Musings on the Funding of Stuttering Treatment

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Editor’s Note: This post is another viewpoint on Speech Pathology Australia’s recent proposal and does not necessarily reflect the views or position of ASHA. 

Volunteer firefighters are not presently supported by government funding; instead they rely on local fundraising and private donations. Everyone values their work, and all agree that firefighters should be compensated.

The professional association for volunteer firefighters proposes to the government that payment be provided for their services. Due to demands on legislators’ time and attention, the association selects one method for putting out fires – water – and suggests that firefighters should be compensated when they use water to put out fires.

Many firefighters ask, “What do we do when water is not the best way to fight a particular fire?” They point out that other methods for fighting fires have been shown to work just as well as water. They are told that water has more data, and they don’t want to confuse the legislators with multiple options.

Some firefighters express concern that their input was not solicited before the proposal was submitted. They further worry that their options will be limited by such legislation. The association says, “You will not be limited in what you do—only in what you get paid for.” The firefighters ask, “Will we get paid if we use another method?” The answer: “You don’t get paid for anything now, so this will definitely be better.”

The firefighters persist, “Why not seek payment for the service of putting out fires, rather than a particular method?” The association says, “When other methods have as much data as water, we can consider approaching the legislators again, telling them that the issue was not as straightforward as we first suggested. We can ask then them to consider other methods…That would be simpler.”

The firefighters collect numerous comments from specialty firefighters and support organizations in opposition to the proposal. Despite the grass-roots opposition, the proposal proceeds as originally written and is accepted. Volunteer firefighters start to receive government payment for one approach to fighting fires. Those who favor that approach are delighted. Others weren’t being paid before anyway, so nothing changes for them, at least not at first.

Soon, homeowners start to call the fire department to ask, “Does your department use water? I heard that you get paid for water. I want you to get paid, but I don’t want to pay myself. Plus, I read on a professional association’s website that water is ‘best!’” Thus, market forces drive firefighters to use water exclusively, although many know that there are other helpful approaches.

One day, a water-using firefighter finds himself working a fire against which water does not appear to help. He wonders if he should use some other approach in conjunction with—or instead of—water. Other firefighters have long used the method of changing the draft pattern in the house, but that method is not approved for payment. If he does it, his services will no longer be covered. He hesitates.

What is better for the homeowner? For the firefighter? Should he do what he knows is right for the house or what he gets paid for?

Ultimately, he decides that he should only respond to fires that can be put out with water. Other firefighters can deal with more complicated fires. It’s up to them if they don’t want to get paid?

Why has the firefighter been put in this ethical dilemma?

It all could have been avoided if only the professional association had pursued coverage for the service of fighting fires, not the specific treatment that they favored.

But that would evidently have been too complicated…

 

J. Scott Yaruss, PhD, CCC-SLP, is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. He is also associate professor and director of graduate programs in speech-language pathology at the University of Pittsburgh, coordinator of clinical research in audiology and speech-language pathology at Children’s Hospital of Pittsburgh, and director of the Stuttering Center of Western Pennsylvania. He can be reached at jsyaruss@pitt.edu.

Another View on Speech Pathology Australia’s Stuttering Treatment Proposal

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Editor’s Note: This post is a follow-up to yesterday’s post from Craig Coleman regarding a controversial proposal on stuttering treatment and reimbursement from Speech Pathology Australia. We reached out for responses from Ann Packman and Mark Onlsow, two of the originators of the Lidcombe approach to stuttering treatment—on which the SPA proposal centers. We also reached out to SPA and include a statement here from SPA President Deborah Theodoros.

Response from Ann Packman and Mark Onslow:

During the past two decades the Australian government has invested millions of dollars in research funding to develop an evidence-based treatment for early stuttering. The Lidcombe Program is a result of this funding and is now supported by strong evidence from randomized controlled trials. Those randomized trials include evidence for face-to-face treatment, for treatment using webcam, and for group treatment. The Speech Pathology Australia proposal is for our government to further invest in the health of Australian children who stutter, but in a more direct way by contributing to the cost of their treatment.

We wish to clarify that the Speech Pathology Australia proposal is not for a mandate—a directive—that Australian speech pathologists must use the Lidcombe Program to treat preschool children who stutter. Nor is it a proposal to overturn customary evidence-based reasoning and standardize how Australian preschoolers who stutter in Australia are managed. Nor is there any suggestion that the Australian government would not in the future fund any other evidence-based intervention that is supported by randomized controlled trials. Indeed, if such evidence emerges for the efficacy of another treatment for early stuttering, we would encourage Speech Pathology Australia to approach the Australian government to consider it also for taxpayer-assisted support.

 

Message from Deborah Theodoros, president, SPA:

Speech Pathology Australia is advocating for public funding (Medicare) rebates for early stuttering intervention at a level which is demonstrated to be highly efficacious and supported by the strongest level of evidence. However, SPA is not suggesting any policy or legislation which would restrict interventions to one program over another or would require a speech pathologist to use a specific treatment, intervention or service. SPA continues to strongly support the principle of practice that speech pathologists remain free, and duty-bound, to exercise their clinical decision-making in relation to the interventions they provide to clients.

 

Ann Packman, PhD, SLP, is associate professor and senior research officer for the Australian Stuttering Research Centre, The University of Sydney. She has more than 30 years’ experience in the area of stuttering as a clinician, teacher and researcher and researches nature and treatment of stuttering. Packman recently served as associate editor for fluency for the American Journal of Speech-Language Pathology and is associate editor for fluency for Language, Speech, and Hearing Services in Schools. Packman is an international affiliate of ASHA. She can be reached at ann.packman@sydney.edu.au.

