A Tool to Help Children Ask for Help

questioning child
Richie is an engaging 9-year-old boy who is in treatment to improve his language skills. He is compliant and cooperative in sessions and is eager to learn new information. There’s only one problem: Richie is unable to spontaneously ask questions and request clarification when he doesn’t understand what he is told.

He’ll just sit quietly, making nice eye contact with the clinician. His entire body posture says, “I am listening to you!” But when it comes to answering questions about what he’s learned, Richie clearly doesn’t get. He might attempt to answer the questions and stumble halfway through before giving up. He might also provide an answer completely unrelated to the question. But most of the time, much to our frustration, Richie will simply shrug his shoulders and reply, “I don’t know.” This is typically when some might ask him with barely disguised frustration: “Why didn’t you tell me before that you didn’t understand?” Richie will shrug his shoulders again.

But here’s what’s important: He is not trying to be oppositional. He really doesn’t know.

Richie has impaired executive function, and this causes difficulties with initiation—asking questions, getting help, beginning to work on tasks and so forth—and pursuing clarification when he needs it.

Executive function is a set of mental processes regulated by the frontal lobe of the brain that help with optimal life functioning. Intact executive function allows us to manage, plan, organize, strategize, attend to, and remember things appropriately. However, if EF is underdeveloped or impaired (damaged) as a result of an injury or disorder, such as attention-deficit hyperactivity disorder or fetal alcohol spectrum disorder, then the child will present with significant difficulties in various areas of functioning. This will make it difficult to appropriately meet school requirements or engage in successful social interactions.

While it is important that children with EF impairment receive remediation in all affected areas, I typically start by targeting initiation, specifically improving the child’s ability to ask for help when needed. Why is that skill more important than the rest? For starters, it lets you know when something is wrong, or in some extreme cases, very wrong.

Imagine working with a 10-year-old verbal child who all of the sudden shuts down and cries while clutching her stomach. You spend valuable time questioning, prodding and cajoling until, about 10 minutes later, you find out that the child had an acute stomach ache. She was simply unable to initiate and tell you, “I need help. My stomach hurts.”

This is why it is important to use charts and other such strategies to help these children navigate treatment. To illustrate, I’ve created a “Strategies of Asking for Help” chart for my clients who are verbal but have mild cognitive impairment (IQ 70+) or have average cognition. I keep this chart in the child’s line of vision and remind him or her to choose a relevant strategy from the chart to alert me when in need of help. For example, under the category, “if confused,” the chart advises saying, “I don’t know where to find the answer.”

Of course, prior to using the chart, I pre-teach the child the strategies on the chart. I also explain when to use each strategy (during what type of tasks/questions/situations), as well as why it is so important to ask for help. Depending on the severity of the child’s impairment, I may need to spend several sessions pre-teaching these concepts to optimize the child’s success.

I also don’t limit use of the chart to language treatment sessions. What would be the point if the child only learns to ask for help during treatment, but is unable to do so when working on assignments in class or homework at home? Consequently, I provide a copy to both teachers and parents to attach to the child’s desk in class and at home.

Thus, the chart serves as a continuing visual reminder to ask help, along with strategies for how to do it. For your own free copy of the chart, download a copy here from my blog, Smart Therapy LLC.


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

Why Suspected Childhood Apraxia of Speech Requires Careful Assessment

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

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

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

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

Me: And what did the speech therapy evaluation reveal?

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

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

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

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

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

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

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

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

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

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

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

 

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

“Appdapting” Flashcard Apps to Address Social Skills

boy throwing ball

I have to admit, I don’t really like flashcards. I especially don’t like it when parents or SLPs use flashcards to drill vocabulary in toddlers and preschoolers, much less school aged children. I feel that it produces very limited learnability and generalization. I am personally a proponent of thematic language learning, since it allows me to take a handful of words/concepts and reinforce them in a number of different ways. The clients still get the benefit of information repetition, much like one would get during a typical flashcard drill.  However, they are also getting much more.  Thematic language learning allows the client to increase word comprehension, make connections to real life scenarios,  develop abstract thinking skills, as well as to transfer and generalize knowledge (Morrow, Pressley, Smith, &  Smith, 1997; Ramey, 1995).

However, even though I dislike flashcards, I still don’t necessarily want to give up using them completely, especially because nowadays many different type of image based language flashcards can be found for free as both printables as well as Iphone/Ipad apps.  Consequently, I decided to pick a free flashcard app and adapt it or rather  ”appdapt” it (coined by “The Speech Guy”, Jeremy Legaspi, the “Appdapt Guru”) in a meaningful and functional way for my students.

After looking over and rejecting a number of contenders, without a clear plan of action in mind,  I stumbled upon a free app, ABA Flash Cards – Actions by kindergarten.com, which is designed to target verb labeling in ASD children.   When I saw this app, I immediately knew how I wanted to appdapt it.  I especially liked the fact that the app is made for both Ipad and Iphone. Here’s why.

