Beyond Skype for Online Therapy: Protecting Student Privacy

Privacy

 

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

HIPAA: Protecting Individually Identifiable Health Information

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

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

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

FERPA: Protecting Education Records

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

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

COPPA: Protecting Children’s Personal Information

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

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

Recommendations for Online Therapy

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

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

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

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

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

Can Speech-Language Pathologists Diagnose Autism?

Posted response

On February, as part of its Posted series, the ASHA Leader asked on Facebook, “Do you, as an SLP, diagnose autism spectrum disorder independently or as a team?” The response we received was varied and indicated there is some confusion in the profession about what is proper, expected, or even legal. The biggest question that appeared over and over was, “How can an SLP diagnose independently?” The answer bears some explanation.

When it comes to assessing and diagnosing ASD, interdisciplinary collaboration is important due to the complexity of the disorder, the varied aspects of functioning affected, and the need to distinguish ASD from other disorders or medical conditions. Ideally, the SLP plays a key role on an interdisciplinary team, whose members possess expertise in diagnosing ASD.  In cases when there is no appropriate team available, however, an SLP who has been trained in the clinical criteria for ASD and who is experienced in the diagnosis of developmental disorders, may be qualified to diagnose these disorders as an independent professional. For more information check out ASHA’s new Practice Portal and/or position statement on autism.

In most cases, a stable diagnosis of ASD is possible before or around a child’s second birthday (Chawarska, Klin, Paul, Macari & Volkmar, 2009). An early, accurate diagnosis can help families access appropriate services, provide a common language across interdisciplinary teams, and establish a framework for families and caregivers within which to understand their child’s difficulties. Any diagnosis of ASD, particularly of young children, should be periodically reviewed, as diagnostic categories and conclusions may change as the child develops. Interdisciplinary collaboration and family involvement is essential in assessing and diagnosing ASD.

Assessment, intervention, and support for individuals receiving speech and language services should be consistent with the World Health Organization’s International Classification of Functioning, Disability, and Health (2001) framework. This framework considers impairments in body structures/functions; the individual’s communication activities and participation; and contextual factors, including environmental barriers/facilitators and personal identity. There are recommended knowledge and skills for SLPs who are planning on working with individuals with autism spectrum disorder:

Knowledge required:

  • Federal and state laws and regulations regarding scope of practice, referral, and placement procedures.
  • Diagnostic criteria for ASD and related conditions (e.g., DSM-5).
  • Prevalence.
  • How to obtain information regarding etiology and related medical conditions.
  • Importance of early diagnosis and the role of the speech-language pathologis.t
  • How to evaluate the validity of diagnostic tools.
  • The necessary information to gather in a diagnostic evaluation about the child’s health, developmental and behavioral history, past intervention and academic history, and medical history of the family.
  • Other related diagnostic categories and when to make appropriate referrals to identify or rule out related conditions
  • How to rule out or confirm hearing loss while working with an audiologist.
  • The types of speech and language impairments that can co-occur with ASD, including features of language disorders, apraxia, and dysarthria.
  • How to share information about diagnosis with parents.
  • The challenges of determining eligibility for services for individuals with ASD, especially high-functioning individuals.
  • The needs of culturally and linguistically diverse populations, including the selection and/or adaptations of diagnostic instruments (ASHA, 2004b).

Skills required:

  • Observation, recognition, and interpretation of diagnostic characteristics of ASD.
  • Selection and correct use of valid diagnostic tools for ASD.
  • Appropriate referrals to other professionals to identify or rule out related conditions.
  • Diagnosis of the types of speech and language impairments that can co-occur with ASD, including features of language disorders, apraxia, and dysarthria.
  • Integration of findings from diagnostic tools for ASD, diagnostic evaluation, and information from other professionals or members of an interdisciplinary team, to determine diagnosis.
  • Documentation and communication of findings about diagnosis to family members, individually or in conjunction with a collaborative team.
  • Effective, delicate, and empathic communication when informing family members that the child has ASD.
  • Decision making about eligibility for services.
  • Appropriate recommendations and referrals for services and assistance to families in navigating the educational and health care systems, as well as promotion of self-advocacy.

Some state laws or regulations may restrict the scope of practice of licensees, however, and prohibit the SLP from providing such diagnoses. SLPs should check with their state licensure board and/or departments of education for specific requirements.

