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.

Thirty Million Words

Jan 30

Spreading the Words: the Thirty Million Words® Initiative

It’s no secret to speech/language and hearing professionals that children’s early language environments are critical to their speech, language, and academic outcomes.  Yet millions of children fail to receive the input they need to be ready for school when they start, and they fall only farther behind as school continues.

But it doesn’t have to be that way.  Parents, caregivers, speech/language and hearing professionals, teachers, and community members can join in what we at Thirty Million Words® call ‘Spreading the Words.’  By ‘Spreading the Words’ about the power of parents talking to their children to grow their children’s brains, we can ensure every child is ready to learn when they start school.

The Thirty Million Words® Initiative is an evidence-based parent-directed program designed to encourage parents to harness the power of their words to enrich their young children’s language environments, build their brains, and shape their futures.  The Thirty Million Words® and Project ASPIRE (created specifically for children with hearing loss) curricula utilize animation and real parent-child video to teach parents about early brain and language development, along with strategies to encourage and support development.

Watch how your words build your child’s brain

The curricula are supported with LENA® technology, which works as a ‘word pedometer’ to count how much parents are talking with their children and getting their children talking with them.  This feedback from the LENA® helps parents track their progress as they advance through the Project ASPIRE and Thirty Million Words® programs.

The Thirty Million Words® and Project ASPIRE curricula offer parents strategies to enrich their interactions with their children without adding more to their already busy and often overstretched lives.  When parents are equipped with three key tools – the 3Ts – a world of rich language engagement is unlocked.

Tune In: Pay attention to what your child is focused on or communicating to you and change your words to match.  The signals your child gives will change rapidly since her attention span is short while she’s young – staying Tuned In is a dynamic activity!

Talk More: Think of your child’s brain like a piggy bank – every word you say is another penny you invest.  There’s no limit to how many words you can invest to fill your child’s bank and build his brain!  Be as descriptive as possible to build your child’s vocabulary.

Take Turns: Your child is never too young to have a conversation with you!  Respond to your child’s signals to keep the turns going.

Parent talk is the most powerful tool for building children’s brains and sending them to school ready to learn.  With a community of professionals, caregivers, and parents ‘Spreading the Words’ about the power of parent talk, every child can get on track for school.

Hear from Shurand, a Thirty Million Words® graduate.

Learn more about the Thirty Million Words® Initiative at tmw.org.

 

Kristin R. Leffel, BS, is the Director of Policy and Community Partnerships for the Thirty Million Words® Initiative at the University of Chicago.  Her primary focus is curriculum development of Thirty Million Words® and Project ASPIRE, program design and implementation, and evaluation.  Her academic interests focus on health disparities, particularly the social determinants of health and the health of socially disenfranchised populations. 

 

Dana L. Suskind, MD, is a Professor of Surgery and Pediatrics at the University of Chicago Medicine, Director of the Pediatric Cochlear Implantation Program, and Founder and Director of the Thirty Million Words® Initiative. Her research is dedicated to addressing health disparities, specifically early language disparities, through the development of novel intervention programs. She has conceptualized and initiated development and evaluation of two parent-direct, home-visiting interventions: Project ASPIRE and the Thirty Million Words®. These interventions, for parents of children with hearing loss and parents of typically developing children respectively, aim to improve child outcomes through parents’ enrichment of the early language environment.

 

 

 

NIMTR: Not In My Treatment Room!

poison

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

Some interesting facts about toys.

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

So many toys … but are they safe?

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

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

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

What if it is not a toy?

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

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

What is an SLP to do?

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

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

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

 

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

Coaching Parents to Foster Their Child’s Expressive Language Skills

asianmomapple

I recently had the opportunity to provide tele-speech-language services to a toddler with autism spectrum disorder. I knew it would be difficult to have him sit in front of a computer for long periods, so I decided that I would employ a “parent coaching” approach, empowering his parents to more effectively help their son.

I started by having the parents videotape their daily interactions with him, which revealed that they were aware of their son’s difficulties and in-tune with his communication needs. However, even though this little boy appeared quite bright, it was difficult to distinguish when he was answering a question from what he had learned, or if it was a rote response. The parents had specific goals they wanted their son to achieve, so how was I going to help them?

