Tales From Apraxia Boot Camp

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In August of this year, I was selected to be a part of The Childhood Apraxia of Speech Association of North America’s 2014 Intensive Training Institute, otherwise known as “Apraxia Boot Camp.” Twenty-four speech-language pathologists, including myself, trained with three mentors–Ruth Stoeckel, Kathy Jakielski, and Dave Hammer–at Duquesne University over four days. In its third year, the goal of the boot camp is to spread a high level of knowledge about Childhood Apraxia of Speech (CAS) assessment and treatment throughout the United States and Canada. This conference accomplished that and so much more.

This experience was different than any other continuing education seminars that I have attended. We did not listen to speakers discuss CAS. Instead, Ruth, Kathy and Dave became our mentors. This was powerful. They moderated discussions on evaluation and treatment approaches. We reviewed research papers and had long debates on the principles of motor learning. We highlighted and critiqued therapy methods for those brave enough to show videos of themselves. We problem solved and brought up more questions than we knew were possible.

In smaller groups, our mentors provided insights and personal perspectives on how they work. In this intimate setting, we felt comfortable asking questions and sharing our experiences. The mentors shared constructive criticism along with thoughtful suggestions. In all, they made me think, reflect and question everything I do. Why do I give that test? Why do I treat that way? What is the research behind it? They encouraged us to become critical thinkers.

As therapists, we often get used to using the same materials and therapy techniques we learned in graduate school or during our early experiences. Those methods are not always effective with every child we treat nor are they all proven effective with evidence based-research. Specifically, children with CAS require different therapy techniques than other children with articulation or phonological delays.

Ruth, Kathy and Dave provided valuable information in a small, engaging setting. Their mentoring and passion for CAS has inspired me and I hope to pass along this valuable information to others through mentoring, improving my competency in treatment and diagnosis of CAS, and, in the end, helping children to communicate.

Based on my experience, I’d recommend asking yourself a few questions when selecting your next continuing education event:

  • What am I passionate about? Is there a child or an area of speech pathology that truly inspires me?
  • How will it improve my skill set?
  • How will it help me better serve my clients?
  • Who is doing the most current, researched-based evaluation or therapy techniques?
  • How will it further our profession?

 

Amanda Zimmerman, MA, CCC-SLP, is a pediatric speech-language pathologist in Columbus, OH. She can be reached at azimmerman@columbusspeech.org.

ASHA 2014, Here I Come! It’s GO Time!

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Usually, the word scheduling elicits shivers down my spine. Usually that means scheduling 60 kids into speech therapy slots without interrupting ELA, math, lunch, recess, music, PE, art, intervention, OT or PT. It’s an astronomical feat when SLPs complete schedules every year. In contrast, scheduling for ASHA 2014 in Orlando has been a breeze. I’m scheduling lunch dates, meet ups, pool time, and my favorite CEU opportunities! Scheduling for #ASHA14 in Orlando is very different from scheduling therapy clients.

 

I’ve booked my flight. I’ve texted friends and worked out transportation. I’ve got a place to stay! I’ve joined up with some of my blogging buddies and reserved a booth for the exhibitor hall. Most importantly, I’ve started picking out a schedule for the courses I will take in November. I am so looking forward to downloading the mobile app this year. Since most SLPs don’t have time to wait in line for three days for the new iPhone 6, I’m hoping my dinosaur 4s phone will make it until November. The app should make managing my conference schedule a snap.

