent.  If a student is absent during those days, be sure to take data regarding that student’s skills the next therapy session.  Periodic data can be helpful in looking at a child’s performance over time if collected consistently.

Data From Other Sources

There will be times when we write goals and target skills in therapy but would like to determine generalization to the academic environment as previously mentioned in last month’s column.  In an instance such as this, data may be collected in a different way and from a different source. Periodic data can be just as effective as daily data collection, as mentioned above, if done with consistency.

With the implementation of RTI, I have found teachers are much more willing and confident in their own ability to take data within the classroom setting, if I take time to train them on how to collect data and express realistic expectations that data will only be recorded at specific times during the day/week or during specific assignments.  This way, I have gotten reliable data collection from teachers regarding a child’s articulation skills for specific sounds during small reading groups, qualitative data on social skills in cooperative learning situations among classroom peers, data on a student’s ability to expressively answer WH’s in the classroom, information on a child’s ability to recall details of a story, and data on the accuracy of a student’s ability to follow classroom directions.

How can all of this work when the goal is to use thematic lessons in therapy?  Well, here is an example for you.  Remember my student working on vocabulary skills?  Well it would behoove me to target academic vocabulary in the school setting as a means to hopefully translate to improved classroom function.  Therefore, I may be given a list of vocabulary words from my students’ teachers and incorporate those words into stories I create using the theme on which we are currently focusing.  I may pre-teach the vocabulary, use context clues to have my students’ define the same vocabulary in my created story, then I may have my students participate in a vocabulary definitions match-up page post story.  This may occur over the span of several sessions.  Once this is completed and I have my data as to how my students performed with this particular list of vocabulary words, I can then compare their performance in my speech room to that of their classroom performance to determine if carryover has occurred.  This way, I am actually using teacher data (e.g. score on the students’ vocabulary sections of their language arts assignments each week) to determine generalization all while still using themes in therapy.

How do I get teachers on board and how can I ensure data collection is occurring?  Here are few tips:

  1. Keep things a simple as possible by providing all materials needed for tracking data.
  2. Let the staff member choose when to take data:  I ask the teacher/staff member what time of day or which classroom activity would be easiest for them to track a student’s performance.  Teachers are more likely to take data during activities or times of day which are easiest for them.
  3. Training goes a long way: Once a specific classroom activity or time of day is identified by the teacher, I will be sure to go to the classroom during that time and train the teacher on how to take data for the specific skill being targeted.  I keep it as simple as possible and very rarely do I have to do this more than once.
  4. Accountability:  I randomly check the data sheets during class time and ask the teacher every few days how my students are doing in the classroom.
  5. Show gratitude:  When teachers and staff members understand how genuinely grateful I am to them for taking time out of their day to help one of our students by recording data, they are much more willing and likely to continue to take data.

What does the data collection form look like for the school staff?  Here’s an example of what I have used in the school setting.

data collection

I usually provide a folder for the data collection sheets for students so the staff member can pull out the data collection sheet, re-read the goal being targeted, and simply take data on the student during the agreed upon time/activity.

For more functional goals that require data collection in real-time during the classroom, such as using appropriate pragmatic skills or using age-appropriate receptive and expressive skills for functional conversational, I will provide teachers with the data collection sheets as well as a page of blank labels.  The teacher can simply take data on the labels in real-time and stick them onto the data collection sheet later.  This way, he/she does not have to stop the lesson to take data.

The possible ways to record data by ourselves as SLPs or collect data from other school professionals is numerous if we are creative and work collaboratively with others.  I’m sure there are a number of school speech-language pathologists using the above techniques as well as a number of others not mentioned today.  As long as we remain flexible, open-minded and always focus on improving functional skills of our students, I believe the ways in which we can do this are infinite.

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

Kid Confidential: Using Thematic Therapy to Write Goals

creative 

Last month I discussed the benefits of using thematic lessons in speech therapy.  Today I will discuss how I write goals using this type of therapy.  Please understand the following information is based solely on my own clinical experience and information shared with me from other licensed speech-language pathologists.

Taking data for thematic therapy does not differ as compared to taking data for non-theme based therapy activities in general.  However, it does depend on the specific goal for each student and the sources from which you are planning on collecting data.

In the school setting, working as a multidisciplinary team, there are a number of different ways goals can be targeted: in the speech room, in the classroom, in particular academic exercises, in small groups, in large groups, in functional language opportunities, conversation, play, etc.  I also have used data collected by a number of different individuals in the school setting to determine generalization of skills: the SLPA, the reading specialist, the classroom teacher, the special educator, the classroom paraprofessional, etc.  The key to determining effective data collection is to know what you want to target and who will be taking the data.

Goal Writing

First let’s discuss how goal writing can affect data collection.  Goals should always be objective and measurable in nature targeting the individualized needs of each student. However, we must guard against writing goals that are too specific, such as naming particular intervention programs, school curriculum, or technological devices that will be used in therapy.  The problem with writing goals that are too specific is that they are not always able to translate from one school district to another, especially if a new district lacks the same access to such named programs, have different school curriculum or different technological devices.  Therefore, I always like to say my goals must be objective, measurable, individualized and transferable (meaning no matter where this child may move, any SLP can work on each goal as it is written).

Goals to Be Used With Any Thematic Activity

How can an SLP write specific goals with the plan of using thematic therapy in mind?  I tend to write my goals using a particular percentage of accuracy as the measurement, however I base it on the number of opportunities per session.  For example, I may write something like:

“Johnny will receptively and/or expressively label subjective (he, she, they) and objective pronouns (him, her, them) during thematic therapy activities independently (or types of cues-verbal, nonverbal, visual, written, phonemic, semantic, etc., and level of prompting required-minimal, moderate, maximum) with 80 percent accuracy of total opportunities per session, across three consecutive data collection days.”

The reason I write my goals in this manner is because in natural conversation or in the classroom, there may not be an exact number of trials/opportunities to demonstrate a skill.  So functionally, if my student begins to demonstrate that skill successfully at 80 percent accuracy, regardless of the number of opportunities across three consecutive data collection days, then I feel I can confidently say this student has learned this skill.  Writing goals this way also allows me to easily take data throughout an entire session regardless of the number or types of thematic activities my student participates in that day.