I provided the boy’s parents with information about expressive language development and explained that their expectations appeared to be beyond this child’s current capabilities (determined by the boy’s age, as well as his disability). Next I took the language and vocabulary skills the parents wanted their son to learn—such as labeling an apple—and broke them out into smaller steps. These are the types of activities I suggest parents use to help a child grasp a language concept:

  • Present the child with several apples, preferably of different colors.
  • Talk about the outside of the apples: color, shape, size, smell, taste and texture.
  • Cut open the apples (“What do you see?”) , and eat some of each, talking about how it sounds and tastes as you bite into each piece.
  • Cut an apple in half horizontally and use washable tempera paints to make apple prints on paper using the different colors apples can be.
  • Find a simple recipe to make applesauce or another food from apples.
  • Eat apple slices with peanut butter and talk about how it tastes, and about the messiness and stickiness.
  • Make a pretend apple out of PlayDoh.
  • Compare the “fake” apple with the real one, explaining that you can eat a “real” apple but not the “pretend.” This models analytical thinking.
  • Bring in another fruit, such as an orange, and do the same steps.
  • Try making and drinking homemade orange juice.
  • Compare an apple to an orange.
  • Show video clips of people picking apples and oranges, showing how both grow on a tree.
  • Add bananas, doing the first seven steps (tastes great with peanut butter).
  • Roll the items across the floor and talk about how they roll. Compare.
  • Use this method to teach about common fruits you either purchase or see in the market.

Of course, just relating these steps to parents isn’t enough, because they have a tendency to take over for their child if they see the child struggling. For example, it’s tempting for them to place the child’s hands on the paper to make the apple prints, which removes the child from the process and leads to a loss of interest. To help parents avoid this, I explain that learning involves making mistakes. Other suggestions I provide include:

  • When speaking to your child, keep your sentences simple and to the point (approximately three to four words per utterance: “Are you hungry?” versus “Are you ready to go have some sandwiches for lunch?” Expanding utterances will come along a bit later!
  • Speak slowly because it may take the child additional time to process the information.
  • Do not require the child to look you in the eye when you are speaking to him. A glance at your face, especially at this age, should suffice. Toddlers are busy-bodies and need to keep moving and exploring.
  • If you ask a child a comprehension question, he or she may provide a quick or rote answer to be able to do what he wants to do.
  • Allow time to just play with your child. Let the child direct the play. Have a few toys out to choose from and follow his or her lead.
  • Make simple remarks about what is going on, but avoid asking questions to probe for an answer: “What color is your truck? How about that car? What is this part of the car called?” This is play time, not teaching time.
  • Model out loud how to think about items: “You have a big, blue truck! Wow! Mine is small. I have a small, yellow truck. “
  • Model out loud how to problem-solve (over-and-over-and-over again): “Oops! The wheel came off my truck. Hmmm. How can I fix it? {looking over the whole truck while thinking….} If I get something to help the wheel stay on, I should be able to fix it. If I use glue, the wheel may not spin.”
  • Allow some “quiet” play time as well and let your child do the talking (or not if he so chooses). This is a great opportunity to just sit and listen to what your child is saying (to you and/or the toys).

I have parents send me some YouTube video of them performing some of these activities with their child. In subsequent sessions, we discuss what works well (and not so well) with the child, and I share more activity ideas and literature with them.

Tracy Sippl, MS, CCC-SLP, is a Seymour, Wisc.-based speech-language pathologist and tele-therapist with Cumberland Therapy Services. She is an affiliate of ASHA Special Interest Group 18, Telepractice. This post was adapted from a post on the Cumberland Therapy blog,  Right Therapy–Right Results–Right Now.

How to Use The Language of Baking

1031

Do you want to spice up your therapy sessions? Try this no fail recipe for pumpkin brownies. They are moist, full of chocolate flavor and absolutely delicious. You will not miss the additional oil or eggs in this recipe. There are only two ingredients, which make it easy to make and fit into a therapy session.  Whenever I bake during a therapy session, I try to focus on very simple recipes so that more time could be spent on speech and language goals. When you try to create a recipe that is too complicated, you can get lost in the activity and lose sight of your speech and language goals.

From my perspective, language and baking naturally occur together. Children really enjoy baking because it can be a stimulating sensory activity as well as language rich activity. When baking in a group, pragmatic language goals can be easily targeted (topic maintenance, turn taking, appropriate topics, etc).

