The Language of Menus

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Are you looking for a free and functional therapy tool? How about a take-out menu? Menus are practical, full of language concepts and can be used for a variety of speech and language goals. Many young adults on my caseload have limited literacy skills and often find themselves dependent on others to order for them in dining situations. If they can’t read the menu accurately they won’t know all of their choices unless someone reads it to them.

What’s more functional than being able to read a menu and make a choice for themselves? Some menus have pictures, but most do not. Even menus with images and words are tricky if you’re not familiar with all of the dishes.

When using a menu as a treatment tool, I ask my clients, “What are your favorite places to eat?” Many times they don’t know names of restaurants, but can describe the type of food they prefer (e.g. Mexican, pizza, Italian). This is also an ideal opportunity to connect with family members by getting details about restaurants they visit and food they order.

When I ask a client, “How do you know what to order?” many of them respond by saying: “I just get the pizza/chicken/hamburger,” or: “My parents order for me,” or: “I ask the waitress for the food I want.” All of these answers work when dining out, but none give clients the ability to .take charge of their preferences.

Here are 10 speech and language goals I target when using menus in treatment:

  1. Literacy: Work on learning to read menu-related key words like appetizer, salads, sandwiches, chicken or fish. Create a bingo game with new words, so your client becomes fluent. Review the same menu over several sessions so your client familiarizes themselves with it.
  2. Categorization: What food group is broccoli in? How about chicken? I like to work on this goal of food groups with a game called Healthy Helpings My Plate Game. Try grouping foods by cost depending on your client’s budget or by healthy versus not healthy foods.
  3. Requesting: Practice requesting by asking your client to tell you what they would want from that particular menu, such as: “I want the sesame chicken with brown rice.”
  4. Pragmatics: Work on role playing by pretending you are the waitress and your client is the customer. Reverse roles and practice greetings, turn-taking, being polite, and more.
  5. Describing/Commenting: Review different foods and ask your client to describe specific For example, “What is the difference between thin crust pizza and thick crust pizza?” or, “Describe what crispy chicken tastes like.” If your clients can describe their preferences in detail, the better they’ll get at ordering.
  6. Answering “wh” questions: As you review the menu, ask “wh” questions like: “What is your favorite item on the menu?”, “Why do you like chicken nuggets?”,
  7. Expanding vocabulary: Using varied menus exposes clients to new and unfamiliar vocabulary. I even learn new terms when reading a menu from a restaurant I’ve never visited. (Recently I participated in a cooking class and learned several new words.) Review new vocabulary and discuss its meaning. An ideal way for your consumer to comprehend food-related words is to show your client an image. Using Google Images is an easy way to do this.
  8. Money Concepts: Work on the language of money concepts with your consumer. Present a budget and figure out what they can order within it. Ask “What happens if you go over budget?” or other money-related questions.
  9. Problem Solving: Discuss possible situations that your client might have to solve using a menu. For example, what happens if they run out of your favorite item? What do you do if you have an allergy? What do you tell the waitress if you don’t like your food?
  10. Sequencing: Discuss the order of how you’re going to order food and drink items. For example, you normally order drinks first, appetizers next, entrée and then dessert. Reviewing the menu can be carried over to other activities related to sequencing.

Rebecca Eisenberg, MS, CCC-SLP, is a speech-language pathologist, author, instructor, and parent of two young children, who began her website www.gravitybread.com to create a resource for parents to help make mealtime an enriched learning experience. She has worked for many years with both children and adults with developmental disabilities in a variety of settings including schools, day habilitation programs, home care and clinics. She can be reached at becca@gravitybread.com, or you can follow her on Facebook; on Twitter; or on Pinterest.

Smart PHONeNATION: How My Device Revolutionized My Voice Rehabilitation Practice

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My smartphone has literally revolutionized the way I give sessions. And I don’t mean literally Rachel Zoe style. I use my phone practically every session! Now I hear those of you who are seasoned professionals. You are unfamiliar, maybe apprehensive about technology like this. “It’s too difficult,” you say, “I’m not generation text message-thumb.” I hope this piece encourages you to give it a try.

