SLPs in the Home: What’s Pot Got to Do with It?

brownie

I never thought I’d be writing an article for ASHA about marijuana, but because I live in Colorado, I’ve got the latest news on weed to pass along to my fellow SLPs. In fact, if you were sitting here with me in the privacy of my own home (and you were over 21), we could chat about it while lawfully smoking a joint, munching on an edible cannabis-laced cookie, sucking on a marijuana lollipop or even, inhaling the vapors from an e-cigarette packed with marijuana oil. That’s just a sampling of the options we have to get high in the “mile high city.” Before you shout “I’m coming over!” I should probably disclose that I’m not a marijuana user, medical or recreational. If your next thought is “But I DON’T live in Colorado (or Washington) so this doesn’t apply to me – at least professionally” please read this entire article. Colorado law is considered a “springboard for other states” to legalize marijuana soon. Plus, illegal shipping to other states, often discovered during a routine traffic violation committed by the average Joe next door, has increased significantly. According to the El Paso Intelligence Center & National Seizure System, the mini-vans and SUVs bringing home “souvenirs” from Colorado aren’t just from the states bordering the Rocky Mountains. New York, Florida, Illinois and Wisconsin were some of the most popular destinations and consequently, you may experience some unexpected safety issues if you are providing home-based care for children and adults.

In an effort to educate therapists on the new laws and our responsibility to inform our families of issues that may arise with recreational marijuana use, Jane Woodard, the executive director of Colorado Drug Endangered Children, is traveling the state providing health care professionals the necessary information to keep ourselves and the families we serve safe. SLPs are required by law to report suspected conditions that would result in neglect/safety issues or abuse of children and adults. However, many of our families are simply not aware of the safety concerns and home based therapists are often the first resource for educating those families who choose to partake in using, growing or processing recreational marijuana.

Given the various populations that we serve, here is an overview of some of the safety issues:

Infants: As a pediatric feeding therapist, just one of the populations in my care are babies who require support for breast and bottle feeding. In this Colorado culture of embracing our new freedom, mothers are commenting to me without restraint that they’re using marijuana to combat nausea during pregnancy or enjoy “a little pot now and then” while breastfeeding.Studies indicate that by age four alarming changes occur in children that have had prenatal exposure. It’s noteworthy that the studies focused on a much lower amounts of delta-9-tetrhydrocannibinol (THC: the chemical that produces the psychoactive effect) than what is present in today’s super-charged marijuana products. The children demonstrated “increased behavioral problems and decreased performance on visual perceptual tasks, language comprehension, sustained attention and memory.” Marijuana use while breastfeeding is contraindicated because the THC is excreted into breast milk and stored in fat and is suspected to impact a baby’s motor development. There are no established “pump and dump” guidelines for THC and it stays in the bloodstream for much longer than other drugs. Consider the increased risks from both second-hand smoke and third-hand smoke or the “contamination that lingers” after smoking, including an increased risk for SIDS and more. For the home-based SLP, exposure to second and third-hand smoke or residue means that I will likely carry that aroma with me to the next home. I am responsible for the safety of all of the children I treat, and many are medically fragile and/or have sensory challenges and would be impacted by these odors. Today, I am faced with difficult conversations with parents that I never imagined I would have.

Children: In four short months, from January to April 2014, Colorado’s Poison Control Center has reported 11 children who ingested edibles, one as young as five months old. Over half of those children had to be hospitalized and two were admitted to the ICU. Consider that those are the reported cases – and what goes unreported is difficult to ascertain. While the law requires that the packaging cannot be designed to appeal to kids, current practices are questionable. Some argue that edibles are packaged too much like junk food, with boxes of “Pot-tarts” similar to the popular toaster pastry, bottles of fizzy “soda-pot” and candy bars with labels that rival Mars® and Hershey’s®.  In April 2014, Karma-Candy was the marijuana candy that a father in Denver consumed just before hallucinating and killing his wife, who was on the phone with 911 dispatchers at the time. She could be heard yelling to her kids to go downstairs as she desperately tried to get help for her family.

Packaging of certain products must also be in an opaque and re-sealable container, but that law only applies to the time of purchase. Plus, most edibles contain multiple servings and it’s not unusual for one cookie to serve six people. Even adults are mistakenly eating whole cookies and in April 2014, one visiting college student consequently jumped to his death from a hotel balcony after eating too much of an edible. A New York Times columnist visiting Colorado ate a whole candy bar labeled as 16 servings, and “laid in a hallucinatory state for 8 hours.” Home baked marijuana options are equally confusing. As a feeding therapist, I used to be comfortable offering foods to a child from a family’s pantry. But now, a tempting plate of brownies may be more than just a plate of brownies. By law, edibles, like any marijuana product (even plants), must be in an “enclosed, locked space.” However, it is not unusual for Colorado therapists to arrive for their home visit and find a bong, topical lotions or a half-eaten edible on the living room coffee table. Early intervention and home health care agencies are considering how to educate families on the first day of contact, during the intake process. Susan Elling, MA, CCC-SLP, who treats both children and adults in the home, notes that “It will be very important to have an open and honest conversation with a patient (and their family) regarding marijuana use as part of taking the medical history – just as we do for alcohol and smoking.”