 

The Program Planner has been an easy way to browse for courses. It’s more user-friendly than my IEP writing program and my Medicaid billing programs. You can browse through courses by keyword, author, title, etc. So far I’ve searched for topics that apply directly to my caseload. My search terms were “school,” “autism,” “evaluation,” “preschool,” “apraxia” and “AAC.” Here are seven sessions that I’ve chosen so far:

 

  1. I really think research is valuable and there is just so much to choose from. I am trying to pick courses that relate directly to me or courses that really excite and interest me. In my current job I’m doing two preschool evaluations per week. I’m having the ‘articulation, phonology, and apraxia’ conversation with parents every week as I explain characteristics of each and their differences. The presentation “Differential Diagnosis of Severe Phonological Disorder & Childhood Apraxia of Speech” by Matthews and Rvachew sounds like a great refresher. I’m hoping to find some more evaluation-specific courses before November.
  2. I’m thinking the Phillips, Soto, & Sullivan presentation called “Strategies for SLPs Working with Students with AAC Needs in Schools” sounds perfect for a lot of my caseload. I need strategies for AAC students so this should be a big help.
  3. I can’t wait to see “iPad to iPlay 2: Teaching Play to preschoolers through Apps” from Tara Roehl. I love my iPad so I can’t wait to see how she is using it to teach play in preschoolers. This is really a skill I’d love to pass on to my teachers and parents.
  4. On the other hand I’m always careful to limit screen time with my students. There is a presentation called “The Impact of Technology on Play Behaviors in Early Childhood“ from Hagstrom, Smith, Witherspoon. Hopefully once I listen to both presentations I’ll feel good about balance and not leave feeling conflicted!
  5. Michelle Garica Winner is presenting four times. I’m hoping to catch “ASD Treatment: Cognitive Behavioral Therapy & Mental Health Problems Associated With Social Learning Challenges” and “Implementation Science & Social Thinking®: Discovering Evidence in Our Own Backyard”. I love her work and just can’t wait to finally see her present in person.
  6. Barbara Fernandez from Smarty Ears is presenting about one of her apps for data collection and caseloads. I can’t wait to talk to her about all the new Smarty Ears apps coming out in the future so I’ll be hitting up the Smarty Ears booth.
  7. Lastly, I decided to search my schools to check out what the faculty at Ohio University and The Ohio State University are presenting. “Skiing, Horseback Riding, & Communication With Individuals With Complex Communication Needs: Experiences From Community Volunteers” sounds really interesting from McCarthy, Benigno, and Hajjar at Ohio University. They are presenting information on recreational activities for individuals with complex communication needs. Interviews were conducted with volunteers in adaptive sport programs in New England.

 

I don’t think we will have any typical celebrities at ASHA. At least not the kind you see on entertainment television every night. There will however be some #SLPcelebrities to be found! I searched two of my favorites to check when they will be presenting. Hopefully you’ll see me posting a #slpselfie with some of my favorites SLPs over the weekend in Orlando.

That initial scheduling took about 30 minutes and I didn’t have to email 20 different teachers. Scheduling for ASHA is way more fun than making a therapy schedule. Now the countdown begins!

 

 

Jenna Rayburn, MA, CCC-SLP, is a school-based speech-language pathologist from Columbus, Ohio. She writes at her blog, Speech Room News. You can follow her on Facebook, Twitter, Instagram, and Pinterest. Jenna is one of four guest bloggers for ASHA’s convention in Orlando.

Can Speech-Language Pathologists Diagnose Autism?

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

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

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

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

Knowledge required:

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

Skills required:

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

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

 

Understanding Autism: Restaurant Meltdowns

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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.

Collaboration Corner: In Defense of the Whole Child

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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.

Best New Games for Speech Intervention

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I’m lucky to have enjoyed the unique opportunity to attend the International Toy Fair in New York City as a member of the press, viewing the exciting new products being introduced. After seeing hundreds of new games, toys and books, I shared my first impressions of what stood out, delivering language learning potential. Now that I have had a chance to catch my breath, the boxes are arriving with Ninja Turtle games and fuzzy chick puppets to review for my PAL Award (Play Advances Language). As speech language pathologists, we are a busy crew, spinning many plates at once–serving our clients, keeping data, attending meetings, planning therapy and keeping up with what’s new. Many of you have told me how much you appreciate my selection process and the products I recommend, saving you time, so here are my newest recommendations with descriptions on how I have found them to be helpful. As always, I love your comments on how YOU use them in new and creative ways too!