My primary setting is an out of district day school inside a partial psychiatric hospital.  So in my line of work I  frequently do therapy with students just coming out from  ”chill out rooms” and “calm down areas”.  This is definitely not the time when I want to bring or use a lot of materials in the session, since in a moment’s notice the session’s atmosphere can change from calm and productive into volatile and complicated.  I also didn’t  want to use a bulky Ipad in sessions with relatively new children on the caseload, since it usually takes a few sessions of careful observations and interaction to learn what makes them “tick”. Consequently, I was looking for an app which could ideally be downloaded onto not just the Ipad but also the Iphone. I reasoned that in unexpected  situations I could simply put the phone into my pocket, unlike the Ipad, which in crisis situations can easily become a target or a missile.

Given the fact that many children with psychiatric disorders present with significant social pragmatic language deficits (Hyter, 2003; Hyter et al 2001; Cohen et al., 1998; Bryan, 1991; Goldman, 1987 ), which is certainly the case for the children on my caseload, I planned on adapting this app to target my students’ pragmatic language development, social problem solving skills as well as perspective taking abilities.

So here are just a few examples of how I appdapted the cards.  First, I turned off the sound, since the visual images were what I was going after.  Then I separated the cards into several categories and formulated some sample questions and scenarios that I was going to ask/pose to the students:

Making Inferences (re: People, Locations and Actions)

iPhone Screenshot 2

What do you think the girl is thinking about?

How do you know what she is thinking?

How do you think she is feeling?

How can you tell?

Where do you think she is?

How do you know?

 

Multiple Interpretations of Actions and Settings: 

iPhone Screenshot 3

What do you think the girl is doing?

What else could she be doing?

 

 

 

 

 

 

 

 

 

How does the boy feel about the flower?

Give me a different explanation of how else can he possibly feel?

 

 

 

 

 

 

 

 

Who are the boys in the picture? (relationship)

Who else could they be?

What do you think the boy in a blue shirt is whispering to the boy in a red shirt?

What else could he be saying?

How do you know?

 

 

Supporting Empathy/Sympathy and Developing Peer Relatedness:

 

 

 

 

 

 

 

 

 

How does this child feel?

Why do you think he is crying?

What can you ask him/tell him to make things better?

 

 

 

 

 

 

 

 

The girl is laughing because someone did something nice for her?

What do you think they did?

 

Interpreting Ambiguous Situations:

 

 

 

 

 

 

 

 

 

What is the boy doing?

Who do you think is the woman in the picture?

How do you know?

How does she feel about what the boy is doing?

How do you know?

 

My goal was to help the students how to correctly interpret facial features, body language, and context clues in order to teach them how to appropriately justify their responses. I also wanted to demonstrate to them that many times the situations in which we find ourselves in or the scenes that we are confronted with on daily basis  could be interpreted in multiple ways. Moreover, I wanted to teach how appropriately speak to, console, praise, or compliment others in order to improve their ability to relate to peers. Finally, I wanted to provide them with an opportunity to improve their perspective taking abilities so they could comprehend and verbally demonstrate  that other people could have feelings, beliefs and desires different from theirs.

Since I knew that many of my students had significant difficulties with even such simple tasks as labeling and identifying feelings, I also wanted to make sure that the students got multiple opportunities to describe a variety of emotions that they saw in the images, beyond offering the rudimentary labels of “happy”, “mad”, “sad”, so I took pictures of Emotions Word Bank as well as Emotion Color Wheel courtesy of the Do2Learn website, to store in my phone, in order to provide them with extra support.

                

The above allowed me not only to provide them with visual and written illustrations but also to teach them synonyms and antonyms of relevant words.  Finally, per my psychotherapist colleagues request,  I also compiled a list of vocabulary terms reflecting additional internal states besides emotions (happy, mad) and emotional behaviors (laughing, crying, frowning). These included words related to:  Cognition (know, think, remember, guess), Perception (see, hear, watch, feel), and Desire (want, need, wish), (Dodd, 2012) so my students could optimally benefit not just from language related therapy services but also their individual psychotherapy sessions as well.

I’ve only just began trialing the usage of this app with the students but I have to admit, even though its still the early days, so far things have been working pretty well. Looks like there’s hope for flashcards after all!

References:

———Bryan, T. (1991). Social problems and learning disabilities. In B. Y. L. Wong (Ed.), Learning about learning disabilities (pp. 195-229). San Diego, CA: Academic Press.

—Cohen, N. & Barwick, M. (1996) Comorbidity of Language and Social-Emotional Disorders: Comparison of Psychiatric Outpatients and Their Siblings. Journal of Clinical Child Psychology, 25(2), 192-200.

Goldman, L. G. (1987). Social implications of learning disorders. Reading, Writing and Learning Disabilities, 3, 119-130.

—Hyter, Y. D., et al (2001). Pragmatic language intervention for children with language and emotional/behavioral disorders. Communication Disorders Quarterly, 23(1), 4–16.

Hyter, Y. D. (2003). Language intervention  for children with emotional or behavioral disorders. Behavioral  Disorders, 29, 65–76.

