Using Menus as a Treatment Tool

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Are you looking for a free and functional therapy tool? How about a take-out menu? Menus are practical, full of language concepts and can be used for a variety of speech and language goals. Many young adults on my caseload have limited literacy skills and often find themselves dependent on others to order for them in dining situations. If they can’t read the menu accurately they won’t know all of their choices unless someone reads it to them.

What’s more functional than being able to read a menu and make a choice for themselves? Some menus have pictures, but most do not. Even menus with images and words are tricky if you’re not familiar with all of the dishes.

When using a menu as a treatment tool, I ask my clients, “What are your favorite places to eat?” Many times they don’t know names of restaurants, but can describe the type of food they prefer (e.g. Mexican, pizza, Italian). This is also an ideal opportunity to connect with family members by getting details about restaurants they visit and food they order.

When I ask a client, “How do you know what to order?” many of them respond by saying: “I just get the pizza/chicken/hamburger,” or: “My parents order for me,” or: “I ask the waitress for the food I want.” All of these answers work when dining out, but none give clients the ability to .take charge of their preferences.

Here are 10 speech and language goals I target when using menus in treatment:

  1. Literacy: Work on learning to read menu-related key words like appetizer, salads, sandwiches, chicken or fish. Create a bingo game with new words, so your client becomes fluent. Review the same menu over several sessions so your client familiarizes themselves with it.
  2. Categorization: What food group is broccoli in? How about chicken? I like to work on this goal of food groups with a game called Healthy Helpings My Plate Game. Try grouping foods by cost depending on your client’s budget or by healthy versus not healthy foods.
  3. Requesting: Practice requesting by asking your client to tell you what they would want from that particular menu, such as: “I want the sesame chicken with brown rice.”
  4. Pragmatics: Work on role playing by pretending you are the waitress and your client is the customer. Reverse roles and practice greetings, turn-taking, being polite, and more.
  5. Describing/Commenting: Review different foods and ask your client to describe specific For example, “What is the difference between thin crust pizza and thick crust pizza?” or, “Describe what crispy chicken tastes like.” If your clients can describe their preferences in detail, the better they’ll get at ordering.
  6. Answering “wh” questions: As you review the menu, ask “wh” questions like: “What is your favorite item on the menu?”, “Why do you like chicken nuggets?”,
  7. Expanding vocabulary: Using varied menus exposes clients to new and unfamiliar vocabulary. I even learn new terms when reading a menu from a restaurant I’ve never visited. (Recently I participated in a cooking class and learned several new words.) Review new vocabulary and discuss its meaning. An ideal way for your consumer to comprehend food-related words is to show your client an image. Using Google Images is an easy way to do this.
  8. Money Concepts: Work on the language of money concepts with your consumer. Present a budget and figure out what they can order within it. Ask “What happens if you go over budget?” or other money-related questions.
  9. Problem Solving: Discuss possible situations that your client might have to solve using a menu. For example, what happens if they run out of your favorite item? What do you do if you have an allergy? What do you tell the waitress if you don’t like your food?
  10. Sequencing: Discuss the order of how you’re going to order food and drink items. For example, you normally order drinks first, appetizers next, entrée and then dessert. Reviewing the menu can be carried over to other activities related to sequencing.

Rebecca Eisenberg, MS, CCC-SLP, is a speech-language pathologist, author, instructor, and parent of two young children, who began her website www.gravitybread.com to create a resource for parents to help make mealtime an enriched learning experience. She has worked for many years with both children and adults with developmental disabilities in a variety of settings including schools, day habilitation programs, home care and clinics. She can be reached at becca@gravitybread.com, or you can follow her on Facebook; on Twitter; or on Pinterest.

How to Evaluate Misbehavior

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Editor’s note: This is an excerpt of a blog post written by Tatyana Elleseff for her Smart Speech Therapy blog. Her full post can be read here.