Animal Soup The Mixed-Up Animal Board Game! by The Haywire Group

Just setting up this game gets lots of giggles going as kids look at the pictured math showing the sum of a tiger plus a rhinoceros equals, of course, a “tigeroceros!” Preschoolers request that I read through each zany combination of animals before starting the game. Players make their way around the forest game board, which cleverly uses the box, as they land on different animals, collecting the corresponding picture card. Kids continually check the large reference chart of combined animals to see what they need to complete their “croctopus,” “birdle” or “squale”–(crocodile+octopus, bird+turtle, or squirrel+whale). Thankfully they have a “trade” option to land on so they can negotiate with a peer for the animal to complete their creature. Flip the two matching cards over, and you are rewarded with a hilarious animal soup combination. Two completed mixed-up animals wins the game. This game, based on the best selling book by Todd S. Doodler, can be used to further speech and language skills:

  • Articulation: repeat the goofy combined animal names, which I’ve found helpful in making preschoolers aware of moving their mouths and listening to include all the sounds in a word.
  • Practice negotiating skills as they realize cards needed for a trade and anticipate where their needed card is coming up on the board.
  • Follow directions.
  • Comparisons between the game and the book it is based on.

Suggested age: 3 and up. This is so popular with my preschoolers, they consistently request to play.

Teenage Mutant Ninja Turtles Clash Alley Strategy Board Game by Wonder Forge

Start your social language lesson as kids set up the 3-D game board, stacking boxes at different levels for the Teenage Mutant Ninja Turtles to traverse through the maze-like warehouse. A collaborative effort, players help each other to customize the board. An excellent introduction to strategy games, Clash Alley has many options to enhance the turtle’s success as they run, climb and leap to race to complete their mission, uncovering the card to rescue April, retrieve the AI chip, grab the Mutagen or even pick up a pizza! Earning and playing action cards are the key to successful travel across the board as your turtle can team up to battle villains–Kraag, powerful mutants and even Shredder–to collect spy cards to peak under a mission disk, swipe card to steal from another player, or Team Up, which allows two turtles to combine attack points to overcome a villain. The directions take a little time to understand but once kids got them, they couldn’t get enough of this game. Speech and language goals to address:

  • Description: I use this multi-leveled game of strategy in my group with higher-level kids on the autism spectrum and their typical peer play partner. I have my client explain the directions (which have many options for beating the villains) which can be challenging. The visual prompts of action cards and triple option dice help.
  • Social language: Learning to take turns and a group attack option to join forces with another player.
  • Academic language: Language of math as kids help each other add up attack points and have to determine what number is greater or less than another to win the battle.
  • Pretend play: Kids surprised me as they got into the game because even though they were competing against each other, there was a feeling of camaraderie against the villains.

Suggested age: The manufacturer says 6 years and up but I found the directions are more suited to 7 or 8 and up although you certainly can adapt this game to younger kids, since Teenage Ninja Turtles are so hot right now.

On the Farm Who’s In the Barnyard by Ravensburger

This farm set with characters, vehicles and animals is a puzzle, pretend play set and first game all in one. Open the barn like a book, identifying all the animals and objects from pigs, chicks and bunnies to tools and bales of hay. Talk through the illustrations on the outside of the barn with the fruit stand, conveyor with bales of hay and parked tractor. Kids love to snap out the windows and door as a puzzle experience so they can peer inside, or even play a game of peek-a-boo. Add the base and roof and you have a perfect house for your barnyard friends to practice your animal sounds as kids match and place your cut-out figures next to corresponding pictures on the barn. Take the play up a notch with a matching game as you switch game figures and others have to guess who moved! This set is so open-ended, I used it for several activities with 2 year-olds. Here are some speech and language skills to build:

  • Teach animal sounds, as you play with the corresponding figures.
  • Articulation. I had plenty of /p/ and /h/ words to model with this set.
  • Pretend play as the barn is built and animals can move in and out of the play scheme.
  • Verbs, and prepositions can be modeled as you play with this set.