Age knows no bounds when you apply technology, because most everyone can benefit from these innovations. I’ll echo a recent ASHA post on SLP hats and inquire the same about the many jobs of your smartphone:

  • Stop-watch. I have one less item to worry about if I use my phone for timing maximum vowel prolongations, S/Z ratios and structured session tasks. Your phone timer also tracks session length. We all have those clients who love (I mean REALLY love) to talk, which is good when you advance to structured conversational tasks, but sometimes they carry on too long. Use your phone timer if you feel it’s appropriate for signaling a wrap-up.
  • Recording device. I record my acoustic measures when I analyze cepstral peak prominence and fundamental frequency, but during therapy—where the hard work begins—I employ my voice memo app. I also teach patients how to use their own voice memo programs, which is important for home practice. Follow-through is such a different game now, because most patients have recording options on their phones. You can record session highlights for easy patient access on his or her own device, versus cassette-taping the session.
  • Biofeedback. It’s great if you have a state-of-the-art Computerized Speech Lab setup. If you don’t, your smartphone has an app for that. (Ha! You were waiting for that phrase, weren’t you?) Bla | Bla | Bla works as a visual sound meter. As you get louder, the faces change. It doesn’t replace the software that helps you stay within a target pitch range, but can provide biofeedback for intensity tasks. I use smartphone video recorders to improve self-awareness for laryngeal and upper body tension. Instant review of these videos may help your patient meet goals sooner.
  • Piano. For Joseph Stemple’s Vocal Function Exercises, I use my MiniPiano app for pitch matching on Warm-up and Power. For the small group of clients with NO musical inclination, just do you best to find a mid-range pitch for VFE’s, but for your type-A’s (you know who they are), the option to have perfect pitch right at your fingertips wastes no time.
  • Anatomy. I used to lug around literally (Ha, Rachel again!) thousands of copies of anatomy drawings for patients. The copies usually ended up in the trash. The Dysphagia app has been my most effective tool for explaining the anatomy of a swallow, vocal folds as well as reflux. It has nice color videos demonstrating disordered and normal swallows and dramatically enhances patient education. Plus, the video action makes a more lasting impression.
  • Alarm. Ever get a patient who doesn’t practice? (You can always tell.) With a smartphone, you can name each alarm and set them to go off at certain times. The patient can deliberately practice diaphragmatic breathing and single syllable target words every hour on the hour! We’re going for making new muscle memory here, so it’s key to entice the patient to practice mindfully and not just be on autopilot. It’s beneficial for whole body exercise to take place for short periods throughout the day, so why not phonation training? And it keeps patients accountable.

Embracing the technology out there doesn’t mean you need to de-humanize sessions. The relationships you build with your clients are special. Their progress depends on how comfortable they feel in the room. Don’t spend the entire session glued to your phone, but strive to find a good balance where you use it when you think it will make a difference.

We SLP’s and AuD’s are in the people business and let’s not forget we’re professional voice users ourselves. Voice therapy techniques used to be difficult to maintain out of the treatment room. Now our clients have a fighting chance to recreate that buzzy forward-focused sound every time they glance at their smartphone between Facebook updates and Yahoo news articles.

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She provides voice, swallowing and speech therapy in her own private practice, a tempo Voice Center, LLC. She also lectures on the singing voice to area choirs and students. She belongs to ASHA’s Special Interest Group 3-Voice and Voice Disorders. She keeps a blog on her website at www.atempovoicecenter.com. Follow her on Twitter @atempovoice or like her on Facebook at www.facebook.com/atempovoicecenter.

How to Evaluate Misbehavior

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Editor’s note: This is an excerpt of a blog post written by Tatyana Elleseff for her Smart Speech Therapy blog. Her full post can be read here.

Frequently, I see a variation of the following scenario on many speech and language forums:

The SLP is seeing a client with speech and/or language deficits in either school setting or private practice, who is having some kind of behavioral issues. Some issues are described as mild such as calling out, hyperactivity, impulsivity, or inattention, while others are more severe and include refusal, noncompliance, or aggression such as kicking, biting, or punching.

Well-meaning professionals immediately offer an array of advice. Some behaviors get labeled as “normal” due to the child’s age (toddler), others are “partially excused” due to a psychiatric diagnosis (ASD). Some might recommend reinforcement charts, although not grounded in evidence. Letting other professionals deal with the behaviors is common: “in my setting the ______ (insert relevant professional here) deals with these behaviors and I don’t have to be involved.”

These well-intentioned advisors are overlooking several factors. First, a system to figure out why particular set of behaviors takes place, and second, if these behaviors may be manifestations of non-behaviorally based difficulties such as sensory deficits, medical issues or overt/subtle linguistically-based deficits.