Morrow, L. M., Pressley, M., Smith, J.K., & Smith, M. (1997). The effect of a literature-based program integrated into literacy and science instruction with children from diverse background. Reading Research Quarterly, 32(1), 54-76.

Petersen, D. B., Dodd, J & Finestack, L. H (2012, Oct 9) Narrative Assessment and Intervention: Live Chat. Sponsored by SIG 1: Language Learning and Education. http://www.asha.org/events/live/10-09-2012-narrative-assessment-and-intervention/

Ramey, E. K. (1995). An integrated approach to language arts instruction. The Reading Teacher, 48(5), 418-419.

 

(This post originally appeared on the Smart Speech Therapy LLC blog)

 

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

Therapy Fun with Ready Made Fall and Halloween Bingo

 

There are many fun therapy activities you can do with your preschool and school aged clients in the fall. One of my personal favorites is bingo. Boggles World, an online ESL teacher resource actually has a number of ready made materials, flashcards, and worksheets which can be adapted for speech language therapy purposes. For example, their Fall and Halloween Bingo comes with both call out cards and a 3×3 and a 4×4 (as well as 3×3) card generator/boards. Clicking the refresh button will generate as many cards as you need, so the supply is endless! You can copy and paste the entire bingo board into a word document resize it and then print it out on reinforced paper or just laminate it.

Fall vocabulary words include: corn, crops, farmer, scarecrow, apples, acorns, oak leaf, maple leaves, ginkgo leaves, grapes, mushrooms, salmon, geese, squirrel, jacket, turkey, Jack-O’-Lantern, rake, pumpkins, harvest moon, hay, chestnuts, crow, and sparrow

Halloween vocabulary words include: witch, ghost, skeleton, skull, spider, owl, Jack-O’-Lantern, devil, cobweb, graveyard, clown, pirate, robot, superhero, mummy, vampire, bat, black cat, trick or treaters, alien, werewolf

Now the fun begins!

Some suggested activities:

Phonological Awareness:

  • Practice Rhyming words (you can do discrimination and production activities): cat/bat/ trick/leaf/ rake/moon
  • Practice Syllable and Phoneme Segmentation  (I am going to say a word (e.g., ghost, spider, alien, etc) and I want you to clap one time for each syllable or sound I say)
  • Practice Isolation of initial, medial, and final phonemes in words ( e.g., What is the beginning/final  sound in mummy, vampire, robot, etc?) What is the middle sound in bat/cat/geese/rake etc?
  • Practice Initial and Final Syllable and Phoneme Deletion in Words  (Say spider! Now say it without the der, what do you have left? Say trick, now say it without the /t/ what is left; say corn, now say it without the /n/, what is left?)

Articulation/Fluency:

  • Practice production of select sounds/consonant clusters that you are working on or just production at word or sentence levels with those clients who just need a little bit more work in therapy increasing their intelligibility or sentence fluency.

Language:

  • Practice Categorization skills via convergent and divergent naming activities: Name Fall words, Name Halloween Words, How many trees  whose leaves change color can you name?, how many vegetables and fruits do we harvest in the fall? etc.
  • Practice naming Associations: what goes with a witch (broom), what goes with a squirrel (acorn), etc.
  • Practice providing Attributes via naming category, function, location, parts, size, shape, color, composition, as well as accessory/necessity.  For example, (I see a pumpkin. It’s a fruit/vegetable that you can plant, grow and eat. You find it on a farm. It’s round and orange and is the size of a ball. Inside the pumpkin are seeds. You can carve it and make a jack o lantern out of it).
  • Practice providing Definitions: Tell me what a skeleton is. Tell me what a scarecrow is.
  • Practice naming Similarities and Differences among semantically related items: How are pumpkin and apple alike? How are they different?
  • Practice explaining Multiple Meaning words:   What are some meanings of the word bat, witch, clown, etc?
  • Practice Complex Sentence Formulation: make up a sentence with the words crops and unless, make up a sentence with the words skeleton and however, etc.
  • Or you can just make up your own receptive, expressive and social  pragmatic language activities to go along with these games.

So join in the fun and start playing!

(This post originally appeared on the Smart Speech Therapy LLC blog)

 

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

Adventures in Word Finding or is Their Language Comprehension Really THAT Bad?

One Word IV

Photo by LauraLewis23

This summer I am taking an online course on word finding with Dr. Diane German, and I must say, in addition to all the valuable information I have learned so far, this course has given me a brand new outlook on how to judge the language comprehension abilities of my clients with word finding difficulties.  It all started with a simple task, to determine the language comprehension abilities of my client with word finding deficits.  Based on available evidence I’ve collected over the period of time I’ve been working with him, I had determined that his comprehension was moderately impaired. I was then asked by Dr. German what language tasks I had used to make that determination.  She also pointed out that many of the formal language comprehension tasks I’ve listed in my report required an oral response.

