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.

 

Helping Clients With Aphasia Retrieve Words—On Their Own

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Eric Broder Van Dyke / Shutterstock.com

“I can’t hear it!” This was said by Mrs. A, a 67-year-old woman with aphasia, who actually hears fine. What she meant to say is that she can’t recall the sequence of sounds to express a particular word or idea. When we have that tip-of-the-tongue loss of a name, how do we try to remember it? What strategies are we using to get to that word that we can’t remember?

Our success depends on our ability to hunt and gather—and on the number of neural connections we can tap into to access the information. These skills are cognitive, not simply learned operantly.

In my last blog post, I talked about establishing cueing hierarchies and functional activities for our adult clients. This post looks at using the cueing hierarchy to stimulate the rewiring process. Sometimes I think that I am a sort of electrician rather than an SLP. I work on finding the connections based on observed behavior from evaluations or activities (like writing, gesturing or drawing) that require least intervention.

How do we develop these skills? How can we teach strategies for short and long-term functional success?

Sometimes, we spend the therapy session working on the most disabled aspects of the communication disorder: comprehension, word retrieval, writing and reading. But if we don’t tap clients’ best abilities to foster some success, and if we don’t address whether they are continuing to practice these skills outside the therapy room, how will compensatory skills, adaptive skills and new connections work for them?

Let’s look at Mrs. A, who said, “I can’t hear it.” She was telling me about the very connection that she lacks due to her aphasia: re-auditorization. She can’t hear the words or the phonemes that make up the words in what I call “her mind’s ear.” If given the first phoneme, or a carrier phrase, she almost always names the word. She is able to write the word about 75 percent of the time but can only read it aloud about 30 percent of the time. She will often be able to speak complex multisyllabic words or a short phrase when discussing a topic. Auditory and reading comprehension is 75 percent for paragraphs. She is very intact cognitively, but her affect varies emotionally from congenially engaged to depressed and angry.

She is about two years post-stroke and has an all-in-one AAC that she doesn’t use. Our goals must address her frustration by establishing immediate successful compensatory strategies for communication. Then we need to build skills that will help in the rewiring, so that she begins to cue herself. The rewiring will be difficult here because she doesn’t link the phoneme to the letters she is able to write. But if she can write the word and then read it aloud more often, she can develop a clear strategy for verbalization that will reduce her frustration.

We will begin by simply reviewing phonetic placement in monosyllabic words. I like to use real words—which have semantic value—rather than nonsense syllables. Consonant-vowels alone don’t work as well as consonant-vowel-consonants that mean something. Mrs. A started relearning that a /b/ means that the lips come together when starting a whole word like “beer.” We chose beer for the visceral, emotional connection it has for many people. We talked about when she might drink beer, such as at a baseball game, which lends itself to picture assistance to boost cognitive links. We initially used a mirror to model the placement while sitting next to her. We highlighted the first letter and said it with her. She saw the picture, then wrote the word.

Mrs. A can now produce the whole word “beer” after seeing a picture of it. Looking at the Cueing Hierarchy, we have moved from most clinician involvement to independent self-cueing for this phoneme. She is moving on to more phonemes rapidly so that we may not need to review every letter after a period of time. Mrs. A. is beginning to generalize the link to other sounds. New neuro-behavioral links and relinks are helping her associate the orthographic letter with a physical movement and the sound that is produced. New cognitive links and self-cueing has begun!

Next, she will need to use the strategy in controlled conversation and small groups to increase her comfort level and functional use outside of treatment. This is a big hurdle. Families and caregivers are crucial players and need to be instructed how to encourage communication without frustration. When possible, teach the caregivers and families how the strategy works. They will use it more readily at home and will see how it can work in a variety of situations, such as in restaurants.

Another client, Mrs. C, had a similar functional ability to write but not verbalize. With time, she was able to trace the first letter in the air to cue herself to say a word.

In both cases, skills that had been present were improved, then used to create a compensatory strategy for functional communication. We must teach our clients strategies for improving the scope of their communication without our cues, using their own strategies, thereby making them more independently functional. While available strategies are unique to each client, they usually take the form of low tech gesturing, drawing, writing, even circumlocution.

We want our clients to be learning and improving communication dynamically. If we always fill in all of the sentences or speak for them, they cannot make their own connections. When allowed to use strategies independently, they then blossom, not only communicatively but socially.

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.

Tiffani Wallace’s 2012 Top CEU Courses, Books and Apps Related to Dysphagia

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2012 was full of a lot of new experiences for me.  I was approached at the beginning of the year to begin speaking on dysphagia for PESI.  My first speaking engagements were in North Carolina in December.  I absolutely loved it!  Granted, I still have some kinks to iron out in the professional speaking world, but all in all, I thought it went pretty well.  I can’t wait for my next speaking engagement in January down south again, then in Illinois in June. I continued work on my BRS-S and finally was accepted!  Not only accepted, I passed my test!  I can now officially put BRS-S after my name.  Such long-sought and hard-earned letters!