Mark Onslow, PhD, SLP, is the foundation director of the Australian Stuttering Research Centre, The University of Sydney. He was a principal research fellow of the National Health and Medical Research Council of Australia. Onslow’s research interests are the epidemiology of early stuttering in preschoolers, mental health of those who stutter, measurement of stuttering, and the nature and treatment of stuttering. He is a member of the international Lidcombe Program Trainers Consortium. Onslow is an international affiliate of ASHA. He can be reached at mark.onslow@sydney.edu.au.

Deborah Theodoros, PhD, SLP, national president of Speech Pathology Australia, is also professor and head of the division of speech pathology in the University of Queensland’s School of Health and Rehabilitation Sciences. She is a founder and co-director of the multidisciplinary Telerehabilitation Research Unit in the school and past chair of the Telerehabilitation Special Interest Group of the American Telemedicine Association. She can be reached at president@speechpathologyaustralia.org.au.

 

 

A Controversial Proposal on Stuttering Treatment from Speech Pathology of Australia: What It Means and What Happens Next

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Editor’s note: This blog post was submitted by ASHA member Craig Coleman and does not necessarily reflect the views or position of ASHA. Here is the original release from Speech Pathology Australia that spurred Coleman to submit this post. It was published in the February 2015 issue of SPA’s publication Speak Out:

Speech Pathology Australia recently submitted a proposal to the Australian Government Department of Treasury for the federal budget 2015-2016. Given the difficult political and budgetary climate, and in anticipation of a government response to the recommendations made from the Senate inquiry—the budget proposal focused on a single budget initiative.

We argue that Medicare should be targeted towards health interventions that are evidence-based, effective, safe and minimise future health treatment needs. Our proposal focused on an internationally recognised intervention, developed in Australia and based on the most robust scientific evidence of effectiveness—the Lidcombe Program—to treat stuttering in young Australian children.

Tomorrow, we will run a post on this proposal from two of the originators of the Lidcombe approach, Mark Onslow and Ann Packman, along with a statement from the president of SPA, Deborah Theodoros. We encourage your comments on this issue, which you can post below this post from Coleman.

 

Recently, Speech Pathology Australia (the national speech-language pathology association of Australia) submitted a proposal to the Australian Government Department of Treasury that would require Medicare rebates be made available for children who stutter, but only if they are treated using the Lidcombe Program.

I feel this action gravely limits the scope of treatment for stuttering. Many interventions for preschool stuttering have shown to be effective. What happens when a child receives treatment with the Lidcombe program and doesn’t make progress? Does the child have other treatment options? From this proposal, it would appear that is not the case.

How are new (and perhaps more effective) treatment approaches expected to emerge when only treatment with an existing evidence-base is funded? Imagine if all infections were still treated using penicillin because it was an early treatment option. Would the government and medical associations support such a position? Perhaps a clearer question is would pharmaceutical industry lobbyists allow legislators to even remotely consider the idea? Do we think less of ourselves as a profession to allow this to happen?

This proposal also highlights a concerning trend of what constitutes “evidence.” While certain treatments might have more data than others it doesn’t always mean that treatment is more effective. Evidence-based practice includes current scientific evidence, clinician experience and client /family values. What if the clinician is not properly trained in the treatment approach? What if the personality of the client, family or clinician is not a good fit for one particular approach? Surely, the best “evidence” comes not from group data, but the individualized outcome of each client we serve. While group data certainly present scientific evidence, individual outcomes present actual evidence-based practice. That type of data takes into account all aspects of the evidence-based practice triangle.

After this precedent has been established, we would be naïve to think this could not happen with other disorders in all parts of the world. This is not an issue for the stuttering community of Australia to deal with. It is an issue for the speech-language-hearing community of the world to deal with.

So, where do we go from here? Here is a potential plan I would like to suggest:

  1. Advocate for reimbursement for stuttering. The state of reimbursement for stuttering treatment in the United States can best be described as dire. One of our missions as SLPs should be to work with insurance providers and demand that they pay for stuttering treatment. Somewhere along the way, we have allowed insurance companies to dictate that stuttering treatment should not be reimbursed. We must reverse that trend.
  2. Create a consortium of professionals. This would allow a database of treatment outcomes to be collected from clinicians in the field. Not only would this help with reimbursement, but it would also allow publication of data collected from individualized treatment approaches. We are professionals, not technicians. Our clients deserve better than “follow-the-manual” based programs and protocols.
  3. We need to educate our professionals and the public about stuttering. Stuttering is not merely a disruption in the flow of speech. It is much more than that.

As concerning as this proposal is, it can be a positive if we choose to act with reason, courage and passion.

In order to provide both sides of the discussion, I am including a recent statement from Speech Pathology Australia. While this statement seeks to clarify that this is not an endorsement of one approach, advocating for reimbursement for only one approach certainly seems to send the opposite message. Many insurance companies will not pay for stuttering treatment here in the United States. But responding to that by supporting a policy that would cover only one approach would be very dangerous and erroneous.

It is also important to understand that once Medicare programs establish a policy, private payers soon follow suit. It’s very naive to believe this policy won’t have major negative ramifications in the long run. While it may benefit some children in the short term, there is no doubt in my mind it will not benefit people who stutter or our profession in the long term.

You can read Coleman’s original blog post in full here.