The ingredients in this recipe do not need to be refrigerated and are easily found at any supermarket. They are also very affordable and yield about a dozen brownies! With no added fat, they are much healthier than the normal brownie. Also, the brownies do not contain any additional eggs or oil.

Ingredients:

1 can of pureed pumpkin (15 oz can of pureed pumpkin, not pie filling)

1 box of brownie mix (I used chocolate fudge brownies, 19.5 box)

Sprinkles or topping of your choice

Directions:

  1. Preheat oven to 375 degrees.
  2. Wash hands.
  3. Grease 8 X 8 inch square pan.
  4. Open brownie box and pumpkin can.
  5. Combine pumpkin and brownie mix in a bowl.
  6. Stir until smooth.
  7. Pour batter into greased pan.
  8. Sprinkle batter with topping of your choice (I used 3-4 tablespoons of sprinkles).
  9. Bake at 350 degrees for about 30-35 minutes or until done (till toothpick comes out clean).

10. Cut and let cool.

11. Eat and enjoy!

pumpkin brownies

Ten  speech and language goals that can targeted during baking time:

 

  1. Sequencing. Work on “first, then” and have the child retell the steps to the recipe in the correct order.
  2. Following Directions. Work on one- to two-step directions (e.g. “open the box and pour in the brownie mix”).
  3. Asking For Help: Create situations that a child needs to ask for help such as opening the box of brownies or opening the can of pumpkin.
  4. Expanding vocabulary. You can expand the child’s vocabulary by focusing on new vocabulary such as cooking utensils, ingredients, appliances, etc.
  5. Turn taking. This recipe is excellent to do in a group. Each child can take a turn pouring the ingredients into the bowl, stirring the mixture together and pouring it into the pan. Use a turn card when baking so that each child knows when it’s their turn.
  6. Describing. Have your client describe the ingredients focusing on what they look, smell and feel like. Have the child taste the pumpkin and describe the flavors. Discuss the colors of the ingredients and toppings (if you are using). Does the pumpkin look smooth? What does the brownie mix feel like? What does it smell like?
  7. Actions: Focus on actions such as, “wash,” “open,” “pour,” “combine,” “stir,” “bake,” “cut,” “sprinkle,” “eat,” etc.
  8. Choice making: Baking time is an excellent opportunity to improve choice making such as choosing what step they would like to do, what topping they want, etc. Although the recipe seems very simple, there are a lot of opportunities for making choices.
  9. Recalling information/narratives: Ask the child questions such as “What did we do first?” etc. Ask the child to tell you a story about “making pumpkin brownies.” When you are baking, take some photos with your phone or camera (if you have written permission) and use the photos to recall information and create a narrative. There are many wonderful apps out there that are ideal for creating stories with photographs. Don’t have an electronic device? Have the child draw a story about the pumpkin brownie activity.
  10. Pragmatic language goals: When baking together, pragmatic goals can be worked on. Discuss appropriate and inappropriate language and behavior when baking. If you are baking in a small group, help facilitate conversation between peers and encourage maintaining appropriate topics of discussion.

If your client is nonverbal or minimally verbal, create a communication board so they can communicate during the activity.

Carryover Books: Try reading some of these books after making the brownies together. These books can help carryover the concept of pumpkins and baking.

How Many Seeds in a Pumpkin? By Margaret McNamara

Seed, Sprout, Pumpkin Pie by Jill Esbaum

Betty Bunny Loves Chocolate Cake by Michael Kaplan

It’s Pumpkin Day, Mouse! By Laura Numeroff and Felicia Bond

Carryover Activities: Bring in a small pumpkin and decorate it during a therapy session. Each child can take home a small pumpkin that they decorated themselves.

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

 

Why Suspected Childhood Apraxia of Speech Requires Careful Assessment

toddlerpointing
Recently I got one of those phone calls that speech-language pathologists often dread. It went something like this:

Parent: Hi. I am looking for a speech therapist who uses PROMPT [Prompts for Restructuring Oral Muscular Phonetic Targets] to treat my son’s childhood apraxia of speech. Are you PROMPT-certified?

Me: I am PROMPT-trained and I do treat motor speech disorders but perhaps you can first tell me a little bit about your child? What is his age? What type of speech difficulties does he have? Who diagnosed him and recommended the treatment?

