Our Perception of Taste: What’s Sound Got to Do with It?

music

My first love as a speech-language pathologist is pediatric feeding.  I spend lots of time talking to little kids about “carrot crunchies” and “pea-pops” and various silly names for the sounds that different foods make in our mouths as we explore all of the sensory components of food in weekly treatment sessions.

Is it possible that sound is a larger component of our eating experience than many of us realize? What’s sound got to do with eating, or more specifically, with taste? Discovering how the sound of a crunching potato chip affects flavor is more than just curiosity.  Prof. Charles Spence, who leads Oxford’s Crossmodal Research Laboratory, studied how the sound that food makes in our mouths influences our perception of freshness.  It’s an important point for potato chip manufacturers, who strive to create the “crunchiest crisp possible.”

Background sounds in the environment also influence our interpretation of taste.  Spence conducted an experiment where individuals were presented with 4 pieces of identical toffee.  Two pieces were eaten while the subjects listened to the lower pitch of brass instruments.  Two other pieces were eaten while listening to the higher pitch of a piano.  The pieces eaten during the higher pitched piano music were rated “sweet” by the subjects and the pieces eaten during the lower pitched music were rated “bitter.”

Chef Blumenthal, owner of The Fat Duck near London, has taken Spence’s research findings to the next level.  Order the “Sound of the Sea” and you’ll enjoy more than seafood delicacies  presented on “a sand of tapioca and fried panko, then topped with seafood foam.” The dish is accompanied by an iPod nestled in a seashell, “so that diners can listen to the sound of crashing waves as they eat.” Spence reports that diners experience stronger, saltier flavors with the sound of the ocean in the background.  Another London restaurant, the House of Wolf, serves a cake pop along with instructions to dial a phone number and then, before tasting,  press 1 for sweet and 2 for bitter.  Diners who listened to the first prompt heard a high pitched melody and those who pressed “two” heard a low brassy tones.   In an article for the Telegraph, Spence said,  “We have also looked at the crispiness of crisps and biscuits and found that by boosting certain high frequency sounds when volunteers bit into them we could make them taste crunchier, and they became softer if we dampened those frequencies.”  It’s not just diners across the pond who are experiencing the marriage of sound and taste. Major food companies in the United States also have consulted with Spence, who developed a soundtrack to “complement”  the coffee at Starbucks®.  Speaking of coffee, in a recent study, Spence found that humans can detect whether a liquid is hot or cold, just from listening to the sound of it being poured into a glass, porcelain, paper and/or plastic cup.  I’ll consider this the next time I’m waiting for my drink at the local coffee shop.  Perhaps, from now on,  I can just listen to the sound of the pour, grab my drink and avoid the barista announcing “Lite Iced Triple Venti Half-Pump Americano Skinny for High Maintenance Melanie” with that smirk on his face.  But, I digress…

When I consider my little clients in feeding therapy, I wonder how this research might be expanded to detect possible differences in taste perception in children with sensory processing challenges, including kids with autism. Certainly, respecting the differences in a child’s sensory system is an integral part of feeding therapy for most clinicians.  Could it be that this hiccup in auditory, visual, gustatory or other sensory systems communicating efficiently with one another makes eating a variety of foods especially difficult for some children, more than we know at this time?  A recent article in The Journal of Neuroscience reported that kids with “autism spectrum disorders (ASD) have trouble integrating simultaneous information from their eyes and their ears” and discussed how this might affect their language skills. Wendy Chung, MD, PhD at Columbia University Medical Center explained in a recent video for parents how a poorly functioning pathway for simultaneous auditory and visual information (and the secondary problems of processing and responding to sensory signals) causes a child with ASD to be overwhelmed in environments that we find quite comfortable.  Perhaps future research may include Spence’s work and how it might apply to children in feeding therapy. Would certain tones be more soothing while eating?  Would certain music in the school cafeteria help children eat faster or even choose more nutritious foods? The common phrase “a feast for the eyes” may one day turn out to be “a feast for the eyes and ears” as we consider all the possibilities.

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.

Just Breathe. Really?

breathing

Easy for you and me to say.  But for 7.1 million U.S. school children it’s not. Childhood asthma rates continue to rise and from 2001 through 2009 those rates were the highest for African American children, almost a 50 percent increase. Asthma accounts for 10.5 million school absences each year. The main trigger of asthma in school children are the same contributors to poor indoor air quality. Yeah, that’s right … open a window.

Air is mostly composed of nitrogen (78 percent) and oxygen (20 percent), air also has about 1 percent of water vapor and tiny amounts of argon and other gases.  For most of us, air quietly passes through our nasal passages into our lungs and out again; taking in the oxygen needed for our blood supply during inhalation and disposing the carbon dioxide by-product during exhalation.  We do this without thought, without effort–unless you are a child with asthma.

