Beyond Skype for Online Therapy: Protecting Student Privacy

Privacy

 

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

HIPAA: Protecting Individually Identifiable Health Information

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

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

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

FERPA: Protecting Education Records

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

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

COPPA: Protecting Children’s Personal Information

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

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

Recommendations for Online Therapy

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

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

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

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

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

Can Speech-Language Pathologists Diagnose Autism?

Posted response

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

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

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

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

Knowledge required:

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

Skills required:

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

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

 

ASD Support Groups: Looking Out for My Brother

siblings

My dad, my brother and I arrived at the coffee shop and made our way to the back room where 20 or so adult men sat with their eyes cast downward on the floor. I coaxed my brother to join them; my dad and I sat further back with the other family members, nervously looking at each other. At that moment, I had doubts as to whether this was going to be successful. Would they start to talk? Did we need to help them? Was that the point of having a social group for adults on the autism spectrum? Over time, however, all of us became more relaxed and, as we got to know one another, the group slowly flourished. Family members were able to become more of a backdrop and natural part of the group, and now it has the feel of a family reunion every time we get together. It is such a safe, comfortable place where everyone fits in, and there’s never a wrong way to do anything.

 

Growing up with loved ones with autism spectrum disorder has shaped my life and determined my professional and personal life paths. As a professional I have become very passionate and dedicated not only to helping individuals with ASD, but also mentoring student speech-language pathologists. I focus on helping new SLPs understand the “why” underlying how individuals with ASD think, so these SLPs can better help these individuals with learning and generalization of skills.

 

Autism also has affected my personal life, in particular, my relationship with my brother (see the April 2014 issue of the Leader “Terra Incognita”). As an adult he has overcome so many challenges. He works fulltime, and enjoys his job. He is one of the kindest and most generous people I know, and I truly admire him. For all that my brother has achieved; however, he (like so many other adults with ASD) has struggled to develop friendships and social relationships. I worry about him becoming socially isolated and that’s where social groups come in.

 

Social groups (notice I do not use the word “therapeutic”) are informal get-togethers where individuals like my brother can meet and participate in activities. In Pittsburgh we are very fortunate to have many such social groups in the city. Over the past several years, I have helped organize events and helped individuals with autism find and develop social networks.

 

Starting a group was actually fairly easy and straightforward. The group that I helped to initiate was sponsored by a nonprofit organization, Autism Connection of PA. They are well-known in the autism community in and around Pittsburgh.  They also included our contact information on their website and advertised our group for us.  In addition, they provide a small stipend to the volunteer organizers to help offset the minimal costs involved (e.g., some advertising, costs of food, etc.) Currently we have approximately 100 members in our group and, depending on the activity and interest of the group members, anywhere from 10 to 25 members show and participate.

 

The group began with a mom looking for a social outlet for her adult son, and I happened to be searching for a social networking opportunity for my brother. Fate lent a hand and brought us all together that day at the coffee shop. We found the easiest way to contact everyone was through email. Through meetup.com we were able to establish a way for everyone to be able to keep in touch with ongoing activities and to email each other (We also have an email group list for those that found the meetup.com website a bit overwhelming). Family members also are allowed to sign up on behalf of someone on the spectrum if using a computer is not comfortable for them.

 

We took a survey and developed a list of activities based on the interests of the group members. Potlucks, bowling, movies, museums, and going to sports games are the most popular activities. Costs for participation and transportation also are factors to keep in mind when planning for an activity.

 

There’s another smaller and more structured group that meets two Sunday afternoons a month. Only adults on the autism spectrum are allowed to attend; family members can drop them off before the meeting and pick them up after. A facilitator leads this discussion group. The group has talked about relationship difficulties, not fitting in, employment, housing, driving, and depression. The facilitator presents a topic beforehand for the group to focus on, so that the group doesn’t perseverate on their difficulties. These discussions have been very popular with some of the adults with the goal being to let them to share stories about themselves, their interests, etc., and not to be a “therapeutic” setting. Occasionally, outside speakers are brought in (psychiatrists, etc.). I volunteered my time and offered three free sessions of speech services for those who wished to participate. But we found that mostly the adults really don’t want “therapy.” They just want a chance to relax and meet people.