 

Understanding Autism: Restaurant Meltdowns

asd

I sat in a popular restaurant chain and watched an 8 year old boy have a major meltdown at his table.  His mother cringed as lunch time patrons stared.  An irritated couple at a nearby booth got up and moved, but only after glaring at the mother.  I’ll be honest, the child was disrupting my lunch too, but one thing I suspected was that this child had autism.  He appeared to be just like any other child, but the intensity of his outburst was out of proportion to the issue he was yelling about: The waiter had served him waffle fries and he had expected “skinny fries” just like the french fries served at home.

April is National Autism Awareness Month.  The U.S. Centers for Disease Control and Prevention (CDC) reports that 1 in 68 children are reported to have autism (ASD) and most are boys. Chances are, you know someone with autism.

What distinctive characteristics of ASD can affect a child’s ability to adjust to unexpected life events, even something as incidental as waffle fries?  Let’s look very briefly at some of the central features of ASD, while keeping in mind that this a spectrum disorder, with symptoms ranging from mild to severe and this list does not encompass all of the elements of a diagnosis. Just some of the central features that kids with ASD have difficulty with are:

  1. Social interaction, often including social reciprocity or that back and forth communication exchange known as conversation.
  2. Restricted behaviors and the need for “sameness” or the inability to be flexible with change.
  3. Hypersensitive and/or hyposensitive “to sensory aspects of the environment” which can hinder their ability to tolerate different tastes, temperature and/or textures of food and deal with change in general.

As a pediatric therapist,  I assess and treat a child’s ability to allocate specific cognitive resources in the brain to manage day-to-day life.  As adults, we too have to utilize many different parts of our brains throughout the day.  But what happens when we are bombarded with sensory input and suddenly, we have to adjust to unfamiliar stimuli? To understand what it’s like, consider this example:

You are driving the minivan full of kids to soccer practice, radio blaring, kids chattering.  Your brain is operating relatively smoothly, filtering auditory, visual, tactile and other sensations, while remembering to use your turn signal, maintain the speed limit, etc.  Suddenly, the weather changes and it starts to hail.  What’s the first thing you do?  Turn off the radio and tell the kids “Shush…Mommy needs to concentrate on the road.”  Perhaps you even slow down so that you can focus on the sudden change in driving conditions.  You have eliminated as much sensory input as possible so that you can concentrate on the task at hand – driving safely.  Isn’t it interesting that  you were driving perfectly fine until one unpredictable event changed in your environment?

Now consider the child with autism as he attempts to engage in mealtimes.  The reality is that daily life changes as easily as the daily weather report and for him, some days are just like driving through a hailstorm.  This child is already challenged by poor sensory processing; he has limited ability to take in information through all of the senses, process it and filter out the unimportant info, and then act upon only the relevant sensory input.

Now, bring that child to the family dinner table, which is all about social interaction and conversation.  Put a plate of food in front of him which looks and smells completely different from the last meal he was served.   Then, tell him to try that steamed broccoli for the very first time.  He doesn’t get to turn down the sensory input bombarding him at the table and focus just on the broccoli.  Because he has autism, he can’t always filter out which stimuli might be inconsequential and it feels so much safer to follow rigid behavior patterns and never try anything new.  Life for a child with autism is all about sticking to sameness. My role as a therapist is to help the child learn to deal with change.

A 2013 study from the Department of Pediatrics at Emory University indicated that kids with ASD are five times more likely to have feeding problems compared to their peers.  Once feeding difficulties are addressed in the home, restaurants are the next step for their families.  Here, the visual input is completely different and it changes constantly, the inconsistent auditory input can be overwhelming, the fluctuating smells may be interpreted as noxious, etc.   Every input to every sense has changed.   Once again, the child with autism is encountering a hailstorm and has to learn to tune out the distractions and focus on the task at hand – in this case, eating a meal away from home.  In this young man’s case, waffle fries were just too much to handle after managing all of the other sensory stimuli at the restaurant.

Perhaps you are a parent of a child with ASD.  Perhaps you have observed a child whom you suspect may be dealing with the daily challenges  of autism.  Thank you for considering what mealtimes feel like for him and his family.  It does get better, but it is a journey that requires patience from family, friends and the community.

Please share this article with a friend so that we can continue to raise awareness of autism spectrum disorder and if you know someone who loves a child with ASD, do something special for them this month in honor of National Autism Awareness Month – thank you!

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.

Kid Confidential: The Latest on Treatment of Ear Infections

ear infection

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

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

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

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

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

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

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

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

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

Please refer to the resources below for further information.