Asthma is a chronic lung disease characterized by inflammation of the airways. Recurring symptoms include wheezing, shortness of breath, chest tightness, and coughing.  Asthma develops in childhood as early as 6 months of age and lasts a lifetime.  About one in 12 Americans are living with asthma and over one third of them are children. In adults women are more likely than men to have asthma and more boys than girls among children. Those with asthma pay a huge price, about $3,000 per year per person to be exact. This figure includes medical care, medications, lost work/school days and deaths.

Various triggers not easily controlled can cause an asthma attack such as changes in weather. However, there are other triggers that can be controlled such as the presence of dust mites, roaches, pets, and mold affecting indoor air quality.  Asthma is particularly more prevalent to those living in poor neighborhoods.  A recent episode of NBC Dateline revealed that the childhood asthma rates in East Harlem run at 19 percent compared to the adjoining Upper East Side neighborhood at 7 percent.  They breathe the same New York City air, so what accounts for the difference?

Water leaks, pest infestation and general contract repairs are the responsibility of a rental unit’s landlord. As economically disadvantaged families tend to reside in these units, they are at the mercy of their landlord. Water damage leads to mold; pest infestation carries allergens; both of these conditions create a significant trigger for asthma in children. Even a child without an asthma history may become asthmatic as a result of repeated and chronic exposure to such poor indoor air quality.

School absences are of particular concern; children who miss more than 18 school days are year are more likely to drop out of school. Children with asthma miss more days of school due to their disease compared to children without asthma.  The number of missed days rises with severity—on average a child with severe and persistent symptoms misses 11.5 days of school in a year.  That’s a lot of missed homework and make up speech sessions. Asthma also affects a child’s sleep quality, which in turn affects a child’s ability to pay attention in class and lowers their quality school work.

 What can you do? 

  • Know which children on your caseload have asthma and know how to deal with an asthma emergency, including the location of the child’s inhaler.
  • Take a look at your therapy treatment room or classroom. Are the floors hard wood or are they carpeted?  If hard wood, hooray! If carpeted, make sure they get vacuumed every day and shampooed at the end of the school week.
  • Got pets? If there are in your classroom, better to send them to another home. Animals carry dander that can trigger asthma. If you have a pet at home, make sure your work wardrobe is free of pet hair.
  • Are you working out of a trailer or portable classroom?  These type of environments generally trap moisture than can turn into nasty mold. Make sure spills and leaks are taken care of quickly.
  • Skip the perfume spritz and after shave before leaving the house for work. Fragrances can trigger an asthma episode.
  •  Refrain from fuzzy or scented materials, pillows or upholstered furniture; these can collect dust mites, which are (surprise!) asthma triggers. If the furniture must stay, vacuum it frequently.
  • No clutter!  Cockroaches and dust mites love clutter … and produce more asthma triggers.
  • If your room has a window that faces high volume vehicular traffic, keep it closed during the vulnerable morning hours and cold temperatures.
  • Stay away from phthalate-based toys  as phthalates are known triggers for asthma.
  • Don’t use pesticide sprays in your room.  Go for integrated pest management strategies instead.
  • Like team work?  Collaborate with your school nurse and district’s administration to develop an asthma management plan at your school if one does not exist.  Another excellent resource is to adopt ideas from the IAQ Tools for Schools Action Kit.  Work with your district’s transportation department to monitor school bus engine exhaust near open windows.

 

Although asthma is prevalent, with some forethought and preventive measures, it can be controlled. Now breathe a sigh of relief!

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. 

 

 

 

Baby Led Weaning: A Developmental Perspective

blw

One of the things I like best about teaching courses on feeding to parents and professionals around the United States is learning what new trends are evolving around family mealtimes. Over the past year,  one of the common questions I’m asked is, “What about Baby Led Weaning?”

Baby Led Weaning (BLW) is a term coined by Ms. Gill Rapley, co-author of “Baby-led Weaning: The Essential Guide to Introducing Solid Foods.”  Rapley graciously chatted with me about her philosophy and explained that although she did not invent BLW, she found the method to be successful in her work as a former health visitor and midwife in the United Kingdom and continues to study the topic today while earning her PhD.

In a nutshell, BLW centers on the philosophy that babies are developmentally capable of reaching for food and putting it in their mouths at about 6 months of age. As stated on the BLW website “You just hand them the food in a suitably-sized piece and if they like it they eat it and if they don’t they won’t.”  Please note that the word “wean” is not referring to weaning from breast or bottle, but instead refers to a term commonly used in the United Kingdom for adding complementary foods to the baby’s current diet of breast milk or formula.  According to the BLW website, ideas for first foods include “chip size” steamed vegetables such as a broccoli spear with the stem as a handle, roasted potato wedges, meat in large enough pieces for the baby to grasp and chew, rice cakes, cucumber, celery and dried apricots.

As a SLP who focuses on pediatric feeding, I view feeding as a developmental process.  Whether I’m working with a child experiencing delays in development or offering advice to a parent whose child is meeting milestones with ease, I always ask myself “How can I respect and support this family’s mealtime culture while guiding this child safely through the developmental course of learning to eat?”  Thus, for families who are interested in following the BLW method, whether their child is in feeding therapy or not, I try to support their wishes if the child is capable,  while offering the following BLW points to consider:

BLW encourages parents to eat with their children, since everyone is eating the same food. 

