Baby Led Weaning: A Developmental Perspective

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One of the things I like best about teaching courses on feeding to parents and professionals around the United States is learning what new trends are evolving around family mealtimes. Over the past year,  one of the common questions I’m asked is, “What about Baby Led Weaning?”

Baby Led Weaning (BLW) is a term coined by Ms. Gill Rapley, co-author of “Baby-led Weaning: The Essential Guide to Introducing Solid Foods.”  Rapley graciously chatted with me about her philosophy and explained that although she did not invent BLW, she found the method to be successful in her work as a former health visitor and midwife in the United Kingdom and continues to study the topic today while earning her PhD.

In a nutshell, BLW centers on the philosophy that babies are developmentally capable of reaching for food and putting it in their mouths at about 6 months of age. As stated on the BLW website “You just hand them the food in a suitably-sized piece and if they like it they eat it and if they don’t they won’t.”  Please note that the word “wean” is not referring to weaning from breast or bottle, but instead refers to a term commonly used in the United Kingdom for adding complementary foods to the baby’s current diet of breast milk or formula.  According to the BLW website, ideas for first foods include “chip size” steamed vegetables such as a broccoli spear with the stem as a handle, roasted potato wedges, meat in large enough pieces for the baby to grasp and chew, rice cakes, cucumber, celery and dried apricots.

As a SLP who focuses on pediatric feeding, I view feeding as a developmental process.  Whether I’m working with a child experiencing delays in development or offering advice to a parent whose child is meeting milestones with ease, I always ask myself “How can I respect and support this family’s mealtime culture while guiding this child safely through the developmental course of learning to eat?”  Thus, for families who are interested in following the BLW method, whether their child is in feeding therapy or not, I try to support their wishes if the child is capable,  while offering the following BLW points to consider:

BLW encourages parents to eat with their children, since everyone is eating the same food. 

In today’s busy culture, it feels easier to many parents to feed the baby prior to the adult or family meal, and in BLW the thought is that jarred purees contribute to this habit and it’s important to include baby at the table at an early age.  Even in feeding therapy,  the ultimate goal is for families to be able to gather around the table at mealtimes with everyone enjoying the same foods.  Plus, Columbia University reports that consistent family dinners are an integral and valuable part of raising children.

BLW emphasizes that babies must be the ones to put the food in their mouths.

Feeding therapists encourage self-feeding  for all kids because it allows them to get messy.  Babies are programmed to explore the world with all of their senses, especially their hands and mouths, and often the two together!  BLW notes that the time to begin self-feeding is at 6 months when baby can sit upright on his/her own. I explain to parents that first, every child must have the gross motor stability to support fine motor skills, including reaching and raking for food and controlling their grasp to bring the food to the mouth to be chewed.  For children who have this capability, I feel comfortable with large pieces of food that will not snap off (or allow a solid chunk to fall into the mouth) in addition to short spoons and chewable toys for practicing the skills that will eventually lead to self-feeding.

BLW follows the baby’s cues rather than the parent controlling the feeding via the spoon.

I explain that whether presenting food to your child by placing it on the high chair tray in front of them, directly on a spoon or even mouth to mouth as done in some cultures, reading baby’s cues for readiness is crucial.  Like a beautiful, flowing conversation, feeding children is a reciprocal experience.

According to the BLW blog, BLW introduces chip-size foods (rather than purees or mashed foods) so that baby learns to chew first and then spit out if unable to swallow, noting that with purees on a spoon, babies learn to swallow first and then chew.

From a developmental perspective,  this doesn’t quite fit with my understanding of how infant reflexes integrate  and babies acquire oral motor skills. Babies can begin the process of BOTH spoon and finger feeding between the ages of 5 and 6 months using both purees and soft, safe foods.  Why?  Because this is when babies acquire better lip control and movement as they suck the puree off of a parent’s finger, their own hands or a spoon.  As noted in Diane Bahr’s book “Nobody Ever Told Me (or My Mother) That!” this is when babies use their rhythmic bite reflex to bite off soft pieces of safe, soft or meltable foods that they can hold in their tiny fists or when presented by a parent to their open mouths. If the food is placed onto the gums where we will one day see molars, a rotary chew pattern will begin to emerge over time, thanks to reflexive patterns that soon become purposeful movements.  It’s a developmental process and BOTH purees and finger feeding facilitate the progression of skills. It makes sense to me to transition gradually from thinner  liquids (breast milk/formula) to thicker (thus, a smooth puree) to consistently mashed or chopped  while introducing soft meltables over time.  Keep in mind that I also encounter families who are moving too slowly through graduation of textures, as noted in this article by Bahr.  But, jumping straight to only large pieces of foods to be chewed and then either swallowed or spit out feels like skipping crucial steps in the developmental process.  “Feels like” is the key phrase here: We need research to determine if children who follow this model eventually acquire skills traditionally learned prior to chewing chunks of food as listed in this article found in ASHA Perspectives.  Unlike my previous post on sippy cups, where therapists have raised concerns based on their professional experience over several years and observation of prolonged sippy cup use,  consistent BLW practices are a relatively new phenomenon in the United States.  So, when any parent asks “What about Baby Led Weaning?” I try to integrate my own practitioner expertise and knowledge of feeding development while honoring the family’s preferences and mealtime culture.  Still,  my biggest concern for any 6 month old child is choking.