Resources:

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

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

 

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

Collaboration Corner: In Defense of the Whole Child

wholechild

I treat children with autism. I’ve been doing it for a while now. As the numbers of children with autism peak a staggering 1:88 (Center for Disease Control, 2014), the demand for trained staff has gone through the roof. Many districts have specialized paraprofessionals whose primary job is to teach and support children with autism. In the Boston area, graduate and certificate programs related to ABA are cropping up everywhere, churning out new and enthusiastic graduates by the boatload.

Before I go on, there are three things you should know about me: 1) I have never been a diehard, one-shoe-fits-all clinician, 2) I embrace whole-heartedly the principals of ABA. It’s as an evidenced-based approach, and it works wonders for all sorts of kids, not just ones with autism, and, 3) If I couldn’t be silly with my students, I would just close up shop.

As an SLP, I know there are mountains of other kinds of research, and that child language and cognitive development that are important too. In this age of ABA, I find myself wanting to shout from the rooftops, “Wait! Stop! There’s more to this kid than just autism!”

Our role as SLPs and educators

Working with so many professionals “trained in autism” made me realize that, as SLPs, we bring to the table our knowledge of childhood language development, learning, motivation and context. Never before has this been more evident to me. We also bring the friendly reminder the importance of a playful approach and rapport building.

I’ve found myself shifting discussions to the whole child, and what we know about children and learning.

Here are some pointers I frequently share with staff:

  1. Appeal to the inner child first (yours and theirs). The individual comes before the label.
  2. Not every behavior can be attributed to one definitive cause. Environments, emotional state/regulation, personality, medical/biological components, all should be up for consideration.
  3. Assessment and intervention is a daily process, which is sometimes messy and dynamic (see #2). We won’t always get it right the first time. Or even the second time.
  4. It’s possible (and OK!)  to be structured and silly at the same time. Sometimes silliness increases engagement.
  5. Watch and learn from your kindergarten teachers (see #4). I’ve learned a lot from them about having fun while being structured, thoughtful and flexible.
  6. Use visuals even if the child is verbal or becoming verbal. We can model language through PECS, topic boards and Aided Language Stimulation techniques, within natural play activities.
  7. Strive to meet every child “where they are” in all aspects of learning: attention, behavior, communication and language development.
  8. We can’t make someone ready to learn or communicate; we simply lay the foundation.
  9. Learning can’t happen in a bubble. Context is just about everything. I know what a zoo is, because I’ve been in one, not because I’ve seen a flashcard of one.
  10. And finally, my favorite: Provide random acts of praise and compliments. Make daily deposits into that relationship bank. It’s a worthwhile investment.

 

Kerry Davis Ed.D., CCC-SLP,is a speech-language pathologist in the Boston area, working with children who have significant communication challenges. She conducts trainings and workshops, and serves as a volunteer speech pathologist and consultant for Step by Step Guyana, a school for children with autism in South America. The opinions expressed in this blog are her own, and not those of her employer.

Apps with Elders

elderapps

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

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

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

Five Tips to make using an iPad in therapy easier

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

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

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

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

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

Favorite Adult SLP Apps

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

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

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

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

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

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

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

Avoidance Reduction Therapy: A Success Story

true colors

I was interviewing for assistant positions at our summer speech and language camp when I first met Ben Goldstein.  Ben is a graduate of the University of Maryland and was in the midst of taking his pre-requisite courses to apply for graduate school to become a speech-language pathologist.  Ben also happened to be a person who stutters (PWS).    As the interview continued he shared that he was introduced to avoidance reduction therapy by Vivian Sisskin at the College Park campus of UMD.  I had already been applying aspects of avoidance reduction therapy with my clients,  however Ben helped solidify my feelings on this approach.  Ben was kind enough to answer some questions and walk me through his experience with avoidance reduction therapy, which is included below.

Avoidance reduction therapy is an approach to stuttering therapy that can be used with both school-aged and adult clients.  This approach views stuttering as an approach-avoidance conflict; a theory that states that a PWS experiences the desire to speak and interact with others while simultaneously experiencing an urge to hide their stuttering.   The result of these competing desires culminates in the maladaptive secondary behaviors that interfere with communication (ex. eye blinking, leaning forward, use of fillers, etc.).  These competing desires also result in a feeling that one can not partake in certain activities and situations due to their speech.

Avoidance reduction therapy works toward reducing these maladaptive behaviors, leaving in its place a more comfortable, forward moving form of stuttering.  It also works toward reducing the handicap of stuttering, whereby increasing a person’s willingness to participate in various activities and situations, whether or not they show some stuttering.   Unlike other approaches that focus on fluency, this particular approach views a person’s strong desire to be fluent as perpetuating the problem and ultimately what contributes to their word and situational avoidances, as well as much of the struggle behaviors you see in their speech.  Avoidance reduction therapy does not put an emphasis on fluency, but rather on improving a person’s ability to successfully communicate in the “real” world.