In today’s busy culture, it feels easier to many parents to feed the baby prior to the adult or family meal, and in BLW the thought is that jarred purees contribute to this habit and it’s important to include baby at the table at an early age.  Even in feeding therapy,  the ultimate goal is for families to be able to gather around the table at mealtimes with everyone enjoying the same foods.  Plus, Columbia University reports that consistent family dinners are an integral and valuable part of raising children.

BLW emphasizes that babies must be the ones to put the food in their mouths.

Feeding therapists encourage self-feeding  for all kids because it allows them to get messy.  Babies are programmed to explore the world with all of their senses, especially their hands and mouths, and often the two together!  BLW notes that the time to begin self-feeding is at 6 months when baby can sit upright on his/her own. I explain to parents that first, every child must have the gross motor stability to support fine motor skills, including reaching and raking for food and controlling their grasp to bring the food to the mouth to be chewed.  For children who have this capability, I feel comfortable with large pieces of food that will not snap off (or allow a solid chunk to fall into the mouth) in addition to short spoons and chewable toys for practicing the skills that will eventually lead to self-feeding.

BLW follows the baby’s cues rather than the parent controlling the feeding via the spoon.

I explain that whether presenting food to your child by placing it on the high chair tray in front of them, directly on a spoon or even mouth to mouth as done in some cultures, reading baby’s cues for readiness is crucial.  Like a beautiful, flowing conversation, feeding children is a reciprocal experience.

According to the BLW blog, BLW introduces chip-size foods (rather than purees or mashed foods) so that baby learns to chew first and then spit out if unable to swallow, noting that with purees on a spoon, babies learn to swallow first and then chew.

From a developmental perspective,  this doesn’t quite fit with my understanding of how infant reflexes integrate  and babies acquire oral motor skills. Babies can begin the process of BOTH spoon and finger feeding between the ages of 5 and 6 months using both purees and soft, safe foods.  Why?  Because this is when babies acquire better lip control and movement as they suck the puree off of a parent’s finger, their own hands or a spoon.  As noted in Diane Bahr’s book “Nobody Ever Told Me (or My Mother) That!” this is when babies use their rhythmic bite reflex to bite off soft pieces of safe, soft or meltable foods that they can hold in their tiny fists or when presented by a parent to their open mouths. If the food is placed onto the gums where we will one day see molars, a rotary chew pattern will begin to emerge over time, thanks to reflexive patterns that soon become purposeful movements.  It’s a developmental process and BOTH purees and finger feeding facilitate the progression of skills. It makes sense to me to transition gradually from thinner  liquids (breast milk/formula) to thicker (thus, a smooth puree) to consistently mashed or chopped  while introducing soft meltables over time.  Keep in mind that I also encounter families who are moving too slowly through graduation of textures, as noted in this article by Bahr.  But, jumping straight to only large pieces of foods to be chewed and then either swallowed or spit out feels like skipping crucial steps in the developmental process.  “Feels like” is the key phrase here: We need research to determine if children who follow this model eventually acquire skills traditionally learned prior to chewing chunks of food as listed in this article found in ASHA Perspectives.  Unlike my previous post on sippy cups, where therapists have raised concerns based on their professional experience over several years and observation of prolonged sippy cup use,  consistent BLW practices are a relatively new phenomenon in the United States.  So, when any parent asks “What about Baby Led Weaning?” I try to integrate my own practitioner expertise and knowledge of feeding development while honoring the family’s preferences and mealtime culture.  Still,  my biggest concern for any 6 month old child is choking.

BLW encourages parents to become comfortable with gagging episodes and understand the difference between gagging and choking. 

Gagging versus choking are two different experiences.  Typically, an infant’s gag reflex is triggered when the back three quarters of the tongue is stimulated, but by the time a child reaches  9 months of age, the reflex covers less area, lying on the back third of the tongue. Eventually, the gag reflex shifts posteriorly even more as the child learns to tolerate the stimulation. Gagging is nature’s way of protecting the airway, where true choking occurs.  Choking happens when food (or other substances) obstruct the airway and thus, often has no sound or intermittent, odd sounds.  Other signs of choking include but are not limited to: gasping for breath, turning blue around the lips and beneath the eyes and/or staring with an open mouth while drooling.

Gagging is an uncomfortable sensation where the soft palate suddenly elevates, the jaw thrusts forward and down, and the back of the tongue lifts up and forward.  It is not unusual for a child to vomit after gagging.  In between the gags, the child is still able to breathe, cry and make vocal noises.  The occasional gag is an important built-in safety mechanism, but frequent gags and/or vomiting can lead to an aversion to food.