BLW encourages parents to become comfortable with gagging episodes and understand the difference between gagging and choking. 

Gagging versus choking are two different experiences.  Typically, an infant’s gag reflex is triggered when the back three quarters of the tongue is stimulated, but by the time a child reaches  9 months of age, the reflex covers less area, lying on the back third of the tongue. Eventually, the gag reflex shifts posteriorly even more as the child learns to tolerate the stimulation. Gagging is nature’s way of protecting the airway, where true choking occurs.  Choking happens when food (or other substances) obstruct the airway and thus, often has no sound or intermittent, odd sounds.  Other signs of choking include but are not limited to: gasping for breath, turning blue around the lips and beneath the eyes and/or staring with an open mouth while drooling.

Gagging is an uncomfortable sensation where the soft palate suddenly elevates, the jaw thrusts forward and down, and the back of the tongue lifts up and forward.  It is not unusual for a child to vomit after gagging.  In between the gags, the child is still able to breathe, cry and make vocal noises.  The occasional gag is an important built-in safety mechanism, but frequent gags and/or vomiting can lead to an aversion to food.

In summary, when asked for advice from any family that would like to follow Baby Led Weaning principles, I stress the importance of reading baby’s cues and monitoring them closely for safe feeding while supporting them through the developmental process of learning to eat, no matter what age.  This includes proper positioning in the feeding chair for optimal stability and presenting only manageable pieces of safe, meltable and/or solid foods that do not pose a choking hazard.  For children in feeding therapy, incorporating some aspects of BLW is dependent on that child’s individual delays or challenges and where they are in the developmental process, regardless of chronological age.  My primary concern for any child is safety – be aware and be informed, while respecting each family’s mealtime culture.

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.

NIMTR: Not In My Treatment Room!

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You’ve heard of NIMBY, “not-in-my-backyard” haven’t you?  Well there’s a new acronym, NIMTR or “not-in-my-therapy-treatment-room!”  Speech-language pathologists are inundated by catalogs filled with wonderful colorful, fragrant, pliable toys as treatment materials.  We use these every day with our students, our clients in clinics, our bedside patients.  But how much do we really know about the safety and makeup of those therapy materials your shrinking budget dollars are purchasing every year?

Some interesting facts about toys.

Toys are BIG business. Just visit any mall in America or website such as Amazon.com.  Worldwide, over 80 billion dollars were spent on toys in 2009, with more than a quarter of that money consumed in the United States. The latest figures by the Toy Industry Association Inc., places the annual U.S. domestic toy market at $22 billion in 2012.  Of this, $6.63 billion covers toys and articles for infants and toddlers, puzzles and games, and arts and crafts.  I mention these specific categories because they are materials most likely to be used by SLPs working with young children in early intervention, preschool, or school settings.

So many toys … but are they safe?

The United States imports many more toys from foreign countries compared to its exports. China, Japan, Mexico, Canada and Denmark lead the way in toy imports.  Since other countries do not implement the same environmental protections in manufacturing as we do in the states, the question of safety looms large.  The Consumer Product Safety Commission (CPSC) is the main body responsible for overseeing the safety and recall of unsafe toys and products manufactured in or imported into the United States.  In 2012, the CPSC released a new risk assessment tool to help improve the screening of imported products. About 5 percent of the total number of these screenings identified children’s products.  One example: a shipment of 28,000 baby bottles imported by Dollar Tree was seized after determining they were defective and unsafe using the new risk assessment tool. You can read more about the successes of CPSC online.