Adults: Ms. Elling reported that “the population in need of homecare services may be more likely to use marijuana to control pain and nausea” because family members are more likely to suggest it and there will no longer be a need to obtain a medical marijuana card. Ms. Elling also notes that marijuana “affects sleep, balance, coordination, and cognition.  This may be amplifying the conditions a patient is already dealing with related to medical issues.  It can also significantly raise anxiety.  These are all factors that increase fall risk, confusion, lead to poor judgment, and can setback a patient’s recovery. It may be very difficult to determine what issues are related to the patient’s medical condition and which are related to the marijuana use.  Interventions, progress and prognosis may be affected.” Edibles in particular are a safety hazard for this population, because of the inability to self-regulate. There is no predicting how an edible will effect one person or another.

“It’s not your grandmother’s marijuana,” reported Dr. Richard Zane, who is the head of the Department of Emergency Medicine at the University of Colorado Hospital. Well-meaning family members, hoping to control their loved one’s discomfort, may not realize that the strength of today’s marijuana is significantly higher than the pot your cool grandma smoked in the 60’s. In fact, THC levels represent a 121% increase just from 1999 to 2010. Family members may not understand that the strength and effect of the drug varies from product to product. For example, compare two hits on today’s joint and an individual will ingest approximately five mg of the chemicals that produce the psychoactive and/or sedative effects compared to up to 100 mg in one packaged edible. Plus, even using the exact same method of ingestion does not guarantee the exact same dosage every time. Zane reported in this interview with Colorado Public Radio that the “drug isn’t always spread evenly through food or candy, so several people eating the same amounts can be ingesting different quantities of marijuana.”

The uncertainty of dosage and effects has Elling on guard: “I am concerned that the high potency, unpredictable effect, easy availability, and unclear dosage information of edibles may have serious consequences for homecare patients with already fragile health. It is also misleadingly considered quite “benign” and safe compared to alcohol consumption and smoking.  I feel the need to know the signs and symptoms of a marijuana overdose and know the contraindications with any other prescription or OTC drugs they may be taking and be able to educate my patients and their caregivers regarding this issue.”

Additional Safety Concerns: In the course of this short article, it’s impossible to cover all of the safety issues, including those related to growing and processing marijuana in the home. These concerns include electrical hazards from impromptu wiring (not to code); cultivation hazards such a mold and poor air quality for medically fragile patients;  increased carbon dioxide and carbon monoxide necessary for growing; chemical exposures and improper storage of pesticides and poisonous fertilizers; THC on household surfaces and airborne exposure; and exploding hash oil labs. From January to April 2014, hash oil explosions occurred on a weekly basis in Colorado, some triggered just by turning on a nearby light switch.

Consider Family Functioning: The impact on safety is the tip of the iceberg. Woodard explained that home health professionals must consider a parent’s behavior when using marijuana, the impact on a child’s behavior and family functioning overall. Difficult but often necessary questions to ask include: What steps have you taken to protect your children and family members? How do you store your marijuana and paraphernalia? What are you like when you use? Most importantly, she recommended asking yourself “Do I believe that the conditions in this home could reasonably result in harm” to anyone in this household? If so, educate the family and be mindful of mandatory reporting laws.

 

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

10 Trillion Microorganisms versus Your Toothbrush

dental

“The mouth is dirty,” Dr Kenneth Shay stated frankly; AND, it is “the biggest hole in your body!”

Warning: You may want to finish eating, brush your teeth, floss, use mouthwash, and then come back…

OR

If it is early morning, and you haven’t brushed your teeth yet: then scrape the gunk off your teeth with your fingernail. You may have found 10 billion microorganisms in that cubic millimeter.

There are 1 trillion to 10 trillion microorganisms in your mouth. Simply brushing your teeth can get rid of that nasty bacteria film in your mouth. It can also prevent “some of that schmutz” from getting into your lungs. If you are having trace aspiration (saliva, food, and/or liquids getting into your lungs), try to make what gets into your lungs less nasty. You can prevent pneumonia. Pneumonia due to poor oral care is a major avoidable infection, per Shay.

Ross & Crumpler (2006) noted that despite strong evidence in the literature on the role of brushing the teeth in preventing pneumonia, medical staff continue to view oral care as a comfort measure and only use foam swabs.