In summary, when asked for advice from any family that would like to follow Baby Led Weaning principles, I stress the importance of reading baby’s cues and monitoring them closely for safe feeding while supporting them through the developmental process of learning to eat, no matter what age.  This includes proper positioning in the feeding chair for optimal stability and presenting only manageable pieces of safe, meltable and/or solid foods that do not pose a choking hazard.  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.

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.

Step Away From the Sippy Cup!

sippy

Sippy Cups became all the rage in the 1980s, along with oversized shoulder pads, MC Hammer parachute pants and bangs that stood up like a water spout on top of your head.   A mechanical engineer, tired of his toddler’s trail of juice throughout the house, set out to create a spill-proof cup that would “outsmart the child.”  Soon,  Playtex® offered a licensing deal, the rest is history and I suspect  that mechanical engineer is now comfortably retired and living in a sippy-cup mansion on a tropical island in the South Pacific.

Geez. Why didn’t I invent something like that?  I want to live in a mansion in the South Pacific. By the way,  I also missed the boat on sticky notes, Velcro® and Duct Tape®–all products I encounter on a daily basis, just like those darn sippy cups I see everywhere.  I truly shouldn’t be so bitter, though – in my professional opinion, over-use of sippy cups is keeping me employed as a feeding specialist and I should be thankful for job security.  Thank goodness for the American marketing machine – it has convinced today’s generation of parents that transitioning from breast or bottle to the sippy cup is part of the developmental process of eating.  Problem is, those sippy cups seem to linger through preschool.

As an SLP who treats babies with feeding challenges, I frequently hear from parents how excited they are to begin teaching their baby to use a sippy cup.  They often view it as a developmental milestone, when in fact it was invented simply to keep the floor clean and was never designed 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.   That’s my issue with the sippy-cup: It continues to promote the anterior-posterior movement of the tongue,  characteristic of a suckle-like pattern that infants use for breast or bottle feeding.  Sippy cups limit the child’s ability to develop a more mature swallowing pattern, especially  with continued use after the first year.  The spout blocks the tongue tip from rising up to the alveolar ridge just above the front teeth and forces the child to continue to push his tongue forward and back as he sucks on the spout to extract the juice.

Here’s another important take-a-way on this topic:   A 2012 study by Dr. Sarah Keim of Nationwide Children’s Hospital in Columbus, Ohio reported that “a young child is rushed to a hospital every four hours in the U.S. due to an injury from a bottle, sippy cup or pacifier.”   Dr. Keim theorized that as children are just learning to walk, they are often walking with a pacifier, bottle  or sippy cup in their mouths.  One stumble and it can result in a serious injury.

Before I ever climbed onto the anti-sippy cup soap box, I let my own two kids drink from them for a short time.  I even saved their first sippy cup – I’m THAT mom who saved EVERYTHING.  If it’s too hard to let go of the idea of using a sippy cup, let the child use it for a very short time. Then, step away from the sippy cup if the child is over 10 months old or beginning to show signs of cruising the furniture.  In the near future, it will soon be time to conquer two genuine developmental milestones–mastering a mature swallow pattern and learning to walk.

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.

How 2013 Taught Me To Be a Better SLP

2013

We have successfully completed another year owning a private practice in a location that is densely populated with speech language pathologists. And by “we” I mean myself and my husband. We are implementing a business plan that he poured sweat and tears over (everything just short of the blood…) and the doors to our business still remain open.

Given the multitude of stresses that come from running and owning a business, I have learned to measure my success in ways that seems contrary to the ordinary. Here’s what I have learned and how I measured my success as a speech-language pathologist in the year 2013.

1. Being a parent is hard work and I cannot fully grasp and understand that just yet. No matter what a family’s situation is, the energy, effort, resources, skills, brainpower, love, patience, problem solving, planning, and determination it takes to be a parent and caretaker of a child with special needs is really immeasurable. As an SLP I can listen, sympathize, show compassion, and provide resources, but I am not in their place at the present time. Although I am trained to be a support for these families and I respond with new ideas, I am lacking a component of what it really means to live what they are living. Coming to this realization and maintaining awareness of it is huge for me.


2. Baby steps are crucial–for everyone.
 I have learned that so often I attempt to “conquer” a child’s speech or language delay in just one day. My expectations are high and I want the family to see the benefits of my services. But I am not a magician and they need to realize this. And we are working with a human being, not a PowerPoint presentation that we can edit with the click of a mouse. Coming in with realistic expectations and using daily, small stepping stones to increase a child’s skills is what is most beneficial. One of the mothers I work with often repeats this back to me as we summarize sessions with her child (who has many needs). “Baby steps, baby steps,” she says. Yes, so unbelievably true.