Suggested age: 2 years and up. I’d say this is best for the toddler set. Excellent educational suggestions are included in the box so this is also a good product to suggest to parents who would like some assistance in how to encourage language learning with this toy.

WordARound by Thinkfun

I never knew reading in circles could be so much fun! Each round card has blue, red and black concentric circles, with a single word written in each ring. Players race to unravel the word and shout it out to win a card. Flip the card over and you will see what color ring to examine on the next round, searching for a word. With no beginning or end to the word, players look for patterns, prefixes and suffixes like “ant,” in “hesitant” and ” er,” in “finger.” I found myself looking for consonants to start a word, until other players beat me at “uneven” and “almost,” leading me to factor in initial vowels too. Some cards flipped over to present the word so I could read it easily like “porcupine,” which made for an easy turn. Starting anywhere on the ring and sounding out the string of sounds also brought results as players recognized parts of words like “typical.” WordARound is addictive, and watch out because little clients can beat you at this! I use it for:

  • Vocabulary: Discuss meanings and practice using new words.
  • Reading: Develop strategies to find words in the circle.
  • Articulation carryover for older kids.

Suggested age: 10 years and up

What’s It? by Peaceable Kingdom

What’s It? is a cooperative game where players interpret doodle cards and score points for thinking alike. Roll the dice with category options such as you love it, use it, wear it, don’t want it, or make up your own category. Flip over a doodle card, start the 30-second timer and play begins. Players record at least three guesses based on the drawing and category but try to think like their fellow players. This is where I was at a bit of a disadvantage, playing with 8 year-olds. They saw buttons when I saw a pearl necklace and they saw shark teeth when I saw a zipper! Players earn points when their answers match. I’ve used this game with higher functioning kids on the autism spectrum, encouraging more abstract thinking.

  • Calling up words in categories
  • Word-finding
  • Description

Suggested age: 8 and up

Qualities by SimplyFun

SimplyFun’s game, Qualities, is a natural language catalyst and a creative way to get to know and be known by friends. Up to seven players take turns identifying and rating certain qualities in themselves, while game-mates offer up their own perceptions. “Qualities” runs off of a Preference Board as players accumulate points as they match their assessment of player’s personalities to their own judgement. What gives you the most energy… going to the park, going to a museum or organizing? Lots of conversation follows as players defend their answers with examples of that behavior. Players rate the extent to which a player is “tolerant,” “cautious,””empathic” or “sympathetic,” to name a few. The trait and value cards were a vocabulary lesson in themselves.

  • Vocabulary
  • Language of persuasion
  • Explanation of how traits are manifested in a person’s actions or activities
  • Abstract thinking

Suggested age: 12 years and up. This game is great with adults too.

Disclosure: The above games were provided for review by their companies.

Sherry Y. Artemenko MA, CCC-SLP, has worked with children for more than 35 years to improve their speech and language, serving as a speech language pathologist in both the public and private school systems and private practice.

Kid Confidential: “Join In on the Stim!”

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Autism Spectrum Disorders (ASD) is one of the great loves in my professional career. Persons with ASD are fascinating and wonderful and many times their behavior actually makes sense to me. I know what you are thinking, “This woman has got to be on the spectrum herself.” Well although I do believe that we all exhibit hyper- and/or hypo-sensitivities to various stimuli and that we all have what I like to call “a little autism in us,” it just may not be on the scale of persons who are diagnosed with ASD formally. It may not consume our entire interactions as it does for some students with ASD. So the question is, what do we do about it?

When I was in graduate school, the prevailing acceptable intervention was based on behavioral modification techniques. I was expected to spend time determining why that stimulatory behavior occurred (i.e. avoidance, stress, seeking sensory input, coping mechanism, sensory overload, etc.) and replace it with a more appropriate behavior. I still agree that this treatment strategy is appropriate in certain situations. For instance, if the student is seeking sensory input, let’s provide him/her with an appropriate sensory diet (under the supervision of an OT with the appropriate experience). If the student is exhibiting behaviors that are harmful to him or herself or others, they MUST be replaced by more appropriate safe behaviors. If the student is overloaded and attempting to escape/avoid a situation, let’s give him/her a break and/or modify the activity and expectations.

