Maximize Treatment Minutes by Assigning Homework

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A recently published article in Frontiers of Neuroscience supports what we as clinicians know: The more time clients spend on meaningful treatment tasks, the better their outcomes.

Yet there are only so many hours in the work day, so many sessions that insurance covers and only so many minutes of treatment we can give. So how do we get around these limitations? Give your clients homework.

The article mentioned above states that patients who do exercises at home in addition to their weekly sessions improve significantly more than patients who only attend sessions. But how do we find time to create, assign and track homework in the midst of packed schedules, IEP meetings and productivity expectations?

A go-to for SLPs are worksheets and activities like those found in the Workbook of Activities for Language or Cognition and Handbook of Exercises for Language Processing series. Many SLPs also develop their own activities or assignments that they write or print for clients. These paper-based exercises are free and individualized, plus they cover any range of skills from visuospatial reasoning to word-finding.

In addition, the increasing availability of technology offers several online-based options. The app featured in the study referenced above (Constant Therapy, free for clinicians) allows SLPs to assign a variety of language or cognitive homework tasks for clients to do throughout the week on their iPads, Androids or Kindles. Plus, clinicians and patients see all of the progress tracked by the app.

There are also several other apps that help patients work on specific skills. For instance, growing numbers of interactive, pediatric-oriented games allow parents to play with their children to practice treatment skills. (I like the Bag Game from all4mychild, for example.) There are also apps aimed specifically at adults, such as those from Lingraphica, Tactus, and Virtual Speech’s new, adult-oriented series of apps (like Verbal Reasoning). There are even apps that are built into many tablets and smartphones—calendars and alarm systems—that we can use with our clients to practice executive function skills independently and functionally.

The practice of assigning homework allows the clinician to more effectively manage our time and also has a great advantage of engaging patients in their own treatment programs. Today’s technology also allows clinicians to monitor clients’ compliance while empowering them to take responsibility for their improvement.

In today’s fast-paced, schedule-packed world, we must maximize our time and that of our patients! Try out a new homework option today—then share it with a clinician friend to help them save some time, too.

 

Jordyn Sims, MS, CCC-SLP, is a speech-language pathologist working in the Boston area. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; 2, Neurophysiology and Neurogenic Speech and Language Disorders; and 15, Gerontology.  Sims has experience with adults and pediatrics and is a clinical consultant for Constant Therapy. jordyn.sims@gmail.com 

Using Menus as a Treatment Tool

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

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

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

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

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

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

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

Smart PHONeNATION: How My Device Revolutionized My Voice Rehabilitation Practice

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My smartphone has literally revolutionized the way I give sessions. And I don’t mean literally Rachel Zoe style. I use my phone practically every session! Now I hear those of you who are seasoned professionals. You are unfamiliar, maybe apprehensive about technology like this. “It’s too difficult,” you say, “I’m not generation text message-thumb.” I hope this piece encourages you to give it a try.

Age knows no bounds when you apply technology, because most everyone can benefit from these innovations. I’ll echo a recent ASHA post on SLP hats and inquire the same about the many jobs of your smartphone:

  • Stop-watch. I have one less item to worry about if I use my phone for timing maximum vowel prolongations, S/Z ratios and structured session tasks. Your phone timer also tracks session length. We all have those clients who love (I mean REALLY love) to talk, which is good when you advance to structured conversational tasks, but sometimes they carry on too long. Use your phone timer if you feel it’s appropriate for signaling a wrap-up.
  • Recording device. I record my acoustic measures when I analyze cepstral peak prominence and fundamental frequency, but during therapy—where the hard work begins—I employ my voice memo app. I also teach patients how to use their own voice memo programs, which is important for home practice. Follow-through is such a different game now, because most patients have recording options on their phones. You can record session highlights for easy patient access on his or her own device, versus cassette-taping the session.
  • Biofeedback. It’s great if you have a state-of-the-art Computerized Speech Lab setup. If you don’t, your smartphone has an app for that. (Ha! You were waiting for that phrase, weren’t you?) Bla | Bla | Bla works as a visual sound meter. As you get louder, the faces change. It doesn’t replace the software that helps you stay within a target pitch range, but can provide biofeedback for intensity tasks. I use smartphone video recorders to improve self-awareness for laryngeal and upper body tension. Instant review of these videos may help your patient meet goals sooner.
  • Piano. For Joseph Stemple’s Vocal Function Exercises, I use my MiniPiano app for pitch matching on Warm-up and Power. For the small group of clients with NO musical inclination, just do you best to find a mid-range pitch for VFE’s, but for your type-A’s (you know who they are), the option to have perfect pitch right at your fingertips wastes no time.
  • Anatomy. I used to lug around literally (Ha, Rachel again!) thousands of copies of anatomy drawings for patients. The copies usually ended up in the trash. The Dysphagia app has been my most effective tool for explaining the anatomy of a swallow, vocal folds as well as reflux. It has nice color videos demonstrating disordered and normal swallows and dramatically enhances patient education. Plus, the video action makes a more lasting impression.
  • Alarm. Ever get a patient who doesn’t practice? (You can always tell.) With a smartphone, you can name each alarm and set them to go off at certain times. The patient can deliberately practice diaphragmatic breathing and single syllable target words every hour on the hour! We’re going for making new muscle memory here, so it’s key to entice the patient to practice mindfully and not just be on autopilot. It’s beneficial for whole body exercise to take place for short periods throughout the day, so why not phonation training? And it keeps patients accountable.