What are the reasons kids present with behavioral deficits? Obviously, there could be numerous answers to that question. The underlying issues are often difficult to recognize without a differential diagnosis. In other words, we can’t claim that the child’s difficulties are “just behavior” if we don’t appropriately rule out other contributing causes. Here are some steps to identify the source of a child’s behavioral difficulties in cases of hidden underlying language disorders (after, of course, ruling out relevant genetic, medical, psychiatric and sensory issues).

Start by answering a few questions: Was a thorough language evaluation—with an emphasis on the child’s social pragmatic language abilities—completed? And by thorough, I am not referring to general language tests, but a variety of formal and informal social pragmatic language testing. Let’s say the social pragmatic language abilities were assessed and the child found/not found to be eligible for services. Meanwhile her behavioral deficits persist. What do we do now?

Determine why the behavior is occurring and what is triggering it (Chandler & Dahlquist, 2015). Here are just a few examples of basic behavior functions or reasons for specific behaviors:

  • Seeking Attention/Reward
  • Seeking Sensory Stimulation
  • Seeking Control

Most behavior functions tend to be positively, negatively or automatically reinforced (Bobrow, 2002). Determine what reinforces the child’s challenging behaviors by performing repeated observations and collecting data on the following:

  • Antecedent or what triggered the child’s behavior.
    • What was happening immediately before behavior occurred?
  • Behavior
    • What type of challenging behavior/s took place as a result?
  • Response/Consequence
    • How did you respond to behavior when it took place?

Once you determine behaviors and reinforcements, then set goals on which behaviors to manage first. Some techniques include modifying the physical space, session structure or session materials as well as the child’s behavior. Keep in mind the child’s maintaining factors or factors that contribute to the maintenance of the problem (Klein & Moses, 1999). These include: cognitive, sensorimotor, psychosocial and linguistic deficits.

Choose your reward system wisely. The most effective systems facilitate positive change through intrinsic rewards like pride of own accomplishments (Kohn, 2001). We need to teach the child positive behaviors to replace negative, with an emphasis on self-talk, critical thinking and talking about the problem instead of acting out.

Of course, it’s also important to use a team-based approach and involve all related professionals in the child’s care along with the parents. This ensures smooth and consistent care across all settings. Consistency is definitely a huge part of all behavior plans as it optimizes intervention results and achieves the desired outcomes.

So the next time the client on your caseload is acting out, troubleshoot using these appropriate steps in order to figure out what is REALLY going on and then attempt to change the situation in a team-based, systematic way.

 

Tatyana Elleseff, MA, SLP, is a bilingual speech-language pathologist with Rutgers University Behavioral Healthcare and runs a private practice, Smart Speech Therapy LLC, in Central New Jersey. She specializes in working with multicultural, internationally and domestically adopted children and at-risk children with complex communication disorders. Visit her website for more information or contact her at tatyana.elleseff@smartspeechtherapy.com.

Know Your CAS

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When I was pregnant, I remember dreaming about my new baby. My husband and I wondered aloud if she would be a musician like him, an athlete like me, or have some individual talent all her own. We had absolutely no doubts about what strong communications skills she’d have, however. Her mother was an SLP after all.

During her first year, my daughter lagged in all developmental milestones. I went to at least five different conferences on early intervention, but I couldn’t figure out why my daughter wasn’t a chatterbox. She met her first word criteria at one saying “hi” to everyone she met.

My husband’s mother reported he was late to talk and didn’t really say much of anything until after two. I had heard of late talkers, but because I worked at the elementary level, I never treated preschool kids. I brushed aside my pediatrician’s suggestion to seek treatment because I was convinced my daughter must be like her Daddy and that I could help her.

I finally took her in for an evaluation when she was close to three and received a diagnosis of childhood apraxia of speech and global motor planning deficits. After starting therapy based on motor learning principles, she made progress immediately.

Upset that I missed this diagnosis in my own child, I went on to endlessly and obsessively research childhood apraxia of speech. I was disappointed to find maybe eight pages on the subject in my graduate school materials. I know CAS is rare, but SLPs need to know about it and need to have the tools to diagnose and treat it correctly.

That summer I attended the national conference for CAS. The next summer I applied and was accepted into the Apraxia Intensive Training Institute sponsored by CASANA, the largest nonprofit dedicated exclusively to CAS. I was trained under three leading experts: Dr. Ruth Stoeckel, David Hammer and Kathy Jakielski.