 

Craig E. Coleman, MA, CCC-SLP, is an assistant professor at Marshall University and a board-certified specialist in fluency disorders. Coleman is also an adjunct instructor at Indiana University of Pennsylvania and co-director of the Stuttering U. summer program for children who stutter, their families and SLPs. He is coordinator of ASHA Special Interest Group 4, Fluency and Fluency Disorders. He can be reached at craig.coleman@marshall.edu

Just Flip the Lip! The Upper Lip-tie and Feeding Challenges

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While many pediatric professionals are familiar with a tongue-tie, the illusive lip-tie hides in plain sight beneath the upper lip. Because I focus on feeding difficulties in children and an upper lip-tie can be a contributing factor if a child has trouble feeding, then I probably encounter more lip-ties than some of my colleagues. Still, I’d like to encourage my fellow SLPs to just flip the lip of every single kiddo whenever assessing the oral cavity. And document what you observe. Help increase general knowledge among professionals on different types of upper lip-ties by raising awareness of how they may impact the developmental process of feeding.

Upper lip-ties refer to the band of tissue or “frenum” that attaches the upper lip to the maxillary gingival tissue (upper gums) at midline. Although most babies should have a frenum that attaches to some degree to the maxillary arch, the degree of restriction varies. So it’s important to flip the lip of every child we evaluate in order to gain a better understanding of the spectrum of restriction – especially if you are an SLP who treats pediatric feeding.

During the feeding evaluation process, consider four things: 1) The mobility of the upper lip for breast, bottle, spoon and finger feeding; 2) How well it functions in the process of latching and maintaining the latch; 3) If the lip provides the necessary stability for efficient and effective suck-swallow-breath coordination; and 4) If the lip is an effective tool for cleaning a spoon, manipulating foods in the mouth and contributing to a mature swallow pattern.

Dentist Lawrence A. Kotlow has created an upper lip-tie classification system to better identify, describe and consider the need for treatment. The tie is classified according to where the frenum connects the lip to the gums, known as “insertion points.” Envision a child with a very big “gummy” smile and the upper gum line exposed. Divide the gums into three zones, as described in this article by Kotlow:

“The soft tissue covering the maxillary bone is divided into 3 zones. The tissue just under the nasal area (zone 1) is called the free gingival area; this tissue is movable. Zone 2 tissue is attached to the bone and has little freedom of movement… Zone 3 extends into the area between the teeth and is known as the interdental papilla. This is where the erupting central incisors will position themselves at around 6 months of age.”

Now, consider the insertion points. A Class I lip-tie inserts in Zone I and (unless extremely short and tight) does not inhibit movement of the upper lip and should not interfere with breast or bottle feeding. However, if the lip itself is retracted to the degree that a child cannot flange his upper lip for adequate latching and for maintaining suction, further consideration of this type of lip tie may be necessary. Class II lip-ties have an insertion point in Zone 2, where the tissue is attached to the bone. Kotlow describes the Class III tie as inserting in Zone 3, where “the frenum inserts between the areas where the maxillary central incisors will erupt, just short of attaching into the anterior incisor.”  A Class IV lip-tie “involves the lip-tie wrapping into the hard palate and into the anterior papilla (a small bump located just behind where the central incisor will erupt).”

How might an upper lip-tie impact the developmental process of feeding?

The impact of the upper lip-tie can vary according to its classification and, in my professional experience, the fullness of the upper lip also comes into play. But, in general, consider these key points:

Breastfeeding and Bottle Feeding

  • Breast – Inadequate latch: An infant must flange the lips to create enough suction and adequate seal around the tissue that includes the areola and not just the nipple. It is essential that babies take in enough breast tissue to activate the suckling reflex, stimulating both the touch receptors in the lips and in the posterior oral cavity in order to extract enough milk without fatiguing. When the baby suckles less tissue, painful nursing is also a result. One sign (not always present) is a callus on baby’s upper lip, directly at midline. While not always an indicator of a problem, it’s typically associated with an upper lip-tie. It’s simply a reminder to flip the lip!
  • Bottle – Inadequate Seal: Because bottles and nipple shapes are interchangeable and adaptations can be made, it’s possible to compensate for poor lip seal. However, these compensatory strategies are often introduced because all attempts at breastfeeding became too painful, too frustrating or result in poor weight gain…and the culprit all along was the upper lip-tie. It is then assumed that the baby can only bottle feed. I’ve assessed too many children held by teary-eyed mothers who reported difficulty with breast feeding – and no indication in the chart notes that the child had an upper lip-tie. But, upon oral examination, the lip-tie was indeed present and when observing the child’s feeding skills, the tie was at the very least a contributing factor. Releasing the tie resulted in improved ability to breast feed and progress with solids.
  • In addition, an inadequate latch and/or a poor lip seal may contribute to the following partial list of symptoms:
    • Gassiness; fussiness; “colicky baby”
    • Treatment for gastroesophogeal reflux disease, yet to be confirmed via testing
    • Fatigue resulting in falling asleep at the breast
    • Discomfort for both baby and mother, resulting in shorter feedings
    • Need for more frequent feedings round the clock
    • Poor coordination of suck, swallow, breathe patterns
    • Inability to take a pacifier, as recommended by the American Academy of Pediatrics and noted here.