But are there times when we should actually encourage the stimulatory behavior? Are there times when we should not only support it, but “join in on the stim”? My answer to this is ABSOLUTELY! I know I just lost a few of you, but hear me out. The first time I read this idea, I was skeptical as well.

Jonathan Levy, author of “What You Can Do Right Now to Help Your Child with Autism,” challenges parents and therapists alike to do just this, join the child in his/her world by simultaneously imitating the stimulatory behavior. The idea is that for children who are profoundly affected by ASD and who spend all or most of their time exhibiting stimulatory behaviors actually need us to invade their world and physically pull them out of it by imitating them.

According to Levy, by joining your child/student in their stimulatory behavior you are telling them several things:

  • You understand their need to use this behavior.
  • You have something in common with them.
  • You want to interact with them and you are willing to enter their world.
  • They are safe to “be themselves” around you and you will not interrupt their need to stimulate themselves using these behaviors.

Does this actually work? According to Jonathan Levy, this is a technique Barry and Samahria Kaufmann, authors of the Son-Rise Program and founders of the Autism Treatment Center of America (ATCA), not only believe in, but have used successfully on their own child as well as numerous children nationally and internationally for more than 25 years. Anecdotally, I can tell you from my personal experience, I have done this and I have noted several positive changes with consistency:

  • Almost immediate increase in eye contact or facial referencing.
  • Students with ASD began to approach and/or gravitate to me whenever I entered their classrooms.
  • Students began to tolerate my touch or would take my hands and place them on their own bodies. For example, I had a female student once start pulling on my arms. I figured out very quickly she wanted me to do this to her. Although nonverbal, she made a request for the first time in her life! After I provided that sensory feedback, she was able to sit on the floor with her class during a large group lesson for the very first time.
  • And after a few weeks of joining in the stimulatory behaviors, I began to hear vocalizations. And for some of these children, it was the first time they ever vocalized!

Yes I was that therapist, jumping around in circles, flapping my hands, vocalizing various moans and groans along with my students. I was that therapist sitting at the lunch table filtering light through my fingers and screeching with my student as he attempted to eat. I was also the first person they made eye contact with; the first person, to which they handed a picture (i.e. PEC); the first person, with whom they exhibited joint attention; and the first person to whom they intentionally vocalized when making a request.

So does this technique work? I believe that it does if used properly for the appropriate students. This is not a technique that I believe every student with ASD requires or can benefit from, but it certainly appears to make significant changes in those who are so profoundly affected that they cannot find a way out of their own worlds without us stepping in and meeting them where they are.

Mr. Levy does leave us with a word of caution. Some children do not respond immediately to this technique as they are so far within their own worlds it could take them weeks to even notice your attempts to join the stimulatory behavior. But he ensures us, that this is not a reason to give up and believes that by giving the child adequate time, he will take note of your attempts to enter his world and you will break through the child’s barriers of stimulatory protection (Levy, 2007).

This has not been the case for me as I saw changes fairly immediately. However, I do believe that can be attributed to the fact that if the child is in a school setting, they are aware at some level that there are other people within the room, whether they seem to show it or not. I believe the school setting is unique in that just the setting itself forces the child with ASD to, even on a subconscious level, acknowledge there is a world bigger and different than what is found within themselves.

So the next time you have a student with ASD on your caseload that is profoundly affected and appears to spend all or most of his/her time exhibiting stimulatory behaviors, no longer ask yourself “What do I do with this child?”. Rather, make an attempt to enter their world and “join in the stim”. By doing this, you may just be the first person who has ever been able to connect with them.

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 New Jersey, Maryland, Kansas and now Arizona. 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.