If I could get one message out to pediatric SLPs, it would be for them to research and become familiar with the principles of motor learning and change their treatments accordingly for a client with CAS or suspected CAS. I know many like me get so little training or even information on it in graduate school. I’ve met other SLPs who were told it was so rare they would probably never treat it or even that it didn’t exist.

ASHA recognized CAS as a distinctive disorder in 2007. Taking the time to learn more about how treatment for childhood apraxia of speech differs from other approaches for speech and language disorders is crucial for kids with this motor speech disorder.  The importance of a correct diagnosis leads to a successful treatment plan. To briefly summarize, sessions should focus on movement sequences rather than sound sequences taking into account the child’s phonetic repertoire and encouraging frequent repetition.

For more information visit apraxia-kids.org and become familiar with ASHA’s technical report on the subject.

 

Laura Smith MA, CCC-SLP is a speech/language pathologist in the Denver metro area specializing in childhood apraxia of speech. CASANA-recognized for advanced training and expertise in childhood apraxia of speech, she splits her time between the public schools and private practice. She speaks at conferences and consults for school districts or other professionals. Email her at lauraslpmommy@gmail.com, Like her on Facebook, follow her on Pinterest, or visit her website at SLPMommyofApraxia.com.

 

 

The Possibilities are Endless!

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Having been an SLP since 2004, I know the feeling of “burn out” as well as being comfortable. I have learned that there is far too much opportunity in this field to settle for status quo or unhappiness. Perhaps the most valuable lesson I learned was recognizing that simply venting to family, friends and fellow SLPs was only a short-term solution.  I had to learn to be a doer and motivate myself within my chosen profession.

I often see many Facebook posts about SLPs feeling tired of the profession, often citing endless paperwork, disrespectful supervisors, caseload overload, lack of resources, unreasonable expectations and unfair pay. They are often looking to change careers for a “quick fix” to these problems, but overlook the changes they can make within their profession.

I was feeling frustrated at my district job six years ago and my lack of connection with other SLPs. I did my best to reach out to others and was ultimately nominated by my colleagues to become the lead SLP. That experience empowered me to talk to administration about changing to the 3:1 service delivery model. My presentation worked!

From then on, monthly SLP meetings were built into our indirect weeks and the 15 of us worked and supported each other throughout the school year. Our motto was “we’re all in this together,” because we are the only people who knew what our jobs are like on a day-to-day basis.

Fast forward six years, I loved my position as lead but craved a change. One fateful day I happened to be talking to a friend/fellow SLP in my district who said, “Annick, why don’t we just quit and start our own private practice?” My response, “Why don’t we?” My friend laughed but I wasn’t joking.

That was the question I needed to ask myself. I hadn’t thought about that option before. Coming out of our master’s program, the questions on everyone’s mind were: Are you going to the schools? Hospital? Or private practice? We never asked each other: “Do you think you’ll ever start your own practice?” For me, that question was life altering. Although my friend was kidding, her words were far from a joke for me. Within months, I registered my business, created a website and printed business cards.

I now grow my practice while working as a part-time, school- based SLP. But it doesn’t end there. I supervised three graduate students earlier in my career and one them recommended me to a professor as a possible lecturer. I jumped at that opportunity and have made yet another discovery: I love teaching adults! I am about to begin my second semester teaching college courses.

Looking to the future, I want to continue to teach more classes, build my practice, present at conferences and perhaps look into other areas of our profession such as telepractice and corporate speech therapy. Whatever I do, it is comforting knowing the possibilities are endless within our field.

 

Annick Tumolo, MS, CCC-SLP is currently a school based SLP, lecturer at San Francisco Sate University and founder of Naturally Speaking San Francisco, a private practice specializing in home-based speech and language treatment. She is Hanen certified in It Takes Two To Talk ® and holds a Augmentative and Alternative Communication Assessment and Services Certificate awarded by the Diagnostic Center of Northern California. Like her on Facebook, follow her on Pinterest or contact her at Annick@naturallyspeakingsf.com.

Ten Speech and Language Goals to Target during Food/Drink Preparation

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Food and/or drink preparation can be an excellent way to help facilitate speech and language goals with a variety of clients that span different ages and disabilities.