“Toothette sponges are wimpy,” stressed Shay. They don’t get the gunk (plaque) off the teeth. Plaque is sticky. If not removed, it hardens into tarter (also known as calculus). Then a visit to the dentist is needed to get it off (debridement).

Why is the mouth forgotten in healthcare? We help the dependent elder go to the bathroom many times a day. So why don’t we help brush his teeth?I’ve heard some nurses say they are squeamish about the mouth! It makes them gag! Well, we should be gagging over the costs of neglecting the mouth.

This simple prevention technique of brushing costs pennies a day against the cost of a pneumonia. Based on CDC numbers from 2011, there were 157,500 Hospital Acquired Pneumonia infections that year. CDC states the average extra cost of that hospital acquired infection is $22,875. This equals over 3 billion dollars!

Why are we not protecting this wide open gateway to the body? Imagine your gingival space between the tooth and gum as a huge parking lot. Germs love these 1-3 millimeter deep parking spaces. If germs park in the gingival space for more than 24 hours, they become calcified into plaques. Bacterial loves to stick to plaque. Only brushing removes it. No brushing leads to a build-up of plaque in the gingival space and inflammation (gingivitis).

It only takes 48 hours of hospitalization in a critically ill patient to change this bacteria from the usual gram-positive streptococci to gram-negative microorganisms (the nasty pathogenic bacteria that cause pneumonia).
Maybe we don’t brush our patients teeth because the gums bleed? Blood is okay, per Shay, even if you are on a blood thinner. Shay stated that bleeding is a sign that you need to brush more. It is due to the inflammation, and regular brushing will prevent bleeding. Shay warned that bleeding is only risky if the patient has a blood disorder or disease that causes excessive bleeding.

Most cases of gingivitis do not progress to the more serious periodontitis, but…Immune-compromising events can cause an autoimmune response that can lead to periodontitis, per Shay. Examples of immunocompromising events are not only hospitalization and critical illness; they could also be the following:

• life stressors
• flu
• depression, and
• pregnancy

Periodontitis is inflammation caused by bacteria that affects the attachment between the tooth and the bone. It is an irreversible destruction of the supporting tissues (i.e., the periodontal ligament to alveolar bone). Then bone-absorbing cells eat away at the bone. The bone will not be regenerated. Additionally, with the gums receding, “there is more surface area to collect gunk,” said Shay. The periodontal pocket that is formed creates a larger “parking garage” of 6-8 millimeters deep. Lots of gram-negative anaerobic bacteria can park there! Pathogenic microorganisms. “These are the same things that cause aspiration pneumonia,” stated Shay.

See the full blog post at www.swallowstudy.com.

Karen Sheffler, MS, CCC-SLP, BCS-S, graduated from the University of Wisconsin-Madison in 1995 with her master’s degree. There, she was under the influence of the great mentors in the field of dysphagia like Dr. John (Jay) Rosenbek, Dr. JoAnne Robbins, and Dr. James L. Coyle. Once the “dysphagia bug” bit, she has never looked back. Karen has always enjoyed medical speech pathology, working in skilled nursing facilities and rehabilitation centers in the 1990s, and now in acute care in the Boston area for more than 14 years. She has trained graduate student clinicians during their acute care internships for more than 10 years. Special interests include neurological conditions, esophageal dysphagia, geriatrics, end-of-life considerations, and patient safety/risk management. She has lectured on various topics in dysphagia in the hospital setting, to dental students at the Tufts University Dental School, and on Lateral Medullary Syndrome at the 2011 ASHA convention. She is a member of the Dysphagia Research Society and the Special Interest Group 13: Swallowing and Swallowing Disorders. Karen obtained her BCS-S (Board Certified Specialist in Swallowing and Swallowing Disorders) in August of 2012. You can follow her blog, www.swallowstudy.com.

7 Clues in the Medical Record to Discover Dysphagia

7 clues

Medical speech pathology has its uncertainties.This may cause the speech-language pathologist to be very conservative, possibly over-treating or overcompensating, per James Coyle, PhD, CCC-SLP, BCS-S at his talk on April 11, 2014, at the ASHA Healthcare & Business Institute.

“When the cause of dysphagia is not obvious: Sorting through treasure and surprises in the medical record.”

Coyle advised clinicians to value the medical record just as much as our direct examination of the patient. The “medical record is a messy place,” per Coyle. It is our job to dig for clues to distinguish which came first: the illness or the dysphagia. Some conditions can mimic dysphagia-related aspiration pneumonia. Some community acquired infections can create weakness and delirium, which then cause an acute dysphagia.

