Apps with Elders

elderapps

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

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

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

Five Tips to make using an iPad in therapy easier

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

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

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

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

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

Favorite Adult SLP Apps

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

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

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

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

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

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

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

Avoidance Reduction Therapy: A Success Story

true colors

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

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

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

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

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

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

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

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

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

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

How were you introduced to avoidance reduction therapy?  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

music

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

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

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

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

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

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

Just Breathe. Really?

breathing

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

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

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

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

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

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

 What can you do? 

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

 

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

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

 

 

 

Top Ten Apps for Adolescents and Adults with Developmental Disabilities

10 apps

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

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

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

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

Apps Adults DD 2

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

Rebecca Eisenberg, MS, CCC-SLP, is a speech-language pathologist, author, instructor, and parent of two young children, who began her website www.gravitybread.com to create a resource for parents to help make mealtime an enriched learning experience . She discusses the benefits of reading to young children during mealtime, shares recipes with language tips and carryover activities, reviews children’s books for typical children and those with special needs as well as educational apps. She has worked for many years with both children and adults with developmental disabilities in a variety of settings including schools, day habilitation programs, home care and clinics. She can be reached at becca@gravitybread.com, or you can follow her on Facebook; on Twitter; or on Pinterest.

 

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.