The Consumer Product Safety Improvement Act of 2008 made it mandatory for all toys aimed at children under the age of 14 to meet new federal safety standards.  Some of these include testing lead content and concentration of phthalates (DEHP, DBP and BBP* in particular). Here is a video to see how CPSC works collaboratively with other government agencies to seize toy imports that are unsafe for children.

Even though we have protections, toys of questionable safety continue to enter the consumer market.  Recently DNAinfo in New York released this alarming report, which shows many toys in stores tested positive for elevated levels of toxic substances, including phthalates, which have been found to be associated with asthma, birth defects and hormone disruption, among other health problems. One item on the list, a Teenage Mutant Ninja Turtles pencil case manufactured by Innovative Design was found to contain 150 times the legal phthalate limit for toys. But alas, currently, it does not qualify as a toy under federal regulations.

What if it is not a toy?

And that’s a good point: Sometimes SLPs use materials in their practice that are not toys. Like the pencil case mentioned above or what about commonly used rubber tubing that a speech-language pathologist may use during treatment for oral exercises?  Would such rubber tubing be considered a toy, a medical device, or something else?  Who oversees the safety of products such as these?

Two organizations responsible for developing standards of safety are the International Organization for Standardization (ISO) in Switzerland and the American Society for Testing and Materials International  based in Pennsylvania.  Both provide standards to industries that produce just about everything, from iron bolts to bathmats.  Each provides standards for purchase to companies, who in turn use the standards to manufacture and distribute their product to specification.  I contacted both these organizations to find what standards exist for the rubber tubing example.  As of this writing, no responses to my request have been received.

What is an SLP to do?

So what can you do to ensure that the materials you use with your students and clients are safe?  Here are a few suggestions:

  1. If you are purchasing from a distributor online, check their website for more information. For example, SuperDuper Publications places a Product Safety statement on their website and invites customers to email them for more information.  Companies who openly provide statements such as these make it easier for the consumer to trust the safety of their purchases.  If you cannot find information on product safety or product testing, email the company and ask for it.
  2. Check the CPSC’s website for toy and product recalls. You can find the latest recalls, search for recalls by product name or by country of manufacture, and also report an unsafe product.
  3. Read the manual! Electronics such as iPads and tablets come with a manual that will often provide the ISO or ASTM Int’l standard used to insure safety and will list potential hazards.
  4. Contact the manufacturer of the product and ask for the MSDS – materials safety data sheet.  This would be a good choice if the product you have or consider purchasing lacks a manual or an information sheet on standards testing.  You also can look up a product by name and manufacturer on the MSDS website. On this site a search for “rubber tube” gave me 34 hits.  While searches can be daunting and time consuming, the insurance of safety provides peace of mind to you and the clients on your caseload.
  5. Avoid buying inexpensive toys or materials from questionable sources such as street vendors.

Informed SLPs can now approach their materials purchases with a new savvy.  Next time you are tempted to buy inexpensive therapy materials composed of questionable ingredients, just say “NIMTR”!!!!

 

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.

Aphasia: How a Video IS Worth a Thousand Words

 

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I have been a practicing speech-language pathologist for the past 40 years. My last position prior to my retirement in September of this year was as an out-patient SLP at Virginia Commonwealth University Health System (VCUHS) rehab clinic working primarily with stroke and head injury patients. Ours is a rewarding profession but during the past year and a half my involvement in a community aphasia support group has been one of the most gratifying experiences of my career.

Approximately two years ago, the daughter of a stroke survivor contacted VCUHS Speech/Language Pathology Department asking for volunteers to help her start an aphasia support group in Richmond, Va. She indicated that she wanted to form the support group to provide her mother and others living with aphasia the opportunity to exchange information, opinions, and feelings about this communication disorder.

The first group meeting was held in February 2012. The discussions during the monthly meetings often focused on how little the general public knew about aphasia. Other recurring topics included: loss of insurance coverage for out-patient speech treatment due to “plateau in skills” or insurance caps; false assumption that loss of language means loss of intellect; family members and others lacking appreciation of what it is like to have a head full of thoughts and ideas but not be able to communicate these thoughts to others. One of the group members, a corporate trainer prior to his stroke and subsequent aphasia, had an idea about how to address these problems/misconceptions: He proposed making a video that recorded the personal narratives of group members to educate healthcare professionals as well as their own families and friends on the daily challenges of living with aphasia and strategies for being a good communication partner. He and other group members felt that who best to advocate for aphasia patients than those living with aphasia themselves?

