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.

 

Baby Led Weaning: A Developmental Perspective

blw

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is  offered for ASHA CEUs and includes both her book and CD for each attendee.  She can be reached at Melanie@mymunchbug.com.

Five Ways to Empower Your Client

empower

For the past two years, I have shared an article with my graduate AAC class that a close colleague gave me. The article, titled Empowering Nonvocal Populations: An Emerging Concept was written by Sandy Damico in 1994. Although this article is now almost 20 years old, there are certain concepts that are timeless and empowerment is one of them. According to Ashcroft (1987), an “empowered individual is one who believes in her or his ability to act, accomplish some objective, or control his or her situation.”

Each time I read this article, it empowers me to do a better job as a speech-language pathologist and continue to empower the people around me. It also always gives me perspective on why certain clients are more successful than others. It also helps me reflect on how to empower not just my clients, but my own children. At a recent lunch with a friend who has two children with special needs, we started discussing goals for our children. She shared with me that she does not have high hopes for her children because they have special needs.  I talked to her about empowering her own children because if she didn’t believe in their ability, how can she expect them to believe in themselves?

Here are five ways that you can empower your clients:

  1. Complete a comprehensive assessment to create goals that are appropriate and attainable. If a proper assessment is not done, then the goals may not be appropriate. For example, we need to think about “What are my client’s strengths?”, “What goals will be most functional for him/her?” On the other hand, focusing on goals that have already been attained previously will not empower a person.  If a child or adult feels that a person doesn’t expect anything from them, then why try? We need to challenge our clients but in a way that is attainable with appropriate and functional goals.
  2. Tell your client, “You can do it,” and believe it yourself. This is a simple tip but has worked for me time and time again. There are two parts to this statement. Saying “You can do it,” and not believing it in yourself will not empower your client. We need to tell your client this statement, but in our hearts know they can do it. There have been many evaluation and therapy sessions where others have told me “He can’t do anything,” “He is very low functioning and doesn’t communicate,” etc. I strongly believe that everyone communicates in their own way and it’s our job to find that way and expand on it.
  3. Empower your client’s family. This is a very important tip. Some families may feel defeated or have given up on your client’s ability to communicate. They may have been told time and time again that their child can’t do this, can’t do that, etc. After awhile, a person can start believing it. Empowering families and giving them positive feedback and suggestions about their loved ones is key.
  4. Teach your client a new skill that will change their life (e.g. cooking, etc). Teaching a child or adult a new skill that can positively affect their life can be extremely empowering. I currently see a client who is independent in many aspects of his life as far as hygiene, transportation, etc. However, one skill he was lacking was his ability to prepare food for himself. He was limited to microwaving unhealthy foods because he did not know how to cook simple dishes.  To empower him, we decided to use cooking as an activity to meet his speech and language goals. I am a true believer in increasing independence because with independence comes empowerment.
  5. Don’t give up. Reach out to supervisors, colleagues, etc. It is important to reach out to others if you feel that your strategies and/or techniques are not working for an individual. If you feel defeated with a client, he or she will sense that and in turn feel disempowered. It may just take one or two sessions with some help from a supervisor or colleague to change your entire perspective of your client. If you still feel that you cannot meet their needs, it may be appropriate to refer your client.  Also, use outside resources. I find many excellent posts written on one of my favorite websites (written by Carol Zangari and Robin Parker).

 

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.

NIMTR: Not In My Treatment Room!

poison

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

Some interesting facts about toys.

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

So many toys … but are they safe?

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

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

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

What if it is not a toy?

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

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

What is an SLP to do?

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

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

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

 

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

Step Away From the Sippy Cup!

sippy

Sippy Cups became all the rage in the 1980s, along with oversized shoulder pads, MC Hammer parachute pants and bangs that stood up like a water spout on top of your head.   A mechanical engineer, tired of his toddler’s trail of juice throughout the house, set out to create a spill-proof cup that would “outsmart the child.”  Soon,  Playtex® offered a licensing deal, the rest is history and I suspect  that mechanical engineer is now comfortably retired and living in a sippy-cup mansion on a tropical island in the South Pacific.