How do you incorporate avoidance reduction therapy into your sessions?  Start by helping your client to identify their own stuttering patterns and assist them in recognizing how much of their pattern is “true” stuttering and how much of what we see is actually habits they formed in an attempt to mask stuttering.  Challenge clients to allow themselves to show true stuttering (or perhaps use voluntary stuttering), beginning in the safety of the therapy room and eventually branching out to different “real-life” situations.  As you work through these challenges, clients will often discover ways in which their stuttering was holding them back that they may not have realized before.   Read on to learn about Ben Goldstein’s first-hand experience with avoidance reduction therapy.

Before jumping into avoidance reduction therapy, how would you describe your speech intervention experience leading up to it?

Ben: Prior to avoidance reduction therapy, I saw two SLPs as a private client. Both focused primarily on common fluency shaping techniques (easy onset, breath control, continuous phonation). My parents felt that the therapy helped me sound better, but I don’t remember sounding better. I also don’t remember feeling better about myself or my stuttering through therapy.

Can you describe your stuttering pattern prior to beginning avoidance reduction therapy?  Do you feel like stuttering impacted your quality of life?   

Ben: When I showed my stuttering I usually blocked for long periods of time, contorted my lips and mouth, tapped my leg to release a block, used fillers such as “umm” and “you know,” and closed my eyes. There was little actual stuttering going on. It was mostly secondary behaviors.

In particularly scary situations, I would avoid talking altogether if I felt that I was going to stutter.  If somebody asked me a question and I felt a disfluency coming on, I would often pretend that I didn’t hear the person. I would constantly change words that I thought I was going to stutter on. I would not go to parties and avoid hanging out with friends sometimes.

All of that avoiding had a huge impact on my life. For one, I never showed my real personality. If I had a joke I wanted to tell or a comment I wanted to say, I usually wouldn’t say it. My mindset everyday was “Let’s get through today without showing stuttering. Say only what you absolutely have to say.” That kind of mindset suppresses one’s personality and it can lead to a lot of feelings of shame, guilt and feeling less than others.

How were you introduced to avoidance reduction therapy?  

Ben:  After my first semester freshman year at the University of Maryland, I found my way to the on-campus Hearing and Speech Clinic.  It was there that I was introduced to avoidance reduction therapy.

How would you define avoidance reduction therapy and the rationale behind this approach?  

Ben: I think the most basic definition of avoidance reduction therapy is to reduce one’s avoidances related to stuttering, speaking, and really, in life.  In other words, the goal is to reduce how often one actively avoids stuttering, avoids various speaking situations, and avoids different opportunities in life. The rationale behind the therapy is that stuttering is perpetuated by habit and fear.  If I have a fear of speaking in class, every time I keep silent in class, I reinforce that behavior and the fear of speaking in class grows. Avoidance reduction therapy is about reversing that process.  If you face your fear head on and with a different attitude of what is a success and what is a failure, the fear eventually dissipates, and once the fear of speaking weakens, you can start to make choices to stutter in a more comfortable and effective way.

Most clients seek therapy to try and reduce or eliminate stuttering and may be initially concerned with the premise of avoidance reduction therapy. How long did it take for you to “buy in” to this approach?  

Ben:  Great question. For me, I bought in pretty quickly. No one before in my life had explained to me the cycle of avoiding stuttering, the feelings and thoughts that I had, and how those feelings and thoughts perpetuated and worsened my speech.  Once these ideas were laid out for me it was almost like a lightbulb went off in my head. “Yes, finally what I’ve experienced my entire life makes a little sense.”

Can you explain what a typical therapy session would look like?

Ben:  A typical therapy session usually begins with the client talking a bit about how their week went. The client might talk about a speaking-related success they had the previous week (talking about my successes helped me feel good about myself as a communicator), a situation that is really bothering them (these always helped me relieve some anxiety and develop a plan), or a topic unrelated to speech altogether. While the client is speaking, the SLP is taking note of the client’s speaking pattern and assessing how successfully they are hitting their target from the previous week.