Let’s start with a story: An active-independent elderly female develops a urinary tract infection (UTI). She feels sleepy and stops eating/drinking regularly. This worsens the UTI and causes dehydration. She gets to the hospital four days after the onset of symptoms. Dehydration causes electrolyte imbalances, leading to delirium. Delirium + infection = more lethargy and a global cognitive decline. Being out of her usual environment causes more confusion and agitation. Antipsychotic medications are used to control the acute agitation. The patient becomes septic, as the infectious process spreads. Her urosepsis spreads to a pneumonia. The SLP notes a high aspiration risk, as the patient looks severely impaired. Unfortunately, without a thorough medical record review, the patient is labeled with dysphagia-related aspiration pneumonia. She stays on thickened liquids and pureed foods until hospital discharge. Will the patient fall through the cracks and never eat regular food again? Will the “Big-A-word” (ASPIRATION) follow her the rest of her life? Or will an SLP re-evaluate her in two weeks and discover that her dysphagia has disappeared?

I have summarized Coyle’s talk into these seven clues (more details and references in my full post).

1)    Is it pneumonia?

  • New infiltrate on CXR. Dependent lobes? Not necessarily only the lower lobes if the patient is bedridden or aspirating while laying down on the couch.
  • Leukocytosis (WBC count of >11.5-12.0). Warning: immune-compromised patients cannot make white blood cells.
  • Fever (>38 Celsius for >24 hours)

 

2)    What type of pneumonia is it?

  • Ventilator Acquired Pneumonia (VAP): May be widespread infiltrates. Strong correlation with oral pathogens.
  • Dysphagia-Related Aspiration Pneumonia (DAP): A recurrent pneumonia may be one big infection from ongoing aspiration. Perform a swallow study to determine if dysphagia is present and why. This is so important. If we label them with DAP, that patient’s past medical history will forever say “Aspiration Pneumonia.” Then medical personnel may be overly conservative in the future.
  • Non-Dysphagia-Related Aspiration Pneumonia (NDAP) and/or Aspiration Pneumonitis: if no dysphagia present before infection, check history for chemical irritants, allergens, reflux, a vomiting event, or use of acid-suppression therapy (i.e., Proton-Pump Inhibitors).
  • Hospital Acquired Pneumonia (HAP) or Health Care Acquired Pneumonia (HCAP): pathogens from the institution getting into the lung. Aspiration?
  • Community Acquired Pneumonia (CAP): may be diffuse infiltrates and not in dependent lobes.

 

3)    What was the patient’s baseline? “You got to have dysphagia to have dysphagia,” joked Coyle. “But seriously,” he added, “I can’t underscore this enough.” Dysphagia-Related Aspiration Pneumonia (DAP) requires the finding of difficulty swallowing prior to getting sick. Be a detective.

 

4)    Is there a systemic spread of infection (e.g., septicemia or sepsis)?

  • Sources: The lung is not the sole source for the primary infection. Wound, oral cavity, urinary tract?
  • Problem: The patient may not develop sudden signs, but it can unfold rapidly. Coyle urged SLPs to be careful when predicting goals for the future, as “sick people look pretty darn sick.” Good communication is needed at discharge to ensure re-evaluations.
  • Ask the medical team questions: Is this a short-term reversible problem? Could this be an acute dysphagia due to the illness?

 

5)    Was there a surgical procedure that could have caused the dysphagia? For examples: cardiothoracic surgery, lung transplant, lung resection, esophagectomy, head/neck cancer resection. Coyle recommended Atkins, et al (2007). See references on my full post.

 

6)    Was there a medical procedure that could have caused the dysphagia or an aspiration? For examples: feeding tubes, prolonged intubation, traumatic intubation, peri-operative aspiration event, chemotherapy/radiation.

 

7)    Are there medications that could be causing the aspiration, dysphagia, or pneumonia?

  • Polypharmacy increases a patient’s pneumonia risk.
  • Coyle recommended reading Knol, et al (2008). This was a case controlled study of elderly patients with age-matched controls. Patients who received antipsychotics where 60% more likely to have pneumonia.
  • Read more possibilities on my full post.

 

Our answers to these questions have a great impact on all we do: from our initial examination and instrumental evaluations through our discharge plan and beyond. SLPs do not diagnose pneumonia, but our communication with the medical team is an extremely valuable contribution to their differential diagnosis.