Writing Thematic Vocabulary Goals

Thematic therapy is such a great way to improve semantic skills!  One way to do this is to use academic vocabulary within thematic therapy activities and keep a running record of the targeted and learned vocabulary words.  It is believed that the average child can learn approximately 10 new vocabulary words every day (from approximately 3 years old on through elementary school), setting a total number of vocabulary words a child would typically learn in a week at approximately 70, and the total number of words per school year (36 week) at approximately 2,520. Not all of these words will be useful in the academic environment; therefore, when working on vocabulary goals for school age children, I tend to rely on academic vocabulary to guide my therapy as I know giving a child words they can use in the classroom will translate into improved academic performance.  As some children who are receiving speech and language services may not be able to learn 10 academic vocabulary words a day, due to cognitive delays or other reasons, I prefer to write a goal of learning new academic vocabulary words over the course of a marking period (9 weeks) based on teacher input.  I may write goals that target learning anywhere from 10-20 new academic vocabulary words a week, depending on the number of new vocabulary words the teacher will present to the student in the classroom on a weekly basis, as well as the student’s learning ability.  A simple example of this type of goal would be:

“Over a nine week period, Johnny will increase his understanding and use of academic vocabulary as determined via the academic curriculum and classroom teacher by demonstrating improvement in defining vocabulary, correctly using vocabulary in sentences, and/or labeling synonyms and antonyms of vocabulary for at least 90 new words during thematic therapy activities in small group speech therapy sessions.”

Keeping a simple running record of the academic vocabulary presented and learned during each nine week period serves as a simple way to collect data during therapy sessions.

When working in early childhood, I wrote goals specifically for thematic vocabulary that aligned with the weekly classroom themes for my preschool students.  An example would be:

“Johnny will demonstrate an increase in thematic vocabulary repertoire, by receptively and/or expressively labeling objects related to various developmental themes as determined by the classroom teacher (e.g. transportation, clothing, seasons, foods, etc.) via structured thematic therapy activities given phonemic and semantic cues with minimal assistance (cuing less than 25 percent of the time) with 80 percent accuracy of total opportunities, per theme presented.”

As preschool classrooms are based on thematic education, this particular goal could transfer to any preschool classroom.  Also adding in that this goal would be targeted for each theme presented throughout the academic year, helped to ensure that this goal would continue for each classroom thematic lesson.

Writing Goals to Accept Data From Other Sources

As I briefly mentioned above, another affective way to demonstrate if speech services are having a positive effect on a student in other settings is to accept data recorded from other sources within the academic setting–classroom teacher, classroom paraprofessional/aide, special education teacher, reading specialist, etc.  To do this, it should be identified within a goal that certain sources will be used for data collection.  For example:

“Johnny will demonstrate generalization of understanding and use of subjective pronouns (he, she, they) and objective pronouns (him, her, them) to the general education classroom by verbally expressing and/or writing the correct pronouns during class participation (e.g. responding to teacher questions, reading group discussions, etc.) or in classroom assignments (e.g. classroom journal, worksheets, homework, etc.) with 80 percent accuracy of total opportunities as per teacher report and graded classroom assignments, across 3 separate data collection dates.”

In this particular example, the goal here is to demonstrate generalization of a language skill to another environment. Therefore, as an SLP, I may continue to target this specific skill through various thematic therapy activities, however I will use teacher report and classroom assignments to determine if generalization has occurred.

Help from Other Colleagues

Some of the best goals I have found come from other speech-language pathologists.  Tatyana Elleseff, a colleague and owner of Smart Speech Therapy, LLC, has shared some of her preferences in writing goals with the use of thematic lessons in mind, which I very much like.  The following are examples simple skills one can target using thematic therapy.  Adding your own measurements systems and identifying ways in which data will be collected are necessary to complete these particular goals to create something objective, measurable, individualized and transferable.

Short-term Vocabulary and/or Grammar Skills:

  1. Child will be able to appropriately label 150 functional objects (nouns) related to his academic and home environment.
  2. Child will be able to appropriately label 70 functional actions (verbs) related to his academic and home environment.
  3. Child will be able to appropriately label 35 functional descriptors (adjectives) related to his academic and home environment.
  4. Child will define and use curriculum/related vocabulary words in discourse and narratives.
  5. Child will improve his ability to formulate semantically and grammatically correct sentences of increased length and complexity.

These particular skills lend themselves very nicely to SLP data collection simply by keeping running records or recording performance during therapy sessions.

Story Telling/Narrative Skills:

  1. Child will increase ability to produce cohesive age-level narratives containing 5+ story grammar elements
  2. Child will identify main ideas in presented text.
  3. Child will identify details in presented text.
  4. Child will answer simple inferencing and predicting questions (e.g., “How did this happen?”/ “What would happen…?”) based on presented text.

The above skills can be measured either in the therapy room by the SLP during specific language tasks, within classroom assignments and teacher report, or a combination of both depending on how many sources of data collection you would like to use.

Other Long-Term Language Skills

Receptive Language: Client will demonstrate age-level receptive language ability (listening comprehension, auditory processing of information) in order to effectively communicate with a variety of listeners/speakers in all conversational and academic contexts.

Expressive Language: Client will demonstrate age-level expressive language ability in order to effectively communicate with a variety of listeners/speakers in all conversational and academic contexts.

Pragmatic Language: Client will demonstrate age appropriate pragmatic skills in all conversational contexts.

As you can tell from the particular skills targeted above, data collection from an SLP alone is not going to be enough to demonstration functional skills throughout the academic environment or in all conversational contexts.  Therefore, using a number of data sources within the academic environment is necessary to accurately measure these particular skills.

In general, data collection does not change drastically when using thematic therapy lessons versus the “drill and kill” concept.  However, when planning to use thematic therapy, you may notice the way you write your goals and the sources from which you collect data can differ slightly from when skills are traditionally targeted by the SLP alone.