Embracing the technology out there doesn’t mean you need to de-humanize sessions. The relationships you build with your clients are special. Their progress depends on how comfortable they feel in the room. Don’t spend the entire session glued to your phone, but strive to find a good balance where you use it when you think it will make a difference.

We SLP’s and AuD’s are in the people business and let’s not forget we’re professional voice users ourselves. Voice therapy techniques used to be difficult to maintain out of the treatment room. Now our clients have a fighting chance to recreate that buzzy forward-focused sound every time they glance at their smartphone between Facebook updates and Yahoo news articles.

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She provides voice, swallowing and speech therapy in her own private practice, a tempo Voice Center, LLC. She also lectures on the singing voice to area choirs and students. She belongs to ASHA’s Special Interest Group 3-Voice and Voice Disorders. She keeps a blog on her website at www.atempovoicecenter.com. Follow her on Twitter @atempovoice or like her on Facebook at www.facebook.com/atempovoicecenter.

How to Evaluate Misbehavior

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

The Possibilities are Endless!

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Having been an SLP since 2004, I know the feeling of “burn out” as well as being comfortable. I have learned that there is far too much opportunity in this field to settle for status quo or unhappiness. Perhaps the most valuable lesson I learned was recognizing that simply venting to family, friends and fellow SLPs was only a short-term solution.  I had to learn to be a doer and motivate myself within my chosen profession.

I often see many Facebook posts about SLPs feeling tired of the profession, often citing endless paperwork, disrespectful supervisors, caseload overload, lack of resources, unreasonable expectations and unfair pay. They are often looking to change careers for a “quick fix” to these problems, but overlook the changes they can make within their profession.

I was feeling frustrated at my district job six years ago and my lack of connection with other SLPs. I did my best to reach out to others and was ultimately nominated by my colleagues to become the lead SLP. That experience empowered me to talk to administration about changing to the 3:1 service delivery model. My presentation worked!

From then on, monthly SLP meetings were built into our indirect weeks and the 15 of us worked and supported each other throughout the school year. Our motto was “we’re all in this together,” because we are the only people who knew what our jobs are like on a day-to-day basis.

Fast forward six years, I loved my position as lead but craved a change. One fateful day I happened to be talking to a friend/fellow SLP in my district who said, “Annick, why don’t we just quit and start our own private practice?” My response, “Why don’t we?” My friend laughed but I wasn’t joking.

That was the question I needed to ask myself. I hadn’t thought about that option before. Coming out of our master’s program, the questions on everyone’s mind were: Are you going to the schools? Hospital? Or private practice? We never asked each other: “Do you think you’ll ever start your own practice?” For me, that question was life altering. Although my friend was kidding, her words were far from a joke for me. Within months, I registered my business, created a website and printed business cards.

I now grow my practice while working as a part-time, school- based SLP. But it doesn’t end there. I supervised three graduate students earlier in my career and one them recommended me to a professor as a possible lecturer. I jumped at that opportunity and have made yet another discovery: I love teaching adults! I am about to begin my second semester teaching college courses.

Looking to the future, I want to continue to teach more classes, build my practice, present at conferences and perhaps look into other areas of our profession such as telepractice and corporate speech therapy. Whatever I do, it is comforting knowing the possibilities are endless within our field.