Geez. Why didn’t I invent something like that?  I want to live in a mansion in the South Pacific. By the way,  I also missed the boat on sticky notes, Velcro® and Duct Tape®–all products I encounter on a daily basis, just like those darn sippy cups I see everywhere.  I truly shouldn’t be so bitter, though – in my professional opinion, over-use of sippy cups is keeping me employed as a feeding specialist and I should be thankful for job security.  Thank goodness for the American marketing machine – it has convinced today’s generation of parents that transitioning from breast or bottle to the sippy cup is part of the developmental process of eating.  Problem is, those sippy cups seem to linger through preschool.

As an SLP who treats babies with feeding challenges, I frequently hear from parents how excited they are to begin teaching their baby to use a sippy cup.  They often view it as a developmental milestone, when in fact it was invented simply to keep the floor clean and was never designed for developing oral motor skills.  Sippy cups were invented for parents, not for kids.  The next transition from breast and/or bottle is to learn to drink from an open cup held by an adult in order to limit spills or to learn to drink from a straw cup.  Once a child transitions to a cup with a straw, I suggest cutting down the straw so that the child can just get his lips around it, but can’t anchor his tongue underneath it.   That’s my issue with the sippy-cup: It continues to promote the anterior-posterior movement of the tongue,  characteristic of a suckle-like pattern that infants use for breast or bottle feeding.  Sippy cups limit the child’s ability to develop a more mature swallowing pattern, especially  with continued use after the first year.  The spout blocks the tongue tip from rising up to the alveolar ridge just above the front teeth and forces the child to continue to push his tongue forward and back as he sucks on the spout to extract the juice.

Here’s another important take-a-way on this topic:   A 2012 study by Dr. Sarah Keim of Nationwide Children’s Hospital in Columbus, Ohio reported that “a young child is rushed to a hospital every four hours in the U.S. due to an injury from a bottle, sippy cup or pacifier.”   Dr. Keim theorized that as children are just learning to walk, they are often walking with a pacifier, bottle  or sippy cup in their mouths.  One stumble and it can result in a serious injury.

Before I ever climbed onto the anti-sippy cup soap box, I let my own two kids drink from them for a short time.  I even saved their first sippy cup – I’m THAT mom who saved EVERYTHING.  If it’s too hard to let go of the idea of using a sippy cup, let the child use it for a very short time. Then, step away from the sippy cup if the child is over 10 months old or beginning to show signs of cruising the furniture.  In the near future, it will soon be time to conquer two genuine developmental milestones–mastering a mature swallow pattern and learning to walk.

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.

How 2013 Taught Me To Be a Better SLP

2013

We have successfully completed another year owning a private practice in a location that is densely populated with speech language pathologists. And by “we” I mean myself and my husband. We are implementing a business plan that he poured sweat and tears over (everything just short of the blood…) and the doors to our business still remain open.

Given the multitude of stresses that come from running and owning a business, I have learned to measure my success in ways that seems contrary to the ordinary. Here’s what I have learned and how I measured my success as a speech-language pathologist in the year 2013.

1. Being a parent is hard work and I cannot fully grasp and understand that just yet. No matter what a family’s situation is, the energy, effort, resources, skills, brainpower, love, patience, problem solving, planning, and determination it takes to be a parent and caretaker of a child with special needs is really immeasurable. As an SLP I can listen, sympathize, show compassion, and provide resources, but I am not in their place at the present time. Although I am trained to be a support for these families and I respond with new ideas, I am lacking a component of what it really means to live what they are living. Coming to this realization and maintaining awareness of it is huge for me.