Next month, I will discuss how I collect data during thematic therapy and how I get teachers on board to become an additional data source as well.

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.

Kid Confidential: Using Thematic Instruction in Speech Therapy

pirate

I have seen many speech and language activities labeled as “themed” therapy activities just by the mere coincidence that they may sport graphics or clip art associated with a particular theme or holiday.  However, simply pasting an associated picture on a stimulus card while asking a student to perform a generic speech or language task is the not the same thing as participating in a themed activity.  Until I learned from my educator colleagues what it truly meant to teach via themes, I made this same mistake, too.  Regular and special educators are taught to understand the importance of themes and how they relate to child development and learning.  However, at least based on my own personal experience, newly graduated speech-language pathologists lack the instruction needed to fully understand what thematic teaching is really all about.

I see myself as an educator first and foremost.  Therefore, I learned many valuable things about education through colleagues and by reading educational research and textbooks.  This particular topic has been no exception.  Marjorie Kostelnik, Anne Soderman and Alice Phipps Whiren, spend an entire chapter explaining what thematic units really are and how they can effectively be used within the academic environment in their book titled, Best Practices in Early Childhood Education.  The following information is adapted from this source.

What is a theme and why would we use them in speech interventions?  A theme can be defined as the creation of various meaningful activities planned around a central topic or idea. The activities are then integrated into all aspects of the curriculum (i.e. language arts, reading, math, science, social studies, etc.).  Thematic instruction has been researched and observed to help children learn about concepts (i.e. ideas about objects and events in a child’s world) and facilitates in connecting various concepts together cognitively. In SLP lingo, this means thematic instruction helps to teach our children about categories. Through first-hand experience and additional learning activities, our students are improving their semantic mapping/networking skills thus improving receptive and expressive vocabulary, understanding and using synonyms and antonyms, word retrieval skills, story comprehension and story retelling skills, answering “WH” questions, as well as improving their ability to make inferences and predictions, thus resulting in improvements in overall language skills.

How do we create effective thematic lessons for our speech sessions?  According to Kostelnik, et al., there are five necessary components to creating an effective theme:

  1. Relevance: The theme must be relevant to your student’s real-life experiences and timely in that themes should be targeted based on your students’ current interests.  For example, a field trip to the pumpkin patch may be planned in the fall. Creating a theme-centered around fall harvest/fruits and vegetables, around this time would be an appropriate time to maximize your students’ interest in learning about this topic.
  2. Hands on activities: Concepts whose informational content can be accessed through hands on activities are appropriate for students 3-8 years of age.  These activities can be offered via exploratory activities, guided discovery, problem-solving activities, group discussions, cooperative learning, demonstrations or direct instruction.  I think as SLPs we tend to be very good with demonstrations and direct instruction (i.e. speech/language activities, what I like to call “drill and kill” activities) as well as guided discovery (particularly in book reading when asking student’s to infer or make predictions), however we miss opportunities for students to use self-talk to problem solve or use cooperative learning to have a discussion with peers.  These are important executive function and social skills that should be trained at an early age so as to generalize to other environments as our students mature.  If, during our group therapy sessions, we step out of the equation as facilitators, will our students educate each other on the necessary skills for continued development (e.g. teaching each other to self-monitor speech production or how to use appropriate social skills in real-time, or even help each other use correct grammar in sentence formulation)?  We must create opportunities for our students to use what they learn independently to help themselves and their peers.
  3. Diversity and balance across the curriculum:  Many of you might be reading this and think, well this doesn’t apply to me because I teach speech and language skills.  However, the truth is, you are already doing this!  Through your planning of speech therapy activities you are incorporating science (e.g. matching pictures of clothing to correct seasons, mixing red and blue paint to make purple, etc.), social studies (e.g. discussing community helpers and matching up the helpers to the objects/tools they use), math (e.g. counting and sorting animals into correct categories), and language arts (e.g. recalling details of a story or retelling a story in correct sequence).  Therefore, the use of “academic” or “curriculum-based” materials in the upper elementary grades, middle school and high school is, more than likely, what most of you have been doing for years!
  4. Primary and secondary sources of information must be available:  When planning a theme, thought must be given to the primary and secondary sources of information.  Primary sources of information are seen as what the child already knows (background knowledge) or can determine via concrete information present.  Secondary sources of information are sources that provide students with additional information they had not known nor can determine via concrete information present.  For example, when focusing on “farm animals” as a theme, a child may already know that a pig says “oink” and can see from a picture that it has four legs.  This is known as primary information.  An example of secondary information would be using books, pictures or other additional resources or materials to explain the role of pigs on a farm or the types of pigs and where they live.  So in a nutshell, a good theme uses the background knowledge your students already have and builds on that by providing additional new information.  Doesn’t this sound a lot like reading comprehension strategies (background knowledge, pre-teaching vocabulary, introducing new information, recalling information, etc.)?
  5. Potential for projects/“discovery learning”:  A good theme must lend itself to discovery learning. Discovery learning simply means you present your students with opportunities to problem solve and/or reason information not factually presented to them.  These projects are child-centered and/or child directed.  This piece is very important in planning themes because as you introduce information to your students you want to follow their lead and listen to the questions they have about the information presented.  Then you want to create a “project” that addresses the student’s questions or concerns.  For example, if when discussing farm animals a child asks have you (as the SLP) ever been to a farm? Your student is expressing the interest to learn more about others personal experiences about farms.  So you guide a “project” where your student asks the other students in your therapy group (language practice in formulating appropriate questions) or classroom if providing in class therapy, and you graph their responses.  Now you’ve just incorporated math (graphing, counting, adding, concepts of more/less) into a “project” your student directed and by the end your student has problem solved a way to survey his/her peers to find out more information about themselves.

I can hear the collective frustrated sigh from many of you out there reading this. “I have my students for 30 minutes, two days a week.  How am I supposed to use thematic units to teach them what they need to learn in that time?”  The first thing I would suggest to do is to start small.  Focus on the use of thematic teaching for a small portion of your language delayed students. Listen to what they are interested about learning and begin to create activities based around those topics. Remember you need to know what your students already know (primary source) so you can provide appropriate expansion materials/activities (secondary source).  Then compare your results.  See how the use of themes aid in learning and language development for this group as compared to the therapy groups for which you do not provide thematic lessons.