This past year, Marcia Robbins and Kate Schmick (two other SLPs who volunteer with the group), Jan Thomas (support group member who has taken a leadership role in the group), and I applied for and received funding through the VCUHS Speech/Language Pathology Department to produce a documentary style video on living with aphasia. Eric Futterman, a Richmond-based videographer, filmed and narrated scenes of aphasia support group members going through their daily routines and one member interacting with SLP. The 18-minute video highlighted the fact that those living with aphasia were not a homogenous group but rather individuals with unique needs and challenges as they faced the difficult road to recovery from their stroke. The video also showed support group members getting on with living and finding new talents. Our group had a community premier of the video entitled “Patience, Listening and Communicating with Aphasia Patients” during our September, 2013 monthly support group meeting. 90 people from the community attended. Attendees remarked on the powerful and informative message of the film.

In an effort to spread the word about aphasia, we have contacted the National Stroke Association and the National Aphasia Association about posting this video on their websites. NSA already has posted the video on their website.

Susan Hapala, M.Ed.,CCC-SLP, is a retired speech-language pathologist who volunteers with the Richmond, Virginia Aphasia Support Group. She can be reached at rva.aphasia@gmail.com.

All I Want for Christmas is My G-Tube Out!

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A Parent’s Expectations and an SLP’s Goals

As a pediatric SLP who focuses on feeding, I guide families through the process of transitioning from g-tube feedings to 100% oral feeds and ultimately, removal of the g-tube.  This year, I had the unique experience of learning more about the emotional process through the eyes of one mom who happened to be an SLP, too.  In the course of nine months of feeding therapy,  her daughter Payton has taught us both that goals and expectations aren’t always met on the SLP’s or parent’s timeline and that most importantly, the child sets the pace.  Payton’s mom graciously shared her thoughts on the process:

History: Payton was born in December 2012 at 38 weeks, 4 days and weighed 4 lbs., 13 oz..  One month  later, Payton was hospitalized due to congestion, but it soon became apparent that this was a more serious matter.  On January 9th, surgeons performed a Ladd’s procedure to repair a malrotation of the stomach and intestines, a Nissen fundoplication to control reflux and secondary aspiration, removed her appendix, repaired a hernia and placed the g-tube.

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Melanie: When I first met you in March 2013, your family and of course, Payton, had been through so much!  What did that feel like, knowing that she needed surgery and consequently, a g-tube? 

Payton’s Mom: This was my baby; my flesh and blood. I was so mad, sad, overwhelmed, devastated, in denial, and didn’t want any of this to happen. There had to be another option, another way to make her better. My child was not going to eat through a tube and I was going to do all that I could to get that thing out as soon as I could.  I was SO mad and devastated that this had to happen to MY baby.  It felt to us that when she was in the hospital, that the goal was to “fix” her and then we were sent home (feeling totally alone and shattered) to cope with all that we needed to get her to grow and thrive.  Short and long term goals were not clearly communicated to us.  In the back of my mind I knew that this would be a long journey, but I didn’t exactly know how long or what it would entail and I wanted to know NOW! Everyone in the hospital kept telling me that Payton would do this at her own pace (“Payton’s Pace”) but I didn’t want to wait. I wanted my baby better now!

Melanie: We have often talked about the difference between setting goals and setting expectations.  Your journey with Payton has helped me to have a better understanding of the difference.  Goals are targets or objectives.  Expectations feel more passionate and focus on hope, anticipation and personal beliefs.

Payton’s Mom:  As an SLP, I set goals and benchmarks all the time. There is a target behavior you want your client to meet and you set reasonable, attainable steps to get there over a specific, realistic time period.

As a parent, when you have a child with any challenge, you have expectations for them that are based on your emotions, including sadness, anger, denial and/or hope.  From the beginning of our journey, I remember having the expectation that Payton would eat a normal birthday cake and drink milk from a cup on her 1st birthday. Even though Payton just had a feeding tube placed and we were not sure when she would be eating orally again, I still had this expectation.

Melanie: I remember that so well!  I asked you what I ask every parent in feeding therapy: “Tell me what you want for your child” and you answered “I want her to eat birthday cake on her first birthday” and then, you stated it clearly to me once again, just to ensure that I understood.  “She’s GOING to eat BIRTHDAY CAKE on her FIRST birthday” and you had tears in your eyes.  That was a big lesson for me – you’ve taught me so much.  Expectations are very emotional. 