2. Baby steps are crucial–for everyone.
 I have learned that so often I attempt to “conquer” a child’s speech or language delay in just one day. My expectations are high and I want the family to see the benefits of my services. But I am not a magician and they need to realize this. And we are working with a human being, not a PowerPoint presentation that we can edit with the click of a mouse. Coming in with realistic expectations and using daily, small stepping stones to increase a child’s skills is what is most beneficial. One of the mothers I work with often repeats this back to me as we summarize sessions with her child (who has many needs). “Baby steps, baby steps,” she says. Yes, so unbelievably true.

3. I need to squish, trample, and eliminate my need for a box. I naturally go through life with a black or white mentality. If something is not one way then of course that would make it be _____ (the opposite of the initial way). I come from a long line of black and white thinkers. Nope. Nada. Not the case. Just because one child was one way, does not mean that child X will be that way as well when they get to point B. Follow? Although I try, I realize that so often I don’t factor in the child’s overall personality into my daily interactions with him or her. I’m not talking about a child’s behaviors. I’m talking about their likes, loves, and dislikes. When I was a kid I loved watches, Hello Kitty, big red soft robes, Where’s Spot? books, music, and bear hugs. This was what allowed me to flourish as a child and I need to help other families do the same with their unique kiddos.

4. You never know when someone is listening…… On occasion I feel myself turning red with frustration at my inability to “get through” to a family (thus the need for lessons 2 and 3). However, on several different instances this year a parent or caregiver summarized the very basis of what we were working on in therapy. Whoops. I love when my husband teaches me that I am not always right he was listening but it may be even more humbling when a family that I work with shares in the same lesson.

5. There is never a limited supply of resources to work with and it’s OK not to reinvent the wheel sometimes. When I’m planning for my sessions I will at times squeeze in another sheet of laminated pictures, more books, or have ready more toys within arm’s reach. Four out of five times I don’t even need these items as I survey the house and begin using whatever toy the child had already been playing with. But I have found that the magic number of three materials in a session usually does it. Why? No scientific basis for it really. A book, one toy, and a small sensory item (bubbles, play dough, etc) usually do the “trick” (whatever that is). This makes me slow down. (Yes, let’s once again go back to number 2.) It gives us enough time to play together and enough time to engage in coaching the family. The reason why there are so many cute, easily adaptable pre-made lesson plans out there is because the crafty people that make them are good at it. Really good at it. And they take pleasure in knowing that people like me are occasionally using their lessons for materials in therapy. We’ve all got our skills and using time efficiently to make materials is not one of mine. That’s what my great, far-reaching community is for.

So given all of the above lessons, how have I measured my success as a therapist this past year? Simply by the fact that I have learned. I have grown. And it only looks like there will be more of that to come in the New Year. While my feet are beginning to be planted in my current practice, the certainty of this stability does not always ring true. But my ability to continuously learn in my profession? Always there without fail. I cannot wait to continue the relationships with the families I am already working with and establish trust in new relationships to come.

Meredith Mitchell, MSP, CCC-SLP, is a pediatric speech-language pathologist who owns a private practice in North Carolina.  She maintains a blog for families on her website and also maintains a separate blog for speech therapists focusing on early intervention.  She can be reached at meredith@sterlingtherapync.com.

 

How to Provide Bilingual Services (Even When You’re Monolingual)