Spoon Feeding

  1. Inability to clean the spoon with the top lip
  2. Inadequate caloric intake due to inefficiency and fatigue
  3. Tactile oral sensitivity secondary to limited stimulation of gum tissue hidden beneath the tie
  4. Lip restriction may influence swallowing patterns and cause compensatory motor movements which may lead to additional complications

Finger Feeding

  1. Inability to manipulate food with top lip for biting, chewing and swallowing
  2. Possible development of picky, hesitant or selective eating because eating certain foods are challenging
  3. Lip restriction may influence swallowing patterns and using compensatory strategies (e.g. sucking in the cheeks to propel food posteriorly to be swallowed) which may lead to additional complications

Oral Hygiene & Dental Issues

  1. Early dental decay on upper teeth where milk residue and food is often trapped
  2. Significant gap between front teeth
  3. Periodontal disease in adulthood
  4. Possible changes in dentition with certain compensatory methods to propel bolus posteriorly for swallowing, such as finger sucking.

After documenting what we observe during the evaluation, clear communication with parents and other professionals will help to determine next steps. In feeding therapy, our role is to provide information for involved parents and professionals (this may include pediatricians, lactation consultants, otolaryngologists, gastroenterologists, oral surgeons and/or pediatric dentists). Our primary role is to determine, document and communicate to what degree the restricted top lip is influencing a child’s difficulty feeding.

For detailed information and additional photos, please read Kotlow’s article, Diagnosing and Understanding the Maxillary Lip-tie as it Relates to Breastfeeding, published in the Journal of Human Lactation in May 2013.

In a future post for ASHA, we’ll discuss tongue-ties (ankyloglossia) and the impact on feeding. Upper-lip ties are frequently associated with tongue-ties, so please remember to look for both during oral examinations.

Have you had an experience with an upper lip-tie impacting the feeding progress of one of your clients? If so, please tell us in the comments below.

 

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is the co-author of Parenting in the Kitchen: How to Raise Happy and Healthy Eaters in Our Chicken Nugget World (Aug. 2015), 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.  She can be reached at Melanie@mymunchbug.com.  

 

 

Snow Day Recap

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It’s a snow day here at ASHA and for many of our members on the East Coast. So whether (pun intended!) you’re snowed in or not, curl up with some of our most popular posts from 2014 in this compilation published earlier this year.

 

From stuttering to aphasia, hearing loss to hearing aids, early intervention to telepractice and more, ASHA’s blog posts are written by you—our members—sharing knowledge with peers on a variety of subjects. But there’s no doubt about it, pediatric feeding has been the topic on ASHAsphere in 2014!

Check out your five favorite posts from last year:

Step Away From the Sippy Cup!

SLP Melanie Potock specializes in pediatric feeding and explains that sippy cups were created to keep floors clean, not as a tool to be used for developing oral motor skills.

“Sippy cups were invented for parents, not for kids. The next transition from breast and/or bottle is to learn to drink from an open cup held by an adult in order to limit spills or to learn to drink from a straw cup. Once a child transitions to a cup with a straw, I suggest cutting down the straw so that the child can just get his lips around it, but can’t anchor his tongue underneath it.” – Potock

Baby Led Weaning: A Developmental Perspective

For parents interested in following the Baby Led Weaning (BLW) philosophy of pediatric feeding, which states that babies are developmentally capable of reaching for food and putting it in their mouths at about 6 months of age, SLP Melanie Potock shares some thoughts to consider.

“For children in feeding therapy, incorporating some aspects of BLW is dependent on that child’s individual delays or challenges and where they are in the developmental process, regardless of chronological age. My primary concern for any child is safety—be aware and be informed, while respecting each family’s mealtime culture.” – Potock

Collaboration Corner: 10 Easy Tips for Parents to Support Language

Paying attention to body language, reading every day and using pictures are just a few tips SLP Kerry Davis shares with parents to support their child’s language development.

“Take pictures of your child’s day and talk about what is coming up next, or make a photo album of fun activities (vacation, going out for ice cream) to talk about.” – Davis

What SLPs Need to Know About the Medical Side of Pediatric Feeding

To overcome pediatric feeding problems, SLP Krisi Brackett explains the importance of first figuring out why the child’s in a food rut.

“Whether the child is dependent on tube feedings, not moving to textured foods, grazing on snack foods throughout the day, failing to thrive, pocketing foods or spitting foods out, using medical management strategies can greatly improve a child’s success in feeding therapy.” – Brackett

Preventing Food Jags: What’s a Parent to Do?

For kids who only eat a limited number of foods, it can be difficult for parents to provide the right nutrition for their kids. SLP Melanie Potock shares her top 10 suggestions for preventing food jag.

“Food Left on the Plate is NOT Wasted: Even if it ends up in the compost, the purpose of the food’s presence on a child’s plate is for him to see it, smell it, touch it, hear it crunch under his fork and  perhaps, taste it.  So if the best he can do is pick it up and chat with you about the properties of green beans, then hurray!  That’s never a waste, because he’s learning about a new food.” – Potock

 

ASHA always welcomes new blog contributers. Interested? Apply to here become an ASHAsphere blogger.

Sara Mischo is the web producer at ASHA. She can be reached at smischo@asha.org.

Know Your CAS

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When I was pregnant, I remember dreaming about my new baby. My husband and I wondered aloud if she would be a musician like him, an athlete like me, or have some individual talent all her own. We had absolutely no doubts about what strong communications skills she’d have, however. Her mother was an SLP after all.

During her first year, my daughter lagged in all developmental milestones. I went to at least five different conferences on early intervention, but I couldn’t figure out why my daughter wasn’t a chatterbox. She met her first word criteria at one saying “hi” to everyone she met.