 

Karen Sheffler, MS, CCC-SLP, BCS-S, graduated from the University of Wisconsin-Madison in 1995 with her master’s degree. There, she was under the influence of the great mentors in the field of dysphagia like Dr. John (Jay) Rosenbek, Dr. JoAnne Robbins, and Dr. James L. Coyle. Once the “dysphagia bug” bit, she has never looked back. Karen has always enjoyed medical speech pathology, working in skilled nursing facilities and rehabilitation centers in the 1990s, and now in acute care in the Boston area for more than 14 years. She has trained graduate student clinicians during their acute care internships for more than 10 years. Special interests include neurological conditions, esophageal dysphagia, geriatrics, end-of-life considerations, and patient safety/risk management. She has lectured on various topics in dysphagia in the hospital setting, to dental students at the Tufts University Dental School, and on Lateral Medullary Syndrome at the 2011 ASHA convention. She is a member of the Dysphagia Research Society and the Special Interest Group 13: Swallowing and Swallowing Disorders. Karen obtained her BCS-S (Board Certified Specialist in Swallowing and Swallowing Disorders) in August of 2012. You can follow her blog, www.swallowstudy.com.

 

What SLPs Need to Know About the Medical Side of Pediatric Feeding

no food

Pediatric feeding problems come in all shapes and sizes. They tend to be complicated and often result from a combination of factors. This can make effective treatment challenging for the feeding therapist. A feeding problem is defined as “The failure to progress with feeding skills. Developmentally, a feeding problem exists when a child is ‘stuck’ in their feeding pattern and cannot progress.”

So where should the speech-language pathologist start? We should always begin by trying to figure out why the child is stuck and not progressing with eating and oral motor skills. Whether the child is dependent on tube feedings, not moving to textured foods, grazing on snack foods throughout the day, failing to thrive, pocketing foods, or spitting foods out, using medical management strategies can greatly improve a child’s success in feeding therapy.

A significant number of children with feeding difficulty also have a history of gastrointestinal problems such as gastroesophageal reflux, constipation, poor appetite, poor weight gain, and sometimes food intolerance. These issues can cause eating to be painful for the child which can lead to food refusal and avoidance and subsequent oral motor delay due to decreased practice eating the needed volumes for growth and poor acceptance of age appropriate foods. Research has shown the relationship between feeding difficulty and gastroesophageal reflux.

Most of the children we work with can’t tell us what is wrong. Their eating behavior tells us a lot about their digestive tract. These children often graze, volume limit, or avoid food because filling up their stomachs hurts. Some children complain that they have stomach pain while others vomit, spit up or cry with eating. We know that if these problems persist for any length of time, they become learned patterns of behavior.

Medical strategies that promote “gut” comfort and encourage appetite will help the child be receptive to eating and can improve response to feeding therapy. These strategies typically involve the following:

 

  • Addressing weight gain and growth as the priority of a feeding program.
  • Treating constipation and establishing a routine of daily soft stooling.
  • Treating gastroesophageal reflux and hypersensitivity in the GI tract.
  • Using hydrolyzed formulas that are easier to digest and promote gastric emptying and stooling.
  • Adjusting tube feeding rates and schedules to promote comfort.
  • Using appetite stimulants to boost hunger.

Some children’s feeding skills improve dramatically with medical management alone. Other children will need feeding therapy using techniques to improve acceptance of volume and variety of foods as well as oral motor therapy to progress to age appropriate oral motor patterns. No matter what type of feeding therapy approach you are using, the child will respond better if they feel better.

Many therapists have been taught to start with the mouth. That means addressing the oral motor hypersensitivity or oral motor delay first. Many clinicians feel that the doctor or medical specialists are addressing the reflux and constipation issues. However, it really is a team effort. Most physicians do not watch the child eat or see a child as often as we do as therapists. Therefore, it is important to work closely with the referring physicians to assist with proper diagnosis and treatment in order to assure the best outcomes for our patients.

Depending on the child, using medical management strategies can take multiple visits over time with the physician. If the child’s symptoms persist despite using medicines for reflux and constipation, a pediatrician may decide to refer the child to a gastroenterologist or feeding team for specialized care. A child also may undergo further testing to rule out medical diagnoses that can negatively effect eating such as anemia, food allergy, eosinophillic esophagitis, malrotation, and motility disorders.

The most important reason to recognize and treat the underlying medical issues of children with pediatric feeding problems is to help them progress. As SLPs, we need to recognize and identify GI issues prior to starting therapy so that we are not reinforcing pain or discomfort for the child. Our goals for most clients involve weight gain and growth, age appropriate oral motor patterns, and acceptance of a variety of foods from all food groups for healthy eating. These are attainable goals for many of our clients. Using medical strategies to help the child feel better will improve response to feeding therapy and eventually outcomes.