After the client has spoken for a bit, he or she usually receives feedback from the SLP. This feedback can be related to the thoughts and feelings of the client (dependent on what the client was saying) and/or his /her motor pattern (dependent on how the client was saying it.) Following feedback, the client and SLP engage in some specific practice where the client has the opportunity to put the SLP’s suggestions into action in a safe speaking environment. This allows the client to play around with the new assignment (whether motor-based or cognitive-based) and allows the client to begin to reinforce the new behavior.

Following target practice, the client and SLP finalize the client’s assignment or plan for the week. The client is told what the rationale behind the assignment is, and how that target or goal fits into the client’s longer-term plan.

What aspects of avoidance reduction therapy do you think are most beneficial to you and to the individuals in your group? 

Ben:  I can’t speak for everyone in my group, but to me, the lessons I’ve taken from avoidance reduction therapy are that it’s OK to stutter, it’s OK to be vulnerable and it’s OK to not be perfect everyday. Contrary to what I used to think, stuttering is not some giant, evil monster that I need to run away from for the rest of my life. It’s a part of me and not a negative thing. Perhaps most importantly, my goals have changed since starting avoidance reduction therapy. In the past, my priority was to avoid stuttering at all costs regardless of how it affected the way I connected with others and how I felt about myself. Today, my goal is to be true to myself, connect with other people, say what I want to say, and enjoy life as much as I can. If stuttering wants to come along for the ride, that’s OK.

How do you think your stuttering has changed?  Does stuttering affect your life in the same way it did prior to receiving avoidance reduction therapy?

Ben:  A lot has changed since starting avoidance reduction therapy. For one, my stuttering pattern has definitely changed. Now, I keep eye contact during disfluencies. The habit of tapping my knee is gone. I no longer use interjections with the same degree of frequency. I still contort my lips and mouth sometimes, but hey, it’s my next goal to tackle.

In terms of life impact, it’s night and day. Now, I say most of what I want to say. I show my personality. I also have a completely different perspective of what constitutes a success for me at this point and time and what is a failure. I recently gave a short talk in front of 600 people and stuttered a great deal. Four years ago, I wouldn’t have even thought of doing it, and if I had been forced to, I would have viewed my immense amount of stuttering as a failure. Today, I recognize what an accomplishment it is for me to voluntarily speak in front of that many people. I’m slowly chipping away at avoidances and those are my successes.

Do you think that there are individuals who would not benefit from this approach?  

Ben:  I think one really has to be motivated to change to undertake avoidance reduction therapy. It’s not easy work. Doing things that petrify us is so counterintuitive. If one has never talked in class before, talking in class that first time is going to be really scary. But talking the second time is going to be a little easier.

My experience of diving right into the therapy isn’t the common one. (And my initial experiences with avoidance reduction therapy probably weren’t as smooth as I’m remembering them). It takes time to truly change one’s attitudes and beliefs. This isn’t an intensive, short-term kind of therapy. But in my experience, and the experience of many of my peers, it’s a therapy that leads to real, meaningful, long-term change.  The motto “short-term pain, long-term gain” really applies here. I do think everyone is capable of receiving meaningful benefits from it, but they’ve got to put a lot in as well.

If you want to learn more about Avoidance Reduction therapy, I highly suggest Vivian Sisskin’s video Avoidance Reduction Therapy in a Group Setting, available through the Stuttering Foundation of America.

Brooke Leiman, MA, CCC-SLPis the fluency clinic supervisor 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

 

Ben Goldstein is a graduate of the University of Maryland. He will begin work toward a master’s degree in Speech Pathology in the Fall of 2014.  Ben is a member of the Rockville Chapter of the National Stuttering Association and formerly served as it’s co-chapter leader.  He can be reached at bagoldstein@gmail.com.

Our Perception of Taste: What’s Sound Got to Do with It?

music

My first love as a speech-language pathologist is pediatric feeding.  I spend lots of time talking to little kids about “carrot crunchies” and “pea-pops” and various silly names for the sounds that different foods make in our mouths as we explore all of the sensory components of food in weekly treatment sessions.

Is it possible that sound is a larger component of our eating experience than many of us realize? What’s sound got to do with eating, or more specifically, with taste? Discovering how the sound of a crunching potato chip affects flavor is more than just curiosity.  Prof. Charles Spence, who leads Oxford’s Crossmodal Research Laboratory, studied how the sound that food makes in our mouths influences our perception of freshness.  It’s an important point for potato chip manufacturers, who strive to create the “crunchiest crisp possible.”