My husband’s mother reported he was late to talk and didn’t really say much of anything until after two. I had heard of late talkers, but because I worked at the elementary level, I never treated preschool kids. I brushed aside my pediatrician’s suggestion to seek treatment because I was convinced my daughter must be like her Daddy and that I could help her.

I finally took her in for an evaluation when she was close to three and received a diagnosis of childhood apraxia of speech and global motor planning deficits. After starting therapy based on motor learning principles, she made progress immediately.

Upset that I missed this diagnosis in my own child, I went on to endlessly and obsessively research childhood apraxia of speech. I was disappointed to find maybe eight pages on the subject in my graduate school materials. I know CAS is rare, but SLPs need to know about it and need to have the tools to diagnose and treat it correctly.

That summer I attended the national conference for CAS. The next summer I applied and was accepted into the Apraxia Intensive Training Institute sponsored by CASANA, the largest nonprofit dedicated exclusively to CAS. I was trained under three leading experts: Dr. Ruth Stoeckel, David Hammer and Kathy Jakielski.

If I could get one message out to pediatric SLPs, it would be for them to research and become familiar with the principles of motor learning and change their treatments accordingly for a client with CAS or suspected CAS. I know many like me get so little training or even information on it in graduate school. I’ve met other SLPs who were told it was so rare they would probably never treat it or even that it didn’t exist.

ASHA recognized CAS as a distinctive disorder in 2007. Taking the time to learn more about how treatment for childhood apraxia of speech differs from other approaches for speech and language disorders is crucial for kids with this motor speech disorder.  The importance of a correct diagnosis leads to a successful treatment plan. To briefly summarize, sessions should focus on movement sequences rather than sound sequences taking into account the child’s phonetic repertoire and encouraging frequent repetition.

For more information visit apraxia-kids.org and become familiar with ASHA’s technical report on the subject.

 

Laura Smith MA, CCC-SLP is a speech/language pathologist in the Denver metro area specializing in childhood apraxia of speech. CASANA-recognized for advanced training and expertise in childhood apraxia of speech, she splits her time between the public schools and private practice. She speaks at conferences and consults for school districts or other professionals. Email her at lauraslpmommy@gmail.com, Like her on Facebook, follow her on Pinterest, or visit her website at SLPMommyofApraxia.com.

 

 

Picky Eaters in the Preschool Classroom: 7 Tips for Teachers

Two scoop sizes allow children to select a smaller portion for unfamiliar foods.

Two scoop sizes allow children to select a smaller portion of unfamiliar foods.

As a pediatric feeding therapist, part of working in the child’s natural environment is making regular preschool visits to offer teachers and staff guidance when a child is not eagerly participating in mealtimes. Whether a child is a selective eater or the more common picky-eater, here are seven tips for teachers that focus on the seven senses involved in food exploration and eating:

  1. Sight: New foods are better accepted when the sight of them is underwhelming. When serving foods family style, include TWO utensils for scooping from the main bowl or platter [see above]. Present each food with one larger scoop and a standard spoon. The kids at the table can choose which scoop/spoon they would like to use, which allows the more hesitant eater to choose a small sample instead of what might feel like an overwhelming shovel-full. If meals are served pre-plated, offer smaller portions (1 tablespoon) of new foods and allow the kids to request more after their first taste.
  2. Smell: Warm foods often have a stronger aroma and for some kids, this can be a quick turn-off before the food ventures toward their lips. In regards to the hesitant eater, begin passing the bowl of warm foods so that it ends up at his seat last, when it will be less aromatic. For meals that are pre-plated, simply dish up his first but place it in front of him last, so that the food has time to cool a bit. Straws are an excellent option for soups, because they allow the child to sample by sipping. The longer the straw, the farther away they are from the smell. The shorter the straw, the less distance the soup needs to travel to reach the tongue, but the closer the nose is to the aroma. Consider what suits each child best and adjust accordingly. Thinner straws allow for a smaller amount of soup to land on the tongue, but if the soup is thick, you may need a slightly wider straw. Keeping the portion as small as possible also keeps the aroma to a “just right” amount for little noses. Try tiny espresso cups, often under $2, for serving any new beverage, soup or sauce.
    espresso cups
  3. Taste: Experiencing food doesn’t always mean we taste it every time. If the best a hesitant eater can do that day is help dish up the plates or lick a new food, that’s a good start! But when it comes to chewing, encourage kids to taste a new food with their “dinosaur teeth.” A fun option are these inexpensive tasting spoons commonly found in ice cream shops. Keep a small container in the center of the table for kids to take tiny sample tastes direct from their plates.
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  4. Touch: Like any new tactile sensation, few of us place our entire hand into a new substance with gusto. It’s more likely that we’ll interact with a new tactile sensation by first using the tip of one finger or the side of our thumb. Take it slow – and remember that touch doesn’t just involve fingers and hands. The inside of the mouth has more nerve endings than many parts of our bodies, so it may be the last place that the hesitant eater wants to experience a new texture, temperature or other type of sensation. Start with where he can interact and build from there.
  5. Sound: The preschool classroom is abuzz with activity and thus, noise. Beginning each snack or mealtime with a song or a ritual, such as gently ringing some wind chimes to signal “it’s time to be together with our food” is a routine that centers both teachers and children. Whatever the ritual, involve the most hesitant eaters in the process and encourage their parents to follow the same routine at home if possible. Kids do best with when routines are consistent across environments.
  6. Proprioceptive Input: The sense of proprioception has a lot to do with adventurous eating. One fun routine that provides the proprioceptive input to help us focus is marching! In one preschool classroom, we implemented a daily routine where the kids picked a food and marched around the table with it as a way to mark the beginning of a meal and provide that much-needed stomping that is calming and organizing for our bodies. Download the song “The Food Goes Marching” here (free till February 1, 2015) as the perfect accompaniment!
  7. Vestibular Sense: While we all know the importance of a balanced diet, you may not be aware that a child’s sense of balance has a lot to do with trying new foods! Our sense of balance and movement, originating in the inner ear and known as the vestibular system, is the foundation for allfine motor skills. In order to feel grounded and stable, kids need a solid foundation under the “feet and seat.” Many classroom chairs leave preschoolers with little support and feet dangling. Create a footrest by duct taping old text or phone books together or if you’re extra handy, create a step stool that allows the chair legs to sit inside the stool itself.
    footrest
    An inexpensive version can be made with a box of canned baked beans from COSTCO, like this one. Carefully open the box because you’ll be using it again to create the footrest. Simply remove the cans, empty just two, then rinse thoroughly and discard the lids. Now place the cans back in the box with the two empty cans facing up, so that the legs of the chair will poke through the box and into those two cans. Reinforce with duct tape. Instant footrest!