Payton’s Mom: I also had other expectations: that she would be running the hallways of the hospital on the week of her first birthday and say hello to the doctors who treated her!  When I stated these expectations, I knew in the back of my mind that it was unfair to myself and especially to Payton to expect this, because if she couldn’t do it, then would I feel guilty, disappointed, angry and upset that the therapists and doctors didn’t do their job right, or that I wasn’t doing my job.  It was all based on my hope for her to be “normal” and desperately wanting all the emotions of sadness and anger to go away after this difficult journey

Melanie: Is there anything else you feel would be helpful for parents and therapists to understand?

Payton’s Mom: Most importantly, follow your instinct as a parent. I truly believe that following my instinct saved Payton’s life.  A parent should trust that feeling inside of them and advocate for their child as they know them best. The opinions of doctors and therapists should be respected as they are knowledgeable and experienced;  however as the parent you go through life with your child all day, every day and it’s important to communicate and discuss the issues  with the doctors and therapists. Come to an agreement what is reasonable and feasible for your child and family. Sometimes when doctors and therapists are not on the same timetable as you it “gets in the way” of your expectations as a parent. A lot of time is spaced between appointments and as a family, life goes on. Another lesson is to pick your team well. When you have a child who works with many different specialists, it’s important that you work well with them as a family and that your child responds positively to them. There are many options when it comes to professionals and you don’t have to work with who was assigned to you, specifically in the hospital, if you do not communicate well with them, agree with their overall philosophy, or feel that there is mutual respect in the relationship.  Lastly, I have learned to respect my child’s pace of development and progress. Getting your child the therapy they need and following through with the  recommendations from doctors and therapists is essential, but that doesn’t necessarily mean they are going to meet the goals and expectations for them on your timeline. I have tried to remind myself when things get tough/or my expectations are not met that this is “Payton’s Pace.” She is her own being who will determine what she does and when she does it.

Melanie:  Yes, she sets the pace.  So, we don’t know if she’ll get her tube out at Christmas.  What’s  most important is what a fantastic year this has been for her and for Team Payton!   Plus,  this is her birthday month!  She’ll have cake and something delicious to drink from a cup.  Probably a purple cup … because she loves purple.  Happy Birthday, Payton!

Payton-One-Year-Old2

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.

Handling Verbally Disruptive Behavior in Patients With Dementia

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

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

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

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

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

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

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

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

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

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

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

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

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

Tricks to Take the Pain Out of Writing Treatment Goals

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

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

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

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

Let’s look more closely at SMART.

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

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

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

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

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

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

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

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

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


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

On the Other Side of the Table: Receiving the Diagnosis

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As a professional working with communication disorders for 13 years, I find it second nature to complete evaluations and report results and recommendations to families. Due to my graduate training and a couple of wonderful professors—in addition to an understanding of assessment and treatment of speech/language impairments—I feel I came away with effective skills in counseling and empathizing with families in the face of an unexpected diagnosis.

It was not until recently, however, that I found myself on the other side of the table, watching my father go through neurological and cognitive testing and hearing the impending diagnosis: moderate Alzheimer’s.  Though I was confident he was showing clear signs of dementia prior to the evaluation, as I sat with him during the exam, it was difficult, yet eye opening, to watch him struggle through simple language and memory tasks that previously would have been so easy for him.

Even more eye opening was his own unawareness of the problem, his inability to understand the reason he was seeing a neurologist in the first place, and the fact that most of his responses were incorrect, though he thought he nailed them!

At home with my mother, more eye openers came very quickly.  Though I primarily work with children, I have always been a big advocate for family and parent training, and I have sought to educate and include parents and family members as much as I can in the treatment of my clients. I have learned that my skills—what comes naturally to me, how I engage with children, how I intuitively attempt to promote speech and language at every turn—are not skills I can assume that parents and caregivers possess, and this understanding has helped me shape my family/parent education model.

With adults, however, I haven’t always thought in those terms.  I have come to realize that I tend to assume that adults, especially educated adults without impairment, should know how to engage with other adults who have cognitive-communication impairments.

It took me by surprise that my mom did not possess the understanding or the skills to handle my father’s memory lapses, lack of retention, confusion, reduced reasoning skills, and disorientation to time, place, and people.  The changes that are needed in their current home environment and in my mom’s interactive style with him appear obvious to me, and I can immediately “frame-switch” with him, changing the way I respond, react, reassure and redirect due to his current deficits. My mom, however, doesn’t know where to begin. Though she is an intelligent and very caring person, she appears stuck in the relational style she has always had with him, demonstrating by her words and actions that she expects from him the same sharpness and clarity of mind.