vogl

Evaluation is one huge hurdle to working with English Language Learners (ELL). The second is providing therapy. Once you’ve determined there is a disorder, what do you do? Do you provide treatment in English? What goals do you target? Can you provide competent treatment in English only?
It may be easier to address some of these ideas for specific age ranges. For the children under 3 years of age, working with an interpreter in the primary language with the family on how to talk with toddlers and babies is your best friend. It is important to be mindful of possible cultural differences in how adults and children relate to each other. Not every culture values parent-child verbal interactions as the stereotypical white middle class family might. How to address these differences is like a dance. If one person is too powerful of a leader the other cannot follow, might stumble, and ultimately will quit dancing. A parent/caretaker who does not share the value we place on parent-child interactions will most likely not follow through on our recommendations. In which case it may be better to train a sibling how to model language for a younger sibling. Make sure you understand the family and/or cultural relationships as much as possible first.
For preschool age children (depending on family views of preschool) your efforts should go toward encouraging the family to enroll the child in Head Start, preschool, daycare, or even scheduling consistent “play dates” to expose the child to typical language development. If possible, encourage both languages (primary language and English). What about therapy? Targeting social language, the Basic Interpersonal Communication Skills, in English is essential. Children will need these skills to be successful in the academic world.
For school age children, research suggest that there is a strong correlation between ELL students with a language learning disorder and poor and/or inappropriate social skills and therefore, have fewer friends when compared to other students who are ELL. Social skills groups are very important for these students. Simultaneously, targeting Basic Interpersonal Communication Skills and Cognitive Academic Language Proficiency will help close the language gap these students have. One approach to do that is by teaching root words, suffixes, and prefixes (morphology). As we learn in linguistics, they are like puzzle pieces. For example, you can take the root word “view” and the prefix “re-“ and teach students that the view means “to look” and re- means “again.” When added together form “review” or “to look at again.” Then applying context, “The teacher tells you to review your work,” what does she want you to do? Helping students understand contexts for which they might hear the word and then additional contexts for when they might use the word is important. How does your work in English translate over to the primary language? Here is where parents come into play. Most parents I’ve worked with prefer you send the list of “academic” words (from curriculum and/or state standards) home in English. They can then use their personal dictionary to look up the correct correlating word in their home language, versus us guessing on a translation website. Have the parents talk with the child about these words in their home language. This builds the foundation for carryover from primary language to English. When using root words you can also can help students make educated guessed on definitions for words. Once students have a decent grasp on root words, some great games to play are Scrabble, Boggle, or Balderdash. An added benefit for teaching root words, is it’s included in the Common Core State Standards.
Here is some personal evidence. Last school year I had a 5th grade student who scored Level 1 (Beginning) on an English Language Proficiency Assessment for all of his academic years, Kindergarten through 4th grade. His 5th grade year we implemented a social skills group and taught root words from the curriculum. With the entire team’s support (student, parents, teacher, SLP) this student scored a Level 3 (Intermediate) on the same assessment. Some beliefs for such success was that our intervention targets were meaningful to him. Social skills helped his friendships and the root words helped him understand and communicate in the academic setting, which is the majority of his day Monday through Friday.
I am sure that there are other evidence-based therapy approaches to working with this population and they should all be founded on the same principals. 1) It is better to target both BICS and CALPs together that waiting for BICS to be mastered well enough to move to CALPs. Reason being, the language gap will only increase exponentially. 2) It is also better to work with the family.
I’d love to hear about other approaches. How do you address therapy for children and families who are not fluent in English?

 

Leisha Vogl, MS, CCC-SLP, is a speech-language pathologist with Sensible Speech-Language Pathology, LLC, in Salem, Oregon. She can be reached at leisha@sensiblespeech.com.

 

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

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A Parent’s Expectations and an SLP’s Goals

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

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

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

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

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

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

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

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

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

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

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

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

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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.

Planning for Holiday Meals with a Picky Eater

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As an SLP  focused on the treatment of pediatric feeding disorders,  there is one common denominator among all the families on my caseload:  The stress in their homes at mealtimes is palpable.   Now that Thanksgiving and other food-centered holidays are approaching,  the anticipation of an entire day focused on food has many parents agonizing over the possible outcomes when well-meaning relatives comment on their child’s selective eating or special diet secondary to food allergies/intolerances.

This time of year, I try to find practical ways to reduce the stress for these families.   One of the first steps in feeding therapy is for parents to lower their own stress level so that their child doesn’t feed into it (pardon the pun).   I often address parent’s worries with a “What IF” scenario.  I ask, “What’s your biggest fear about Thanksgiving?”   The top 3 concerns are as follows:

What IF Junior won’t take a bite of Aunt Betty’s famous green bean casserole?