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is the co-author of Parenting in the Kitchen: How to Raise Happy and Healthy Eaters in Our Chicken Nugget World (Aug. 2015), 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.  She can be reached at Melanie@mymunchbug.com.  

Are You Wearing Your Play-Based Hat Today?

Importance of play

Ever leave the house and not know what to wear? As an early intervention SLP, I wear many hats, and there are days when I’m not sure which hat (or hats) I’ll put on. As any therapist knows, the nature of our job is not just treatment related, but often much more. Of course the hat I wear most often is my speech therapy hat but when I enter the homes of my “kids” every week I sometimes encounter life that requires me to be more than just an SLP.

There is a trust that forms when you regularly enter someone’s home. Families respect you not only as their child’s SLP, but also as a resource for other parenting questions. These questions might require my community resource hat, my fellow parent hat or my support hat. Because the parents of our clients trust us to meet many needs, it is important that when they ask questions or seek guidance we are there to help.

For example, many families today experience a societal pressure to push their child well beyond what is developmentally appropriate. Parents set unrealistic expectations for their children and panic if they feel their child isn’t “keeping up.” I’m concerned when I enter homes filled with obscene piles of toys, a television constantly going and a toddler who manipulates my phone and tablet more skillfully than I do! Through my sessions I model play, in the absence of fancy toys and electronic devices, hoping the parents will realize how simply PLAYING with their child is enough. There’s no better way to achieve developmental milestones and enrich children than through play.

Sometimes my example isn’t enough…well OK, it’s often not enough. So frequently I have a conversation about age-appropriate expectations, age-appropriate toys and what children need most from their parents.

When pondering how to start this conversation, I often find myself asking: What can I do to educate families on the importance of play? What can I say to drive home age-appropriate expectations? What are some of the most important points to stress to the families I serve? Professionally, I branched into owning a business devoted to play, plus I learned about how play is changing and why it matters.

Here are some tips you may find helpful to educate parents about the importance of simple play:

• Remind families that children need unstructured playtime and give specific examples of what is learned when a child does “nothing.” A toddler’s day should consist mostly of unstructured play and opportunities to experience their world with all their senses. Tell parents that this is the best way for their child to learn.

• Share with parents the American Academy of Pediatrics’ recommendation of no screen time before age 2 and only two hours per day for children older than 2. Parents are usually shocked to hear this, but even a television in the background distracts a baby/toddler and can make it more difficult for them to focus and learn.

• Inform parents that babies and toddlers do not truly learn anything from flashcards. The powerful marketing beast can sell just about anything to an anxious parent who wants that best for her child. However, research and experience do not support their use, particularly at such an early age. Share what you know about play-based options for teaching language skills.

• Encourage parents to slow down and follow their instincts. Oftentimes parents know what’s best for their child, but are influenced by outside sources. As professionals, we can reassure parents to trust themselves.

If you are an EI SLP I hope you realize your importance not only in the life of the child you serve, but his family as well. You are appreciated and trusted, so may you guide your families so that they are able to enjoy the miracle of their child to the fullest. Choose your hats wisely and don’t keep all that knowledge about PLAY under your hat. We all have a role in supporting families and enriching children’s lives.

Lacy Morise, MS, CCC-SLP of Berryville, Virginia works for the West Virginia Birth to Three Program as an early intervention therapist. She also owns Milestones & Miracles (with her EI PT bestie, Nicole Sergent, MPT) Read her blog and like her on Facebook, follow her on Twitter @milestonesm and Pinterest

Kid Confidential: Parent Education and Training, Part 3

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I began this series noting the positive effects of parent education and training and sharing tips for how to provide it.  Then, in part 2, I discussed how I implement parent education/training in my therapy sessions.  Here, in part 3, I discuss how I use digital recording to support parent training and education.

Although I own a tablet for therapy, my most valued device on that tablet is the video camera. Most of the time you will not find me with some speech or language app open on my tablet. Rather, you’ll see me with toys all over the floor and my tablet set up with the camera ready to record.

When working closely with parents during therapy, I find that digital recordings provide helpful feedback on a parent’s use of therapy techniques.  It works especially well during real-time education and training (you can read about this in part 2 of this series), as so much of language development depends on the ways caregivers communicate with young children.