Krisi Brackett MS, CCC-SLP, is a feeding specialist with over 20 years of experience working with children with feeding difficulties. Krisi is co-director of the pediatric feeding team at the NC Children’s Hospital, UNC Hospitals, Chapel Hill, N.CFollow her at www.pediatricfeedingnews.com. The blog is dedicated to up to date pediatric feeding information. Krisi teaches a two-day workshop on using a medical/motor/behavior approach, is an adjunct instructor teaching a pediatric dysphagia seminar at UNC-Chapel Hill, and has co-authored a chapter in Pediatric Feeding Disorders: Evaluation and Treatment, Therapro, 2013.

Rockin’ the ASHA Health Care & Business Institute

gary blog 2


Where the heck is everyone? Oh. I get it.

So…here’s a tale to share, OK? Yours truly, this intrepid, Down Easterner editor-in-chief for the ASHA Leader news magazine, is attending his first ASHA Health Care & Business Institute. It’s Vegas (baby!), glistening with probabilities and paradox: palm-tree-lined streets press against yellow-brown desert; a chiming, smoke-filled casino perches an escalator-ride above a bustling, professional conference. And there’s me, all nimble-like, sprinting the gauntlet of one-armed bandits, dashing down the escalator, caught up in a dizzying quest to nab an interview or two. It’s the perfect time, ay-uh. Sessions are running now, but—if my experience at hundreds of other professional conferences holds true—there’ll also be a fair number of folks milling and networking outside the meeting rooms or chatting up the exhibitors.

Nope. The hallway stands silent. I duck into the exhibit hall.

Nada. There be tumbleweeds a’ blowin’. Heck, even a fair number of exhibitors are nowhere to be found.

My goodness—everyone’s in the meeting rooms. Yes, folks, the sessions at the ASHA Health Care & Business Institute are that darn good.

Packed with more sessions and CEU opportunities than ever (hey, check out the awesomely convenient and affordable PLUS Package recorded courses CE option), the 11th ASHA Health Care & Business Institute attracted a near-record-breaking crowd from April 11—13. It’s not difficult to understand why.

  • Tons and tons of practical advice. Interested in the most effective strategies for contracting with employees and third parties? How about the six principles of influence to best leverage yourself and your brand? The impact of using mainstream versus less mainstream speech on your career? Tips for reading the body language of your clients and colleagues? Want candid advice from an entrepreneur on how to build your own practice? The sessions on business management and strategies were packed!
  • Up-to-the-minute coverage and tips. Want to learn the best way that your program or practice can thrive under the Affordable Care Act? What about the latest, greatest apps for pediatric populations and adults? Need to know about Medicaid for children in 2014 or this year’s billing procedures and codes for SLPs? What about the newest requirements for securing health information? Attendees had at their fingertips the most recent goings on affecting communication sciences and disorders at these popular sessions!
  • The latest advances from the frontlines of treatment. Session after session, many featuring legendary CSD researchers and clinicians, showcased the latest approaches to assessment and treatment for clients affected by a wide range of communication disorders—aphasia, dementia, dysphagia, childhood apraxia of speech, and autism spectrum disorder, among others. Some of these sessions were so well attended that folks were sitting in the aisles and on the floor in the hallway outside—I gave up my chair many times…

1HCBI1

So, with such a gang buster conference going on, what was this editor-in-chief supposed to do? When in Rome….I immediately jettisoned the interview-heavy approach to coverage and swore a courageous but ultimately foolhardy vow to cover the sessions as completely as possible through the Leader’s social media channels.

Picture this: It’s early Friday morning, and I begin hopping like a killer rabbit (beloved Holy Grail reference required) from one session to another, tweeting and posting photos at #ashaigers on Instagram. Listen, snap and tweet; listen, snap and tweet. Whew! By lunch I was stretched rather thin, and then I had to do it all again that afternoon, the next day, and the morning of the third day. I didn’t waver. My grandmother was right—when a notion takes my noggin’, I get as set and fixed-purposed as an old New England stone wall.

And now it’s time for a slice of humble pie. In the end, I must admit that the Great Social Media Effort was nobly conceived but executed imperfectly, because 1.) there were so many wonderful sessions going on that I simply could not do justice to all of them; and 2.) in many cases, I found myself so drawn in by a presenter, subject, and/or an audience’s enthusiasm and engagement that it was very difficult to leave the room. Grrrr. I. Just. Couldn’t. Cover. It. All.

At long last, with the Luxor and its Strip kin fading behind, I had time on the flight back to reflect on an outstanding conference. The attendees LOVED it and learned much. Those I spoke with were uniformly excited about the sessions; many pronounced the meeting as the best yet. They’ll be back next year, I reckon. Come hell or high water, I’ll be there, too. Perhaps leading an army of Leader editors to help cover it ALL next time. Ay-uh.

Gary Dunham, PhD, is ASHA publications director and editor-in-chief of The ASHA Leader.