That question really got me thinking. The truth of the matter is that many formal tests and informal assessments that probe language comprehension abilities rely on learners oral responses. But as it had been pointed out to me, what of our clients with impaired oral skills or significant word retrieval deficits? Most of the time we judge their language comprehension based on the quality of the oral responses they produce, and if their answers are not to our satisfaction, we make sweeping judgments regarding their comprehension abilities, which as Dr. German rightfully pointed out “is the kiss of death” for learners with word finding difficulties and could potentially result in “a spiral of failure”.

Now, in the case of this particular client in question, his language comprehension abilities were truly moderately impaired. I knew that because I tested him by showing him pictures of situations and asked him questions, which did not rely on oral responses but on him selecting the correct answer from a series of pictures and written sentences.

However, had I not performed the above tasks and simply relied on the “language comprehension” subtests from popular standardized tests alone, I would not have had a defensible answer and would have had to admit that I had no clue whether his language comprehension was truly as impaired as I had described.

Following that discussion I decided to take a “fresh look” at the other expressively impaired clients on my caseload but first I needed to figure out which tasks truly assessed my clients’ language comprehension abilities. I didn’t just want to assess their listening skills and vocabulary knowledge (some of the more “easily” assessed non-verbal skills). I wanted to know whether their memory, problem solving skills, figurative language, perspective taking abilities or knowledge of multiple meaning words were actually better than I had originally judged.

Thus, I set out to compile language comprehension materials (formal or informal), which could be used to assess various aspects of language comprehension (multiple meaning words, problem solving abilities, etc) without relying on the child’s ability to produce verbal responses.  However, this task turned out to be far more difficult than I had originally anticipated. For example, when I took a closer look at one of the more popular standardized tests available to me, such as the CELF-4, I realized that there were only two subtests on the first record form 5-8 years (“Concepts and Following Directions” and “Sentence Structure”) and 3 subtests on the second form 9-21 years (“Concepts & Following Directions”, “Sentence Assembly”, and “Semantic Relationships”) that relied on the listener’s ability to point to pictures or use written visuals to answer questions. Moreover, two of the subtests on the second record form (Sentence Assembly”, and “Semantic Relationships”) still required verbal responses.  All other subtests testing “listening comprehension abilities” relied purely on oral responses for correct score determination.

As I reviewed other popular tests (TOLD, CASL, OWLS, etc) I quickly realized that few of these tests’ subtests actually satisfied the above requirement.  Moreover, tests that actually did considerably rely on nonverbal responses (e.g., pointing) such as the Test for Auditory Comprehension of Language-3 (TACL-3) or the Test of Language Competence- Expanded Ed (TLC-Expanded Ed), were unfortunately not accessible to me at my place of work (although I did manage briefly to borrow both tests to assess some clients).

So, I decided to adapt some of the existing tests as well as create a few of my own materials to target language comprehension abilities in various areas.  Surprisingly, it wasn’t as difficult as I imagined it to be, though some tasks did require more creativity than others.

The easiest of course were the assessment of receptive vocabulary for nouns, verbs, and adjectives which was accomplished via standardized testing and story comprehension for which I created picture answers for the younger children and written multiple choice responses for the older children. Assessment of synonyms and antonyms was also doable. I again printed out the relevant pictures and then presented them students.  For example, to assess synonym knowledge the student was shown a relevant picture and asked to match it with another similar meaning word:  “show me another word for “trail” (requires the student to point to a picture depicting “path”) or “show me another word for “flame” (requires the student to point to a picture depicting “fire”). For recognition of antonyms, the student was presented with pictures of both synonyms and antonyms and told: “show me the opposite of child” or “show me the opposite of happy” and so on.

To assess the student’s understanding of “Multiple Meanings” I borrowed the sentences from the Language Processing Test-3 Elementary (LPT-3E), and printed out a few pictures from the internet. So instead of asking the student to explain what “Rose” means in the following sentences:  “Ask Rose to call me”, or “The sun rose over the mountains”, I asked the student to select and point to a corresponding picture from a group of visually related multiple meaning items.  For some children, I also increased the complexity by presenting to them pictures which required attention to details in order to answer the question correctly (e.g., differentiating between boy and girl for the first picture or between actual sunrise and sun peeking through the clouds for the second picture).   Similarly, to assess their problem solving abilities I again printed out pictures to go with select verbal reasoning questions: “Point to what you would do if …”; “Point to how you would solve the following situation…?”

I do have to admit that one of the more challenging subtests to adapt was the “Recalling Sentences” task.  For that I ended up creating similar sounding sentences and asked the child to select the appropriate response given visual multiple choice answers (e.g., point to which sentence did I just say? “The tractor was followed by the bus?” “The bus was followed by the tractor?” “The tractor was followed by the bicycle.”

Again, the point of this exercise was not to prove that the learners’ comprehension skills were indeed impaired but rather to assess whether their comprehension was as significantly impaired as was originally judged. Well the truth of the matter was that most of the children I’ve reassessed using the “pure” auditory comprehension tasks ended up doing much better on these tasks than on those which required verbal responses.