Parent: He is turning 3. He was diagnosed by a neurodevelopmental pediatrician a few weeks ago. She recommended speech therapy four times a week for 30 minutes, using PROMPT.

Me: And what did the speech therapy evaluation reveal?

Parent: We did not do a speech therapy evaluation yet.

Sadly, I get these types of phone calls at least once a month. Frantic parents of toddlers ages 18 months to 3+ years call to inquire about PROMPT therapy based on a neurodevelopmental pediatrician’s diagnosis. The speech-language diagnosis, method of treatment and treatment were typically specified by the physician in the absence of a comprehensive speech language evaluation and/or past speech-language therapy treatments.

The conversation that follows is often uncomfortable. I listen to the parent’s description of the symptoms and explain that the child needs a comprehensive speech language assessment by a certified SLP before being treated. I explain to the parent that, depending on the child’s age and the findings, the assessment may or may not substantiate CAS because symptoms are similar in a number of other speech and communication disorders.

Parents react in a number of ways. Some hurriedly thank me for my time and resoundingly hang up. Some stay on the line and ask me detailed questions. Some request an evaluation and become clients. A number of them find that their child never had CAS! Past misdiagnoses have ranged from autism spectrum disorder (CAS was suspected because of imprecise speech and excessive jargon) to severe phonological disorder to dysarthria secondary to cerebral palsy.

CAS is a disorder that disrupts speech motor control and creates difficulty with volitional, intelligible speech production. Research indicates that while children with CAS have difficulty forming words and sentences at the speech level, they also struggle with areas of receptive and expressive language. In other words, “pure” apraxia of speech is rare.

This condition needs to be diagnosed by an SLP. In fact, due to the disorder’s complexity, it is strongly recommended that parents seek an assessment by an SLP specializing in assessment and treatment of motor speech disorders. Here’s why.

  • CAS has a number of overlapping symptoms with other speech sound disorders, such as severe phonological disorder and dysarthria.
  • Symptoms that may initially appear as CAS may change during the course of intervention, which is why diagnosing toddlers under 3 years of age is problematic. Instead, a “suspected” or “working” diagnosis is recommended in order to avoid misdiagnosis.
  • Diagnosis of CAS is nuanced, complex and challenging, though a new instrument—Dynamic Evaluation of Motor Speech Skill (DEMSS)—shows promise with respect to differential diagnosis of severe speech impairments in children.

When children with less severe impairments, SLPs need to determine where the breakdown is taking place by designing tasks assessing:

  • Automatic versus volitional control.
  • Simple versus complex speech productions.
  • Consistency of productions on repetitions of same word.
  • Vowel productions.
  • Imitation abilities.
  • Prosody.
  • Phonetic inventory before and after intervention.
  • Types and levels of cuing required for response.

Given the complexity of CAS assessment and treatment described here, you can see that the PROMPT approach may not even be applicable to some children. Thus, I strongly urge developmental clinicians to first refer a child for a speech language assessment—and refrain from making recommendations for specific types and frequencies of treatment—when difficulty with speech production is observed.

For more information on childhood apraxia of speech, please visit the Childhood Apraxia of Speech Association of North America website or visit the ASHA website to find a professional specializing in the diagnosis and treatment of CAS near you.

 

Tatyana Elleseff, MA, CCC-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. This post is adapted from a post that originally appeared on her blog, Smart Speech Therapy LLC. She specializes in working with multicultural, internationally and domestically adopted children and at-risk children with complex communication disorders. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education, 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, and 16, School-Based Issues.

A Lesson Learned From a Preemie

Kaitlyn then and now

This week, my daughter, Kaitlyn, will graduate from high school. As I look at this vibrant 18 year-old young woman, I find myself thinking back to her birth. She was born at just 26 weeks gestation, weighing only 1 lb., 12 oz. A few days later, her weight dropped to 1 lb., 6 oz. The neonatologists were cautious; they spoke in hushed tones and could only muster a guarded prognosis. We didn’t know if she would survive.