There is no overt denial of his condition, but there appears to be what I’m calling a “relational denial.”  She knows his cognitive function is progressively deteriorating, but she does not know how to modify her way of interacting with him. She cannot even identify that her expectations have not changed. The take-home point that has been solidified for me is this: One of the most important and effective roles I have as a speech-language pathologist serving adult populations is caregiver education and training.  I realize this is not a breakthrough discovery in the field of speech-language pathology, but I believe many of us do not spend enough time giving caregivers the tools and strategies to help themselves and their loved ones.

Even though my mom and I talked openly, honestly and lovingly about the needed changes, she could not readily implement them. Switching her frame of mind and subsequent actions and reactions has required much intentional modeling and repetition on my part. It has required identifying how she automatically responds and reacts, then identifying what a more effective way to respond and react would be to reduce her own frustration and his.

One discussion session would not have been enough.  A set of handouts or a brochure would not have been enough. Recommending a good book on Alzheimer’s would not have been enough.

This experience has caused me to evaluate not only my views on caregiver education and training for adult populations but also my investment in a hands-on family education model that is thorough, caring, and thoughtful. Families and caregivers desperately need our expertise in practical ways to effectively cope and help their loved ones!

 

Ana Paula G. Mumy, MS, CCC-SLP,  is a trilingual speech-language pathologist who provides school-based and pediatric home health care services in Colorado Springs, Colo. The author of various continuing education eCourses, leveled storybooks and instructional therapy materials for speech/language intervention, she also offers resources for SLPs, educators and parents on her website The Speech Stop.

The Blame Game

July 4

 

Although researchers are gradually learning more about stuttering and its cause/s, there is still a lot that remains a mystery. With “the unknown” comes room for parents to try and fill in the gaps with their own guesses as to what caused their child to begin stuttering. One of the questions I most often hear from parents is “Is it something I did?” The answer is a resounding “No!”

What We Know

According to the Stuttering Foundation, there are four factors that most likely play a role in the development of stuttering. It is hypothesized that a combination of these factors may result in a child with a predisposition for stuttering.

1. Genetics: Approximately 60 percent of people who stutter have a close family member that stutters as well. In addition, recent research by Dr. Dennis Drayna has identified three genes as a source of stuttering in families studied.

2. Neurophysiology: Brain imaging studies have indicated that people who stutter may process language in different areas of the brain than people who do not stutter.

3. Child development: Children with developmental delays or other speech/language disorders are more likely to stutter. (Note: By no means, is this implying that all people who stutter have delays in other areas. There is simply an increased likelihood of stuttering in children with developmental delays and language disorders.)

4. Family dynamics: High expectations and fast-paced lifestyles may play a role in stuttering.

Family Dynamics?? I Thought I Wasn’t the Cause??

You’re not! There are plenty of “fast-paced” families out there that do not have children who stutter. However, there are certain environments that may exacerbate disfluencies in a child who already has the increased propensity to stutter. This does not mean that you have to lower your expectations for your child or take them out of their extra-curricular activities. However, there are some changes that may help. Although I advise parents not to tell a child to “slow down” or “relax,” I do suggest slowing your own rate of speech and inserting more pauses. This decreases time pressure and models a more relaxed way of speaking. Indicate you are listening to your child with eye contact and by trying to set aside some time during the day that they have your undivided attention. Try your best to reduce interruptions. This can be easier said than done so don’t beat yourself up over this one, especially when there are siblings involved! On days that your child is having particular difficulty, reducing questions and language demands (i.e. “Tell grandma what we did yesterday.”) is a good idea. Let them initiate when they want to talk. Keep your expectations high, but give them a break on rough days!

If I’m Not To Blame, Then Why Does My Child Stutter More at Home And Around Me?

Although this is certainly not true of all children, many of my clients have stated that their child stutters more at home. Contrary to what most parents would believe, this is usually a positive thing and not a sign that they are doing something wrong. What these parents are witnessing is “open stuttering.” Open stuttering occurs when a child (or adult) speaks freely and without hiding, avoiding or “going around” words that they worry they may stutter on. Instead of feeling accountable for this increase in disfluencies, parents should be praised for creating a supportive environment that has allowed their child to be themselves and has encouraged their child to express themselves whether or not they stutter. At school or around peers your child may not stutter as frequently, however this may be a result of avoidance behaviors such as switching words or opting to speak less. These avoidance behaviors can be exhausting and frustrating. Home should be a place for your child to take a break from “avoiding” and say exactly what they want to say, when they want to say it (even if it means taking a little longer to come out!).