Frequently, I see a variation of the following scenario on many speech and language forums:

The SLP is seeing a client with speech and/or language deficits in either school setting or private practice, who is having some kind of behavioral issues. Some issues are described as mild such as calling out, hyperactivity, impulsivity, or inattention, while others are more severe and include refusal, noncompliance, or aggression such as kicking, biting, or punching.

Well-meaning professionals immediately offer an array of advice. Some behaviors get labeled as “normal” due to the child’s age (toddler), others are “partially excused” due to a psychiatric diagnosis (ASD). Some might recommend reinforcement charts, although not grounded in evidence. Letting other professionals deal with the behaviors is common: “in my setting the ______ (insert relevant professional here) deals with these behaviors and I don’t have to be involved.”

These well-intentioned advisors are overlooking several factors. First, a system to figure out why particular set of behaviors takes place, and second, if these behaviors may be manifestations of non-behaviorally based difficulties such as sensory deficits, medical issues or overt/subtle linguistically-based deficits.

What are the reasons kids present with behavioral deficits? Obviously, there could be numerous answers to that question. The underlying issues are often difficult to recognize without a differential diagnosis. In other words, we can’t claim that the child’s difficulties are “just behavior” if we don’t appropriately rule out other contributing causes. Here are some steps to identify the source of a child’s behavioral difficulties in cases of hidden underlying language disorders (after, of course, ruling out relevant genetic, medical, psychiatric and sensory issues).

Start by answering a few questions: Was a thorough language evaluation—with an emphasis on the child’s social pragmatic language abilities—completed? And by thorough, I am not referring to general language tests, but a variety of formal and informal social pragmatic language testing. Let’s say the social pragmatic language abilities were assessed and the child found/not found to be eligible for services. Meanwhile her behavioral deficits persist. What do we do now?

Determine why the behavior is occurring and what is triggering it (Chandler & Dahlquist, 2015). Here are just a few examples of basic behavior functions or reasons for specific behaviors:

  • Seeking Attention/Reward
  • Seeking Sensory Stimulation
  • Seeking Control

Most behavior functions tend to be positively, negatively or automatically reinforced (Bobrow, 2002). Determine what reinforces the child’s challenging behaviors by performing repeated observations and collecting data on the following:

  • Antecedent or what triggered the child’s behavior.
    • What was happening immediately before behavior occurred?
  • Behavior
    • What type of challenging behavior/s took place as a result?
  • Response/Consequence
    • How did you respond to behavior when it took place?

Once you determine behaviors and reinforcements, then set goals on which behaviors to manage first. Some techniques include modifying the physical space, session structure or session materials as well as the child’s behavior. Keep in mind the child’s maintaining factors or factors that contribute to the maintenance of the problem (Klein & Moses, 1999). These include: cognitive, sensorimotor, psychosocial and linguistic deficits.

Choose your reward system wisely. The most effective systems facilitate positive change through intrinsic rewards like pride of own accomplishments (Kohn, 2001). We need to teach the child positive behaviors to replace negative, with an emphasis on self-talk, critical thinking and talking about the problem instead of acting out.

Of course, it’s also important to use a team-based approach and involve all related professionals in the child’s care along with the parents. This ensures smooth and consistent care across all settings. Consistency is definitely a huge part of all behavior plans as it optimizes intervention results and achieves the desired outcomes.

So the next time the client on your caseload is acting out, troubleshoot using these appropriate steps in order to figure out what is REALLY going on and then attempt to change the situation in a team-based, systematic way.

 

Tatyana Elleseff, MA, SLP, is a bilingual speech-language pathologist with Rutgers University Behavioral Healthcare and runs a private practice, Smart Speech Therapy LLC, in Central New Jersey. She specializes in working with multicultural, internationally and domestically adopted children and at-risk children with complex communication disorders. Visit her website for more information or contact her at tatyana.elleseff@smartspeechtherapy.com.