Just before delivery, while my wife, Maria, was in preterm labor, we had a parade of physicians and residents who visited her hospital room to check her status. The hospital was affiliated with a medical school, so we became accustomed to a regular flow of medical students who were more than a bit curious about the possibility of delivering an infant so early. Each time two of them came into the hospital room to check on my wife (they seemed to travel in pairs), they would do a quick exam and then reach into their coat pockets to get the “card.” This seemingly magical card contained a set of statistics that detailed the survival rates of infants born at various birth weights and gestational ages. Each physician would then proceed to recite these statistics, which sounded something like this:

“Mrs. Houston, you’re at 26 weeks gestation, and according to our research, infants delivered at this gestational age have a 20% chance of survival. If you deliver at 27 weeks gestation, the survival rate improves slightly to 26.8%. Of course, if you deliver later, the percentage of children who survive continues to increase.”

Like clockwork, each physician and/or medical student would reach for his or her card after every visit to the room. The story was basically the same except for a few additional potential “complications” for a child born at each gestational age – such as blindness, deafness, cerebral palsy, brain bleeds, and a variety of other medical conditions. After witnessing a few of these episodes, my wife and I could recite the statistics from memory!

At the time, repeatedly hearing what could happen to our daughter was difficult to absorb. The information could have been delivered in a more patient-friendly – and parent-friendly – manner. The statistics that were shared were grim, but knowing what could happen helped us to prepare. Those two days in the hospital trying to prevent and then waiting for Kaitlyn’s delivery allowed us to understand the worst possible scenario but, at the same time, hope and pray for the best outcome.

As I reflect on that experience, the statistics that the physicians cited were quite impressive. In fact, I’m a bit envious that we can’t say something similar for children born with hearing loss, which is the population that I work with most frequently. That is, I wish we had the ability to confidently state that: “…an infant identified at birth with a severe to profound bilateral sensorineural hearing loss and fitted with XYZ hearing aids and immediately enrolled in early intervention will have a 96% success rate in developing intelligible spoken language by the time s/he is five years old” or “an infant who fails to develop adequate listening, speech and language outcomes with hearing aids and then gets cochlear implants by one year of age will achieve age-appropriate developmental outcomes within 18 months if the parents are fully engaged in the intervention process and when services are delivered by a qualified provider.”
To accomplish something like this would require enormous resources and standard protocols for professionals across many disciplines, including but not limited to: Pediatric Medicine, Audiology, Speech-Language Pathology, Deaf Education, Special Education, and Early Childhood Education.

The myriad factors one would have to control to obtain similar outcome data for children with hearing loss truly boggles the mind. Some of those factors would include: cause of hearing loss, degree of hearing loss, age of diagnosis, type of hearing technology used, communication approach, type and frequency of early intervention, level of parent engagement in the intervention process, the skills of the service provider, the family’s socio-economic status, and additional medical conditions or disabilities beyond deafness –and that would be just to capture the most basic information.

Parents today who have a child with hearing loss deal with too many challenges to ensure their child is successful. Too often, they face obstacles securing appropriate audiological services and early intervention that supports their preferred mode of communication. Furthermore, the variability in services from community to community is alarming, and if the family lives in a rural area, there’s an even greater chance the child will be grossly underserved or not receive services at all.

Kaitlyn, my 1 lb., 12 oz. baby girl, is leaving high school and will be entering college this summer studying pediatric nursing. Aside from spinal surgery for scoliosis about six years ago, she is a rather typical teenager making the transition into adulthood. We owe her success to treatment and intervention that was well-defined, consistent, and delivered by practitioners who were highly-trained. Someday, I hope all parents who find themselves dealing with a premature infant or some other medical condition at birth – such as hearing loss – can receive the same level of support from the professionals surrounding them.

(Note: This blog was adapted from an original posting by the author on the Better Hearing Institute’s Pediatrics Blog.)

 

K. Todd Houston, Ph.D., CCC-SLP, LSLS Cert. AVT, is an Associate Professor in the School of Speech-Language Pathology and Audiology at The University of Akron. His primary areas of research include spoken language acquisition in children with hearing loss, strategies for enhancing parent engagement in the intervention process, Auditory-Verbal Therapy, and telepractice. He directs the Telepractice and eLearning Laboratory (TeLL), an initiative to evaluate clinical practices in the area of distance service delivery in Speech-Language Pathology.

Early Intervention: How Questions Can Guide Your Practice

Question mark made of puzzle pieces

Photo by Horia Varlan

In my article “A Therapist’s Mantras for Early Intervention” on Pediastaff’s Blog, I mention the importance of asking questions in early intervention. We all ask a series of questions when we are completing an evaluation, then during treatment we often ask families how things are going to check in on a child’s progress, but there are so many more questions to ask that can help build a healthy parent-therapist relationship. These questions get to the heart of what’s going on and can truly impact the success of intervention.

