When Patients Won’t Practice

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You give 100 percent in each session, but end up repeating last week’s activities because your patient didn’t practice. Who’s at fault?

We all tend to get complacent with the materials and techniques we use. Thankfully, we also take CEU courses to keep ideas and implementations fresh. But what if you try everything in your bag of tricks and your patient still doesn’t improve?

I discussed this exact issue with two of my patients recently. Each one had a different situation, but both were making limited progress. “John,” for example, sought treatment with the hope that others would stop complaining about his voice quality. He says he stopped doing the diaphragmatic breathing exercises I assigned, because his voice wasn’t any better. I replied that it takes more than a week of doing only breathing exercises to make improvement. Breathing is just the first component of coordinating a new voice.

He and I talked about the real reason he was here. I discovered that although he felt his voice sounded disordered, it was really only affecting those around him. It really didn’t bother him that others thought his voice was annoying, so he decided not to continue sessions. Fair enough.

“Sara’s” case was different. She and I worked together for several weeks and ended up going through almost the same session each time. She reported practicing, but I didn’t see evidence of that in her productions. Frustrations arose and she felt like she was getting nowhere.

In our most recent session, we talked at length about life and the projected outcomes of her condition. Her voice issues affect her life, which upsets her. This emotional roadblock gets in the way of her dedicating time to practice outside the treatment room. She also feels guilt and blames herself for the issue, even though it’s not at all her fault. She realizes that these feelings are holding her back, so she’s taking time off from sessions and coming back when she’s ready to commit.

We should try to build up patients when they come to us feeling down on themselves. That might be tricky, however, because we also point out their mistakes in order to correct them. Sometimes sharing personal experiences as encouragement helps. It’s never a bad idea to refer clients to a therapist or counselor as supplemental treatment—it’s even in our code of ethics and scope of practice.

I do this occasionally when sessions frequently turn into “therapy.” If I think a patient would benefit from talking through issues with a trained professional, I always refer out. That way when the patient comes to our sessions, we focus on the voice disorder and I know the other issues are being addressed.

If your patient isn’t practicing, it’s time to find out why. Is it motivation? Is it you? Do your best to figure out what else the patient needs from you to be successful, and offer many options. Sometimes all you have to do is ask.

 

 

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

 

A Voice Lift? Is It Really Necessary?

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It’s an image-driven world in which we live. Instagram, Facebook, SnapChat, Twitter and YouTube launch llamas and two-toned dresses into stardom. We are also definitely not interested in showing our age. Botox and cosmetic surgeries work wonders for our outward appearance. But what is a person to expect as the larynx ages? Is a voice lift out of the plausible realm?

Some presbyphonia is present in many clients I see. As the male vocal folds lose mass, they bow outward and voice quality becomes breathy and high-pitched. The voice becomes lower in pitch as the female ages. This happens because muscle fibers do not regenerate as quickly when we get older, so the vocal folds begin to atrophy. The lamina propria (second layer of the vocal folds) is not as flexible and fibers tend to break down.

Three subsystems of the voice need to be in balance to have a fully functioning mechanism: breath, sound and resonance. When we age, lung tissues lose elasticity and rib-cage cartilages begin to ossify. Ossification also affects cartilages of the larynx. This is not always bad, as vocal scientist Ingo Titze suggests, because this hardening can help stabilize the voice box as it anchors the acrobatic muscles for speech or singing. A thoughtful article by Claudia Friedlander discusses this in further detail, as does this post from Gray Matter Therapy.

It’s helpful to think about our voices and how they differ because of gender. The female voice is affected by androgens, estrogen and progesterone. Wendy D. LeBorgne and Marci Rosenberg report in their book, “The Vocal Athlete,” that during menopause, low levels of estrogen cause the once thick mucosal membrane of the vocal folds to lose mass and flexibility. Progesterone has been shown to help shed cells off the vocal fold mucus membranes. Prior to menstruation, secretions and mucus on the vocal folds thicken, the larynx dries out, the voice becomes less agile and range may be affected. Hemorrhage risk and swelling is great at this time because capillaries change how they transport blood. Robert Sataloff has said in a NATS Chat recently, that the vocal fold swelling is protein-bound and cannot be shed by diuretics.