As Adults With Intellectual Disabilities Live Longer, They Need More AAC Support

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Communication for adults with intellectual disabilities and complex communication disorders is a team effort. People with these disorders are living longer, higher quality, independent, and more productive lives thanks, in part, to alternative and augmentative communication technology.

Speech-language pathologists need to understand the settings in which these adults live. No longer do they live in large institutions but in more intimate and natural independent or small group homes.

A crisis may also be at hand as aging caregivers, whose adult children with intellectual disabilities and complex communication disorders live at home, can no longer care for them. According to The State of the States in Developmental Disabilities (2013), in 2011, 71.5 percent of people with these disabilities lived with family caregivers. Over the next few decades this group will flood the group home system as their parents age.

Communication is always important and critical for a person’s independence. Family caregivers may tend to speak for the adult with a disability and anticipate needs more than staff at a group home. Independent means of communication becomes that much more important once that adult moves into a new environment. This is where the SLP has a major responsibility in finding the most appropriate, functional evidence-based AAC intervention.

Many factors exist beyond the skills of the adult with intellectual disabilities and our AAC recommendations, however. Future AAC success is a team effort between the SLP, families and paid caregivers/group home staff. Some staff members are highly supportive; some are not. Informal assessment of the environment in which the affected adult lives is crucial. It can be a delicate process to help the staff member see the purpose of AAC. If the group home staff does not “buy in” to the AAC device recommendation and plan, there is a high risk of abandonment.

Group homes, although typically a better solution than nursing homes for those without complex medical conditions, have their own challenges. Moving to a group home is a major life change for people who have typically lived their whole life with their families and who often have a significant difficulty adjusting to change. In the state of Pennsylvania, where I practice, I have been encouraged to see that the group home system has placed a high level of priority on communication over the past few years. As a result, I have been seeing more adults with intellectual disabilities and complex communication disorders in my practice.

Another challenge in group homes is staff turnover. The State of the States in Developmental Disabilities (2013), reports that hourly wages for workers in community intellectual/developmental programs averaged only $10.14 per hour. A report published by the Paraprofessional Healthcare Institute in 2011 noted that almost half of direct care workers (including group home staff) live below the federal poverty level. Meanwhile, their work can be rewarding but is often psychologically and physically challenging, so it is clear why staff turnover is high. And, unfortunately, frequent staff turnover is confusing, frightening and can lead to a lower quality of life for these adults.

I have seen many adults with intellectual disabilities and complex communication disorders go years if not decades without AAC intervention. It is especially painful when, as children, they used AAC in school and transition into the adult world with no reliable means of expression because either the device was returned to school or the device had become obsolete. There is also a high level of abandonment of AAC devices once the school support is gone. In nursing homes, there can be speech therapy support available. In group homes residents must be seen for therapy as outpatients. Once the resident is back home, it becomes the responsibility of the group home staff to ensure the AAC device use is supported and maintained.

As part of the intervention plan, we must assist the group home staff to add communication goals to their mandated plan of care. We must also train the staff members in the care, maintenance and programming of the recommended device. Adults with ID are living longer, and, as technology has become an accepted part of all of our lives life, AAC interventions will continue to be a necessity. We should remember that an AAC device recommendation is not a once and done process. An adult with ID may need numerous device upgrades throughout their lives. Determining the best AAC device is not the end of the process, it is only the beginning.

Carrie Kane, a speech language pathologist at the Good Shepherd Rehabilitation Network in Allentown, Pennsylvania,  specializes in AAC assessment and treatment for adults with communication disabilities. She developed and is the coordinator of the adult outpatient AAC program in Good Shepherd’s Assistive Technology Center.

Kid Confidential: Parent Education and Training, Part 2

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Last month I discussed why parent education and training is important and offered tips to effectively train and educate parents.  Today I’ll be discussing how I realistically implement parent training and education.

There are two main ways in which I incorporate parent training and education: at the end of a therapy session and during real-time.