Another important key to successful themes is the stay flexible.  Follow your students’ lead.  Remain on one theme only as long as your students’ interest in the topic lasts.  This means, you don’t have to perform five or six thematic activities within your two therapy sessions a week. You can take as long or short a time as needed.  You might even take two sessions to participate in one activity.  I used to work with a colleague who used two or three sessions of repeated book reading as part of thematic teaching and it was amazing to see the improvements in numerous linguistic skills of her students after these sessions.  It just depends on your students’ current level of skills and interest.

So the next time International Pirate Day rolls around on the calendar throw out those multi-step direction cards that have nothing remotely related to learning about pirates. Rather, spend a week or two reading pirate stories while increasing the use and understanding of pirate-associated vocabulary (e.g. treasure, map, spyglass/telescope, etc.), and pirate lingo (e.g. “Shiver me timbers!” “Matey” and “Land ho!”), recalling details and or retelling the stories read (language arts), discussing famous historical pirates and from where they originated (history, geography), creating a “treasure hunt” for your students to cooperatively complete (following directions with pirate lingo, problem solving and reasoning, use of appropriate social skills), and spend time creating a pretend play scenario about pirates (hands-on, expansion activity) using all the information your students’ learned throughout your therapy sessions.  I promise you that your students will have just as much fun learning from you as you will have teaching them.

 

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.

Kid Confidential: Tips for Working with Students with Hearing Impairment in the Schools

1114

This month I revisited the topic of classroom difficulties and possible accommodations and modifications for students with hearing loss in the School Matters column of the ASHA Leader.  As there is so much to discuss on this topic, I was unable to share some of the inside tips I have learned when working with students with hearing impairment in the academic setting.  So I thought I would share this information with you today.

Here are the top five lessons I learned when working with students with hearing impairment in the schools:

  1. Work with the student’s audiologist.  I am not a specialist in the area of hearing.  Therefore, every time I have a student with hearing loss referred to me or placed on my caseload, the first thing I do (after reading the audiological evaluation report) is contact the audiologist to ask all of my questions and voice any concerns.  I know, as school-based speech-language pathologists, you struggle to have enough time in the day to do everything you need to do but this is the first and foremost important piece of advice I can give you when working with children with hearing loss of any severity (including children with sound field amplification systems, hearing aids, and cochlear implants-CI).  Audiologists do not expect us as SLPs to know everything about their field.  In fact, they are more than happy to share their wealth of knowledge.  I have learned so much regarding simple tests I can perform for quick assessment of my student’s hearing perception at varying distances to determine how they are perceiving that audiological input (i.e. Ling 6 sound test), how and when to recommend a student with CI to return to their audiologist to once again MAP their CI, what classroom behaviors are evidence of improved hearing and understanding and conversely which suggest possible malfunction of hearing equipment.  Without an audiologist’s guidance, I would not be able to do these things today.
  2. Consult with your district’s teacher of the hearing impaired frequently.  Although, the teacher of the hearing impaired may not be an audiologist, he/she knows the practical strategies and techniques to use while teaching students with hearing impairments in the academic setting.  I have learned how to teach speech and language skills effectively in 1:1 therapy, small group therapy, and in-class therapy for children with hearing loss.  I have learned how to troubleshoot if a hearing aid isn’t working correctly, how to hook up the FM system “boots” to a CI, and what to look for in the classroom and therapy setting that may indicate the need for further analysis of hearing equipment.  Using the teacher of the hearing impaired as a frequent resource to share ideas and answer your questions can be an invaluable and integral part of your therapy plan.
  3. Record in-depth observations:  This is a technique I use to determine if growth is being made in all observed areas even if not specifically targeted on current IEP goals (e.g. improvement in social skills, changes in responding to environmental noises, changes during large group classroom lessons, etc.) or if current progress is not yet quantifiable.  Quality records can help you to share the changes effectively (positive or negative) in your student’s speech, language, or academic skills with the student’s audiologist and hearing impaired teacher to determine the next steps in the therapy process.  I have found emailing my in-depth observations to audiologists for my clients with CI is an enormous help when they are working on MAPping my client’s CI. Parents cannot notice nor may they fully understand the big and small improvements or difficulties a child may exhibit in the school environment.  Therefore, it can be a challenge for audiologists to determine MAPping changes and needs based solely on parent report and child response.  Noting these observations, such as environmental and speech sounds, to which the child no longer responds, assists the audiologist in making the appropriate adjustments to the students CI so as maximal learning can occur.  Don’t underestimate the importance of functional observations.
  4. Get the classroom teacher on board.  Many times classroom teachers just feel lost when expected to appropriately modify for students with hearing loss in their classroom.  They may be anxious about working with this population, which can manifest itself in what seems to be uninterest or even noncompliance.  However, the truth is the classroom teacher may not know what do to and may be looking to you, the SLP, for assistance.  Showing how simple modifications made in the classroom, in real-time, result in improved learning opportunities for their student is one of the quickest ways to get your student’s teacher on board.  Also frequent classroom visits can help you in identify and address additional situations that may be inhibiting your student’s learning (e.g. environmental noises affecting hearing, lack of sufficient visual support in the classroom, classroom instructional language used is too complex, instructor not appropriately amplified at all times, etc.).  Helping to address and make the appropriate changes and adjustments needed in the classroom environment throughout the school year, can be extremely helpful for your student as well as for the classroom teacher.
  5. Do not be afraid to say “I don’t know, but I’ll find out.”  This is the best tool to use when working collaboratively with a number of various professionals.  You can bring your current knowledge and clinical experience to the table, however, no one expects you to know everything about treating every disorder or deficit.  It really is OK to say “I don’t know,” but just make sure you follow that with “but I’ll try to find out for you,” because ultimately classroom teachers, parents, staff members, and other therapists just want to know you are there to help and support them.  Since you already established a great working relationship with your student’s audiologist, I would recommend you start there when you have additional questions you cannot seem to easily answer or research.