 

Beyond Skype for Online Therapy: Protecting Student Privacy

Privacy

 

The trend for kids online is sharing more, not less. Today’s kids consciously and unconsciously share so many aspects of their life using Facebook, Skype or even newer tech tools like Snapchat. But, as educators, we hold ourselves to a much higher legal and professional standard for protecting the information of these very same students. We’ve all heard about the laws—FERPA, HIPAA, COPPA— that set the standards for privacy of student records and personally identifiable information, but what do the laws mean in the context of delivering speech-language therapy online?

HIPAA: Protecting Individually Identifiable Health Information

Created by the Department of Health and Human Services in 1996, The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects patient medical records. HIPAA specifically protects “individually identifiable health information,” which includes:

  • the individual’s name, address, birth date and Social Security number.
  • the individual’s past, present or future physical or mental health or condition.
  • the provision of health care to the individual.
  • the past, present or future payment for the provision of health care to the individual.

HIPAA gives patients a variety of rights regarding individually identifiable health information. With consent, HIPAA permits the disclosure of health information needed for patient care, such as speech therapy.

FERPA: Protecting Education Records

The Family Educational Rights and Privacy Act (FERPA) is a federal law that protects student education records. FERPA gives parents certain rights with respect to their children’s education records until they turn 18 or transfer to a school higher than the high school level, thus making them “eligible students.” The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. Under FERPA, parents or eligible students have the right to:

  • Inspect and review the student’s education records.
  • Request a school to correct records they believe to be inaccurate or misleading.
  • Prevent a school from releasing information from the student’s education record without written permission (with some exceptions).

COPPA: Protecting Children’s Personal Information

The Federal Trade Commission instituted COPPA (Children’s Online Privacy Protection Act) in April, 2000 to protect children’s personal information on websites and applications that target children under the age of 13. Under the legislation, websites and apps that collect this information must notify parents directly and get their approval prior to the collection, use or disclosure of a child’s personal information. The FTC describes personal information as:

  • A child’s name, contact information (address, phone number or email address.
  • A child’s physical whereabouts.
  • Photos, videos and audio recordings of the child.
  • A child’s “persistent identifiers,” like IP addresses, that can be used to track a child’s activities over time and across different websites and online services.

Recommendations for Online Therapy

Clinicians and educators often focus on the capabilities of individual pieces of technology, and, indeed, a secure therapy platform is highly recommended both to ensure the privacy of sessions as well as student data. However, it is the information, and the sharing of that information by the adults responsible for the care of each child, that these laws focus on. So educators need to focus on a systems approach that considers the end-to-end process of handling and securing student data.

While clinicians are trained in student identity protection, non-disclosure methods and the maintenance of student record confidentiality, it is ultimately the school’s responsibility to ensure agreements they have in place with online therapy service providers support them in protecting student privacy. So what are the practical considerations in this end-to-end approach to protecting the privacy of students receiving online therapy?

  1. Ask what type of security is in place. Solutions with bank-level security offer the strongest protection of data. This includes 256-bit encryption using TLS 1.0, restricted physical access to the servers on which data is stored, and 24/7 on-site security personnel.
  2. Use a secure platform for therapy. Secure platforms use an invite-only, encrypted, secure connection. In this model, only the online clinician and the student assigned to that particular appointment time are permitted to enter the password-protected “therapy room.” Parents may also view a session with a prior written request.
  3. Use a secure server to store data. Make sure all student files containing individually identifiable health information and education records are stored on a secure server using industry-leading security.
  4. Restrict access. Only online clinicians, authorized school administrators and parents should have access to this password-protected information, thus further protecting student privacy.

This “big picture” thinking will let educators take advantage of new online delivery models for therapy services AND stay compliant with privacy laws. And leave Snapchat to the students.

Melissa Jakubowitz, MA, CCC-SLP, is the Vice President of SLP Clinical Services at PresenceLearning. She is a Board Recognized Specialist in Child Language with more than with more than 20 years of clinical and managerial experience. She is the past-president of the California Speech-Language-Hearing Association and is active in ASHA, serving as a Legislative Counselor for 12 years.

Skyrocketing Autism Numbers a Call to Action for SLPs

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

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

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

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

What do the higher numbers mean for SLPs?

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

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

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

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

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

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

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

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

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

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

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

Kid Confidential: The Latest on Treatment of Ear Infections

ear infection

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

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

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

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

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

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

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

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

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

Please refer to the resources below for further information.

Resources:

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

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

 

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

Apps with Elders

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

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

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

Five Tips to make using an iPad in therapy easier

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

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

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

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

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

Favorite Adult SLP Apps

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

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

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

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

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

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

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

Just Breathe. Really?

breathing

Easy for you and me to say.  But for 7.1 million U.S. school children it’s not. Childhood asthma rates continue to rise and from 2001 through 2009 those rates were the highest for African American children, almost a 50 percent increase. Asthma accounts for 10.5 million school absences each year. The main trigger of asthma in school children are the same contributors to poor indoor air quality. Yeah, that’s right … open a window.