 

Annick Tumolo, MS, CCC-SLP is currently a school based SLP, lecturer at San Francisco Sate University and founder of Naturally Speaking San Francisco, a private practice specializing in home-based speech and language treatment. She is Hanen certified in It Takes Two To Talk ® and holds a Augmentative and Alternative Communication Assessment and Services Certificate awarded by the Diagnostic Center of Northern California. Like her on Facebook, follow her on Pinterest or contact her at Annick@naturallyspeakingsf.com.

Be an Advocate for Your Clients

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This summer I had an interesting experience with a major insurance provider. The company initially approved treatment for a 3-year-old client, who I evaluated and diagnosed with severe apraxia of speech. This little guy had maybe five words in his lexicon, all unintelligible to an unfamiliar listener. He could not even consistently attempt to imitate monosyllabic words. His receptive language skills were at least at age level with cognition the same.

After several months of treating him with a motor-planning and sound-sequencing approach, his parents received notification from the insurance company that his treatment was denied because “it was not medically necessary” and his apraxia was deemed “developmental.” The communications stated that my client would “outgrow” his issue in time.

I have been in private practice for almost 28 years and ardently disagree with the insurance company’s reasoning. I consulted with Janet McCarty, at ASHA headquarters, and she provided me with excellent professional advice plus solid evidence to fight for my client. I organized my information then consulted with the family to get their green light to proceed. I went all in to fight this decision with the big insurance company’s medical director.

It became a step by step process to help this medical director understand that apraxia is NOT a developmental disorder, but rather a neurologically based disorder that results in disruptions to a child’s ability to sequence the necessary motor movements to produce speech sounds. My favorite part of this story is when I asked the director how much time I had to discuss my client with him during our peer-to-peer scheduled review, he informed me that “he did not want to be lectured about apraxia because he had Googled it and saw the word ‘developmental’ tossed sporadically around the literature and that was all he needed to see to be convinced that apraxia was not a medical condition with neurological basis.”

I quickly lifted my jaw off my desk, hit my reset button and proceeded to help this “medical expert” understand more about apraxia from this expert in the field of speech and language. While our exchange made some positive impact, he still felt the need to take this case to the next level by calling in a third party pediatric neurologist. I knew that this was going to be a medical professional in my corner. The neurologist and I spoke about my client and I was able to answer specific questions about his treatment and progress. Sure enough, her recommendation was absolutely in favor of this severe speech disorder being neurologically based and treatment medically necessary. She agreed that my client would not outgrow it in time or improve through weekly sessions in small groups.

My point for sharing this story is to say that while it is often frustrating to deal with insurance companies, you have to fight for your clients. When you meet, evaluate, work with a child and their family and you know a child needs treatment, you must advocate and spend the time to fight for this child, no matter how BIG these insurance companies are or how much they try to shut you down.

I need to correct my earlier statement when I referred to my “favorite” part of the story…in fact, my favorite part of this story is that my client, who is now 3.6 years old, was approved for intensive therapy to treat his motor planning disorder. He is making remarkable progress and I am quite confident he can tell Santa what he wants in a complete sentence. Maybe with Mom’s help interpreting, but still excited and able to convey his message!

 

Lorraine Salter, MS, CCC-SLP, has been in private practice in Reading MA since 1986. She studied and earned both degrees from Emerson College in Boston, after deciding that a career in performing arts was not going to pay the bills.  She enjoys the ability to create a strong team for the children she serves through interaction with her clients’ families. You may contact her at lorraine@northshorespeechandlanguageservices.com.

“Cuz You Know I’m All About That Case, Node Trouble”

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Meghan Trainor’s song is so popular that excellent covers are popping up everywhere and I think there is a strong possibility of another definition of “bass” being added to the dictionary by next year. Now, while Meghan has no history of voice issues that I am aware of, others in the spotlight have suffered from vocal pathologies so severe that they have had to cancel tours and even rehabilitate their singing voices for years before performing live again.

Voice care has been in the media recently and I think it is important for clinicians to understand exactly what is going on with these popular cases because it will help them answer tough questions. I am always reading whatever I can get my hands on. I know that most SLP’s and AuD’s out there barely have time to dash to the bathroom during a work day, let alone to thoroughly read a peer-reviewed research study. It is our duty as clinicians to have a strong commitment to lifelong learning because our abilities as competent care providers are supported by the information we can synthesize on the spot. It is always okay to say, “I don’t know,” however, I always feel extra special when I can say: “I read about this last week.”