 

I can only speak from my own experience, but over time my brother’s social skills and independent living skills have increased significantly. It has been the best intervention that my brother could ever have been provided.  Pittsburgh is made up of small neighborhoods, and my brother bumps into other members of the group from time to time, and independently goes up and chats with them. As anyone who is familiar with ASD would understand, this is huge and miraculous. Also along the miracle front, one day out of the blue, my brother told our father that he wanted to start making his own doctor appointments. Again, the enormity of this cannot be emphasized enough.

 

There is a need for this type of group in every community. Just like adult rehab clinics often have aphasia support groups, SLPs who work in transition settings could start social groups for adolescents and adults. The goal is not to “rehabilitate” them, but merely to help them know that they are not alone, and that they are valued and appreciated.

 

Janice Nathan, MS, CCC-SLP, is a speech-language pathologist and, since 2004, owner of Nathan Speech Services, which specializes in the language and learning challenges of individuals diagnosed with autsim.. Her brother, Sam, was diagnosed with high-functioning autism as an adult in his early 50s. Read about Sam’s story in “Terra Incognita” in the April 2014 issue of The ASHA Leader.

Understanding Autism: Restaurant Meltdowns

asd

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

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

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

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

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

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

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

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

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

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

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

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

Aural Rehab: The Role of the Speaker

speaker
In my last blog post, Aural Rehab: Are we getting the job done?, I discussed the challenges faced by audiologists when it comes to the education and counseling aspects of the aural rehab process. I gave a brief overview of our Cut to the Chase counseling program, and introduced the “5 Keys to Communication Success.” Educating our patients about these five simple keys to successful communication will help them to understand a few important points:
• Communication is like a puzzle that requires several pieces to work properly.
• Hearing aids are only one piece of this communication puzzle.
• Involvement of family members, friends, and caregivers is essential.
When patients fully grasp the complexity of communication, and understand that each piece of the puzzle is critical for communication success, they are much more likely to be satisfied with their hearing aids and to comply with our recommendations.
Let’s take a closer look at the first key to communication success: The Speaker. Obviously the speaker and the listener are the two most important keys, as there would not be a communication exchange without them. But the speaker is arguably the most important key as they are responsible for creating a clear message that will be understood by their listener. This is why it is so important to involve family members in the aural rehab process. I’m sure I’m not the only audiologist who has experienced the following scenario:
I just fit Mr. Jones with new hearing aids, verified his fitting, and asked him what he thinks. He smiles and reports that they sound kind of strange, but that my voice seems nice and clear. He then turns to his wife and asks her to say something. Rather than looking at her husband and speaking to him in a normal tone, Mrs. Jones stands, walks to the far side of the office, and (with her back toward him) whispers to her husband, “Can you hear me now?”
Of course, Mr. Jones cannot hear her and, although I may have slightly unpleasant words going through my head for Mrs. Jones, I find this is the perfect time to educate her about her essential role as the speaker. I teach my patients to use their senses as a reminder about their critical role in the communication process.

The first sense is vision. The listener must be able to see the speaker’s face. This means that the speaker will often have to go to the listener before they begin speaking. Other times, the speaker will need to call to the listener, and wait for the listener to come to them before they begin speaking. This eliminates the difficulties associated with speaking from another room, or with their back toward the listener. Sometimes, however, this is not enough. That’s when we turn to the sense of touch.

When the speaker moves close enough to the listener that they can actually reach out and touch them, the speaker and the listener are perfectly situated for a perfect communication exchange. Sometimes the listener is so intent on a television program that they simply don’t hear the speaker calling to them. Rather than getting angry and yelling, I teach my patients to gently touch the listener on the arm to get their attention, and their message will then be received successfully.
Of course, we also teach the family members and caregivers to speak clearly and not to over-exaggerate their words. We encourage them to alert the listener to changes in topic, and to check-in frequently to make sure they are being understood. Most importantly, we try to impress upon the speakers that they are half of the equation when it comes to communication. We let them know that they can either be half of the problem, or half of the solution. This may seem harsh, but the importance should not be understated if we are to provide our patients with complete communication solutions! Next month we’ll focus on the other half of that equation: The Listener.

Dr. Dusty Ann Jessen, AuDis a practicing audiologist in a busy ENT clinic in Littleton, Colo. She is the founder of Cut to the Chase Communication, LLC, a company dedicated to providing “fun, easy, and effective” counseling tools for busy hearing care professionals. She is also the author of Frustrated by Hearing Loss? 5 Keys to Communication Success. Dr. Jessen can be contacted at info@CutToTheChaseCommunication.com.