By asking the right questions you can get to know a family for who they really are and allow them to see your genuine interest in their opinions and their child’s success. With appropriate questioning you can also establish communication with even the most shutdown of families, repair misunderstandings, and most importantly, encourage families to own the early intervention process as their own.

The following are the categories and sequence of questions I have found to be most useful in my own practice, to first build a foundation of trust and then allow for open and honest conversations as the therapeutic relationship grows. The first few categories may seem obvious, but if you stick with me, hopefully by the end you will have found an idea that you hadn’t thought of or tried before. Here goes…

1.  Ask questions that establish roles.

When first working with a family, it’s important to find out what ideas they have about how the intervention will work, what you will do when you come for a visit, and what their part as parents will be. I like to ask questions like these:

  • How would you like my help?
  • What do you hope to get out of working with me?
  • How would you like to take part in your child’s therapy?

The answers to these questions then provide an opportunity for you to discuss things like the importance of attendance, how your sessions will be set up to include them as the parents, and what therapy is and isn’t.

2. Ask questions that set goals.

The next category of questions gets more specific about what a family wants to see their child accomplish. You may have discussed some of this when completing the evaluation or other paperwork with the family, but due to time that has likely lapsed and changes that can happen quickly in a child’s development, it’s important at the beginning of therapy to re-establish those goals. I also like to focus parents very specifically on one thing we can start with that their child can likely accomplish right away so that parents are motivated to continue to work hard and set new goals. Questions to help set goals may sound like this:

  • What time of the day is particularly difficult for your child?
  • When do you get frustrated with your child’s difficulty communicating?
  • What’s one thing you think your child could do with a little help that would make a huge difference in his life?

Keep in mind that answers to the last question may still be broad behaviors like, “pay attention”, “talk more”, “listen better”, or “have better behavior”. It helps to take those answers and explain how a specific behavior, like taking a turn during an interaction, attending to an activity, pointing to make a request, imitating gross motor movements, or looking at an adult to ask for help can be the first steps to helping their child get to the overall goal. Once parents know what specific behavior they are looking for, they know when their child’s accomplished it, and they can see progress happening. Establishing those successes early on goes a long way in earning a parent’s trust for the long-term.

3. Questions that build routines.

Questions that build routines help parents figure out how they are going to implement these new behaviors and strategies you have introduced. Without a plan, a set day, time of day, activity, and specific behavior, it is unlikely that a parent will follow-through on your interventions for the simple fact that change is hard. With a specific plan, established by the family itself, it makes it much more possible to integrate these new behaviors into daily life. Examples of these questions include:

  • What times of the day do you think would be good to help your child practice taking turns?
  • Out of the toys here in this room, what toy do you think you’d like to use this week to help your child practice pointing?
  • What kind of activity would you enjoy doing with your child where he can imitate your movements?
  • Can you think of several times during the day you can make sure your child hears you saying the word “up”?

4. Questions that gather feedback.

This one is easy. To gather feedback you can simply ask, “How’d it go?”

5. Questions that spark action.

The questions that spark action are where the real relationship building happens. This is where you can encourage parents in their successes and help them to solve problems and overcome obstacles. It’s easy enough to guide parents through what therapy is all about, help them set goals, plan activities and then drop the ball. And, yes, just asking, “So, how’d it go?” with no follow-up questions still counts as dropping the ball. We’ve all done it because we’re frustrated that a parent didn’t follow through and we can’t seem to politely muster another question, or we can sense the parent is shutdown and we don’t want to push too hard. BUT the question after the “How’d it go?” is where you get the 411. Those questions are tricky, take special care, and go something like this:

  • So _________ pointed to what he wanted when you were working with him on the puzzle. Wow! How did that feel when he did that for the first time?
  • I know you said you didn’t have a chance to work on the word “up” this past week. Do you think you’ll have a chance this week or would it be easier to work on something different?
  • I know we had a difficult conversation last week after you got the diagnosis from your doctor. How are you feeling about all of that now?
  • I know _______ didn’t want to imitate your movements when you sang “Old McDonald”. What do you think made it difficult for him to participate?
  • Since _______ didn’t want to take a turn with stacking the blocks, would you like to practice it together today so that we can see if we can find a way to make it easier for him to participate?