Not having enough information on a topic usually leads to accusations and rash decision making. I had a client recently ask about the procedure that was performed on Joan Rivers, which ended up causing her death. “Don’t you do that?” she asked. I explained that although I do not biopsy vocal cords, I do look at them with a camera and the patient needs to be awake so he or she can say “eeeeee.” I went on to explain that topical anesthetic is sometimes used when the gag reflex is particularly sensitive, but no patient of mine is ever sedated for an exam. Joan Rivers had some unplanned things happen during her procedure and because her healthcare information is private, just like any patient’s, we are left to read and watch news stories compiled with some facts missing.

Most of us know that Julie Andrews had great success with “The Sound of Music” and “Mary Poppins,” but many might not know that she battled with vocal nodules, also called nodes, in the 1990’s. Speech-Language Pathologists know now that vocal nodules usually respond to behavioral voice therapy without needing surgical intervention. Julie had her nodules removed in 1997, but the surgery left her with the inability to sing. We wonder, as we do in Joan’s case, what actually happened. If Julie had noncancerous nodules and her behaviors were addressed, perhaps surgery wouldn’t have been necessary at all. Nodules shouldn’t come back if the vocally abusive behaviors are replaced with efficient vocal production techniques. We don’t know if Julie had any voice therapy, but we can speculate that she most likely had scar tissue develop where the nodes were removed. Scar tissue inhibits the vocal fold tissue’s elastic properties resulting in pitch breaks or periods of aphonia.

Nodes have also been addressed by mainstream media in the movie “Pitch Perfect.” Chloe tells the Bellas she has vocal nodes in a dramatic scene, but reveals she has continued to sing despite the diagnosis because she loves it so much. We can’t be expected to know every movie or pop-culture reference to our profession, but it helps to be aware so we can connect to younger clients. Chloe’s story is all too familiar. Some clients find it very difficult to follow treatments because their jobs depend on voice use or they are passionate about performing. It is essential to communicate the importance of adhering to all voice therapy recommendations. Explain that while you understand their passion for their craft, you know that they will have more heartache later if they don’t take time to correct behaviors now.

John Mayer very recently opened up on Twitter to discuss his long and emotional struggle with a granuloma. He says, “It’s 2 years to the day that I had my vocal cords paralyzed so they could heal. It took about as long to get all of my voice back. I can’t tell you how good it feels to hit those notes. Especially on new songs. I’m free again. So grateful.” Well done, John. As clinicians, it’s important that we educate our clients about the length of recovery time, especially for professional voice users.

Polyps have plagued singers like Adele and Keith Urban. Adele reportedly used an app on her phone to speak for her while she was on voice rest for her hemorrhagic polyp, but I wonder if she knew about this avatar program. Technology is readily available these days to improve success for any clients on vocal rest. Both performers underwent surgery to correct these conditions, and hopefully some voice therapy too, as polyps and hemorrhages are functionally caused vocal pathologies. There are four different classes of voice disorders: Functional, Neurological, Organic and Idiopathic. With Adele and Keith’s conditions falling under the functional category, voice therapy could reverse bad habits and keep them from developing any future lesions.

Have you ever provided therapy to a famous client? I know you couldn’t tell anyone even if you have, but it’s pretty exciting, right? Sometimes we need a reminder that a high-profile client’s plan of care should be given the same attention as any other on our caseload. It is okay to feel star struck, but remember to remain calm and collected. Any famous clients will thank you for your professionalism and remember how your intervention helped them get back to doing what they love. Trust me on this one.

So whether your patient is red-carpet-ready or your average-Joe, be knowledgeable and treat clients with equal respect and care so you can “bring savvy back” and be “all about that case.

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She provides voice, swallowing and speech therapy in her own private practice, a tempo Voice Center, LLC. She also lectures on the singing voice to area choirs and students. She belongs to ASHA’s Special Interest Group 3-Voice and Voice Disorders. She keeps a blog on her website at www.atempovoicecenter.com. Follow her on Twitter @atempovoice or like her on Facebook at www.facebook.com/atempovoicecenter.

 

Teens and Feeding Therapy:  An SLP’s Top Five Tips!

Making trying new foods fun for teens.