It’s not about the bite, it’s about wanting Aunt Betty’s approval.   Focus on what Junior CAN do.  If he can sprinkle the crispy onion straws on top of Betty’s casserole, call Betty ahead of time and ask if he can have that honor.  Explain how you would love for him to learn to eventually enjoy the tradition of the green bean casserole and his feeding therapist is planning on addressing that skill in time.  But, for now, she wants him to feel great about participating in the process of creating the green bean masterpiece.  If Junior can’t bear to touch the food because he is tactile defensive, what can he do?  Pick out the serving dish perhaps and escort Aunt Betty carrying the dish to the table?  Taking the time to make Aunt Betty feel special by showing interest in her famous dish is all Betty and Junior need to feel connected.

What IF Grandpa Bob reprimands Junior for “wasting food” or not eating?

Keep portions presented on the plate quite small – a tablespoon is fine.  Many families use ‘family-style” serving platters or buffet style, where everyone dishes up their own plate.  Practice this at home.  It’s not wasting food if Junior is practicing tolerating new foods on his plate.  That food went to good use!  If Grandpa Bob grew up during the Great Depression, this might be tough for him to understand.  If he reprimands Junior, change the subject and tell Junior your proud of him for dishing up one whole brussel sprout! That requires some expert balancing and stupendous spoon skills!

What IF Junior gags or vomits? 

Not surprisingly, this is the one sensory reaction that most relatives sympathize with and try desperately to avoid.  Preparing the host ahead of time is gracious and appreciated.    Preparing your child is helpful too and Stress Free Kids.com offers these tips.  I recommend that parents identify what stimuli is most noxious to the child and talk with the host about those, offering assistance in preparing special food or supporting the host’s planned menu as much as possible.  Bring a change of clothes for Junior, just in case, as well as a quiet activity for him to enjoy if you sense that the meal may be just too overwhelming for him.  Plan other activities that don’t involve food to emphasize the message of the season: Being grateful.

Gather together with thankful hearts.  That is the theme for this year’s Thanksgiving.  Let go of the fear and ask “What IF Thanksgiving went just fine?”  Happy Thanksgiving everyone!

 

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: Teaching Parents the Power of Play

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I don’t know if it is just my experience or if you too have found this to be a problem, but I have noticed the more I work with very young children, the more I realize parents do not actually know how to play with their children.  I know this is a trend I am finding to be true more and more often, however, I am still shocked when I see it.

Play is such an integral part of a child’s development as it affects all areas of growth including, but not limited to, social skills, communication development, cognition, problem solving and reasoning skills, and imaginative thinking.  Therefore, for those of us SLPs who are working with infant, toddler and preschool-age populations it is not just enough to model play or target language development, we must teach parents how to play.  You know the saying “If you give a man a fish, he eats for a day.  If you teach a man to fish, he eats for a lifetime.”  Well I believe this to be similar–we need to teach parents how to play so their children can continue to develop during the time we are not present as service providers and throughout their childhood.

I have noticed that sometimes even involved parents who are willing to participate in book reading and speech and language drill type activities, are still not always comfortable participating in play.  Involved parents want to know what they can do to help.  The problem is they don’t fully understand the importance of play or how their child’s thinking skills change and grow via play.