Below are 10 speech and language goals that you can target during food or drink preparation:

  1. Sequencing: Because recipes follow steps, sequencing can be an ideal goal. If there are too many steps in a recipe then break them up into smaller steps. Take pictures of each step and create a sequencing activity using an app such as Making Sequences or CanPlan.
  2. Literacy: If a recipe has complex language that your client has difficulty reading and processing, modify it. I often rewrite recipes with my clients or use a symbol based writing program like the SymbolSupport app.
  3. Expanding vocabulary: Recipes often contain unfamiliar words. When beginning a recipe, target new vocabulary. If your client is an emergent reader, create visuals for the vocabulary words and use aided language stimulation as you prepare the food and/or drink with her.
  4. Articulation: Target specific sounds during food preparation. Are you targeting /r/ during sessions? Prepare foods that begin with r like raspberries, radishes and rice, or even a color like red!
  5. Describing and Commenting: Food/drink preparation can be an excellent time to describe and comment. Model language and use descriptive words such as gooey, sticky, wet, sweet, etc. Encourage your client to use all five senses during the activity (e.g. It smells like ____, It feels like ______).
  6. Actions: Actions can be an excellent goal during food and/or drink preparation. For example, when baking a simple muffin recipe, the actions such as measure, pour, fill, mix, bake, eat, can be targeted.
  7. Answering “wh” questions: As you are preparing food, ask your client open ended “wh” questions, such as “What are we baking?” or “Why are we adding this sugar to our recipe?” and more.
  8. Problem Solving: Forget the eggs? Hmm, what should we do? How about forgetting the chocolate in chocolate milk? Ask your client different ways of resolving specific problems with food preparation, such as: “What do you do if you are missing an ingredient?” or “What do you do if we add too much of one ingredient?”
  9. Turn Taking: Whether you are working with one or two people, turn taking occurs naturally during baking and/or food preparation. If you are working in a group, make assignments before beginning.
  10. Recalling Information: As you prepare the food/drink, ask your client to recall specific After you are done with the recipe, model language and then ask your client to recall the steps of the recipe.

Preparing even a simple beverage such as chocolate milk can be an excellent activity to engage in during a session. Although it’s made up of only two ingredients, you can still work on a variety of speech and language goals including sequencing, describing, problem solving (e.g. what to do if you put in too much chocolate), actions, turn taking and recalling information.

Here are some helpful apps to use during or after food/drink preparation:

I Get Cooking and Create Recipe Photo Sequence Books

Making Sequences

CanPlan

Kid In Story

SymbolSupport App

For more suggestions, check out my post here on getting a child with special needs involved in the kitchen.

 

Rebecca Eisenberg, MS, CCC-SLP, is a speech-language pathologist, author, instructor, and parent of two young children, who began her website www.gravitybread.com to create a resource for parents to help make mealtime an enriched learning experience. She has worked for many years with both children and adults with developmental disabilities in a variety of settings including schools, day habilitation programs, home care and clinics. She can be reached at becca@gravitybread.com, or you can follow her on Facebook; on Twitter; or on Pinterest.

Are You Wearing Your Play-Based Hat Today?

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Ever leave the house and not know what to wear? As an early intervention SLP, I wear many hats, and there are days when I’m not sure which hat (or hats) I’ll put on. As any therapist knows, the nature of our job is not just treatment related, but often much more. Of course the hat I wear most often is my speech therapy hat but when I enter the homes of my “kids” every week I sometimes encounter life that requires me to be more than just an SLP.

There is a trust that forms when you regularly enter someone’s home. Families respect you not only as their child’s SLP, but also as a resource for other parenting questions. These questions might require my community resource hat, my fellow parent hat or my support hat. Because the parents of our clients trust us to meet many needs, it is important that when they ask questions or seek guidance we are there to help.

For example, many families today experience a societal pressure to push their child well beyond what is developmentally appropriate. Parents set unrealistic expectations for their children and panic if they feel their child isn’t “keeping up.” I’m concerned when I enter homes filled with obscene piles of toys, a television constantly going and a toddler who manipulates my phone and tablet more skillfully than I do! Through my sessions I model play, in the absence of fancy toys and electronic devices, hoping the parents will realize how simply PLAYING with their child is enough. There’s no better way to achieve developmental milestones and enrich children than through play.

Sometimes my example isn’t enough…well OK, it’s often not enough. So frequently I have a conversation about age-appropriate expectations, age-appropriate toys and what children need most from their parents.

When pondering how to start this conversation, I often find myself asking: What can I do to educate families on the importance of play? What can I say to drive home age-appropriate expectations? What are some of the most important points to stress to the families I serve? Professionally, I branched into owning a business devoted to play, plus I learned about how play is changing and why it matters.