End-of-therapy session Education/Training

I typically use this type of parent education and training for older children (school-age and up) who are working on specific speech and language goals that require some traditional “drill and kill” therapy.  I will also use this type of training for young children who have been receiving speech therapy from myself for some time, long enough that parents are already familiar with implementing techniques at home.

Tips for effectively implementing end-of-session training and education:

  1.  Time management:  I ensure that I end the speech session with adequate time left (usually 10-15 minutes) to effectively educate and train parents (following the tips I shared in part one of this series).  If I feel rushed, due to numerous parent questions, parents requiring more assistance when demonstrating skills, etc. I take a mental note and end my therapy activities a bit earlier the next session so I can provide appropriate training and education.
  2. Review the session:  I then quickly review the session’s activities.  As parents are usually in the room/area where therapy is being provided they are already familiar with the activities I have provided and will quickly know and understand the goal of therapy that session.
  3. Technique(s)—Explain, Model, Take Turn, Feedback: Then, as in last month’s column, I will follow the same steps: explaining the rationale for the technique(s) used, model the technique(s), have parent(s) take their turn and provide feedback.
  4. Follow up:  I always begin the next session with follow up on how implementing the previous week’s techniques are going.

Real-Time Education/Training

This type of education and training is so effective for my very young clients (birth-5 years) as parents are such an integral part of language development at this stage, that it is necessary they are involved the entire therapy session.  This can sometimes propose a problem with there are numerous siblings present, however I tend to incorporate siblings into therapy in order to save time as well as train siblings how to use communication techniques as well.  My motto in this instance is “if you can’t beat ‘em, join ‘em!”.

Tips for effectively using Real-Time Education/Training:

  1. Techniques—Trial, Explain, Model:  The first thing I do with these young kiddos via play therapy is to trial a number of techniques.  Then I determine the most effective techniques and explain to the parent(s) the rationale for using them.  I then model the use of each technique, one by one, and demonstrate the positive effects of its use several times in a row (I strive for 5-10xs in a row to demonstrate the effectiveness to parents).
  2. Questions: I then ask the child’s parent(s) if they have any specific questions before they trial the technique. Usually they do once they realize they will be asked to perform the same technique.  If I need to provide specific step by step instructions, this is the time.
  3. Parent Model:  Then I have the parent’s take a turn using each technique a number of times (again I strive for several in a row-5 to 10xs-to build confidence).
  4. Feedback:  I provide feedback on each use of the technique.  I share the strengths that I see, I note the positive child responses, and of course address any weaknesses or modifications as needed.
  5. Make a list: For parents new to using therapy techniques, I will sometimes write a list of the techniques or the process of implementing a technique so they can refer to it between therapy sessions.  For my most basic language facilitation strategies/techniques I have created my own parent training/education handouts which you can find here.
  6. Follow up: I always begin the next session with follow up on how implementing the previous week’s techniques are going.

Yes, real-time education/training can eat up a lot of your therapy time.  However, it is time well spent as long as the training is effective and parents can demonstrate independence with the use of the chosen techniques.  In my experience, using real-time parent education/training actually brings up several questions and concerns parents either do not think of prior to our discussions or are reminded of during therapy.  It’s a wonderful way to make the connection between the parent’s ability to change their communication approach and their child’s improved language development.  The goal of course with any parent education/training is to leave the parent feeling empowered in their ability to help their child.  A small amount of training can go a long way!

Next month, I will be sharing how I use digital recording to support parent education and training.

Maria Del Duca, MS, 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.

Building Language and Literacy Skills During the Lazy Days of Summer

Lyndsey-Zurawski-PodcastPodcast: Episode 31
Summers mean a break from academics for most kids, but that doesn’t mean learning should stop, particularly for elementary school children who are building so much foundational knowledge. In this podcast, certified SLP Lyndsey Zurawski offers tips and advice for parents about how to stimulate children’s language skills during everyday activities over the break—helping them build literacy skills and setting the stage for long-term academic success. Read the transcript.