Making trying new foods fun for teens.

As a pediatric feeding therapist, it’s not unusual for me to get a call from a mother who says “My kid’s 14 years old and still eats only six foods. He’s so picky!  I thought he would grow out of it.”  True, with patience and consistent strategies, some kids do indeed grow out of the picky-eater stage, typically at its peak aro

und age three. But if the child had underlying motor, physiological or sensory challenges that stalled the developmental process of learning to eat a variety of foods, it’s not unusual that selective eating behaviors will prevail into the teenage years.  I approach treatment with teens in a similar manner as my younger clients while respecting one important fact: They are teenagers!

Here are my top five tips for interacting with teens while building trust and confidence, plus making feeding therapy successful (and fun!) for both of you:

#5  Use Cool Games:  I always incorporate games into feeding practice.  Learning to try new foods is HARD, at any age.  Including games in the process of biting, chewing and tasting keeps anxiety levels low and still allows learning to take place.  Using games as a means of distraction, such as eating while playing independently on an iPad, does not allow for conscious learning.  Instead, try using games that are reciprocal in nature and where each player’s turn lasts no more than ten seconds.  If your client is working on learning to drink a smoothie, perhaps he might take a drink, get a turn, etc.  Try Blockus, UNO Blast or  Connect-4 Launchers, all interactive and exciting games. Plus, they are easy to clean, which is important in feeding treatment.

#4 Create Your Own Games: To quote a bit of teenage lingo, find out what the teenager “is obsessed with” and create games around that obsession. Does she love three-toed sloths?  Pull up the best sloth videos on YouTube and create a Jeopardy game around them, hiding each video under categories like  “Kristen Bell for One Hundred Please.”   I once had a client who knew every Movie Production Logo in Hollywood.  His mother sent me pictures of ten favorite logos and I laminated two copies of each.  During feeding therapy in his home, we would spread out the laminated pictures all over the kitchen floor and after each bite, try to toss a penny onto a picture.  Get a match, and you get a point.  Another client of mine was obsessed with paintball, but I wasn’t about to do feeding therapy in a paintball bunker.  Instead, I brought my Discovery Toys Marbleworks® and with each bite we added one piece, eventually building intricate contraptions and using the paintballs as marbles.

#3 Ask WHY: Once I get to know a teen, I always ask this question: “Is there a special reason you want to learn to try new foods?” One teen told me that he wanted to ask his girlfriend to Prom, but was afraid that he couldn’t take her to a fancy restaurant for dinner.  “I don’t think they serve pizza there, and that’s all I know how to eat.” That was eye-opening for me!  Now I know his motivation and we have a timeline for success. When there is no motivation, that’s a problem.   It’s common for a teen to reply: “I don’t want to learn to eat anything new – my Mom is making me.”  This is the time to help a teen FIND motivation.  “How’s wrestling going?  Did you know you need protein to build more lean muscle? What types of protein would you like to learn to eat: nuts, hamburger or vegetable protein?”  One of my clients had been consisting on  four strawberry Pediasures mixed with whole milk every day for over three years before starting therapy. He used to eat some solid foods, but over time began to limit his intake until he was food jagging on Pediasure.  He didn’t see a problem, because he liked the way he could gulp down a Pediasure and rush outside during break time to play basketball with his friends. That worked for him because it enabled him to avoid social eating in the cafeteria, which made him very anxious.  I suspected that the high dairy content was making him constipated, thus decreasing appetite.  Let’s face it: A teen is not likely to tell ME about his constipation.  But, I called his pediatrician and requested that they have the constipation talk during the upcoming sports physical.  Once his doctor explained that he would no longer have to struggle with bathroom issues, which was a huge source of embarrassment for him, the teen was open to tasting some new foods.  Feeding therapy, especially with teens, goes best when we focus on the whole child and learning what’s important in his unique world.

#2  Teach positive self-talk: So many older kids engage in negative talk about food because it stops parents from serving it.  Over time, those negative comments become a habit that for lack of better term, is a form of self-brainwashing.  While it’s important to acknowledge a teen’s feelings if he says “I can’t – I’m scared I’ll gag,”  it’s just as important to help him talk positively about eating.  I explain it this way:

I want you to talk to your own brain the way you would talk to your best friend.  If your best friend had practiced with his soccer coach to take a goal kick in soccer but was feeling anxious when it came time to attempt it, he might turn and whisper to you, “I can’t – I’m scared that I’ll miss.” You’d probably tell  him “You’ve practiced with coach and you have the skills to do it!  It’s OK to be nervous – you can still make that goal!”  He needs to hear that from you.  Well, your brain needs to hear the same positive talk from you when you talk about food.  It’s OK to be nervous and it’s OK not to like the taste of it.  We’re just beginning to learn how to how to eat this new food and we are practicing it.”