3. I need to squish, trample, and eliminate my need for a box. I naturally go through life with a black or white mentality. If something is not one way then of course that would make it be _____ (the opposite of the initial way). I come from a long line of black and white thinkers. Nope. Nada. Not the case. Just because one child was one way, does not mean that child X will be that way as well when they get to point B. Follow? Although I try, I realize that so often I don’t factor in the child’s overall personality into my daily interactions with him or her. I’m not talking about a child’s behaviors. I’m talking about their likes, loves, and dislikes. When I was a kid I loved watches, Hello Kitty, big red soft robes, Where’s Spot? books, music, and bear hugs. This was what allowed me to flourish as a child and I need to help other families do the same with their unique kiddos.

4. You never know when someone is listening…… On occasion I feel myself turning red with frustration at my inability to “get through” to a family (thus the need for lessons 2 and 3). However, on several different instances this year a parent or caregiver summarized the very basis of what we were working on in therapy. Whoops. I love when my husband teaches me that I am not always right he was listening but it may be even more humbling when a family that I work with shares in the same lesson.

5. There is never a limited supply of resources to work with and it’s OK not to reinvent the wheel sometimes. When I’m planning for my sessions I will at times squeeze in another sheet of laminated pictures, more books, or have ready more toys within arm’s reach. Four out of five times I don’t even need these items as I survey the house and begin using whatever toy the child had already been playing with. But I have found that the magic number of three materials in a session usually does it. Why? No scientific basis for it really. A book, one toy, and a small sensory item (bubbles, play dough, etc) usually do the “trick” (whatever that is). This makes me slow down. (Yes, let’s once again go back to number 2.) It gives us enough time to play together and enough time to engage in coaching the family. The reason why there are so many cute, easily adaptable pre-made lesson plans out there is because the crafty people that make them are good at it. Really good at it. And they take pleasure in knowing that people like me are occasionally using their lessons for materials in therapy. We’ve all got our skills and using time efficiently to make materials is not one of mine. That’s what my great, far-reaching community is for.

So given all of the above lessons, how have I measured my success as a therapist this past year? Simply by the fact that I have learned. I have grown. And it only looks like there will be more of that to come in the New Year. While my feet are beginning to be planted in my current practice, the certainty of this stability does not always ring true. But my ability to continuously learn in my profession? Always there without fail. I cannot wait to continue the relationships with the families I am already working with and establish trust in new relationships to come.

Meredith Mitchell, MSP, CCC-SLP, is a pediatric speech-language pathologist who owns a private practice in North Carolina.  She maintains a blog for families on her website and also maintains a separate blog for speech therapists focusing on early intervention.  She can be reached at meredith@sterlingtherapync.com.

 

All I Want for Christmas is My G-Tube Out!

santa baby

A Parent’s Expectations and an SLP’s Goals

As a pediatric SLP who focuses on feeding, I guide families through the process of transitioning from g-tube feedings to 100% oral feeds and ultimately, removal of the g-tube.  This year, I had the unique experience of learning more about the emotional process through the eyes of one mom who happened to be an SLP, too.  In the course of nine months of feeding therapy,  her daughter Payton has taught us both that goals and expectations aren’t always met on the SLP’s or parent’s timeline and that most importantly, the child sets the pace.  Payton’s mom graciously shared her thoughts on the process:

History: Payton was born in December 2012 at 38 weeks, 4 days and weighed 4 lbs., 13 oz..  One month  later, Payton was hospitalized due to congestion, but it soon became apparent that this was a more serious matter.  On January 9th, surgeons performed a Ladd’s procedure to repair a malrotation of the stomach and intestines, a Nissen fundoplication to control reflux and secondary aspiration, removed her appendix, repaired a hernia and placed the g-tube.

Payton-Preemie2

Melanie: When I first met you in March 2013, your family and of course, Payton, had been through so much!  What did that feel like, knowing that she needed surgery and consequently, a g-tube? 

Payton’s Mom: This was my baby; my flesh and blood. I was so mad, sad, overwhelmed, devastated, in denial, and didn’t want any of this to happen. There had to be another option, another way to make her better. My child was not going to eat through a tube and I was going to do all that I could to get that thing out as soon as I could.  I was SO mad and devastated that this had to happen to MY baby.  It felt to us that when she was in the hospital, that the goal was to “fix” her and then we were sent home (feeling totally alone and shattered) to cope with all that we needed to get her to grow and thrive.  Short and long term goals were not clearly communicated to us.  In the back of my mind I knew that this would be a long journey, but I didn’t exactly know how long or what it would entail and I wanted to know NOW! Everyone in the hospital kept telling me that Payton would do this at her own pace (“Payton’s Pace”) but I didn’t want to wait. I wanted my baby better now!

Melanie: We have often talked about the difference between setting goals and setting expectations.  Your journey with Payton has helped me to have a better understanding of the difference.  Goals are targets or objectives.  Expectations feel more passionate and focus on hope, anticipation and personal beliefs.

Payton’s Mom:  As an SLP, I set goals and benchmarks all the time. There is a target behavior you want your client to meet and you set reasonable, attainable steps to get there over a specific, realistic time period.