To illustrate, here is a recent case example. I was working with one student on strengthening his knowledge of geography related core vocabulary words (names of the continents and the major bodies of water surrounding them).  This boy had profound difficulty recalling the words even with maximal phonemic cues, after multiple sessions of drill instruction.   Typically after he was shown a specific continent and asked to name it he produced a semantically related response (“South America” for “North America”, “Arctic” for “Antarctica”, etc), which appeared to indicate that his “knowledge” of the words was impaired or at least highly inconsistent.  However, when the verbal naming task was completely eliminated and he was asked to show the examiner specifically named continents and bodies of water on a map (e.g., “Show me Europe”; “Show me Atlantic Ocean”, etc) he was able to do so with 90% accuracy over 3 trials indicating that he did have fairly solid knowledge of where each continent was located visually on a map.

Consequently, as Dr. German has rightly pointed out, when making judgment calls regarding language comprehension abilities of complex clients with severe or at least fairly involved expressive language difficulties, it is very important that SLP’s use tasks that require non verbal responses to questions (e.g., pointing, selecting a picture out of a group, etc), in order not to underestimate these children’s “true” comprehension abilities.

 

References and Resources:

German, D. J. (2009, Feb. 10). Child Word Finding: Student Voices Enlighten Us. The ASHA Leader, 14 (2), 10-13.

German, D.J. (2005) Word-Finding Intervention Program, Second Edition (WFIP-2)  Austin Texas: Pro.Ed

German, D.J. (2001) It’s on the Tip of My Tongue, Word Finding Strategies to Remember Names and Words You Often Forget.  Word Finding Materials, Inc.

Dr. German’s Word Finding Website: http://www.wordfinding.com/

 

This post originally appeared on www.smartspeechtherapy.com/blog/)

 

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

 

Dinner with Friends, or the Value of Interdisciplinary Collaboration and Follow Up

Connexion

Photo by tangi_bertin

Several months ago I had dinner with two of my colleagues, a pediatrician and a clinical social worker, to iron out the details of our upcoming conference presentation. As time went by we managed to discuss every topic under the sun, yet still the subject of our presentation was sadly not on the agenda. Exhausted from working at the hospital a full day and seeing private clients afterwards, I was getting distinctly antsy as the hand clock kept climbing closer to midnight.

The conversation began to feel more productive when we started to touch base on our mutual clients. Mostly they wanted to hear from me, since they both share an office suite and I was the only one located off-site. So, even though we all individually conferred frequently via phone regarding clients, that was the first time all three of us got together in the same room to discuss them. Quickly, I rattled off each of my clients’ progress in therapy, until I got to D, and paused. Oh, don’t get me wrong I am very proud of my work with D, with whom I’ve been working for several years, and who went from being limitedly verbal, severely echolalic, and “autistic-like” at the age of 4.5 to fluent complex sentence speaker, fledgling problem solver, and a little charmer by the age of 6.5. Yet something was still bothering me that I couldn’t put my finger on regarding D’s performance. Despite the absence of a particular diagnosis (e.g., ASD) and significant gains, his issues with attention and cognition persisted, and his progress was still halting and inconsistent, even with rigorous language therapy and supplementary academic instruction at home four times a week.

In my desperation I had already considered and mentally rejected a number of referrals (“No it doesn’t seem to be a psychiatric issue,” “Yes he can benefit from a neurological but should I refer him for a psychological assessment first, could it be an IQ issue?”) I pondered out loud as I shared my concerns with my colleagues. Neither of them have seen him for about six months so the clinical social worker immediately whipped out his chart, busily looking for appropriate information, while the pediatrician frowned, searching her memory for an “appropriate entry.” “Wait a second,” she said, “when I last saw him, during his physical exam I saw brown café au lait spots on his skin that I didn’t like at all, so I referred mom to get some blood work done but I haven’t heard from her since that time. Since you see her every week, can you please ask her to call me ASAP so I could remind her to do the blood test, as the information you are telling me makes it even more imperative that she follow up with the lab work.”

Right away, I became alert. Though the pediatrician was not stating her suspicions explicitly, through years of working with medical professionals I was familiar with the implications of what café au lait spots can potentially represent and that is neurofibromatosis. It is a neurocutaneous syndrome that leads to benign tumor growths in various parts of the body and can affect the brain, spinal cord, nerves, skin, and other body systems. In additional to all the medical implications of this syndrome (e.g. tumors becoming cancerous), it can also cause cognitive deficits and subsequent learning disabilities that affect appropriate knowledge acquisition and retention.

To me the situation was clear; no matter what the outcome, as the only team professional in contact with the parent at the time, it was my job to counsel the parent that she get in touch with the pediatrician so she can successfully pursue the recommended course of action. It may not have been the position I wanted to be in but unfortunately I knew that if this matter was left unpursued, I was left with a whole host of unanswered questions regarding further treatment options for this child.