But What About The Techniques My Child Is Learning In Speech?

The strategies your child is learning with their speech-language pathologist are extremely valuable in giving them a way to regain some control over their speech, especially when entering a difficult speaking situation (i.e. reading aloud, oral presentation, introducing themselves, etc.) However, when it comes down to it, it is up to them when they choose to use their speech tools. They should be praised when they practice or use their techniques but also praised for open stuttering. It may not be easy, but resist the urge to feel (or express) disappointment when your child stutters. Instead, be proud that when they begin to stutter they are choosing to continue to speak and be heard.
Brooke Leiman, MA, CCC-SLP, is the Fluency Clinic Supervisor at National Speech Language Therapy Center in Bethesda, MD. Brooke hosts a blog dedicated to informing people on stuttering and stuttering therapy at www.stutteringsource.com. She can be contacted at Brooke@nationalspeech.com.

Tricks to Help Speech Lessons Carryover into Daily Life

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How can our clients better incorporate new skills into their speech in their daily lives? It seems that they are often limited by their social interactions with caregivers, parents or spouses, so that they can’t practice or complete speech homework between sessions.

Some of my adult clients will avoid practice sessions with their spouses altogether. How can we encourage use of newly acquired skills between visits? Wouldn’t the duration of therapy be reduced and functional communication improved? Research has supported more intensive therapy approaches to promote a more efficient, complete healing process. Because time and funding often limits therapy frequency, we send patients home with work for practice. Follow-through with homework generally rests on the motivation of the client or the client’s family. We need to find ways to make the therapy process efficient and functional.

In Pam Marshalla’s 2010 book “Carryover Techniques (in Articulation and Phonological Therapy),” she defines the term carryover are referring to “a client’s ability to take an individual speech skill learned in the therapy room and to apply it broadly in all speaking situations.”

Getting our students and clients to use their articulation and communication skills outside the therapy environment requires that we begin the process of carryover as soon as the skill is demonstrated in a variety of environments. For children, it might mean saying a fluent word or phrase during a game to get to the next square, or using the correct production of /r/ and /l/ during a short conversation about sports. For adults, the rules of learning after a stroke or traumatic brain injury still may require learning a new skill, like writing the first letter for phonemic placement or using cognitive-semantic linking to ask for coffee.

We need to get more creative to promote carryover across all our clients because of additional sensory, physical, psychological or cognitive difficulties that may impede the process. Charles Van Riper in 1947 wrote that while we cannot rush carryover, we must facilitate its progress.

Pam Marshalla listed some functional ways to promote carryover in children and adolescents, including use of:

  • Fill-in sentences or fill-in stories to stimulate spontaneity.
  • Idioms to stimulate spontaneity.
  • Negative practice to help break the incorrect speech habit.
  • Nonsense syllables and words to strengthen the carryover process.
  • Over practice to cause a hyper-awareness of the goals of therapy.
  • Rapid-fire questions and answers to promote naturalness.
  • Reading aloud as a step between word productions and conversational speech.
  • Rhyming to capture a client’s attention and encourage practice outside of therapy.
  • Riddles because they cause a client to combine practice material with creative thinking.
  • Shortening productions to encourage naturalness.
  • Singing to help children remember their speech work and to encourages effortless practice.
  • Spelling out errors to help the client think about what she is saying and how she is saying it.
  • Story-telling and re-telling to cause stimulate spontaneity and to cause a breakthrough in carryover.
  • Tongue twisters to teach children how to control their articulation.

More on promoting carryover in speech-language treatment can be found on Pam Marshalla’s website.

Many of these techniques are useful for adults as well as children. Here are some additional carryover ideas for adults:

  • Create a script to practice at a favorite restaurant.
  • Use the carryover phrases and substitute other items at a counter deli or a department store.
  • Make a to-do list (or grocery list) each day. Practice writing and reading.
  • Talk about the programs you will watch.
  • Use carryover phrases for conversation, such as, “Hi. How are______?” “What is____?”  “I’m _____.” “Who is____?”
  • Use a calendar and an 8 by 10 dry-erase board to practice drawing,writing and gesturing.
  • Use your smart pad, apps, whiteboard, AAC, text-to-speech, and speech-to-text to send emails and do alphabet board, speech tutor and naming practice.
  • Play your favorite brain games daily. They will help you with focus, learning, word-finding and memory.