Autism Diagnosis and Treatment of Today and Tomorrow: Part 2

Patty-Prelock_PodcastPodcast: Episode 30 (Part 2)
Autism is a topic of significant interest to almost all parents given the spike in children diagnosed with the condition over the past decade. ASHA-certified speech-language pathologist Dr. Patricia Prelock offers an in-depth look at treatment options, and explains the new criteria for diagnosing autism. Read the transcript.

Listen to Part 1 of this podcast: Dr. Patricia Prelock discusses some of the reasons behind the increase, as well as the early signs parents should look for, and when and where parents should go for a diagnosis if they suspect autism.

Autism Diagnosis and Treatment of Today and Tomorrow: Part 1

Patty-Prelock_PodcastPodcast: Episode 30 (Part 1)
Autism is a topic of significant interest to almost all parents given the spike in children diagnosed with the condition over the past decade. ASHA-certified SLP Dr. Patricia Prelock discusses some of the reasons behind the increase, as well as the early signs parents should look for, and when and where parents should go for a diagnosis if they suspect autism. Read the transcript.

Listen to Part 2 of this podcast: Dr. Patricia Prelock offers an in-depth look at treatment options, and explains the new criteria for diagnosing autism.

Early Speech and Language Development of Children

Elizabeth-Crais_PodcastPodcast: Episode 27
How can you tell the difference between a child who may have a speech or language disorder and a “late bloomer?” What are the benefits of early intervention? SLP and ASHA Fellow Elizabeth Crais answers these and other key questions as part of ASHA’s “Identify the Signs” campaign. Read the transcript.

What Every Beginning SLP Wants to Know

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Your course work is over.  Your campus supervision went well but now you are out in the “real world.”  You know about normal development.  You have read up on various language and speech disorders but now what?

During my more than four decades of work, I have found that the answers to the questions I get asked are not in textbooks. They are in the trenches of experience. Clinicians do not want to know when children eliminate fronting or when irregular past tense develops; they can look up things like that.  They want to know about the nitty-gritty of conducting a session.

Today an extern was asking a child to say, “I want the bus,” and he would not respond.  I stopped her and asked her what it was she wanted him to do.  She looked perplexed because this sounded like an odd question when it was so obvious that she wanted him to repeat the sentence.   Noticing her look, I then asked her what she was trying to “accomplish.”   She said she wanted the child to request.  Well,  if the child could repeat her sentence, he obviously had the structure, “I want the train,” and if he was whining, reaching for the train and saying “train,” then he had mastered requesting. So what was it that she really wanted him to do? What was it that she thought he couldn’t do?

When questioned about the child’s skills, the extern said that the child could say, “I want….” in various contexts and that he could label “train,” so she wanted him to use the structure of “I want the train” to get the train. What she was trying to accomplish, without knowing it, was having the child use the skills he already had. She was not teaching him to request. She wanted him to “use his words.”

Carryover is an integral part of therapy, but you cannot force a child to speak or to “use his words.”  This is a battle you will not win.  You can continue to ask him to repeat, withholding the toy until he says what you asked him to say.  But what purpose does that serve other than frustrating everyone?

To aid compliance, we set up a scenario in which there were two different toys in close proximity—so close that the child’s pointing did not make clear which toy he wanted.  Taking the toy he wanted was acceptable, but the extern continued to ask, “What do you want?” even when the child just took the toy.  As he took the toy, the extern would say, “Oh, you want the train.”  The extern then requested a toy she wanted by saying, “I want the ….” and taking it from her pile of toys.  She continued to arrange toys in such a way that pointing did not help the child get what he wanted, and when he whined, she ignored it. She just requested the toy she wanted and took it.