I use the above example to emphasize the value and importance of working as part of a team to treat the “whole” child. Therapists specializing in working with children on the spectrum are most familiar with being part of a team, since they are just one of many professionals such as behaviorists, OT’s, psychologists or neurologists who are working with a child. Being part of a team is also a much more acceptable practice when a child is treated in a hospital or a rehab setting and presents with a complex disorder (e.g. is medically fragile, has a genetic syndrome, etc).

However, in our field, even outside of specialty settings (hospital/rehab) we are frequently confronted with speech or language disordered clients who stump our thinking processes, and who require the team approach (including the involvement of specialized medical professionals). Yet oftentimes that creates a significant challenge for many clinicians who are working contractually (through an agency) in school settings or in private practice. Being part of a team when one is contractor or a sole practitioner in a private practice is a much more difficult feat, especially when the clinicians are just striking out on their own for the first time.

Both interdisciplinary and multidisciplinary teamwork is oftentimes so crucial in our field. Working as part of a team allows us to collectively pursue common goals, combine our selective expertise, initiate a discussion to solve difficult problems, as well as to have professional lifelines when working on difficult cases. Different providers (neurologist, SLP, OT) see different symptoms as well as different aspects of the patient’s disorder. Consequently, different providers bring different perspectives to the table, which ultimately contributes positively to the treatment of the whole child.

Interestingly, many private speech language practitioners have wide referral networks (e.g., pediatricians, OT’s, PT’s and others who refer clients to them) yet when asked regarding frequency of contact with respect to conferences/discussions about the progress of specific clients, many clinicians draw a blank.

So how can we develop productive professional relationships with other service providers that goes beyond the initial referral? I’ll be the first one to admit that it is not an easy task, especially when it comes to physicians such as psychiatrists, neurologists, geneticists, or developmental pediatricians. I can tell you that while some of my professional relationships came easy, others took years to attain and refine.

In my hospital setting I work as part of a team. However, when I first started out in private practice, in a fairly short period of time I ended up having a number of clients with complex diagnoses and no one to refer them to. What complicated matters further that in contrast to them being referred to me by a pediatrician, these clients came to me first, since their most “visible issues” at the time were speech language deficits. I had to be the one to initiate the referral process to suggest to their parents relevant medical professionals, which needed to be visited in order to figure out why their children were having such complex language difficulties (among other symptoms) in the first place.

So here are a few suggestions on how to initiate and maintain professional relationships with medical service providers:

  • Start with doing a little research. You have worked hard to build your practice and your clients deserve the best, so locate the best medical service providers in your area. In the past I’ve had some excellent recommendations from locally based colleagues who were active on the ASHA discussion forums, other client’s parents who already did the necessary legwork, or hospital based colleagues who recommended peers in private practice. Several times I actually liked the initial medical reports I’ve received on a client so much – that I’ve referred other clients to the same doctor.
  • When word of mouth fails to do the trick, I turn to “Google” to provide me with desired results. Surprisingly, simply typing in “best _______in _____(name of state)” frequently does the trick and allows me to locate relevant professionals, after browsing through the multitude of web reviews.
  • Of course depending on the length of client treatment, you will have different relationships with different medical providers. I have collaborated for years with some (e.g., pediatrician, psychiatrist), and only infrequently spoken with others (geneticist, otolaryngologist, pediatric ophthalmologist).
  • Typically, when I refer a client for additional testing or consultation, in my referral letter to the physician, I request to receive the results in writing, asking the physician to also include relevant recommendations (if needed). Oftentimes, I also try to set some time to discuss the findings in a phone call in case I have any additional questions or concerns. Of course, I also send the physician (and other providers working with the child) the information from my end (progress reports, evaluations) so all of us can have a more comprehensive profile of the client’s disorder/deficit.

After all, ST’s, OT’s and PT’s are not the only ones who are dependent on information from doctors in order to do our work better. There are times when physicians need information from us in order to move further in treatment such as order specific tests. For example, just recently a pediatrician used my therapy progress report in conjunction with another provider’s, to order an MRI on our mutual client. The pediatrician had significant concerns over client’s development and presenting symptomatology, and needed to gather additional reports supporting her cause for concern in order to justify her course of action (ordering an MRI) to the HMO.

As mentioned previously there are numerous benefits to teamwork including the fact that it allows for appreciation of other disciplines, creation of functional goals for the child, integration of interventions as well as “brings together diverse knowledge and skills and can result in quicker decision-making” (Catlett & Halper, 1992).

Given the above, it is important that speech language pathologists help coordinate care and maintain relationships with other medical and related professionals who are treating the child. This will improve decision-making, allow the professionals to address the child’s deficits in a holistic manner, an even potentially expedite the child’s length of stay in therapy.