As a parent, when you have a child with any challenge, you have expectations for them that are based on your emotions, including sadness, anger, denial and/or hope.  From the beginning of our journey, I remember having the expectation that Payton would eat a normal birthday cake and drink milk from a cup on her 1st birthday. Even though Payton just had a feeding tube placed and we were not sure when she would be eating orally again, I still had this expectation.

Melanie: I remember that so well!  I asked you what I ask every parent in feeding therapy: “Tell me what you want for your child” and you answered “I want her to eat birthday cake on her first birthday” and then, you stated it clearly to me once again, just to ensure that I understood.  “She’s GOING to eat BIRTHDAY CAKE on her FIRST birthday” and you had tears in your eyes.  That was a big lesson for me – you’ve taught me so much.  Expectations are very emotional. 

Payton’s Mom: I also had other expectations: that she would be running the hallways of the hospital on the week of her first birthday and say hello to the doctors who treated her!  When I stated these expectations, I knew in the back of my mind that it was unfair to myself and especially to Payton to expect this, because if she couldn’t do it, then would I feel guilty, disappointed, angry and upset that the therapists and doctors didn’t do their job right, or that I wasn’t doing my job.  It was all based on my hope for her to be “normal” and desperately wanting all the emotions of sadness and anger to go away after this difficult journey

Melanie: Is there anything else you feel would be helpful for parents and therapists to understand?

Payton’s Mom: Most importantly, follow your instinct as a parent. I truly believe that following my instinct saved Payton’s life.  A parent should trust that feeling inside of them and advocate for their child as they know them best. The opinions of doctors and therapists should be respected as they are knowledgeable and experienced;  however as the parent you go through life with your child all day, every day and it’s important to communicate and discuss the issues  with the doctors and therapists. Come to an agreement what is reasonable and feasible for your child and family. Sometimes when doctors and therapists are not on the same timetable as you it “gets in the way” of your expectations as a parent. A lot of time is spaced between appointments and as a family, life goes on. Another lesson is to pick your team well. When you have a child who works with many different specialists, it’s important that you work well with them as a family and that your child responds positively to them. There are many options when it comes to professionals and you don’t have to work with who was assigned to you, specifically in the hospital, if you do not communicate well with them, agree with their overall philosophy, or feel that there is mutual respect in the relationship.  Lastly, I have learned to respect my child’s pace of development and progress. Getting your child the therapy they need and following through with the  recommendations from doctors and therapists is essential, but that doesn’t necessarily mean they are going to meet the goals and expectations for them on your timeline. I have tried to remind myself when things get tough/or my expectations are not met that this is “Payton’s Pace.” She is her own being who will determine what she does and when she does it.

Melanie:  Yes, she sets the pace.  So, we don’t know if she’ll get her tube out at Christmas.  What’s  most important is what a fantastic year this has been for her and for Team Payton!   Plus,  this is her birthday month!  She’ll have cake and something delicious to drink from a cup.  Probably a purple cup … because she loves purple.  Happy Birthday, Payton!

Payton-One-Year-Old2

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.

Kid Confidential: Teaching Parents the Power of Play

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I don’t know if it is just my experience or if you too have found this to be a problem, but I have noticed the more I work with very young children, the more I realize parents do not actually know how to play with their children.  I know this is a trend I am finding to be true more and more often, however, I am still shocked when I see it.

Play is such an integral part of a child’s development as it affects all areas of growth including, but not limited to, social skills, communication development, cognition, problem solving and reasoning skills, and imaginative thinking.  Therefore, for those of us SLPs who are working with infant, toddler and preschool-age populations it is not just enough to model play or target language development, we must teach parents how to play.  You know the saying “If you give a man a fish, he eats for a day.  If you teach a man to fish, he eats for a lifetime.”  Well I believe this to be similar–we need to teach parents how to play so their children can continue to develop during the time we are not present as service providers and throughout their childhood.

I have noticed that sometimes even involved parents who are willing to participate in book reading and speech and language drill type activities, are still not always comfortable participating in play.  Involved parents want to know what they can do to help.  The problem is they don’t fully understand the importance of play or how their child’s thinking skills change and grow via play.

So what do I do about this?  How do I try to teach parents how to play?  Here are a few techniques I have used:

  1.  Parent education:  The first thing I do is teach parents why play is so important and how learning takes place.  I explain to parents why we need to incorporate play into our therapy and why their child needs to participate in play with them when I am not present. I also explain the types of play their child is currently exhibiting versus what types of play they should be exhibiting at their age (you can find more details on ages and stages of play here).  This truly helps parents fully understand their child’s current level of functioning and why focusing on play skills is so important to communication development.
  2. Never make assumptions:  When I was fresh out of graduate school I made assumptions that parents knew and understood child development.  But the truth is we cannot assume that parents have had the same experiences as we have had.  Even if we are working with parents of a large family, this does not mean they know or fully understand how to play with their children.  I have learned after making many mistakes to never make assumptions about what parents do or do not already know.  Rather than treating parents as if they are in need of education, I will say something like “I would be remiss if I did not explain/show you how to…”.  Other times, I will say something like “I’m sure you already know this but I need to explain that…”.  Again, these are just two ways to help share my knowledge with parents while not treating them as if they are uneducated or making the assumption that they know more than they do.
  3. Model and explain play:  I then create play scenarios at whatever level of play the child is functioning currently while attempting to expand the play and improve language and problem solving skills.  I carefully explain what I am looking for in a child’s play and how I am changing the play slightly in order to achieve those goals.
  4. Give the parents a turn:  It is imperative that I make sure parents have a turn taking over the play interaction.  I want to empower parents and make them feel as if they can play with their child when I am not there.  However, the only way to do that is to make sure they have an opportunity to practice these skills while I’m still there to assist.  If help is needed, I will guide the interactions while continually reducing support throughout the session.
  5. Videotaping for success:  Videotaping parent/child play interactions can be an invaluable way to educate and empower parents.  I like to videotape portions of interactions so parents can refer back to the videos as needed.  When parents see how they have taken suggestions and turned them into positive interactions with their child, they begin to anticipate and invest their time into participating in play more often with their child.
  6. Follow up weekly:  The key to making this technique work is to make sure I follow up with parents and hold them accountable for their child’s play week to week.  I encourage parents to take videos on their smart phones and save them for our next session.  This way I can see the growth in their child and continue to provide assistance as needed.

Parents are always looking for the “right” ways to play.  So I give them a few tips:

  1. Show some emotion:  I explain that parents need to make sure their face, voice and entire body is showing the emotion they want to exude.  So when parents look their child in the eye, smile wholeheartedly and say, “I’m excited to be playing with you today!” or “This is really fun!”, I know they understand the importance of emotional in play.
  2. Play when you can:  Parents often times shut down if they think I am asking them to play for hours a day with their child which ultimately results in no play from them at all.  Instead I ask them to try to play for one or two 15 minute increments a day.  For parents who work full-time and have several children, I have found this to be a more realistic expectation and request from them.  Also encouraging them to involve their other children in play is a stress reliever for some parents as children are great models for each other and many times siblings are vying for their parent’s attention.  Incorporating siblings in play, seems to help provide the much needed parental attention while teaching the whole family how to interact with a child who may have delays.
  3. Turn off the TV and turn on some music:  Parents believe their children do not watch much television however when I ask if parents like to leave the television on for background noise I tend to get more “yes” answers than “no”.  So I encourage parents to get rid of the visual distractions like television and if they must have some background noise, play some child friendly music instead.
  4. Change out toys the child has available to them:  I have noticed even with my own child that when I periodically change out toys available, I see very different types of play.  This can keep a child’s play dynamic and guard against stagnation.
  5. Mix and match toys:  Mixing and matching toys that would not typically go together encourages growth in a child’s imaginative play.  I have seen some amazing pretend play when I brought random toys to therapy for my clients.
  6. Use nondescript toys/objects:  Some of the best pretend play I’ve observed comes from objects that don’t seem to look like anything in particular.  Have you ever placed a few boxes and a bucket of blocks in the middle of a room and watched preschoolers play?  It’s amazing the “thinks they can think”.  The more nondescript the object, the more creativity goes into the play.Parents always ask me if they are “doing it right,”  if they are playing the right way with their child.  My response is always the same “If your child is smiling, laughing or fully engaged with you, then you are doing it right.”

Do you spend time teaching parents about the power of play?  If so, how do you go about it?

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.

Giving Aphasia a Voice in Baltimore

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Nationally, more than one million Americans are living with aphasia. Aphasia is more prevalent than Parkinson’s disease, cerebral palsy, or muscular dystrophy, yet public surveys show that only one in 100 people know about aphasia.  If aphasia is so prevalent, why are so few people aware of this condition?  The answer is simple. How can people with aphasia advocate for themselves and increase awareness when their central problem is communication?

 

Fortunately advances in technology are providing new opportunities for people with aphasia to speak up.  Individuals with aphasia who attend the Snyder Center for Aphasia Life Enhancement, a community treatment center in Baltimore, are dispelling the notion that they are unable to advocate for themselves. Members who attend the center use an array of technologies to enable their ability to express their thoughts and reveal their competencies and during Stroke Awareness Month they were, indeed, heard.

 

Forty members with aphasia who attend SCALE decided to increase awareness about aphasia in Baltimore through the arts. On May 4, SCALE hosted a play about aphasia entitled “Nightsky.” The SCALE community partnered with the Hugh Gregory Gallagher Motivational Theatre, a non-profit organization that raises public awareness of disability issues and discrimination in our society through dramatizations of real-life and fictionalized experiences. SCALE members invited the group to perform “Nightsky” to their friends, neighbors and folks from the larger community. Despite severe communication impairments they sold tickets, wrote presentations and presented to more than 135 guests.