Put ABA to Work: Tie Behavior to Language Goals for Kids on the Spectrum

Photo of marshmallows

(photo credit)

When I was in graduate school in the mid-90s, a family hired me to take care of their two-year old son, Jayden. He did not imitate or make any sounds. Jayden was an adorable toddler with autism who preferred to stare at the patterns on his kitchen floor or the spinning fan in his living room. His loving family flew halfway across the country several times a month to learn about the Lovaas method of applied behavioral analysis (ABA).

To get their son to speak, they flew in ABA-trained specialists, who wrote a binder of lesson plans and left them for graduate students like me to carry out. There were four fairly clueless graduate students who implemented the lessons in four-hour shifts. From our combined efforts, their little boy received eight hours of ABA services a day—every day—focused on communication and play.

Our lessons would go something like this: First, I would show Jayden a picture of an ordinary item, such as an apple. Then I would say, “Apple.” If the toddler made an approximated sound, I gave him a mini-marshmallow. We repeated this exercise in succession dozens of times. My novice grad-school self would wonder, “Does this kid understand the experience of an apple? Or does he now think an apple is a marshmallow?”

Twenty years later, I am a school-based practitioner. Eighty percent of my kids are children with autism, a majority with severe communication challenges. I work closely with several board-certified behavioral analysts, and many behaviorally trained paraprofessionals. I’ve developed an understanding of ABA principles, and the realization that reinforcement compels behaviors to continue or change. We all abide by these principles: You go to work, you get money and derive some job satisfaction. Because your duties are reinforcing (some days more than others), you continue to come into work. It is the same with language and ABA: I show you something is worth requesting, and you start to learn to ask for it by whatever means—pictures, signs, gestures—you need to.

Holistic learning

As practitioners, we must re-examine skill mastery. Mastery is beyond 4/5 opportunities in my speech session, or 8/10 trials with a paraprofessional in a cubicle. Skill mastery demands holistic consideration. We learn through schemas—that is, our experiences shape our understanding of the world. If we have no prior knowledge, then our ability to retain that information is reduced dramatically. If I talk about my vacation to the beach, we all produce a somewhat similar multi-sensory image in our head: There’s an ocean or a lake, sand and the various sounds and smells of a beach. Now imagine if you have never been to the beach (or heard of one) and someone shows you a picture. Then they hand you a marshmallow … do you think marshmallow is another word for beach? Have you really learned about a beach?

On occasion, I will inherit an individualized education program chock-full of language objectives written by someone other than an SLP. However, some of the most effective IEPs I have seen have been created through the coordinated efforts of SLPs collaborating with board-certified behavioral analysts.

Here are some good ways to keep meaningful language consideration alive and well when thinking about IEPs, communication, language and ABA principles:

Tease out language versus behavior.

Although language may provide a function, it does not always reduce behavior. This is why it is important for the team to use tools like preference assessments and functional behavior analyses. Little Susie may be pulling your hair because she wants your attention, or perhaps she is pulling your hair because she doesn’t want to wait. In the first example, the SLP could teach the language (e.g., “I want to talk to you.”). But in the second example, teaching the language “I don’t want to wait” may not be sufficient, because the child may act out anyway (picture a two-year-old being told to wait). In this case, a behavioral intervention with something other than words may be more appropriate.

Examine the language-behavior plan connection.

Behavioral support plans are a great way for the team to address behavior in a consistent way. Many behavior plans that come my way are language-laden. This is a great opportunity to work with board-certified behavioral analysts and other team members in refining what language to use with the child at his or her developmental level, while also refining functional communication.

Combine ABA with language and academic goals.

For my students whose IEPs include ABA, one great way to work on generalization through immersion is having the paraprofessional run programs that address “speech and language” goals. For many of my students who have a board-certified behavioral analyst, each goal area on the IEP has an ABA program that corresponds to each objective. I collaborate with the board-certified behavioral analyst on presentation and prompt hierarchies so that we can all agree on the student’s current performance and level of independence. Paraprofessionals take data for each program. Come progress report time, I consult the data collected from staff and combine it with my own. This allows the team to identify discrepancies in how content is delivered, and provides a great opportunity for the team to troubleshoot any issues in terms of skill mastery or curriculum modifications.