References:
Catlett, C & Halper, A (1992). Team Approaches: Working Together to Improve Quality. ASHA: Quality Improvement Digest. http://www.asha.org/uploadedFiles/aud/TeamApproaches.pdf

National Institute of Neurological Disorders and Stroke (NINDS) Neurofibromatosis Information Page. http://www.ninds.nih.gov/disorders/neurofibromatosis/neurofibromatosis.htm

(This post originally appeared on Smart Speech Therapy)

 

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

Multicultural Considerations in Assessment of Play

Disdyakis dodecahedron

Photo by nfdecomite

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

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

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

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

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

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

References:

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

This post originally appeared on www.smartspeechtherapy.com/blog/)

 

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

Speech-Language Activity Suggestions for Multisensory Stimulation of At-Risk Children

In recent years the percentage of “at-risk” children has been steadily increasing across pediatric speech-language pathology caseloads.  These include adopted and foster care children, medically fragile children (e.g., failure to thrive), abused and neglected children, children from low socioeconomic backgrounds or any children who for any reason lack the adequate support system to encourage them to function optimally socially, emotionally, intellectually, or physically.

At times speech-language pathologists encounter barriers when working with this population, which include low motivation, inconsistent knowledge retention, as well as halting or labored progress in therapy.

As a speech-language pathologist whose caseload consists entirely of at-risk children, I have spent countless of hours on attempting to enhance service delivery for my clients. One method that I have found to be highly effective for greater knowledge retention as well as for increasing the kids’ motivation is incorporating multisensory stimulation in speech and language activities.

To date, a number of studies have described the advantages of multisensory stimulation for various at risk populations. For example, in 2003 a study published in Journal of Research in Nursing and Health described the advantages of multisensory stimulation for 2 week old Korean orphans who received auditory, tactile, and visual stimulation twice a day, 5 days a week, for 4 weeks. This resulted in significantly fewer illnesses as well as significant gains in weight, length and head circumference, after the 4-week intervention period and at 6 months of age. Another 2009 study by White Traut and colleagues published in the Journal of Obstetric, Gynecologic, & Neonatal Nursing, found that multi sensory stimulation consisting of auditory, tactile, visual, and vestibular intervention contributed to a reduction of infant stress reactivity (steady decline in cortisol levels).   Moreover, multisensory stimulation is not just beneficial for young children. Other studies found benefits of multisensory stimulation for dementia (Milev et al, 2008) and coma patients (Doman & Wilkinson, 1993), indicating the usefulness of multisensory stimulation for a variety of at risk populations of different age groups.

After reviewing some studies and successfully implementing a number of strategies I wanted to share with you some of my favorite multisensory activities for different age-groups.

Before initiating any activities please remember to obtain parental permissions as well as a clearance from the occupational therapist (if the child is receiving related services), particularly if the child presents with significant sensory issues.  It is also very important to ensure that there are no food allergies, or nutritional restrictions, especially when it comes to working with new and unfamiliar clients on your caseload.

Multisensory stimulation for young children does not have to involve stimulation of all the senses at once. However, there are a number of activities which come quite close, especially when one combines “touch ‘n’ feel” books, musical puzzles as well as paper and edible crafts.

Here’s one of my favorite speech language therapy session activities for children 2-4 years of age. I use a board book called Percival Touch ‘n’ Feel Book to teach insect and animal related vocabulary words as well as talk about adjectives describing textures (furry, smooth, bumpy, sticky, etc).  As I help the children navigate the book, they get to touch the pages and talk about various plant and animals parts such as furry caterpillar dots, shiny flower petals, bumpy frog skin, or sticky spider web.   We also work on appropriately producing multisyllabic words and on combining the words into short sentences, depending of course, on the child’s age, skills, and abilities.   With this activity I often use animal and insect musical puzzles so the children can hear and then imitate select animal and insect noises.

Also, since all of Percival’s friends are garden insects and animals, it’s fairly easy to turn the book characters into paper crafts. Color paper templates are available from free websites such as www.dltk-kids.com, and range in complexity based on the child’s age (e.g., 2+, 3+ etc).  While looking innocuously like simple paper cutouts, in reality these crafts are a linguistic treasure trove and can be used for teaching simple and complex directions (e.g., after you glue the frog’s arm, glue on his foot) as well as prepositional concepts (e.g., glue the eyes on top of the head; glue the mouth below the nose, etc).

So far we have combined the tactile with the auditory and the visual but we are still missing the stimulation of a few other senses such as the olfactory and the gustatory.  For these we need a bit more creativity, and that’s where edible crafts come in (inspired by Janell Cannon’s ‘Crickwing’).  The child and I begin by constructing and gluing together a large paper flower and dabbing it’s petals with various food extracts (almond, vanilla, raspberry, lemon, root beer, banana, cherry, coconut, etc).  Then, using the paper flower as a model, we make an edible flower using various foods.  Pretzel sticks serve as stems, snap peas become leaves while mango, tomato, apple, peach and orange slices can serve as petals.  After our food craft is finished the child (and all other therapy participants) are encouraged to take it apart and eat it.  The edible flower is not just useful to stimulate the visual, tactile, gustatory, and olfactory senses but it also encourages picky eaters to trial new foods with a variety of textures and tastes, as well as serves to develop symbolic play and early abstract thinking skills.