Skyrocketing Autism Numbers a Call to Action for SLPs

1Sky_Rocketing_Autism_Numbers (3)

Last week the child-development community got a jolt from news of a jump in numbers of children diagnosed with autism spectrum disorder: an increase of 30 percent in just two years. One in 68 children had ASD in 2010, up from one in 88 children in 2008, according to data from the U.S. Centers for Disease Control and Prevention.

And that’s raised many questions among speech-language pathologists and other developmental experts. For one thing, what’s driving the increase? And what does it mean for ASD diagnosis and treatment? There are no clear answers or absolutes. But developmental expert Stephen Camarata is willing to speculate. We talked with the Vanderbilt University hearing and speech sciences professor about his take.

What is behind this increase? Is it really just an increase in identification?

There are three main factors. One is a real increase in incidence. Our technological ability to take preemies weighing less than a pound and have them survive has changed, and it’s not surprising that more of these kids might have challenges.
Second, there’s increased awareness, so more people are looking for ASD in kids. And third there’s the expansion of the definition of spectrum. The numbers of kids identified as high functioning and as having Asperger syndrome has skyrocketed.

What do the higher numbers mean for SLPs?

We’re the speaking profession, so we have a central role in assessing and treating these kids. Based on this, we’re obviously seeing a big increase in caseload, which as a field we need to develop ways to handle. But more basically than that, we need to figure out how to differentially diagnose these young kids, these 2-year-olds, distinguishing between ASD and the new DSM-5 [Diagnostic and Statistical Manual of Mental Disorders] category of social communication disorder.

We are the main profession driving identification and treatment of SCD, and we need to develop assessments and interventions in this area. It’s a huge opportunity and a huge challenge—and we need to be prepared to handle this demand.

The study suggests that there is a lag in identification, with most kids diagnosed at 4 and older when they could be diagnosed as early as age 2. What can SLPs do to help get these kids diagnosed earlier?

First I should point out that when the kids in this study were toddlers, in 2004 and 2005, we weren’t yet able to accurately diagnose autism at those young ages. Now, with the toddler module of the Autism Diagnostic Observation Schedule, we can. And given that with ASD comes late onset of speaking, SLPs are often doing the earliest assessments. Right now, we may be less inclined to put a late-speaker in the SCD category because we want to get these kids services but don’t yet have appropriate assessments, treatments or reimbursement for SCD. Our charge is to develop these. And it’s also to it’s also to continue to develop continuing education for our practitioners to diagnose autism, which we can do, typically as part of a team.

The study suggests that kids who are African American and Hispanic are being underdiagnosed relative to white kids—again, what can SLPs be doing to help close this gap?

It should be noted that, if you look at the report, there actually has been a dramatic increase in diagnosis in both those communities. But yes, the rates still lag behind those in white children a great deal, so there’s a need to close this gap. Part of this is an issue of cultural difference, but it’s also the well-known health-disparities story of lack of access to services. So we need to do more outreach and education in the African American and Hispanic communities about early intervention and their entitlement to public services.

What are the implications of these findings for the services SLPs provide to children on the spectrum?

This is my sense: Some SLPs feel like they’re not necessarily the primary interventionists in cases of autism but if a kid’s primary weakness is in the speech and language domain—which is the case in ASD, along with behavior—then they really have the role. Improved speech improves behavior. And parents want their kids to talk, so we are and should be primary clinicians involved in diagnosing and treating ASD.

As we go forward, we need to work on distinguishing SCD from autism. We need to own this, but to do that we need to provide data that make a difference and train others on what we know.

 Learn more about social communication disorders  and autism spectrum disorder on ASHA’s website. More information on both categories is available from ASHA—e-mail Diane Paul, ASHA director of clinical issues in speech-language pathology, at dpaul@asha.org.

Stephen Camarata, PhD, CCC-SLP, is a professor of hearing and speech sciences at the Bill Wilkerson Center at the Vanderbilt University School of Medicine. He is an affiliate of Special Interest Group 1, Language Learning and Education. Contact him at stephen.m.camarata@vanderbilt.edu.

Kid Confidential: The Latest on Treatment of Ear Infections

ear infection

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

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

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

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

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

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

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

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

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

Please refer to the resources below for further information.

Resources:

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

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

 

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

Collaboration Corner: In Defense of the Whole Child

wholechild

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

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

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

Our role as SLPs and educators

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

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

Here are some pointers I frequently share with staff:

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

 

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

Apps with Elders

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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.