Final thoughts.

The overlap between language, communication and behavior is undeniable. Keeping language separate from behavior can ultimately compromise your teaching process’s efficiency. Schools and special education teams need to carve out opportunities for behavioral specialists and speech-language pathologists to collaborate, and think beyond the “reward” of the mini-marshmallow.

Dr. Kerry Davis is a city-wide speech-language pathologist in the Boston area. Her areas of interest include working with children with multiple disabilities, inclusion in education and professional development. The views on this blog are my own and do not represent those of my employer. Dr. Davis can be followed on Twitter at @DrKDavisslp.

The Bosnia Autism Project

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Over the years, Speech Pathology Group: Children’s Services International (SPG: CSI) and the government of Bosnia-Herzegovina have combined their efforts to establish and implement a ground-breaking program, The Bosnia Autism Project. Our mission has been to “teach the teachers” and provide sustainable aid to children with communication impairments.  Lisa Cameron has recently extended the SPG: CSI efforts to the Himalayan country of Bhutan, and Marci VonBroembsen remains active in South Africa. SPG: CSI is truly expanding and going international!

From 2009-2012, SPG: CSI sent specialized teams of professional volunteers to provide evidence-based assessment and treatment education to professionals, university students and parents in Bosnia- Herzegovina. This past summer, SPG:CSI  worked with a four-year old who was hidden in his house because his family was ashamed of his disability. We met a 12-year-old who had never been to school and whose parents would lock him in his empty “bedroom” (merely a concrete room and a bucket) because he was nonverbal and had become so aggressive that they did not know how to control his behaviors.

Because of the tireless efforts from professionals in Bosnia-Herzegovina, and SPG: CSI’s dedication, together we have achieved amazing results! We are ecstatic to tell you that in October 2012 both our four-year old and the 12-year old started attending school and are doing well. For the first time students with autism and other disabilities are receiving treatment, a home-based intervention program has been established, parents are being educated, and the numbers of treatment centers continue to grow. But our mission is far from complete.

We are now in phase three of the Bosnia Autism Project, which is providing advanced training to the community leaders and medical and educational specialists.  In an effort to maximize our efforts, we have invited seven key professionals and medical specialists to train with us in California for three weeks in the summer of 2013. These trail-blazing pioneers will receive advanced training in communication assessment and treatment strategies for children of all ages and stages, and go back to Bosnia to train other professional peers, leading them through a professional transformation.

For those of you who have wanted to participate with the non-profit but were unsure how, we invite you to get involved. Now is the time—and you don’t have to make the trek overseas!

  1. Visit our website and learn more about the Bosnia Autism Project.  Any and all help is welcomed, without long-term commitments.  Contact us at info@spgcsi.org or spg.csi@gmail.com if you have any questions or want to get involved.
  2. Friend us on facebook at  to follow the most up to date information, see pics and follow the progress of our Bosnian colleagues.
  3. Join us at California Speech Hearing Association Convention for a 90-minute informational seminar (Thursday, March 8th) and Happy Hour at the Hyatt Long Beach on Friday March 9th.  Check out our website for more information.

Larisa Petersen, MS, CCC-SLP is in her third year as a Speech-Language Pathologist.  Currently, she works for The Speech Language Pathology Group in Walnut Creek, California.  She provides speech-language services to students in Kindergarten through sixth grade.  She updates the blog for The Bosnia Autism Project and you can visit her at http://spgcsi.wordpress.com.  Also written by Anna Taggart, Leah Huang, and Raquel Narain.

Autism: Three-Word Phrases to Supported Conversations in 18 Months

WebRTC conversations

Photo by Tsahi Levent-Levi

Just settling back in from the whirlwind trip to Atlanta, Georgia.  ASHA, once again surpassed itself in excellence.  My kitchen table is a mass of brochures, notes and folders; re-organized into priority piles.  The exhibit hall was replete with samples and gadgets.  Now, what to do with that little planter of wheat grass?  Yes, I live in northern California; one would think I’d blend that stuff right up in my morning “green drink,” but I think I’ll find another home for it instead.