Air is mostly composed of nitrogen (78 percent) and oxygen (20 percent), air also has about 1 percent of water vapor and tiny amounts of argon and other gases.  For most of us, air quietly passes through our nasal passages into our lungs and out again; taking in the oxygen needed for our blood supply during inhalation and disposing the carbon dioxide by-product during exhalation.  We do this without thought, without effort–unless you are a child with asthma.

Asthma is a chronic lung disease characterized by inflammation of the airways. Recurring symptoms include wheezing, shortness of breath, chest tightness, and coughing.  Asthma develops in childhood as early as 6 months of age and lasts a lifetime.  About one in 12 Americans are living with asthma and over one third of them are children. In adults women are more likely than men to have asthma and more boys than girls among children. Those with asthma pay a huge price, about $3,000 per year per person to be exact. This figure includes medical care, medications, lost work/school days and deaths.

Various triggers not easily controlled can cause an asthma attack such as changes in weather. However, there are other triggers that can be controlled such as the presence of dust mites, roaches, pets, and mold affecting indoor air quality.  Asthma is particularly more prevalent to those living in poor neighborhoods.  A recent episode of NBC Dateline revealed that the childhood asthma rates in East Harlem run at 19 percent compared to the adjoining Upper East Side neighborhood at 7 percent.  They breathe the same New York City air, so what accounts for the difference?

Water leaks, pest infestation and general contract repairs are the responsibility of a rental unit’s landlord. As economically disadvantaged families tend to reside in these units, they are at the mercy of their landlord. Water damage leads to mold; pest infestation carries allergens; both of these conditions create a significant trigger for asthma in children. Even a child without an asthma history may become asthmatic as a result of repeated and chronic exposure to such poor indoor air quality.

School absences are of particular concern; children who miss more than 18 school days are year are more likely to drop out of school. Children with asthma miss more days of school due to their disease compared to children without asthma.  The number of missed days rises with severity—on average a child with severe and persistent symptoms misses 11.5 days of school in a year.  That’s a lot of missed homework and make up speech sessions. Asthma also affects a child’s sleep quality, which in turn affects a child’s ability to pay attention in class and lowers their quality school work.

 What can you do? 

  • Know which children on your caseload have asthma and know how to deal with an asthma emergency, including the location of the child’s inhaler.
  • Take a look at your therapy treatment room or classroom. Are the floors hard wood or are they carpeted?  If hard wood, hooray! If carpeted, make sure they get vacuumed every day and shampooed at the end of the school week.
  • Got pets? If there are in your classroom, better to send them to another home. Animals carry dander that can trigger asthma. If you have a pet at home, make sure your work wardrobe is free of pet hair.
  • Are you working out of a trailer or portable classroom?  These type of environments generally trap moisture than can turn into nasty mold. Make sure spills and leaks are taken care of quickly.
  • Skip the perfume spritz and after shave before leaving the house for work. Fragrances can trigger an asthma episode.
  •  Refrain from fuzzy or scented materials, pillows or upholstered furniture; these can collect dust mites, which are (surprise!) asthma triggers. If the furniture must stay, vacuum it frequently.
  • No clutter!  Cockroaches and dust mites love clutter … and produce more asthma triggers.
  • If your room has a window that faces high volume vehicular traffic, keep it closed during the vulnerable morning hours and cold temperatures.
  • Stay away from phthalate-based toys  as phthalates are known triggers for asthma.
  • Don’t use pesticide sprays in your room.  Go for integrated pest management strategies instead.
  • Like team work?  Collaborate with your school nurse and district’s administration to develop an asthma management plan at your school if one does not exist.  Another excellent resource is to adopt ideas from the IAQ Tools for Schools Action Kit.  Work with your district’s transportation department to monitor school bus engine exhaust near open windows.

 

Although asthma is prevalent, with some forethought and preventive measures, it can be controlled. Now breathe a sigh of relief!

Anastasia Antoniadis is with the Tuscarora (PA) Intermediate Unit and works as a state consultant for Early Intervention Technical Assistance through the Pennsylvania Training and Technical Assistance Network. She earned a Master of Arts degree in speech pathology from City College of the City University of New York and a Master’s degree in public health from Temple University. She was a practicing pediatric SLP for 14 years before becoming an early childhood consultant for Pennsylvania’s early intervention system. Her public health studies have been in the area of environmental health and data mapping using geographic information system technology.  You can follow her on Twitter @SLPS4HlthySchools.