It is also important to emphasize that multisensory activities are not just for younger children; they can be useful for school-age children as well (including middle school and high school aged kids). In the past, I have incorporated multisensory activities into thematic language and vocabulary units for older children (see resources below) while working on the topics such as the senses (e.g., edible tasting plate), nutrition (e.g., edible food pyramid), the human body (e.g., computer games such as whack a bone by anatomy arcade), or even biology (building plant and animal cell structures out of jello and candy). From my personal clinical experience I have noticed that when I utilized the multisensory approach to learning vs. auditory and visual approaches alone (such as paper based or computer based tasks only), the children evidenced greater task participation, were able to understand the material much faster and were still able to recall learned information appropriately several therapy sessions later.

I find multisensory stimulation to be a fun and interactive way to increase the child’s learning potential, decrease stress levels, as well as increase retention of relevant concepts.  Try it and let me know how it works for you!

 

References:
Doman, G & Wilkinson, R (1993) The effects of intense multi-sensory stimulation on coma arousal and recovery. Neuropsychological Rehabilitation. 3 (2): 203-212.

Ti, K, Shin YH, & White-Traut, RC (2003), Multisensory intervention improves physical growth and illness rates in Korean orphaned newborn infants. Research in Nursing Health.  26 (6): 424-33.

Milev et al (2008) Multisensory Stimulation for Elderly With Dementia: A 24-Week Single-Blind Randomized Controlled Pilot Study. American Journal of Alzheimer’s Disease and Other Dementias. 23 (4): 372-376.

Tarullo, A & Gunnar, M (2006). Child Maltreatment and Developing HPA Axis. Hormones and Behavior 50, 632-639.

White Traut (1999) Developmental Intervention for Preterm Infants Diagnosed with Periventricular Leukomalacia. Research in Nursing Health.  22: 131-143.

White Traut et al (2009) Salivary Cortisol and Behavioral State Responses of Healthy Newborn Infants to Tactile-Only and Multisensory Interventions. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 38(1): 22–34

(This post originally appeared on www.smartspeechtherapy.com/blog/)

Resources:

 

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

Improving Pragmatic and Social Cognitive Abilities of Children with Psychiatric Disturbances

“You have to come and observe him! I know the report we got from his previous school district said his language skills were average, but something is really off.” These were the words I heard from one of the classroom teachers, at my work, which just happens to be an out-of-district school program within a psychiatric day treatment facility. In our transitional program we work with children who, due to their complex diagnoses (e.g., personality, mood, anxiety, and attachment disorders), frequently cannot be accommodated within their local school district until their behaviors can be managed more effectively.

So, I set up a series of observation times for the child in question, a bright seven year-old boy named J.R. Before I did that, I carefully reviewed his records, particularly a speech and language report. A solid language test was administered, scores were explained appropriately, child did not qualify for speech-language services, end of story – but is it? After barely a 10 minute observation of JR in the recreation room, I certainly saw what the teacher meant. Despite possessing average language skills and intelligence, JR didn’t know the first thing about playing and interacting with his peers. He attempted to join games at the most inappropriate times, he tried to dominate every single conversation, and when his peers finally let him join in, he threw a tantrum when he lost a board game. Even when his peers initiated conversations with him, his responses were frequently tangential and his interests were too immature for his age, so other children quickly lost interest in further interacting with him.

To many of us in the field these are all clear signs of social pragmatic language deficits. Formal and informal testing in this area confirmed my initial impressions. The above behaviors interfere significantly with JR’s academic success in the classroom and with his social interactions in school setting, yet somehow in his language assessment report, the social pragmatic language component was not addressed.

JR’s case is not unique. Many of us routinely assess and treat social pragmatic deficits of children on the autistic spectrum. Yet, quite often, I receive speech and language evaluations on a child, diagnosed with emotional, behavioral, and psychiatric disturbances (classified as Emotionally Disturbed or Other Health Impaired in the IEP), which do not include pragmatic language assessments nor make any requests with respect to future assessment or remediation of difficulties in this area. Yet, it’s clearly evident that the child strongly needs these skills for both social and academic success.

It is very important to understand that children with psychiatric diagnoses need more than just medicine and behavior management to make them better. They need to gain the appropriate vocabulary and language abilities to talk about emotions (own and others), understand verbal and nonverbal social cues, as well as routinely engage in perspective taking, all of which, we speech-language pathologists can teach them. More awareness and advocacy is needed among speech-language professionals to understand that given appropriate goal design, we can effectively address social cognitive abilities and positively improve these children’s functioning in both school and social settings.

 

Tatyana Elleseff, MA CCC-SLP, is a bilingual speech-language pathologist. Presently she works for the University of Medicine and Dentistry of New Jersey and has a private practice in Somerset, NJ. She is a New York University Master’s Level graduate with Bilingual Certification from Columbia University. She is licensed by the state of New Jersey and holds a Certificate of Clinical Competence from ASHA. She specializes in working with bilingual, multicultural as well as internationally adopted children with complex medical, developmental, neurogenic, psychogenic, and acquired communication disorders.