Those are my top five tips for working with students with hearing impairment in the school environment.  Do you have additional tips you’d like to share?  Feel free to comment below.

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.

Kid Confidential: Teaching Parents the Power of Play

shutterstock_105193811

 

I don’t know if it is just my experience or if you too have found this to be a problem, but I have noticed the more I work with very young children, the more I realize parents do not actually know how to play with their children.  I know this is a trend I am finding to be true more and more often, however, I am still shocked when I see it.

Play is such an integral part of a child’s development as it affects all areas of growth including, but not limited to, social skills, communication development, cognition, problem solving and reasoning skills, and imaginative thinking.  Therefore, for those of us SLPs who are working with infant, toddler and preschool-age populations it is not just enough to model play or target language development, we must teach parents how to play.  You know the saying “If you give a man a fish, he eats for a day.  If you teach a man to fish, he eats for a lifetime.”  Well I believe this to be similar–we need to teach parents how to play so their children can continue to develop during the time we are not present as service providers and throughout their childhood.

I have noticed that sometimes even involved parents who are willing to participate in book reading and speech and language drill type activities, are still not always comfortable participating in play.  Involved parents want to know what they can do to help.  The problem is they don’t fully understand the importance of play or how their child’s thinking skills change and grow via play.

So what do I do about this?  How do I try to teach parents how to play?  Here are a few techniques I have used:

  1.  Parent education:  The first thing I do is teach parents why play is so important and how learning takes place.  I explain to parents why we need to incorporate play into our therapy and why their child needs to participate in play with them when I am not present. I also explain the types of play their child is currently exhibiting versus what types of play they should be exhibiting at their age (you can find more details on ages and stages of play here).  This truly helps parents fully understand their child’s current level of functioning and why focusing on play skills is so important to communication development.
  2. Never make assumptions:  When I was fresh out of graduate school I made assumptions that parents knew and understood child development.  But the truth is we cannot assume that parents have had the same experiences as we have had.  Even if we are working with parents of a large family, this does not mean they know or fully understand how to play with their children.  I have learned after making many mistakes to never make assumptions about what parents do or do not already know.  Rather than treating parents as if they are in need of education, I will say something like “I would be remiss if I did not explain/show you how to…”.  Other times, I will say something like “I’m sure you already know this but I need to explain that…”.  Again, these are just two ways to help share my knowledge with parents while not treating them as if they are uneducated or making the assumption that they know more than they do.
  3. Model and explain play:  I then create play scenarios at whatever level of play the child is functioning currently while attempting to expand the play and improve language and problem solving skills.  I carefully explain what I am looking for in a child’s play and how I am changing the play slightly in order to achieve those goals.
  4. Give the parents a turn:  It is imperative that I make sure parents have a turn taking over the play interaction.  I want to empower parents and make them feel as if they can play with their child when I am not there.  However, the only way to do that is to make sure they have an opportunity to practice these skills while I’m still there to assist.  If help is needed, I will guide the interactions while continually reducing support throughout the session.
  5. Videotaping for success:  Videotaping parent/child play interactions can be an invaluable way to educate and empower parents.  I like to videotape portions of interactions so parents can refer back to the videos as needed.  When parents see how they have taken suggestions and turned them into positive interactions with their child, they begin to anticipate and invest their time into participating in play more often with their child.
  6. Follow up weekly:  The key to making this technique work is to make sure I follow up with parents and hold them accountable for their child’s play week to week.  I encourage parents to take videos on their smart phones and save them for our next session.  This way I can see the growth in their child and continue to provide assistance as needed.

Parents are always looking for the “right” ways to play.  So I give them a few tips:

  1. Show some emotion:  I explain that parents need to make sure their face, voice and entire body is showing the emotion they want to exude.  So when parents look their child in the eye, smile wholeheartedly and say, “I’m excited to be playing with you today!” or “This is really fun!”, I know they understand the importance of emotional in play.
  2. Play when you can:  Parents often times shut down if they think I am asking them to play for hours a day with their child which ultimately results in no play from them at all.  Instead I ask them to try to play for one or two 15 minute increments a day.  For parents who work full-time and have several children, I have found this to be a more realistic expectation and request from them.  Also encouraging them to involve their other children in play is a stress reliever for some parents as children are great models for each other and many times siblings are vying for their parent’s attention.  Incorporating siblings in play, seems to help provide the much needed parental attention while teaching the whole family how to interact with a child who may have delays.
  3. Turn off the TV and turn on some music:  Parents believe their children do not watch much television however when I ask if parents like to leave the television on for background noise I tend to get more “yes” answers than “no”.  So I encourage parents to get rid of the visual distractions like television and if they must have some background noise, play some child friendly music instead.
  4. Change out toys the child has available to them:  I have noticed even with my own child that when I periodically change out toys available, I see very different types of play.  This can keep a child’s play dynamic and guard against stagnation.
  5. Mix and match toys:  Mixing and matching toys that would not typically go together encourages growth in a child’s imaginative play.  I have seen some amazing pretend play when I brought random toys to therapy for my clients.
  6. Use nondescript toys/objects:  Some of the best pretend play I’ve observed comes from objects that don’t seem to look like anything in particular.  Have you ever placed a few boxes and a bucket of blocks in the middle of a room and watched preschoolers play?  It’s amazing the “thinks they can think”.  The more nondescript the object, the more creativity goes into the play.Parents always ask me if they are “doing it right,”  if they are playing the right way with their child.  My response is always the same “If your child is smiling, laughing or fully engaged with you, then you are doing it right.”

Do you spend time teaching parents about the power of play?  If so, how do you go about it?

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.

Kid Confidential: Typical Aggression in Toddlers

 

sept 9

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.

Kid Confidential: My Top 10 Reasons for Attending the ASHA Schools Conference

aug 8

 

I know I typically write about some topic related to child development but I thought I would take a detour this month and write about my first experience participating in the ASHA schools conference.  The reason I think this is important is because so many SLPs out there are school-based or work primarily with pediatrics and my experience at the schools conference this year was a very good one full of great insight into various topics, issues and research on child development.