 

Some members read their written messages orally. Those who have limited spoken output used programs such as WordQ, and Lingraphica to formulate their messages. Several SCALE members used the Vast Program to enable them to fluently produce the materials that they had written. The Vast Program is an innovative research-based application of video technology designed to facilitate and improve communication abilities for speech-impaired individuals. Following close-up video of mouth movements combined with visual and auditory cues allows individuals to readily produce speech. SpeakinMotion LLC has made this approach available to individuals with motor speech disorders such as aphasia and apraxia through its speech therapy apps and custom recording service.

Howard at NightSky

SCALE participant, Howard Snyder, presents information about “Nightsky” to an audience.

Learning to use these programs, creating their messages and practicing what they intend to say required weeks of preparation and hard work by stroke survivors with aphasia. But, the hard work paid off when they were able to deliver their unique messages themselves to advocate for themselves and to educate the public about the effects of stroke on communication and quality of life.

 

Thanks to the National Aphasia Association for uniting scale and the Hugh Gregory Gallagher Motivational Theatre for this collaborative opportunity to promote aphasia awareness.

 

Denise McCall, MA, CCC-SLP,  is the director for SCALE in Baltimore. She can be reached at dmccall@scalebaltimore.org.

Summertime Prep for the School Cafeteria

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Summer!  Ten luxurious weeks of spitting watermelon seeds, munching on veggies straight from the garden and crafting the perfect s’more over the campfire.  As an SLP who focuses on feeding challenges in children, summer food skills are foremost in my mind this time of year.  However, once a week in the summer, my little clients and their families will focus on preparing to eat in the school cafeteria.  Before you know it, it will be mid-August and those little munch bugs will joining their friends at elementary school, or perhaps all-day kindergarten. For kids who are about to go to their very first day of school, it also means their very first day in a school cafeteria, and that can be quite overwhelming, especially for a child in feeding therapy.

Many kids are truly scared of the school cafeteria. In fact, one little boy I worked  with called it “the Café-FEARia.” Imagine a 5-yea- old, on his first day of school, as he tries to negotiate a sea of kids filing into the school lunchroom, attempting to locate his lunch box among 20 others piled into a giant bin and ultimately squeeze into a tiny place to sit at the assigned table. Now, unlatch that brand spankin’ new lunchbox (how does that latch work, anyway?) and peer inside … the clock is ticking … your little munch bug now typically has 20 minutes left to eat, clean up and get back in line with his class; not the most relaxing lunch for any kid.

 

Introduce Weekly Lunchbox Dinners

Feeding therapy is more than just learning the mechanics of biting, chewing and swallowing.  Generalizing skills to multiple environments is essential.  For kids transitioning to school lunch, introduce once a week “lunch box dinners” where the entire family pretends to eat in the school cafeteria.  At the entrance to the kitchen or dining area, one parent stashes a large bin, just like the kids will find at school.  Each member of the family has their own distinct lunchbox thrown into the bin, along with a few “old” random empty lunchboxes so kids can practice digging down to the bottom to find their own.

 

Once everyone is seated at the table, the child can practice the fine motor skills of unzipping zippers, unfastening Velcro® flaps and opening up containers.  Choose a lunchbox that is easy to open and holds all the food in one container.  It saves precious time!  My favorites are Easy Lunchboxes® and Yumbox® , both simple to open and perfect for cutting the food into bite sized pieces.  I call it “grab and gab” food.  Speaking of “gab,” many of my feeding clients also are working on pragmatic skills with their peers, especially when they are in unfamiliar situations.  As an SLP, I teach the parents to practice this little script: “I’ve got ____ in my lunch!”  In all my years of sitting in school lunchrooms and listening to young kids, it’s ALWAYS the first thing they say to each other.  It’s their traditional conversation starter, usually accompanied by them proudly holding up the celebrity food – the star of the lunchbox. I can attest that I hear just as many kids enthusiastically say “I have fruit today!” as “I have (fill in any junk food here) today!”  Try for  the veggies … it’s really okay … it’s just as cool to have vegetables cut up into stars or other fun shapes so they can announce, “I have CUCUMBER STARS today!”  Better yet, get the kids involved packing the lunches and creating fun shapes so they can exclaim “I made carrot triangles for lunch!”  FunBites® are child safe tools for doing just that.  They may not eat them that day, but they will be comfortable with carrots in their lunchbox, and that’s the first step to trying a new food in a new environment.

 

Once the meal is over, everyone latches their lunchbox and puts it back in the bin, just like at school.  The final piece of advice I offer to families is this: The most important word in the phrase family dinner is “family.”  Enjoy this time!  Happy Summer everyone!

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 kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is approved by ASHA and includes both her book and CD.  She can be reached at Melanie@mymunchbug.com.

Best New Games for Speech Intervention

May23

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

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

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

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

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

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

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

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

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

On the Farm Who’s In the Barnyard by Ravensburger

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

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

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

WordARound by Thinkfun

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

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

Suggested age: 10 years and up

What’s It? by Peaceable Kingdom

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

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

Suggested age: 8 and up

Qualities by SimplyFun

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

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

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

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

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