And this SLP’s #1 Tip? Give Them the Script: Teens may not always have the most descriptive vocabulary, except to narrow taste and texture down to “gross.”   Give them the language and discuss what terms like savory, buttery, creamy truly mean.  A reference list of 345 terms to describe food can be found here.  Plus, it helpful to use comparison phrases such as “It’s similar to tiny dots of corn, but it’s called polenta” in order to build familiarity with a food they’ve experienced in some manner, such as corn.  If the most interaction they’ve had with corn is just staring at it, that’s OK!  Stare at the polenta.  Make it a kitchen science experiment and discuss all the properties of polenta if you need to.  Give them the words that build visual familiarity with polenta: “yellow cornmeal”, “hulled”, etc.  Talk about how it can be baked, fried, grilled or stirred into a porridge.  Interact with it – get to know it.  Now you’ve got a teen whose introducing his brain to polenta by saying: “Polenta is cornmeal, which is made from something I’m familiar with: corn.  I think it looks best when it’s fried, because I like fried foods.” He’s OPEN to the concept of Polenta because he has the terminology to describe it and understand the properties. As you progress from visual interaction to tactile exploration, provide terms that describe the feel of polenta such as “gritty” and “course.” Eventually, you’ll be discussing the same feel in the mouth.  As all SLPs know, language is empowering.

What other strategies do you have when helping teens interact with new foods?  Please list them in the comments section, thank you!

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is  offered for ASHA CEUs and includes both her book and CD for each attendee.  She can be reached at Melanie@mymunchbug.com.

Using Comic Strips in Speech Intervention

comic

For the past couple of years, I have used Carol Gray’s materials extensively during my work with adults with developmental disabilities. Creating comic strip conversations has been extremely helpful in facilitating conversation, resolving social issues between peers, taking turns in conversation and providing different social scenarios within various contexts.

Since I have worked in creating my own comic strip conversations with my clients for some time now, I decided to experiment using the comics section in the newspaper. My clients are motivated by the local newspaper for many reasons. They enjoy browsing through current events, looking at the pictures in the sports section and reading the comics.

The comics within a local paper are inexpensive (in my area it is just $1.00 for the local newspaper), easily accessible and age appropriate for older children, teenagers and adults. Therapy using comic strips has been surprisingly motivating and beneficial to my clients. I never realized how effective using the comics section could be!

I like to keep my favorite comics and laminate them for future use. I have also created a game around using the comics section. My clients take turns choosing from a pile of comic cards and then have a discussion about each particular card. When one client doesn’t understand a particular comic and why it’s funny, I have him ask his peer for assistance. As a group, we have had many extensive and interesting conversations related to the comics. Here are some speech and language goals that can be facilitated with the comics:

1. Expanding vocabulary: The comics are full of language, which make it an ideal time to discuss and define new vocabulary. It will be difficult for a client to understand a particular comic without understanding the actual definition of some of the words. For example in a recent Garfield comic, Garfield thinks “This is a perfect day to stay in bed and contemplate life’s truths.” Discuss what “life’s truths” means with your client. Defining the “contemplate” can help build vocabulary and build in conversation. Ask your client, “What do you contemplate about?”

2. Abstract Language/Humor: The comics are excellent in discussing abstract language and humor. In many comic strips, there are often multiple meanings of words. In a recent comic, the discussion between the characters was about “trail mix.” To one character trail mix was the snack, to the other character trail mix was a bunch of items that you picked up along a trail in the woods (e.g. dirt, sand, rocks). This comic began a conversation about the multiple meanings of words and how they had a miscommunication. Discuss the humor in the comic and why it may be funny to the reader. This can be a tricky exercise for many clients especially with autism, but it can be extremely useful as well. Helping a client recognize humor can help build friendships and improve conversational skills.

3. Taking Turns in Conversation: Between characters, there are natural turns in conversation. This can be a great model for conversation. As a carry-over activity continue the comic with an extra blank comic strips. This can help your clients create their own conversations.