First, let me say that I get no financial or non-financial benefits for writing this article.  So that being said, rest assured this blog post is coming solely from my personal experience and opinions.

This year was the first year in my long career as a speech-language pathologist (yes, you heard that correctly) that I was able to attend the ASHA Schools Conference.  Although I had wanted to go for some time now, between marriage, my husband’s multiple deployments and motherhood, I just couldn’t find the time or financial means to attend before this year.  However, with that said, I had such a wonderful educational experience that I do regret missing out on conferences of previous years and I knew I needed to share with you that it truly is worth saving your quarters, dimes, nickels and pennies over the next year to ensure you can attend.

In an effort not to take myself too seriously and to make this fun for you, I will, like some famous evening talk show host I will not name, give you….(drum roll please)….

 

My TOP 10 Reasons for attending the ASHA Schools Conference:

10.  Location, Location, Location:  Every year it is at a new location in the United States and it’s a nice reason to go check out some parts of the country you might not otherwise ever see.

9.  It’s Some Work and Some Play:  Presentations are over by 3:30 on Friday and Saturday so you have the choice to stay for round table discussions or poster presentations but if you choose not to participate, the rest of the evening is yours to spend sight-seeing.  Sunday, the conference is over by lunch time so you have the rest of the day to grab your camera and officially play tourist.  I was able to head on over to enjoy the beach while the sun was going down one evening, walked about the harbor tourist shops on a Sunday afternoon and strolled along the palm tree lined streets and bike paths with my family.  It was some fun, work, and some super fun play!!!

8.  A Family Affair: I decided to bring along my husband and 3-year-old son on this trip.  They were able to spend some quality Daddy time while I was enjoying the conference and we had some nice family time in the evenings.  It was a win-win situation for me, still having some time to enjoy my summer with my family.

7.  It’s Like Looking in a Mirror:  Have you ever seen a convergence of 1000+ pediatric SLPs on one convention center?  We are all dressed in our khakis and flip flops with our bag of notepads, binders, tablets, pens and pencils slung over our shoulders.  It really is like looking in a mirror and seeing thousands of ourselves out there.  After registration, I was walking back to my hotel room and waiting at the crosswalk were two women who looked like … well me.  So I asked them “Are you SLPs?” and one woman turned around and said “Yes, but that’s a heck of a pick-up line don’t you think?” Ha!  So true!

6.  Feed Them and They will Come:  Yes you guessed it, your registration fee includes (or at least this year included) breakfast each morning, lunch for Friday and Saturday, and snacks.  The food was very healthy and delicious too.  No too shabby!

5.  It’s About What You WANT to Know:  The feel of the schools conference is not about who you know, what researcher you like or who’s work you just finished peer reviewing.  It’s about what you WANT to know.  “What session are you going to next?” was a question I heard often that weekend from strangers who became new found friends because they happened to sit next to each other in a session.  It’s all about what we have come there to learn and what we can share with each other when our sessions are done.  The exchange of educational information for the pure purpose of learning!  Ah, does it get better than that?

4.  The Social Network:  What I love about school SLPs is that although we love our technology, we also love our old school email (strange that email is actually old school now, don’t you think?).  Of the speech pathologists I talked to and exchanged information with, there weren’t any future “tweets” planned or Facebook private messages offered.  It was more of “Shoot me an email when you get back to ____ and we’ll talk.”  So yes, we are able to build our network of SLPs in a way that works for us.  And let’s face it, what SLP can really stick to 140 characters?  Limiting our ability to “talk” is really the worst nightmare for an SLP, don’t you think?!

3.   It’s Not What You Say, It’s HOW You Say It:  The presenters chosen for this conference (I can only speak to the 5 presentations I partook) were down to earth, engaging, interactive and some of them were very, very humorous!  David Hammer, an SLP who presented on CAS, introduced himself by saying he’s NOT an expert but a specialist because he believes he is always learning.  This is one example of how things said really change the dynamic of the session.  Luckily, he was not the exception.  All of the presenters I encountered and talked to were there because they wanted to share their passion for their field with us.

2.  Use Our Time Wisely:  Each presentation was FILLED with useful information, techniques, strategies and therapy activities we can use on a daily basis for a variety of different deficits and disorders.  I was very happy to see that my money and my time was NOT wasted on theory or upcoming research while only spending the last 15 minutes on therapy as many times happens at conferences.  Rather, after every presentation I left with the feeling that I had new tools in my toolbox ready to try in therapy with my clients.

And my number 1 reason for attending the ASHA schools conference is…

1.  It Only Takes a SPARK:  The number one reason I recommend going to the ASHA Schools Conference is because it helps flame the fire and passion we have inside of us for our field.  It only takes a spark, but once our fire gets going, we are hard to stop!

So those are my top 10 reasons for attending the ASHA Schools Conference.  Did you go this year?  What are your impressions?

I have already started saving for next July’s schools conference which incidentally is being held in my old stomping grounds of Pennsylvania.  I hope to see some of you in Pittsburgh next summer!

Maria Del Duca, MS, 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.

Kid Confidential: What Reactive Attachment Disorder Looks Like

July11

 

Over the last few years, I have become aware of an increase in the number of referrals to assess children diagnosed with Reactive Attachment Disorder. Whether this is a coincidence or an indication of statistical increase in incidence of RAD, I cannot say.  What I can tell you is how clinically interesting and extremely frustrating these cases can be.

What is RAD?  According to Nancy Thomas, author of “When Love is Not Enough: A Guide to Parenting Children with RAD-Reactive Attachment Disorder,” RAD,  originally termed “attachment disorder” prior to 1979, is defined as a condition where an individual has difficulty forming lasting relationships and lacks the ability to be genuinely affectionate toward others.  In addition, persons with RAD do not learn to trust others and do not appear to develop a conscience.  This is believed to be caused by abuse or separation (physical or emotional) from one’s primary caregiver during the first three years of life which translates to an internally suppressed rage.  If untreated, children with RAD grow up to be adults who cannot truly ever feel love.  It is suggested that many of these adults will eventually be labeled as sociopaths or psychopaths.