The following are some personal rules I like to follow when using digital recordings in therapy:

  1.  Be careful of confidentiality when recording:  This seems so basic but I always get parents’ permission prior to recording their child.  Also I am very cautious when sharing digital recordings of clients as I always worry about secure emails, websites and such.  I tend to use thumb drives, when I can, to share the digital recordings with parents in person just to ensure security. If I cannot provide the parents with a thumb drive on the spot week to week (the one big problem I have found using my tablet camera) I will be sure to still review the digital recording on the spot during the session for educational purposes.
  2. Record only portions of the session:  I understand parents do not have a lot of time to review recordings, so I try to only record simple models of techniques by myself, followed by parents’ trials with my positive feedback and suggestions for modifications or changes. This way, if parents question how to implement the techniques, they have a quick refresher ready for them. My rule of thumb is to try and keep these recordings to five minutes or so. This way parents can quickly access the information they need.
  3. A few things I like to record when I can:
    1. Initially, I always try to record basic parent interactions and hopefully PLAY with their child (this is not about telling the parent how “wrong” they are in the way they interact with their child, but rather it’s about increasing parental awareness of the types of interactions they tend to have with their child.  For example, are they always asking their child questions? Are they talking “at” rather than “to” their child?  This video review is non-judgmental but educational in nature.
    2. Sibling interactions can also be very helpful as well if the sibling is older and can understand and learn to use various techniques to help the younger child.
    3. Sometimes taping sibling interactions is a great way to teach parents how to play with their language delayed child.
    4. I try to record “before” and “after” the use of strategies. Parents love to see how they themselves have changed over time and I love to show them!
  4. Record great parent and sibling interactions:  The last things I like to try to record are moments of wonderful interactions between the child and his parent and/or siblings. I love sharing those moments and reviewing all the great techniques used by the family members. This is not only a great review, but continues to encourage and empower parents to keep up the good work. I also like to keep previous recordings so that parents can see their personal progress over time.  It is amazing to watch their faces when they see how far they have come!

In my experience, digital recordings can really enhance parent education and training, can be a great reminder and resource for parents, and can encourage and empower parents to continue to use good therapy strategies and techniques at home to continue fostering language development in their child.

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.  She has been practicing as an ASHA certified member since 2003 and is an affiliate of ASHA Special Interest Group 16, School-Based Issues.  She has experience in various settings such as private practice, hospital and school environments and has practiced in New Jersey, Maryland, Kansas and now Arizona.  Maria has a passion for early childhood, autism spectrum disorder, rare syndromes, and childhood apraxia of speech.  For more information, visit her blog or find her on Facebook.

SLPs in the Home: What’s Pot Got to Do with It?

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I never thought I’d be writing an article for ASHA about marijuana, but because I live in Colorado, I’ve got the latest news on weed to pass along to my fellow SLPs. In fact, if you were sitting here with me in the privacy of my own home (and you were over 21), we could chat about it while lawfully smoking a joint, munching on an edible cannabis-laced cookie, sucking on a marijuana lollipop or even, inhaling the vapors from an e-cigarette packed with marijuana oil. That’s just a sampling of the options we have to get high in the “mile high city.” Before you shout “I’m coming over!” I should probably disclose that I’m not a marijuana user, medical or recreational. If your next thought is “But I DON’T live in Colorado (or Washington) so this doesn’t apply to me – at least professionally” please read this entire article. Colorado law is considered a “springboard for other states” to legalize marijuana soon. Plus, illegal shipping to other states, often discovered during a routine traffic violation committed by the average Joe next door, has increased significantly. According to the El Paso Intelligence Center & National Seizure System, the mini-vans and SUVs bringing home “souvenirs” from Colorado aren’t just from the states bordering the Rocky Mountains. New York, Florida, Illinois and Wisconsin were some of the most popular destinations and consequently, you may experience some unexpected safety issues if you are providing home-based care for children and adults.

In an effort to educate therapists on the new laws and our responsibility to inform our families of issues that may arise with recreational marijuana use, Jane Woodard, the executive director of Colorado Drug Endangered Children, is traveling the state providing health care professionals the necessary information to keep ourselves and the families we serve safe. SLPs are required by law to report suspected conditions that would result in neglect/safety issues or abuse of children and adults. However, many of our families are simply not aware of the safety concerns and home based therapists are often the first resource for educating those families who choose to partake in using, growing or processing recreational marijuana.

Given the various populations that we serve, here is an overview of some of the safety issues:

Infants: As a pediatric feeding therapist, just one of the populations in my care are babies who require support for breast and bottle feeding. In this Colorado culture of embracing our new freedom, mothers are commenting to me without restraint that they’re using marijuana to combat nausea during pregnancy or enjoy “a little pot now and then” while breastfeeding.Studies indicate that by age four alarming changes occur in children that have had prenatal exposure. It’s noteworthy that the studies focused on a much lower amounts of delta-9-tetrhydrocannibinol (THC: the chemical that produces the psychoactive effect) than what is present in today’s super-charged marijuana products. The children demonstrated “increased behavioral problems and decreased performance on visual perceptual tasks, language comprehension, sustained attention and memory.” Marijuana use while breastfeeding is contraindicated because the THC is excreted into breast milk and stored in fat and is suspected to impact a baby’s motor development. There are no established “pump and dump” guidelines for THC and it stays in the bloodstream for much longer than other drugs. Consider the increased risks from both second-hand smoke and third-hand smoke or the “contamination that lingers” after smoking, including an increased risk for SIDS and more. For the home-based SLP, exposure to second and third-hand smoke or residue means that I will likely carry that aroma with me to the next home. I am responsible for the safety of all of the children I treat, and many are medically fragile and/or have sensory challenges and would be impacted by these odors. Today, I am faced with difficult conversations with parents that I never imagined I would have.