The extern set up play situations where she was able to ask, “What do you need now?” The child began to say the name of the toy he wanted.  With continued modeling, he said a reasonable approximation of, “I want the train” by the end of the session.  Exuberant praise and the acquisition of the toy were very reinforcing, and the child used the “I want” approximation a few more times during the session.  It did not become a “talk or else” situation. It was a situation where speaking made it easier for the child to get what he wanted.  The intervention was given context and the end product was the child’s obtaining what he wanted by requesting it.

The main point here is to know what you are doing, what you are trying to accomplish, and what is that you are doing that is at cross purposes to what you actually want.  And to not make speaking a challenge for the child or a condition for playing, but to demonstrate that speaking facilitates communication.

I was a beginning SLP once, know the frustrations, and want to help. If you have other not-in-the-textbook questions you’d like answered,  pose them below in the comment spaces so that I might address them in future blog posts.

Irene Gilbert Torres, MS, CCC-SLP, chair of ASHA’s Multicultural Issues Board, is a clinician in New York City. She concentrates primarily on infant and preschool evaluations and supervision of graduate students. She is an affiliate of ASHA Special Interest Groups 11, Administration and Supervision; 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations; 16, School-Based Issues; and 17, Global Issues in Communication Sciences and Related Disorders.

Never Having to Say ‘I’m Sorry’

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“I’m sorry to tell you that Sara has a permanent hearing loss.” One of the less glamorous aspects of being an audiologist is telling a parent that his or her child has a hearing loss. Although this is difficult news to deliver, how you convey that information can potentially have as much of an impact as the hearing loss itself.

Instead of apologizing for delivering this news, another way to frame the conversation is to say, “I know this may come as a surprise to you, but…” Although semantically similar to the apologetic statement, qualitative and anecdotal research has shown that parents will remember verbatim how the news was delivered to them.  As Dr. Jeffrey Lewis, a professor of mental health counseling at Gallaudet University who also teaches counseling skills to audiology students, comments, “This kind of subliminal language, though not intentional, can have real consequences for how the family approaches this news and can set lower or even negative expectations for the abilities of the child”.

Another example of negative messaging is using the word “fail” with regard to newborn hearing screenings.  Not only does “fail” suggest a hearing loss that very well may not be present; it can also make parents defensive. As one parent commented, “How could my daughter fail a test that she didn’t know she was taking?” Many institutions, including Boston Children’s Hospital and Gallaudet University, have incorporated this language into their clinical practice.

Knowing your audience is also important. For example, some deaf parents may be excited and happy to learn that their child has a severe to profound hearing loss. As one deaf parent explained, “With my first child, my husband delivered the results of the newborn hearing screening. He came into my room saying, ‘Alright she did it! Our baby passed the test; she’s deaf!’  When this occurred with our second child however, we were both surprised to learn that he passed in the sense that he was hearing and not deaf like us.”

Other deaf parents may be disappointed or have mixed feelings about this news. Most deaf babies are born to hearing parents who are in complete shock when they learn of the results.  By framing the news in a neutral manner, you are putting yourself in a position to support the parent and answer any questions they may have.

Although we are certainly not denying the shock and grief that most parents experience when facing a diagnosis of hearing loss, the less negative we can make the message, the better. Suhana Alam, a deaf adult recently selected to speak on a panel of successful deaf college students at the Annual Early Hearing Detection & Intervention Meeting in April commented, “The provider…needs to make sure the parents understand that their child’s brain works just fine; he or she just has limited hearing capability.”

As audiologists, we can then work with the family in providing information on the full range of communication options available to them.

Regardless of whether we are seasoned audiologists with years of experience or new audiologists beginning our professional careers, we are constantly adapting to change in audiology and critical evaluation of our language and word choice are easy adjustments that we can make for our patients and family members.
Cynthia Frey wrote this article with Whitney Kidd. Both are graduate clinicians in the Deaf and Hard of Hearing Infants, Toddlers, and Families: Collaboration and Leadership Program at Gallaudet University.