According to Thomas, the following are a list of some signs that put infants at high risk for RAD in the first year of life:

  • Constant crying or a weak crying response
  • Tactile defensiveness (after 8 weeks, flinching or startling)
  • Poor clinging or holding on
  • Resistant to cuddles (may seem “stiff as a board”)
  • Lacks strong sucking response
  • Lacks eye contact and tracking skills
  • Demonstrates developmental delays
  • Does not exhibit a reciprocal smile
  • Doe not demonstrate “stranger anxiety”; appears to be indifferent to strangers
  • Will exhibit self abusive behaviors (head banging, etc.)

 

What can parents do to facilitate bonding with their infant?  Thomas makes several suggestions in her book.  Here are just a few of them:

  • Breastfeed if at all possible; hold bottle, never prop it up
  • Use a sling or carrier to carry the infant front facing toward the child’s mother for 4-6 hours daily
  • Baby massage, 20 mins/daily while smiling and using a high voice
  • Rock and hold infant with good eye contact while singing and taking using “motherese”
  • Sleep with or near parents at night
  • Nap skin to skin on dad’s chest

As these infants may be referred to speech-language pathologists due to feeding problems, we may be the first professionals to see these children.  So I believe it is important for us as professionals and parents to learn the warning signs and make the appropriate referrals as needed.

The following are signs and symptoms of RAD in children found in Thomas’ book:

  • Child is superficially engaging and charming
  • Lacks eye contact on parents’ terms
  • Demonstrates affection with strangers indiscriminately
  • Not affectionate on parents’ terms (no cuddling, etc.)
  • Appears “accident prone” in that the child is destructive to self, others and objects
  • Exhibits cruelty to animals
  • Steals
  • Lies about obvious things (outlandish lies)
  • Lacks impulse control; hyperactive frequently
  • Developmental delays (“learning lags”) due to being in a state of anger and frustration affecting ability to learn
  • Lacks cause and effect thinking
  • Lacks conscience
  • Exhibits abnormal eating patterns (not eating and/or gorging)
  • Has poor peer relationships
  • Seems to be preoccupied with fire, blood/gore, violence
  • Persistent nonsense chattering and questioning
  • Very demanding or inappropriately clingy
  • Exhibits abnormal speech patterns for the purpose of controlling situation
  • Attempts to triangulate adults against each other
  • Tells of false allegations of abuse
  • Feel entitled
  • Parents appear angry/hostile

 

What type of therapy works for children with RAD?  According to Thomas’ attachment therapy is a must. A good attachment therapist will work with the parents and child to create an attachment.  He/she will NOT allow the child to manipulate and triangulate them against their parents.  Additional therapies that can be of use in conjunction with attachment therapy are:  holding therapy, Neurofeedback or EEG biofeedback, EMDR (eye movement desensitization and reprocessing), Theraplay, Therapeutic horseback riding, specialized art therapy, music and sound therapy (Tomatis, Somonis), massage, nutritional supplements, and Psychodrama.

 

As SLPs, we may have children who have been or have yet to be diagnosed with RAD referred to us due to the “abnormal speech patterns” they tend to use.  The difficulty is in determining the true communication abilities of these children.  According to Thomas, little research supports effectiveness of speech services for children with RAD as communication is often times not truly affected.  Therefore, our role becomes more of a referral source either to a child psychologist for diagnostic purposes or to an attachment therapist for possible treatment.

 

Case Study, “Johnny”, 3 years old, seen in early childhood special education classroom setting:

 

Speaking from personal experience, I too was duped with the first child I ever suspected to have RAD.  Although, he was not diagnosed prior to my evaluation, I had come believe RAD was a strong possibility after many, many hours of collaboration and consultation with his early childhood special educator.

 

For confidentiality purposes let’s call this child, Johnny.  Johnny was reported to be a “difficult” child at home, requiring his mother’s constant attention, exhibiting extreme anger during typical play and sharing situations, highly impulsive, and very much enjoyed using language for the purpose of interrupting the classroom and manipulating adults.  As I was not familiar with this child prior to the evaluation, the only information I had were parent complaints of behavior at home.  When speaking to his mother, I was surprised to see that as Johnny tried to snuggle up to his mom in front of me, she would roll her eyes and push him away.  I didn’t understand then, that this reaction was because she knew he was attempting to manipulate me, showing me he was the loving child and his mother was the “bad guy.”  I didn’t know then, that his mother had spent years with little to no sleep because he insisted on sleeping on a cot at the bottom of his parents’ bed at night and woke up every night pretending to sleep walk.  I didn’t know then that Johnny would use a very high pitch and what I can only describe as “baby talk” when he wanted to seem sweet and affectionate all while trying to get something he wanted from someone.  I didn’t know then that this child would demonstrate the most rage and anger I had ever seen in a 3-year-old.  I didn’t know then, that the language he was using during my evaluation was his way of manipulating me.

 

After a few months, it became quite clear that the expressive language deficits Johnny exhibited during the initial assessment were not an accurate view of his true abilities.  In fact, although considered typically developing, he appeared to have higher receptive language skills than he portrayed during testing as well.  Academically, when Johnny would slip up a bit and show us what he really knew, he demonstrated good rote counting skills, early identification of some letters, and understood concepts of sorting and patterning with ease.  However, he had significant difficulties with peer interactions.  At this time, I attempted to change my strategies and help with his social skills by focusing on verbal expression of feelings of anger/frustration and using cognitive problem solving skills to determine appropriate behaviors during peer interactions in order to reduce hitting, grabbing, and physical contact with peers.

 

Yet, it wasn’t until the day, during a school assembly, Johnny picked his nose so long that he was gushing blood, did I realize he did not seem to register pain like you and I do.  As his teacher was unable to leave the rest of the classroom in the assembly without her, I took Johnny back to the classroom bathroom to clean up. Of course this was a day the school nurse was not in so I was on my own.  As he approached the bathroom, I watched as he stood up on the stool, looked in to the mirror and proceeded to smear his blood all over his face and arms while smiling in the mirror.  He did not see me watching him.  I’ve never seen a 3-year-old act like this.  It was in that moment, I became a true believer that he could very well be a child with RAD.