Here are some tips you may find helpful to educate parents about the importance of simple play:

• Remind families that children need unstructured playtime and give specific examples of what is learned when a child does “nothing.” A toddler’s day should consist mostly of unstructured play and opportunities to experience their world with all their senses. Tell parents that this is the best way for their child to learn.

• Share with parents the American Academy of Pediatrics’ recommendation of no screen time before age 2 and only two hours per day for children older than 2. Parents are usually shocked to hear this, but even a television in the background distracts a baby/toddler and can make it more difficult for them to focus and learn.

• Inform parents that babies and toddlers do not truly learn anything from flashcards. The powerful marketing beast can sell just about anything to an anxious parent who wants that best for her child. However, research and experience do not support their use, particularly at such an early age. Share what you know about play-based options for teaching language skills.

• Encourage parents to slow down and follow their instincts. Oftentimes parents know what’s best for their child, but are influenced by outside sources. As professionals, we can reassure parents to trust themselves.

If you are an EI SLP I hope you realize your importance not only in the life of the child you serve, but his family as well. You are appreciated and trusted, so may you guide your families so that they are able to enjoy the miracle of their child to the fullest. Choose your hats wisely and don’t keep all that knowledge about PLAY under your hat. We all have a role in supporting families and enriching children’s lives.

Lacy Morise, MS, CCC-SLP of Berryville, Virginia works for the West Virginia Birth to Three Program as an early intervention therapist. She also owns Milestones & Miracles (with her EI PT bestie, Nicole Sergent, MPT) Read her blog and like her on Facebook, follow her on Twitter @milestonesm and Pinterest

“Cuz You Know I’m All About That Case, Node Trouble”

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Meghan Trainor’s song is so popular that excellent covers are popping up everywhere and I think there is a strong possibility of another definition of “bass” being added to the dictionary by next year. Now, while Meghan has no history of voice issues that I am aware of, others in the spotlight have suffered from vocal pathologies so severe that they have had to cancel tours and even rehabilitate their singing voices for years before performing live again.

Voice care has been in the media recently and I think it is important for clinicians to understand exactly what is going on with these popular cases because it will help them answer tough questions. I am always reading whatever I can get my hands on. I know that most SLP’s and AuD’s out there barely have time to dash to the bathroom during a work day, let alone to thoroughly read a peer-reviewed research study. It is our duty as clinicians to have a strong commitment to lifelong learning because our abilities as competent care providers are supported by the information we can synthesize on the spot. It is always okay to say, “I don’t know,” however, I always feel extra special when I can say: “I read about this last week.”

Not having enough information on a topic usually leads to accusations and rash decision making. I had a client recently ask about the procedure that was performed on Joan Rivers, which ended up causing her death. “Don’t you do that?” she asked. I explained that although I do not biopsy vocal cords, I do look at them with a camera and the patient needs to be awake so he or she can say “eeeeee.” I went on to explain that topical anesthetic is sometimes used when the gag reflex is particularly sensitive, but no patient of mine is ever sedated for an exam. Joan Rivers had some unplanned things happen during her procedure and because her healthcare information is private, just like any patient’s, we are left to read and watch news stories compiled with some facts missing.

Most of us know that Julie Andrews had great success with “The Sound of Music” and “Mary Poppins,” but many might not know that she battled with vocal nodules, also called nodes, in the 1990’s. Speech-Language Pathologists know now that vocal nodules usually respond to behavioral voice therapy without needing surgical intervention. Julie had her nodules removed in 1997, but the surgery left her with the inability to sing. We wonder, as we do in Joan’s case, what actually happened. If Julie had noncancerous nodules and her behaviors were addressed, perhaps surgery wouldn’t have been necessary at all. Nodules shouldn’t come back if the vocally abusive behaviors are replaced with efficient vocal production techniques. We don’t know if Julie had any voice therapy, but we can speculate that she most likely had scar tissue develop where the nodes were removed. Scar tissue inhibits the vocal fold tissue’s elastic properties resulting in pitch breaks or periods of aphonia.