Children: In four short months, from January to April 2014, Colorado’s Poison Control Center has reported 11 children who ingested edibles, one as young as five months old. Over half of those children had to be hospitalized and two were admitted to the ICU. Consider that those are the reported cases – and what goes unreported is difficult to ascertain. While the law requires that the packaging cannot be designed to appeal to kids, current practices are questionable. Some argue that edibles are packaged too much like junk food, with boxes of “Pot-tarts” similar to the popular toaster pastry, bottles of fizzy “soda-pot” and candy bars with labels that rival Mars® and Hershey’s®.  In April 2014, Karma-Candy was the marijuana candy that a father in Denver consumed just before hallucinating and killing his wife, who was on the phone with 911 dispatchers at the time. She could be heard yelling to her kids to go downstairs as she desperately tried to get help for her family.

Packaging of certain products must also be in an opaque and re-sealable container, but that law only applies to the time of purchase. Plus, most edibles contain multiple servings and it’s not unusual for one cookie to serve six people. Even adults are mistakenly eating whole cookies and in April 2014, one visiting college student consequently jumped to his death from a hotel balcony after eating too much of an edible. A New York Times columnist visiting Colorado ate a whole candy bar labeled as 16 servings, and “laid in a hallucinatory state for 8 hours.” Home baked marijuana options are equally confusing. As a feeding therapist, I used to be comfortable offering foods to a child from a family’s pantry. But now, a tempting plate of brownies may be more than just a plate of brownies. By law, edibles, like any marijuana product (even plants), must be in an “enclosed, locked space.” However, it is not unusual for Colorado therapists to arrive for their home visit and find a bong, topical lotions or a half-eaten edible on the living room coffee table. Early intervention and home health care agencies are considering how to educate families on the first day of contact, during the intake process. Susan Elling, MA, CCC-SLP, who treats both children and adults in the home, notes that “It will be very important to have an open and honest conversation with a patient (and their family) regarding marijuana use as part of taking the medical history – just as we do for alcohol and smoking.”

Adults: Ms. Elling reported that “the population in need of homecare services may be more likely to use marijuana to control pain and nausea” because family members are more likely to suggest it and there will no longer be a need to obtain a medical marijuana card. Ms. Elling also notes that marijuana “affects sleep, balance, coordination, and cognition.  This may be amplifying the conditions a patient is already dealing with related to medical issues.  It can also significantly raise anxiety.  These are all factors that increase fall risk, confusion, lead to poor judgment, and can setback a patient’s recovery. It may be very difficult to determine what issues are related to the patient’s medical condition and which are related to the marijuana use.  Interventions, progress and prognosis may be affected.” Edibles in particular are a safety hazard for this population, because of the inability to self-regulate. There is no predicting how an edible will effect one person or another.

“It’s not your grandmother’s marijuana,” reported Dr. Richard Zane, who is the head of the Department of Emergency Medicine at the University of Colorado Hospital. Well-meaning family members, hoping to control their loved one’s discomfort, may not realize that the strength of today’s marijuana is significantly higher than the pot your cool grandma smoked in the 60’s. In fact, THC levels represent a 121% increase just from 1999 to 2010. Family members may not understand that the strength and effect of the drug varies from product to product. For example, compare two hits on today’s joint and an individual will ingest approximately five mg of the chemicals that produce the psychoactive and/or sedative effects compared to up to 100 mg in one packaged edible. Plus, even using the exact same method of ingestion does not guarantee the exact same dosage every time. Zane reported in this interview with Colorado Public Radio that the “drug isn’t always spread evenly through food or candy, so several people eating the same amounts can be ingesting different quantities of marijuana.”

The uncertainty of dosage and effects has Elling on guard: “I am concerned that the high potency, unpredictable effect, easy availability, and unclear dosage information of edibles may have serious consequences for homecare patients with already fragile health. It is also misleadingly considered quite “benign” and safe compared to alcohol consumption and smoking.  I feel the need to know the signs and symptoms of a marijuana overdose and know the contraindications with any other prescription or OTC drugs they may be taking and be able to educate my patients and their caregivers regarding this issue.”

Additional Safety Concerns: In the course of this short article, it’s impossible to cover all of the safety issues, including those related to growing and processing marijuana in the home. These concerns include electrical hazards from impromptu wiring (not to code); cultivation hazards such a mold and poor air quality for medically fragile patients;  increased carbon dioxide and carbon monoxide necessary for growing; chemical exposures and improper storage of pesticides and poisonous fertilizers; THC on household surfaces and airborne exposure; and exploding hash oil labs. From January to April 2014, hash oil explosions occurred on a weekly basis in Colorado, some triggered just by turning on a nearby light switch.

Consider Family Functioning: The impact on safety is the tip of the iceberg. Woodard explained that home health professionals must consider a parent’s behavior when using marijuana, the impact on a child’s behavior and family functioning overall. Difficult but often necessary questions to ask include: What steps have you taken to protect your children and family members? How do you store your marijuana and paraphernalia? What are you like when you use? Most importantly, she recommended asking yourself “Do I believe that the conditions in this home could reasonably result in harm” to anyone in this household? If so, educate the family and be mindful of mandatory reporting laws.

 

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.