All of this happens because hormones are running rampant. A cure? Possibly regulation by birth-control medications, because they balance out those hormones. As menopause hits, hormones tend to disappear, and with them the qualities that made the voice sound female in the first place. Vocal folds thicken, epithelium atrophies, vocal fold nerve connections demyelinate. This might explain why vibrato slows as well.

What about the men? They start off with high-pitched voices, but when change occurs at puberty, pitch lowers with the presence of androgens. Booming male voices are the result of increased blood flow to the voice box. As with women, male hormones decrease with age, so power and tone go with them.

Presbylaryngis is an age-related voice issue caused by nature taking its course, but that doesn’t mean it can’t adversely affect quality of life. Voice pathologists do their best to rehabilitate with vocal function exercises and other treatment techniques. Sataloff says that 80 percent of the time this is sufficient. A surgical option is injection laryngoplasty, often coined the “voice lift.” The procedure consists of fat grafting, injectables or implants, and its necessity is controversial. Do people really need a rejuvenated voice? With an increase in hearing loss as we age, I can see why it’s popular.

 

Read about behavioral voice lifts. 

 

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

Just Flip the Lip! The Upper Lip-tie and Feeding Challenges

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While many pediatric professionals are familiar with a tongue-tie, the illusive lip-tie hides in plain sight beneath the upper lip. Because I focus on feeding difficulties in children and an upper lip-tie can be a contributing factor if a child has trouble feeding, then I probably encounter more lip-ties than some of my colleagues. Still, I’d like to encourage my fellow SLPs to just flip the lip of every single kiddo whenever assessing the oral cavity. And document what you observe. Help increase general knowledge among professionals on different types of upper lip-ties by raising awareness of how they may impact the developmental process of feeding.

Upper lip-ties refer to the band of tissue or “frenum” that attaches the upper lip to the maxillary gingival tissue (upper gums) at midline. Although most babies should have a frenum that attaches to some degree to the maxillary arch, the degree of restriction varies. So it’s important to flip the lip of every child we evaluate in order to gain a better understanding of the spectrum of restriction – especially if you are an SLP who treats pediatric feeding.

During the feeding evaluation process, consider four things: 1) The mobility of the upper lip for breast, bottle, spoon and finger feeding; 2) How well it functions in the process of latching and maintaining the latch; 3) If the lip provides the necessary stability for efficient and effective suck-swallow-breath coordination; and 4) If the lip is an effective tool for cleaning a spoon, manipulating foods in the mouth and contributing to a mature swallow pattern.

Dentist Lawrence A. Kotlow has created an upper lip-tie classification system to better identify, describe and consider the need for treatment. The tie is classified according to where the frenum connects the lip to the gums, known as “insertion points.” Envision a child with a very big “gummy” smile and the upper gum line exposed. Divide the gums into three zones, as described in this article by Kotlow:

“The soft tissue covering the maxillary bone is divided into 3 zones. The tissue just under the nasal area (zone 1) is called the free gingival area; this tissue is movable. Zone 2 tissue is attached to the bone and has little freedom of movement… Zone 3 extends into the area between the teeth and is known as the interdental papilla. This is where the erupting central incisors will position themselves at around 6 months of age.”

Now, consider the insertion points. A Class I lip-tie inserts in Zone I and (unless extremely short and tight) does not inhibit movement of the upper lip and should not interfere with breast or bottle feeding. However, if the lip itself is retracted to the degree that a child cannot flange his upper lip for adequate latching and for maintaining suction, further consideration of this type of lip tie may be necessary. Class II lip-ties have an insertion point in Zone 2, where the tissue is attached to the bone. Kotlow describes the Class III tie as inserting in Zone 3, where “the frenum inserts between the areas where the maxillary central incisors will erupt, just short of attaching into the anterior incisor.”  A Class IV lip-tie “involves the lip-tie wrapping into the hard palate and into the anterior papilla (a small bump located just behind where the central incisor will erupt).”

How might an upper lip-tie impact the developmental process of feeding?