Nodes have also been addressed by mainstream media in the movie “Pitch Perfect.” Chloe tells the Bellas she has vocal nodes in a dramatic scene, but reveals she has continued to sing despite the diagnosis because she loves it so much. We can’t be expected to know every movie or pop-culture reference to our profession, but it helps to be aware so we can connect to younger clients. Chloe’s story is all too familiar. Some clients find it very difficult to follow treatments because their jobs depend on voice use or they are passionate about performing. It is essential to communicate the importance of adhering to all voice therapy recommendations. Explain that while you understand their passion for their craft, you know that they will have more heartache later if they don’t take time to correct behaviors now.

John Mayer very recently opened up on Twitter to discuss his long and emotional struggle with a granuloma. He says, “It’s 2 years to the day that I had my vocal cords paralyzed so they could heal. It took about as long to get all of my voice back. I can’t tell you how good it feels to hit those notes. Especially on new songs. I’m free again. So grateful.” Well done, John. As clinicians, it’s important that we educate our clients about the length of recovery time, especially for professional voice users.

Polyps have plagued singers like Adele and Keith Urban. Adele reportedly used an app on her phone to speak for her while she was on voice rest for her hemorrhagic polyp, but I wonder if she knew about this avatar program. Technology is readily available these days to improve success for any clients on vocal rest. Both performers underwent surgery to correct these conditions, and hopefully some voice therapy too, as polyps and hemorrhages are functionally caused vocal pathologies. There are four different classes of voice disorders: Functional, Neurological, Organic and Idiopathic. With Adele and Keith’s conditions falling under the functional category, voice therapy could reverse bad habits and keep them from developing any future lesions.

Have you ever provided therapy to a famous client? I know you couldn’t tell anyone even if you have, but it’s pretty exciting, right? Sometimes we need a reminder that a high-profile client’s plan of care should be given the same attention as any other on our caseload. It is okay to feel star struck, but remember to remain calm and collected. Any famous clients will thank you for your professionalism and remember how your intervention helped them get back to doing what they love. Trust me on this one.

So whether your patient is red-carpet-ready or your average-Joe, be knowledgeable and treat clients with equal respect and care so you can “bring savvy back” and be “all about that case.

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She provides voice, swallowing and speech therapy in her own private practice, a tempo Voice Center, LLC. She also lectures on the singing voice to area choirs and students. She belongs to ASHA’s Special Interest Group 3-Voice and Voice Disorders. She keeps a blog on her website at www.atempovoicecenter.com. Follow her on Twitter @atempovoice or like her on Facebook at www.facebook.com/atempovoicecenter.

 

“Use Your Speech Tools!” Why Your Child Who Stutters May Not Be Using His Strategies

Stuttering Tools

When a child who stutters demonstrates the ability to change his speech during a treatment session, it seems obvious that he’d want to use the same strategies to improve speech outside the session as well.  Children, especially teenagers, rarely want to stand out in a way that stigmatizes them, provokes questions or increases the chances of teasing.   So the question arises, “Why aren’t they using their tools?!”

Speech and stuttering modification techniques are often learned quickly and easily within the treatment setting.  However, SLPs and parents often feel discouraged when these tools seem to disappear as soon as the client gets to his car.  Is it laziness on the part of the child?  Is it the fault of the family for not following through with home assignments?  Is the SLP not teaching the best strategies?

Instead of placing blame, consider the following three reasons a child may have difficulty generalizing his skills:

Reason # 1: These Techniques Are Too Hard! 

Making changes to one’s speech becomes exponentially harder when you introduce factors that often are not present in the session, such as interruptions, time pressure and feelings of embarrassment or shame associated with stuttering. Learned escape/avoidance behaviors and increased language demands may make it very difficult to use these tools.  Suddenly, what felt like an easy decision to use a new technique, becomes complicated by the person’s desire to be heard in a large group of chatty peers or by the need to formulate an excuse about why he doesn’t have his homework.

How Can I Help?

Children will be more likely to use speech/stuttering strategies if they are first introduced in safe and supportive environments (i.e. home, session room).  To help with this, create a hierarchy of speaking situations and use it to guide where the client practices the strategies.  If a child who stutters is not yet using speech tools in certain situations such as the classroom, it is probably because of where that situation is on his hierarchy. Work with your clients to determine where they would like to use their strategies , while also identifying those situations where they would prefer to concentrate on things other than using their tools.

Reason #2: These Techniques Make Me Sound Weird! 

There are several techniques that may be taught to a child who stutters. Some strategies involve prolonging the initial sound to ease into or out of a word with less physical tension or struggle.  Other techniques include inserting more pauses into speech.   All speech tools require a child to alter their speech in a way that is still different from how his friends sound.  Children may report that they have similar negative thoughts and feelings about using these strategies as they do about their stuttering.  This may play a role in why they are choosing not to use speech strategies outside their sessions.