Soon after I earned my BRS-S, I was promoted to Rehab Director of our department.  I’m still learning the ropes and working on improving our department.  I love the new job duties though.

I went to ASHA and had the opportunity to visit old friends and meet new friends.  As always, I had such a fun time!  I again had the opportunity to present a poster session.  It had a great turnout.  I worked in the SmartyEars booth, which is so much fun.  It’s always great to meet people and show off SmartyEars apps.  I always feel a lot of pride when people want to see a demonstration of Dysphagia2Go.  I would love to say that I attend the ASHA convention for the CEU’s, but I attend for the socialization.  That is one week of the year I feel like I am in “SLP heaven”.

I decided to end this post with a list.  Everyone always wants to know my recommendations.  Here are my top CEU courses, books and apps related to dysphagia.

Top CEU courses:

The VitalStim course by CIAO seminars is invaluable.  It’s absolutely great information, with such a huge emphasis on anatomy and physiology.  It is definitely worth the price whether you use the device or not.

MBSImP course by Bonnie Martin-Harris, provided by Northern Speech Services is another outstanding course.  Again, this course is based on the anatomy and physiology of the swallow and using it in interpretation of Modified Barium Swallow Studies.

Of course, my Dysphagia course.  I like to think that it is full of invaluable information.  :)

Top Books on Dysphagia:

Dysphagia Following Stroke by Stephanie K. Daniels and Maggie Lee Huckabee is absolutely excellent.  I’m in the process of re-reading it.  It is a book I will keep.


Drugs and Dysphagia
.  Great reference.


The Source for Dysphagia
by Nancy Swigert is my bible.  I love that book.


Clinical Anatomy and Physiology of the Swallowing Mechanism
.  Absolutely must-read!!


My Top Apps for Dysphagia

Of course my top vote goes to Dysphagia2Go.  I use this app all the time when I do a clinical evaluation of swallowing.  It lets me input all my data and then allows me to print a report of my findings.  This app is available for $39.99 on iTunes.

Dysphagia by Northern Speech Services costs $9.99 and offers amazing pictures of swallowing and swallowing deficits to share with your patients.

Lab Tests is a $2.99 app that allows you to look up lab values, their meanings and why the tests are performed.  This app does not require wi-fi to run.

Micromedex is a free drug app that is amazing and gives you not only information about the drug, but possible side effects, warnings, etc.  You can look up virtually any drug.

Cranial nerves is a $2.99 app that gives you information on all 12 cranial apps.  Not only does it give you the in-app information, but also allows you to, with the push of a button, access further information on the app on Wikipedia and Google.

 

I hope everyone has an amazing 2013.  I so look forward to all the new and great things to come!

This post is based on a post that originally appeared on Dysphagia Ramblings.

Tiffani Wallace, CCC-SLP, has been an SLP specializing in Dysphagia for over 11 years.  Tiffani has been very active in the social media world, creating 2 Facebook groups, Dysphagia Therapy Group and Dysphagia Therapy Group-Professional Edition.  Tiffani is also the co-author of the app Dysphagia2Go, available on iTunes.  She is preparing to travel nationally and speak on the topic of Dysphagia.  Tiffani writes a blog called Dysphagia Ramblings and is the author of www.dysphagiaramblings.com.  She is a 5 time ACE awardee and recently obtained her BRS-S.

Habilitation – What it is And Why it Matters to You

Most of us are familiar with the term rehabilitation and are comfortable with our role in providing “rehab” services.  Habilitation, on the other hand, may be less common. I don’t know of many SLPs who consider themselves “habilitation providers.” Audiologists may be somewhat more comfortable with the term as providers of aural habilitation, but not in other contexts.

So, what is habilitation? Basically, we are talking about services that help a person learn, keep, or improve skills and functional abilities that they may not be developing normally. Still not clear? Contrast that with services that help a person improve skills that have been lost after a stroke, head injury, illness, or other cause. The latter is rehabilitation – regaining lost skills or functioning. Habilitation refers to services for those who may not have ever developed the skill, such as a child who is not talking as expected for his or her age.  Adults can also benefit from habilitative services, particularly those with intellectual disabilities or disorders such as cerebral palsy who may benefit from services at different points in their life to address functional abilities.

Why the focus on distinguishing habilitation from rehabilitation? Anyone who has dealt with private insurance for a person needing habilitative services likely knows the answer. If you look closely at coverage descriptions for many insurance plans, you’ll likely see language specifying that services like physical therapy or speech-language pathology will be provided when skills have been lost due to illness or injury. This language automatically restricts payment for services to those who haven’t had a stroke or suffered an illness, including most children who don’t have a specific diagnosis underlying their speech, language, swallowing, or hearing problems.