And, reaching in my zipper-top ASHA bag, there’s more: a pink flamingo clip, a recycled “use your own” grocery bag, a pamphlet on social networking, plenty of memories.  Notwithstanding the seminars and short courses which offered a mountain of new information.

I contributed “my rock” of new information this year, too.  I had the honor of presenting a case study of an Autistic teen’s language development over an 18 month period.  Presenting at ASHA is not new to me, but each time it confirms the fact that we, “ in the trenches” daily clinicians, as opposed to university researchers,  have much to offer our colleagues.

ASHA is interested in what we are doing out in the field.  Small treatment programs and case studies contribute as much as research coming out of the more prominent universities.  ASHA is interested not so much whether a given treatment “worked” (as that word is nebulous in itself) but what did it change? And, how did it change?

So, this case study was a sequential presentation of video clips demonstrating an 18 year-old autistic male’s changes in sentence structure, vocabulary and vocal prosody as he learned from video feedback and the use of a speech generating device. The changes over time have been dramatic and offer us windows into understanding how communication skills can change via use of technology.

Treatment is evidence-based, as I took the best available research about children with autism and video monitoring and then applied my clinical best-practice knowledge, along with his values and interests. Computers enthralled him and Disney is his favorite subject!  His comments confirm this.

Combining the use of point-of-view virtual feedback, audio and video self-editing, self-modeling, repetition and practice speaking with a monitor rather than a person, we witnessed movement starting with our teen bolting perseverative repetitive words and phrases across to phases of dependence on written scripts or memorized lines through his success with short supported conversations.

The videos showed a continuum of his vocal changes and the sweet exploration of facial expressions related to his intentions of message delivery. We also watched his ever-growing vocabulary, including the use of temporal and spatial relationships.

Seminar attendees fell in love with this charming young man as they learned how he mastered the use of a speech generating device, including developing his own customized digital icon library as well as video editing and review. They learned how he independently wrote and recorded his own comments and attached them to his personal photos, all in an effort to share the events in his life.

Current Technology

This case study offered a readily-attainable speech and language treatment utilizing a speech generating device for delivering supported and self-study techniques.  The Lingraphica speech generating device (SGD)  offers immediate video feedback, a built-in icon library w/customizing capacity and ease of navigation which can promote patient self-use within this particular population.

Besides considering the use of a *Lingraphica SGD (utilized in the study), one might be creative and use a tablet, a laptop with a video camera, or an app which would lenditself to video modeling techniques.  The course demonstrated how existing research and the availability of developing standardized communication models for independent practice outside of the therapy environment, can substantiate a treatment model of cost efficiency.  The new formula of  “treatment / cost = value” is alive and well with this treatment model, which focuses on extensive independent study. 

Did you miss the session?  You may still be able to download the handout which gives an overview and bibliography.  I have been using some of the same techniques with my other patients and keeping close track of their changes.  Stay tuned; we may see significant outcomes with other populations as well.

I am in the process of developing an online CEU course which you could download with these wonderful video-clips.  So, to whet your appetite for more; here are two clips from the course.  First, a baseline and then a delightful supported conversation Talking about what?  Disney, of course.  Enjoy the videos.

 

*Disclaimer:  I have no fiduciary relationship with either Lingraphicare or Disney Productions.

 

Nancy Horowitz Moilanen, M.A. CCC-SLP; Private practice, Northern CA, 35 yrs.;  Director, Well Together Neuro Rehabtm, a group therapy program utilizing music and community-building as a rehab model;  Presenter ASHA, 2010 & 2012;  ASHAsphere Blogger, Communication Wellbeing and Social Wellbeing…an Aspect of Health, January 2011, Graduate ASHA Leadership in Health program, 2011; ASHA Leadership in Health program graduate presenter, 2012. A proud member of SLPeeps, Facebook’s social networking site.