How Can I Help?

Just as you might spend time trying to help reduce negative reactions to stuttering, you might also spend time desensitizing clients to hearing themselves use strategies through voluntary stuttering assignments.  Children can also benefit from improving their ability to handle listener reactions. This can be addressed by participating in role-playing activities that help the child create “scripts” for responding to curiosity/teasing.  For example: “Why do you sound like that?” “Sometimes I stretch my sounds like that to help me get out of a stutter.”  The more comfortable the child feels with his strategies and ability to respond to questions about his speech, the more prepared he will be to use these techniques outside the session.

Reason #3: These Techniques Aren’t Worth it!  

A cost-benefit analysis can be useful when trying to understand why a child may choose not to use speech/stuttering strategies.  At the surface, it may appear that there are many benefits of using strategies which include increased fluency and improved overall communication. However, SLPs and parents must be careful to consider the costs, as well.  Costs may include increased effort, difficulty concentrating on the content of message, the risk of showing more stuttering and the potential that the strategy doesn’t work.

How Can I Help?

Have discussions with clients about what they perceive as potential costs versus benefits of using strategies in a variety of different speaking situations.  As the child becomes more accepting of stuttering and is better able to tolerate both his feelings about stuttering and listener reactions, physical tension and struggles associated with speaking will decrease.  As this happens, tools become easier to use and costs may not feel so high.

The bottom line 

There are several strategies that may help reduce stuttering frequency and severity.  However, you often can’t offer these tools without first considering and incorporating goals that target how the client thinks and feels about his speech both while stuttering and while using tools.

Brooke Leiman, MA, CCC-SLP, is the Director of the Stuttering Clinic at the National Speech/Language Therapy Center in Bethesda, Md. She is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. This blog post is adapted from a post on her blog, www.stutteringsource.com, which focuses on fluency disorders and their treatment.

 

 

Tales From Apraxia Boot Camp

bootcamp
In August of this year, I was selected to be a part of The Childhood Apraxia of Speech Association of North America’s 2014 Intensive Training Institute, otherwise known as “Apraxia Boot Camp.” Twenty-four speech-language pathologists, including myself, trained with three mentors–Ruth Stoeckel, Kathy Jakielski, and Dave Hammer–at Duquesne University over four days. In its third year, the goal of the boot camp is to spread a high level of knowledge about Childhood Apraxia of Speech (CAS) assessment and treatment throughout the United States and Canada. This conference accomplished that and so much more.

This experience was different than any other continuing education seminars that I have attended. We did not listen to speakers discuss CAS. Instead, Ruth, Kathy and Dave became our mentors. This was powerful. They moderated discussions on evaluation and treatment approaches. We reviewed research papers and had long debates on the principles of motor learning. We highlighted and critiqued therapy methods for those brave enough to show videos of themselves. We problem solved and brought up more questions than we knew were possible.

In smaller groups, our mentors provided insights and personal perspectives on how they work. In this intimate setting, we felt comfortable asking questions and sharing our experiences. The mentors shared constructive criticism along with thoughtful suggestions. In all, they made me think, reflect and question everything I do. Why do I give that test? Why do I treat that way? What is the research behind it? They encouraged us to become critical thinkers.

As therapists, we often get used to using the same materials and therapy techniques we learned in graduate school or during our early experiences. Those methods are not always effective with every child we treat nor are they all proven effective with evidence based-research. Specifically, children with CAS require different therapy techniques than other children with articulation or phonological delays.

Ruth, Kathy and Dave provided valuable information in a small, engaging setting. Their mentoring and passion for CAS has inspired me and I hope to pass along this valuable information to others through mentoring, improving my competency in treatment and diagnosis of CAS, and, in the end, helping children to communicate.

Based on my experience, I’d recommend asking yourself a few questions when selecting your next continuing education event:

  • What am I passionate about? Is there a child or an area of speech pathology that truly inspires me?
  • How will it improve my skill set?
  • How will it help me better serve my clients?
  • Who is doing the most current, researched-based evaluation or therapy techniques?
  • How will it further our profession?

 

Amanda Zimmerman, MA, CCC-SLP, is a pediatric speech-language pathologist in Columbus, OH. She can be reached at azimmerman@columbusspeech.org.