The impact of the upper lip-tie can vary according to its classification and, in my professional experience, the fullness of the upper lip also comes into play. But, in general, consider these key points:

Breastfeeding and Bottle Feeding

  • Breast – Inadequate latch: An infant must flange the lips to create enough suction and adequate seal around the tissue that includes the areola and not just the nipple. It is essential that babies take in enough breast tissue to activate the suckling reflex, stimulating both the touch receptors in the lips and in the posterior oral cavity in order to extract enough milk without fatiguing. When the baby suckles less tissue, painful nursing is also a result. One sign (not always present) is a callus on baby’s upper lip, directly at midline. While not always an indicator of a problem, it’s typically associated with an upper lip-tie. It’s simply a reminder to flip the lip!
  • Bottle – Inadequate Seal: Because bottles and nipple shapes are interchangeable and adaptations can be made, it’s possible to compensate for poor lip seal. However, these compensatory strategies are often introduced because all attempts at breastfeeding became too painful, too frustrating or result in poor weight gain…and the culprit all along was the upper lip-tie. It is then assumed that the baby can only bottle feed. I’ve assessed too many children held by teary-eyed mothers who reported difficulty with breast feeding – and no indication in the chart notes that the child had an upper lip-tie. But, upon oral examination, the lip-tie was indeed present and when observing the child’s feeding skills, the tie was at the very least a contributing factor. Releasing the tie resulted in improved ability to breast feed and progress with solids.
  • In addition, an inadequate latch and/or a poor lip seal may contribute to the following partial list of symptoms:
    • Gassiness; fussiness; “colicky baby”
    • Treatment for gastroesophogeal reflux disease, yet to be confirmed via testing
    • Fatigue resulting in falling asleep at the breast
    • Discomfort for both baby and mother, resulting in shorter feedings
    • Need for more frequent feedings round the clock
    • Poor coordination of suck, swallow, breathe patterns
    • Inability to take a pacifier, as recommended by the American Academy of Pediatrics and noted here.

Spoon Feeding

  1. Inability to clean the spoon with the top lip
  2. Inadequate caloric intake due to inefficiency and fatigue
  3. Tactile oral sensitivity secondary to limited stimulation of gum tissue hidden beneath the tie
  4. Lip restriction may influence swallowing patterns and cause compensatory motor movements which may lead to additional complications

Finger Feeding

  1. Inability to manipulate food with top lip for biting, chewing and swallowing
  2. Possible development of picky, hesitant or selective eating because eating certain foods are challenging
  3. Lip restriction may influence swallowing patterns and using compensatory strategies (e.g. sucking in the cheeks to propel food posteriorly to be swallowed) which may lead to additional complications

Oral Hygiene & Dental Issues

  1. Early dental decay on upper teeth where milk residue and food is often trapped
  2. Significant gap between front teeth
  3. Periodontal disease in adulthood
  4. Possible changes in dentition with certain compensatory methods to propel bolus posteriorly for swallowing, such as finger sucking.

After documenting what we observe during the evaluation, clear communication with parents and other professionals will help to determine next steps. In feeding therapy, our role is to provide information for involved parents and professionals (this may include pediatricians, lactation consultants, otolaryngologists, gastroenterologists, oral surgeons and/or pediatric dentists). Our primary role is to determine, document and communicate to what degree the restricted top lip is influencing a child’s difficulty feeding.

For detailed information and additional photos, please read Kotlow’s article, Diagnosing and Understanding the Maxillary Lip-tie as it Relates to Breastfeeding, published in the Journal of Human Lactation in May 2013.

In a future post for ASHA, we’ll discuss tongue-ties (ankyloglossia) and the impact on feeding. Upper-lip ties are frequently associated with tongue-ties, so please remember to look for both during oral examinations.

Have you had an experience with an upper lip-tie impacting the feeding progress of one of your clients? If so, please tell us in the comments below.

 

Melanie Potock, MA, CCC-SLPtreats children birth to teens who have difficulty eating.  She is the co-author of Raising a Healthy, Happy Eater: A Parent’s Handbook – A Stage by Stage Guide to Setting Your Child on the Path to Adventurous Eating (Oct. 2015), 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.  She can be reached at Melanie@mymunchbug.com

 

Using Menus as a Treatment Tool

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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?

Importance of play

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