Depending on the answers to these last questions, you may also need to go back to the previous questions to make sure you and the family are still on the same page as far as setting goals and building routines.

To sum it up…

And now I would love to hear what you think. What questions have you found to be helpful? How do you feel asking the tough questions? Other than asking questions, how do you keep the lines of communication open?

 

 

Kim Rowe, MA, CCC-SLP, is a speech-language pathologist working in early intervention in Savannah, GA. She is Hanen certified and passionate about family-centered services. When she’s not working, Kim enjoys writing at Little Stories, spending time with her husband, volunteering with her therapy dog Charlie, and listening to her daughter’s story unfold as she develops language.

The Rest of The Story: The Changing Face of Early Intervention

About one year ago now, I started hearing some new buzz words swirling around the Early Intervention Program in my home state of Wisconsin–words like evidence-based practices and coaching, natural learning environments and primary provider. As a pediatric speech-language pathologist, I was a bit intrigued. Mostly though, I was rather annoyed and quite a bit skeptical. After all, I had been trained to look analytically at a child’s speech or language, come up with a plan to fix it, and implement that plan systematically and objectively. Suddenly, it seemed, I was being asked to take a step way back. To work through parents rather than through the child, and to train parents to be speech therapists. And I found it absurd to expect parents to learn in a few short months what I had learned in six years of higher education.

Because I’m the curious type, though, I started asking lots of questions and doing lots of research. I’ll be honest and say that my primary motivation was to prove that this approach was wrong. I dug through the research on speech and language outcomes for early intervention, looking for the “evidence” that was being touted about so loudly. I found research to support the clinician-directed ABA intervention and language facilitation in play with which I was very familiar and some research to show that parent-led intervention could improve child language and phonology as well. Yet I found not one large, well-controlled study that proved beyond a shadow of a doubt that this “new” approach—the one that called for coaching parents to responsively engage their children in the context of natural learning opportunities–was any better than what we were already doing.

A funny thing happened along the way, though. The more I read, the more I began to realize something else. In focusing so narrowly on speech sounds, vocabulary development, and two-word phrases, I was omitting a huge body of research about child development. I started to see that so much of what was being asked of us as early intervention professionals had less to do with speech and language outcomes per se, and more to do with infant and toddler mental health. I began reading research that suggested that most significant factor in a young child’s development was not the amount of time that child spent in therapy, but rather the degree to which that child’s parent was responsive and engaged. And I began to understand that my single biggest source of power as an early interventionist was not to be found in playing on the floor with the child myself, but in helping that child’s parents become more responsive and engaged with him.

This isn’t to say, of course, that I suddenly began to think that there was no value in interacting directly with a child. This is far from true. Interacting directly with children helps us to discover what does and does not work with that child and allows us to model strategies for parents. There is every place for this in our early intervention practices. But this past year, I began to understand that I needed to be much more intentional about when and how I interacted with children. I also needed to be much more careful about building up parent competence in enhancing their own child’s development, rather than giving the appearance that a child’s development was dependent on me. After all, as a weekly early intervention visitor, I was with that child less than 2% of all his waking hours. It seems so silly that I ever assumed that I was the agent of change in a young child’s life, but I did. This past year, it finally dawned on me that early intervention wasn’t about me and what I did with the child…it was about that child’s parents and what they did with him. And if I couldn’t effect change in that, I simply wasn’t doing my job.

One year later, I’ve realized that these evidence-based practices aren’t about me training parents to be speech-language therapists at all. Children under the age of three don’t need their parents to be speech therapists. They need them to be parents. I’m not being asked to give up my role. I’m being asked to take all the information I have about child development, mesh it with what I’ve learned about infant and toddler mental health, and find ways to intricately weave those practices into the fabric of that child’s relationship with his parents. I’m being asked to get into that child’s life, to know his daily routines—no matter what they are–and to work within those. I’m being asked to start where the parents are, not where the child is. It’s complicated, it’s complex, and it’s messy. And it’s my job.


Becca Jarzynski, M.S., CCC-SLP
is a pediatric speech-language pathologist in Wisconsin. Her blog, Child Talk, can be found at www.talkingkids.org and on facebook at facebook.com/ChildTalk.