Habilitation is getting national attention right now due to the implementation of the health care reform law. Part of the law stipulates that insurance plans offered through the state exchanges and Medicaid programs must provide services in 10 categories of essential health benefits (EHBs), including the category of rehabilitation and habilitation services and devices. ASHA has been anxiously awaiting the regulations regarding the EHBs and has been working particularly hard on ensuring adequate coverage for habilitative services through the Habilitation Benefits Coalition. The concern centers primarily on the fact that habilitative services are not common in “typical” employer plans, upon which the EHBs are to be based, and this lack of clarity around what habilitative services are and how they should be covered could result in continued difficulty with reimbursement for these services.

Recently, the Department of Health and Human Services (HHS) issued the Essential Health Benefits Bulletin in lieu of regulations. This bulletin is offered as guidance, but does not have the power of a regulation. Essentially, the bulletin gives the states the responsibility of determining EHBs, allowing for greater flexibility and customization to each state’s unique needs. Some highlights from this bulletin include:

  • States will have flexibility in choosing their benchmark plan and will have to supplement that plan with any of the EHB categories that are lacking
  • Plans cannot discriminate based on age, disability or life expectancy, but no specific guidance on this is offered
  • If a state doesn’t choose a plan, the default plan will be the largest small group plan based on enrollment
  • States will have to submit their choices to HHS for approval
  • Self-insured group health plans, large group plans, and grandfathered plans will not be required to cover essential health benefits at this time
  • Comments on the pre-rule bulletin are being accepted until January 31, 2012

When addressing habilitation specifically in the bulletin, HHS acknowledges that these services are less well-defined and that confusion exists over what exactly is covered by such a benefit. They have proposed two options for situations where the state chosen benchmark plan does not include habilitation. These include:

  1. Habilitative services would be offered at parity with rehabilitative services — a plan covering services such as PT, OT, and ST for rehabilitation must also cover those services in similar scope, amount, and duration for habilitation; or
  2. As a transitional approach, plans would decide which habilitative services to cover, and would report on that coverage to HHS. HHS would evaluate those decisions, and further define habilitative services in the future (p. 11)

As one can see, the issue of appropriate coverage for both rehabilitation and habilitation services is going to come down to state-level debates and decisions. ASHA will continue to monitor developments and take action, when appropriate, but the burden of the work will likely fall to the state associations and members within each state. If this issue resonates with you, we encourage you to contact your State Advocate for Reimbursement (STAR) and state association to assist in any advocacy efforts. Individuals requiring speech and hearing services, regardless of etiology, have a right to services to help them function as independently as possible. We have a tremendous opportunity now to ensure appropriate coverage for habilitative services as an essential health benefit. This is your chance to have a real impact on the future of health care.

Amy Hasselkus, M.A., CCC-SLP, is associate director of health care services in speech-language pathology at ASHA. She is also currently enrolled in a Masters degree program in communication at George Mason University, with an emphasis on health communication.

Patient-Provider Communication

How well do you communicate with your clients? We are, after all, experts in human communication. Shouldn’t that mean that we are good at communicating with the people we serve?

Words and letters


Photo by Chrissy Johnson1

Unfortunately, this may not always be the case. Like many other health care providers, SLPs and audiologists often have trouble communicating clearly so that clients fully understand and can use the information we share. We tend to use jargon and talk in medical or technical terms that are not easily understood by the average person. We use words like “dysarthria” or “sensorineural.” We talk about a person’s “standard scores,” “functional abilities,” and degree of hearing loss in terms of “decibels.” We also tend to share written information that is very dense and complex and do so without spending time explaining the information we’ve given out. This has been demonstrated in studies of the readability of communication disorder-related brochures as well as reflected in responses to ASHA surveys about how consumer materials are used.

Patient-provider communication is a hot topic these days. Do an Internet search of the term “patient provider communication” and you’ll find resources from the Institute for Healthcare Improvement, the American Medical Association, scholarly journals, and more. Go to the Joint Commission website and you’ll find new standards regarding effective, culturally competent patient communication. Closer to home, a group interested parties, including a number of ASHA members, have joined together and formed the Patient-Provider Communication Forum in an attempt to further patient-provider communication across the continuum of care. Patient-provider communication, including issues related to health literacy, is fast becoming as serious an issue in health care as universal precautions. In fact, the Agency for Healthcare Research and Quality (AHRQ) has branded its information about health literacy as a universal precaution. Makes sense if you consider that poor communication can result in very harmful consequences and poor outcomes if medical advice is not understood and followed.

So, how do you think you do in regards to communicating with your clients? Do you think they understand what you are telling them? Do they appear to read brochures and other information you give them? And, more importantly, do you think they understand that information well enough to follow through on any recommendations in it? What do you do to try to improve your communication with clients and families? As experts in human communication, we can lead the charge on effective patient-provider communication. But first we need to be good at it ourselves.

Amy Hasselkus, M.A., CCC-SLP, is associate director of health care services in speech-language pathology at ASHA. She is also currently enrolled in a Masters degree program in communication at George Mason University, with an emphasis on health communication.