So what do I do about this?  How do I try to teach parents how to play?  Here are a few techniques I have used:

  1.  Parent education:  The first thing I do is teach parents why play is so important and how learning takes place.  I explain to parents why we need to incorporate play into our therapy and why their child needs to participate in play with them when I am not present. I also explain the types of play their child is currently exhibiting versus what types of play they should be exhibiting at their age (you can find more details on ages and stages of play here).  This truly helps parents fully understand their child’s current level of functioning and why focusing on play skills is so important to communication development.
  2. Never make assumptions:  When I was fresh out of graduate school I made assumptions that parents knew and understood child development.  But the truth is we cannot assume that parents have had the same experiences as we have had.  Even if we are working with parents of a large family, this does not mean they know or fully understand how to play with their children.  I have learned after making many mistakes to never make assumptions about what parents do or do not already know.  Rather than treating parents as if they are in need of education, I will say something like “I would be remiss if I did not explain/show you how to…”.  Other times, I will say something like “I’m sure you already know this but I need to explain that…”.  Again, these are just two ways to help share my knowledge with parents while not treating them as if they are uneducated or making the assumption that they know more than they do.
  3. Model and explain play:  I then create play scenarios at whatever level of play the child is functioning currently while attempting to expand the play and improve language and problem solving skills.  I carefully explain what I am looking for in a child’s play and how I am changing the play slightly in order to achieve those goals.
  4. Give the parents a turn:  It is imperative that I make sure parents have a turn taking over the play interaction.  I want to empower parents and make them feel as if they can play with their child when I am not there.  However, the only way to do that is to make sure they have an opportunity to practice these skills while I’m still there to assist.  If help is needed, I will guide the interactions while continually reducing support throughout the session.
  5. Videotaping for success:  Videotaping parent/child play interactions can be an invaluable way to educate and empower parents.  I like to videotape portions of interactions so parents can refer back to the videos as needed.  When parents see how they have taken suggestions and turned them into positive interactions with their child, they begin to anticipate and invest their time into participating in play more often with their child.
  6. Follow up weekly:  The key to making this technique work is to make sure I follow up with parents and hold them accountable for their child’s play week to week.  I encourage parents to take videos on their smart phones and save them for our next session.  This way I can see the growth in their child and continue to provide assistance as needed.

Parents are always looking for the “right” ways to play.  So I give them a few tips:

  1. Show some emotion:  I explain that parents need to make sure their face, voice and entire body is showing the emotion they want to exude.  So when parents look their child in the eye, smile wholeheartedly and say, “I’m excited to be playing with you today!” or “This is really fun!”, I know they understand the importance of emotional in play.
  2. Play when you can:  Parents often times shut down if they think I am asking them to play for hours a day with their child which ultimately results in no play from them at all.  Instead I ask them to try to play for one or two 15 minute increments a day.  For parents who work full-time and have several children, I have found this to be a more realistic expectation and request from them.  Also encouraging them to involve their other children in play is a stress reliever for some parents as children are great models for each other and many times siblings are vying for their parent’s attention.  Incorporating siblings in play, seems to help provide the much needed parental attention while teaching the whole family how to interact with a child who may have delays.
  3. Turn off the TV and turn on some music:  Parents believe their children do not watch much television however when I ask if parents like to leave the television on for background noise I tend to get more “yes” answers than “no”.  So I encourage parents to get rid of the visual distractions like television and if they must have some background noise, play some child friendly music instead.
  4. Change out toys the child has available to them:  I have noticed even with my own child that when I periodically change out toys available, I see very different types of play.  This can keep a child’s play dynamic and guard against stagnation.
  5. Mix and match toys:  Mixing and matching toys that would not typically go together encourages growth in a child’s imaginative play.  I have seen some amazing pretend play when I brought random toys to therapy for my clients.
  6. Use nondescript toys/objects:  Some of the best pretend play I’ve observed comes from objects that don’t seem to look like anything in particular.  Have you ever placed a few boxes and a bucket of blocks in the middle of a room and watched preschoolers play?  It’s amazing the “thinks they can think”.  The more nondescript the object, the more creativity goes into the play.Parents always ask me if they are “doing it right,”  if they are playing the right way with their child.  My response is always the same “If your child is smiling, laughing or fully engaged with you, then you are doing it right.”

Do you spend time teaching parents about the power of play?  If so, how do you go about it?

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.