If you encourage your clients to engage in games and functional activities daily, the overall quality of your clients’ understanding and speech production will improve because you are encouraging the growth of new neural connections. Your clients are naturally acquiring and using the new skills in their daily lives because they are using them. Becoming more functional can be the most motivating effect of carryover.

 

Betsy C. Schreiber, MMS, CCC-SLP, is a clinical supervisor at Ladge Speech and Hearing Clinic at LIU/Post on Long Island, and a partner at Hope 4 Speech Associates, P.C. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders, and 18, Telepractice.

 

Giving Peruvian Children the Power of Communication

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In March, I traveled to Lima, Peru, with our Mercy College communications disorders program director, Helen Buhler, and a team of 27 physicians, surgeons, nurses, technicians and other SLPs. We were there as part Mercy College’s partnership with Healing the Children, Northeast, which provides primarily surgical services to children in need in the United States and abroad.

Over the week we were there, 37 children had surgery; some had traveled for 7 days to reach the hospital. We SLPs worked on parent training, peer training and direct service delivery. Here are some excerpts from the blog I kept during our visit.

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I cried when Dr. Manoj Abraham—a surgeon from Vassar Hospital—put the last stitch into the baby’s lip.

On Friday, Helen, Marianella Bonelli—an SLP and Mercy alum—and I visited with all the parents on the ward. For those whose children had had a lip repair, we celebrated together, admiring their beautiful babies. For those who had their lips repaired but still would need palate surgery in the future, we also gave advice on helping the kids develop good speech habits now to establish good airflow from the mouth after the palate is closed. We worked directly with the kids who had newly closed palates and their parents, teaching about how to bring the sounds out through the mouth and not the nose. Needless to say, there were many therapy materials, toys and goodies passed around, ensuring we went home empty handed but the kids did not.

After speech rounds, we put on fresh scrubs and went to surgery. Dr. Abraham was operating on a baby with a cleft lip that went up into her nose all the way, and welcomed us to observe him.

He was putting this baby’s nose together, carefully making it match the other side as much as possible. He worked some more on the deep layers of the lip, making sure it would be able to have free movement. Then he sutured the philtrum, the raised line that runs down from your nostril to the beginning of the red part of your lip. Suddenly, this baby had a sweet Cupid’s bow of a mouth…a mouth that would pout and pucker, shout, whisper…

Even though it was my second time in the OR and I thought I was over it, I cried and cried. Writing this now, I’m crying again.

What a gift.

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As I came into the speech office (a commandeered storage room), I saw Helen doing…arts and crafts? 

Helen always says we do cowgirl therapy on these trips—shooting from the hip. When an 11-year-old girl with cerebral palsy arrived with very few spoken words, and those few only intelligible to her mom, Helen created an old school low-tech augmentative communication device. She used paper, a sheet protector and some of our speech materials to create a board with some basic vocabulary.

The mom was thrilled to have a way for her daughter to communicate some wants and needs to others in her life. Helen showed her how to create more pages for the board as the child mastered its use. The mom’s eyes were shining—it was so obvious that the board would be implemented immediately.

Based on a quick evaluation, it was clear that the child understood a lot more than she could say, so we hope this is a way she can start to “say” something to the world at last.

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We also worked with a four year old boy with hearing loss due to a malformation of the external and middle ear. He has had recurrent ear infections and had drainage from one ear. He was taking an assortment of antibiotics, and his mom had a thick folder of medical records with her. Although his audiological testing shows a hearing loss, he is not currently a candidate for surgery (Dr. Ryan Brown graciously gave him an exam on the fly to double check).

Helen spent some time with the mom, teaching about behavior management, and I taught her about sign language. I taught them three signs: “go,” “more” and “eat.” The kid chased me around the grounds of the hospital, as we worked our way over to our surgical consult, and I would only run if he signed, “go.” We went from hand-over-hand to slight physical prompt, to following a model for the sign “go.”

The mother was shocked at how positive our interaction was—he was laughing as he chased me. Soon, this kid will experience the power of controlling his world through communication.

Score one for the speech department.

Shari Salzhauer Berkowitz, PhD, CCC-SLP, is an assistant professor at Mercy College in Dobbs Ferry, N.Y. She is an affiliate of ASHA Special Interest Groups 10 (Issues in Higher Education) and 17 (Global Issues in Communications Sciences and Related Disorders). Her research interests include cross-language and bilingual speech perception, multi-modal speech perception and integrating technology and instrumentation into the communication disorders curriculum.