 

Unfortunately, Johnny and his family moved out of state prior to ever getting an outside evaluation to determine or rule out RAD.  And as you can imagine, the therapy strategies I attempted failed to carryover to functional play situations, although in the therapy room, he seemed to say all the right things (incidentally another sign that he might have had RAD).

 

I share this story with you because I know how easily one can be mislead and manipulated by a child.  Although I know I cannot diagnose RAD but based on the above signs and symptoms, Johnny exhibited 15 out of 22 of them and in my humble opinion, RAD was a very good possibility.

 

As they say, hind sight is 20/20, and I feel I am still learning long after Johnny is no longer on my caseload.  If I could turn back the clock there are two things I would have done differently.  Firstly, once I knew Johnny and saw him for who he truly was, I would have told his mother with sincerity that I believed her when she was telling me about his behavior problems at home.  Secondly, I would have pushed harder for her to follow through with a psychological evaluation prior to their move out of state.

 

At the end of the day, for the few months that I worked with Johnny, I learned to question everything I thought I knew about child development and language acquisition.  I learned to keep looking, consulting, collaborating and never give up trying to find the source of the problem.  Even if clarity came to us as a multidisciplinary team too late, I find that I will always be grateful to Johnny for the lessons he taught me and how he has personally made me a better diagnostician, therapist, collaborator and yes, even a better parent to my own son.

 

RAD can be a very confusing and trying disorder to understand.  We as professionals can work with a child for a very long time before we realize all the signs and symptoms are really pointing to something other than communication deficits.  However, as long as we never give up trying to help, as long as we continue to consult, collaborate, and research we may just be able to help these children by referring them to the correct professional.

 

 

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.

Kid Confidential-Behavior Disorders and Language Impairment in School-Age Children

Mayblog

 

In January, I read an article published in ASHA’s SIG 16 Perspectives December 2012 issue by Alexandra Hollo from the Department of Special Education, at Vanderbilt University in Nashville, Tenn., titled “Language and Behavior Disorders in School-Age Children: Comorbidity and Communication in the Classroom.”  She brought up some really good points that I think we, as SLPs, need to keep in mind when discussing, assessing and treating children who are labeled with behavior disorders.

Hollo discusses how often times children labeled with EBD (emotional and behavioral disorders) also have undiagnosed LI (language impairment).  According to this article, “Four out of five students with EBD are likely to have an unidentified language deficit,” which may result in children resorting to physical communication rather than effective use of expressive language to resolve issues.  In fact, it is estimated that 80.6 percent of students with EBD also have LI however, more than 50 percent of those LI diagnoses remain unidentified.  If staff members fail to recognize the child’s inability to functionally communicate, negative feelings and interactions between the student and staff members may result, which in turn negatively affects academic achievement. What is known about children with EBD is that they “have the most negative short- and long-term outcomes” (Hollo, 2012).

So what does EBD look like in children?  Well Hollo explains the two subcategories of EBD according to the DSM-IV, difficulties with internalizing and externalizing.  Deficits in internalizing include emotional withdrawal behaviors such as depression, anxiety or mood disorders.  Academic trends for these students with internalizing problems include high rates of absenteeism and low academic achievement.  Deficits in externalizing include disruptive behavior as in ADHD, ODD or conduct disorder.  Students with externalizing deficits tend to be more easily identified and receive services possibly due to the fact that their behavior is disruptive in the academic setting and can more easily be determined to interfere with learning.  Academic trends for students with externalizing issues:  disruptive behavior tends to interrupt and/or terminate instruction and therefore affect learning.  More importantly, it was stated that although students with EBD do perform similarly to those with other disorders on standardized tests, their academic performance tends to be BELOW that of other students with disabilities.

In addition to academic deficits, children with EBD also demonstrate deficits in language and social skills.  These children more often exhibit expressive language deficits rather than deficits in receptive language, and they tend to use simplified language within the classroom environment resulting in teachers grossly overestimating the student’s expressive language abilities.  It is important to note that based on Hollo’s research, the CELF and TOLD were the only two language tests that were able to consistently identify LI in children already diagnosed with EBD.

 

Socially, children with EBD tend to have negative teacher interactions, are often times rejected or victimized by peers, and struggle with use of effective conversational skills due to difficulties in initiating and maintaining friendships, problem solving deficits, and difficulties cooperating and collaborating with peers and adults.  In addition, students with EBD tend to be impulsive and struggle with the use of “inner dialogue” to effectively reason prior to responding to their emotions within various situations.  Their ability to control their emotions, follow directions, and transition between activities, classes and subjects is also affected.

Why is this information important for us as SLPs to know?  Well we must first be educated on the comorbidity between EBD and LI to effectively screen, assess, and treat these students.  We also have the responsibility to train staff members on the child’s communication and social skills deficits so as their behaviors may not be misconstrued.  We as SLPs can be instrumental in implementing linguistic supports for these children which include direct (i.e. teaching emotional language, using self-talk for regulation and problem solving skills, provide opportunities to practice negotiations with peers, etc.) and indirect instruction (i.e. collaborate with staff, train teachers on effective communication styles, teach use of slow rate of speech, etc.).  In addition, we can work with behavioral specialists to follow and enforce the behavioral supports that are deemed necessary to help students with EBD be successful in their daily environments.

So the next time you are in your weekly RTI meeting discussing a “problem child” or a “shy, quiet student,” pay attention, and keep in mind that EBD does not look the same in every child. Some behaviors may in fact be linked to language deficits.  Only we, as SLPs will be able to make that determination effectively in order to ensure students receive the services and support they require.

Note:  This entire article was not discussed in detail here.  I discussed the information I felt was important based on my personal clinical experiences.  I refer you to Hollo’s complete article in the December 2012 SIG 16 issue for further information and details.

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.