Background sounds in the environment also influence our interpretation of taste.  Spence conducted an experiment where individuals were presented with 4 pieces of identical toffee.  Two pieces were eaten while the subjects listened to the lower pitch of brass instruments.  Two other pieces were eaten while listening to the higher pitch of a piano.  The pieces eaten during the higher pitched piano music were rated “sweet” by the subjects and the pieces eaten during the lower pitched music were rated “bitter.”

Chef Blumenthal, owner of The Fat Duck near London, has taken Spence’s research findings to the next level.  Order the “Sound of the Sea” and you’ll enjoy more than seafood delicacies  presented on “a sand of tapioca and fried panko, then topped with seafood foam.” The dish is accompanied by an iPod nestled in a seashell, “so that diners can listen to the sound of crashing waves as they eat.” Spence reports that diners experience stronger, saltier flavors with the sound of the ocean in the background.  Another London restaurant, the House of Wolf, serves a cake pop along with instructions to dial a phone number and then, before tasting,  press 1 for sweet and 2 for bitter.  Diners who listened to the first prompt heard a high pitched melody and those who pressed “two” heard a low brassy tones.   In an article for the Telegraph, Spence said,  “We have also looked at the crispiness of crisps and biscuits and found that by boosting certain high frequency sounds when volunteers bit into them we could make them taste crunchier, and they became softer if we dampened those frequencies.”  It’s not just diners across the pond who are experiencing the marriage of sound and taste. Major food companies in the United States also have consulted with Spence, who developed a soundtrack to “complement”  the coffee at Starbucks®.  Speaking of coffee, in a recent study, Spence found that humans can detect whether a liquid is hot or cold, just from listening to the sound of it being poured into a glass, porcelain, paper and/or plastic cup.  I’ll consider this the next time I’m waiting for my drink at the local coffee shop.  Perhaps, from now on,  I can just listen to the sound of the pour, grab my drink and avoid the barista announcing “Lite Iced Triple Venti Half-Pump Americano Skinny for High Maintenance Melanie” with that smirk on his face.  But, I digress…

When I consider my little clients in feeding therapy, I wonder how this research might be expanded to detect possible differences in taste perception in children with sensory processing challenges, including kids with autism. Certainly, respecting the differences in a child’s sensory system is an integral part of feeding therapy for most clinicians.  Could it be that this hiccup in auditory, visual, gustatory or other sensory systems communicating efficiently with one another makes eating a variety of foods especially difficult for some children, more than we know at this time?  A recent article in The Journal of Neuroscience reported that kids with “autism spectrum disorders (ASD) have trouble integrating simultaneous information from their eyes and their ears” and discussed how this might affect their language skills. Wendy Chung, MD, PhD at Columbia University Medical Center explained in a recent video for parents how a poorly functioning pathway for simultaneous auditory and visual information (and the secondary problems of processing and responding to sensory signals) causes a child with ASD to be overwhelmed in environments that we find quite comfortable.  Perhaps future research may include Spence’s work and how it might apply to children in feeding therapy. Would certain tones be more soothing while eating?  Would certain music in the school cafeteria help children eat faster or even choose more nutritious foods? The common phrase “a feast for the eyes” may one day turn out to be “a feast for the eyes and ears” as we consider all the possibilities.

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.

Just Breathe. Really?

breathing

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

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

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

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

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

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

 What can you do? 

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

 

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

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

 

 

 

Top Ten Apps for Adolescents and Adults with Developmental Disabilities

10 apps

Have you ever downloaded apps that you weren’t satisfied with? Here’s some help  if you work with older adolescents and adults with developmental disabilities.

Within the past 15 years, I have worked with a variety of populations, including adults with developmental disabilities.  In the past, I have used predominately workbooks, adapted books, social stories, and age appropriate therapy materials during my sessions. Within the past five years, the use of the iPad has changed my therapy sessions dramatically.

Within the past couple of years, I have found excellent age appropriate apps that are motivating for my clients and help meet their goals with regard to their social skills, literacy, life skills, language, and increasing independence in the community. I use these apps listed below on a regular basis and find them functional and useful during my therapy sessions. I have received promo codes for a couple of apps listed below but all of my recommendations are solely based on my own personal experience as a speech language pathologist and do not reflect the views of anyone else.

These apps are best used when combined with other therapy materials and real life situations. For example, if I am working with a client who is going to be visiting the library, I would work on that specific topic using Community Success by Attainment Company. I also like that many of these apps can be trialed before purchasing them.

Apps Adults DD 2

Please comment if you have any app recommendations of your own!

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 discusses the benefits of reading to young children during mealtime, shares recipes with language tips and carryover activities, reviews children’s books for typical children and those with special needs as well as educational apps. 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.