4. Improving Literacy/Punctuation: Having your client read the comics can help improve literacy and reading comprehension. Point out different punctuation markers within the comic such as exclamation marks, periods, question marks, etc. Also, discuss the difference between the characters thinking a particular thought versus actually speaking it.

5. Interpreting Facial Expressions and Feelings/Emotions: In many comic strips the characters have extreme emotions. In other comics, the feeling and emotions of a character can be a little tricky due to the high levels of sarcasm. Read the specific comic strip together, discuss the language and then ask your client how the character is most likely feeling.

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

 

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

picky eater

 

As a pediatric feeding therapist, many kids are on my caseload because they are stuck in the chicken nugget and french fry rut…or will only eat one brand of mac-n-cheese…or appear addicted to the not-so-happy hamburger meal at a popular fast food chain. While this may often include kids with special needs such as autism, more than half my caseload consists of the traditional “picky-eaters” who spiraled down to only eating a few types of foods and now have a feeding disorder.  I  even had one child who only ate eight different crunchy vegetables, like broccoli and carrots.  Given his love for vegetables, it took his parents a long time to decide this might be a problem. The point is: These kids are stuck in food jag, eating a very limited number of foods and strongly refusing all others.  It creates havoc not only from a nutritional standpoint, but from a social aspect too. Once their parents realize the kids are stuck, the parents feel trapped as well. It’s incredibly stressful for the entire family, especially when mealtimes occur three times per day and there are only a few options on what their child will eat.

It’s impossible in a short blog post to describe how to proceed in feeding therapy once a child is deep in a food jag.  Each child is unique, as is each family. But, in general,  I can offer some tips on how to prevent this from happening in many families, again, keeping in mind that each child and each family is truly unique.

Here are my Top Ten suggestions for preventing food jags:

#10: Start Early.  Expose baby to as many flavors and safe foods as possible.   The recent post for ASHA on Baby Led Weaning: A Developmental Perspective may offer insight into that process.

#9: Rotate, Rotate, Rotate: Foods, that is.  Jot down what baby was offered and rotate foods frequently, so that new flavors reappear, regardless if your child liked (or didn’t like) them on the first few encounters.  This is true for kids of all ages.  It’s about building familiarity.  Think about the infamous green bean casserole at Thanksgiving.  It’s rare that hesitant eaters will try it, because they often see it only once or twice per year.

#8: 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.

#7: Offer Small Portions:  Present small samples.  Underwhelming – that’s  exactly the feeling we hope to invoke.   Besides, if a tiny sample sparks some interest and your child asks for more peas, well, that’s just music to your ears, right?  Present the foods in little ramekins, small ice cube trays or even on  tiny tasting spoons used for samples at the ice cream shop.

#6: Highlight Three or Four Ingredients Over Two Weeks:  You can expose kids to the same three or four ingredients over the course of two weeks, while making many different recipes.  For example, here are nine different ways to use basil, tomatoes and garlic.  Remember get the kids involved in the recipe, so they experience the food with all of their senses.  Even toddlers can tear basil and release the fragrance, sprinkling it on cheese pizza to add a little green.   If they just want to include it as a garnish on the plate beside the pizza, that’s a good start, too!

#5 Focus on Building Relationships with FoodThat often doesn’t begin with chewing and swallowing.  Garden, grocery stop, visit the farmer’s market, create food science experiments like this fancy way of separating egg whites from the yoke.  Sounds corny (pardon the pun!), but making friends with food means getting to know food.  I often tell the kids I work with “We are introducing your brain to broccoli.  Brain, say hello to broccoli!”

#4 Don’t Wait for a Picky Eating Phase to Pass: Use these strategies now.  Keep them up, even through a phase of resistant eating.  Learning to be an adventurous eater takes time.

#3 Don’t Food Jag on FAMILY favorites.  In our fast paced life, it’s easy to grab the same thing for dinner most evenings.  Because of certain preferences, are the same few foods served too often?  Ask yourself, are you funneling down to your list of “sure things?”  It’s easy to fall into the trap: “Let’s just have pizza again – at least I know everyone will eat that.”

#2 Make Family Dinnertime Less about Dinner and More about Family.  Why?  Because the more a family focuses on the time together, sharing tidbits of their day and enjoying each other’s company,  the sweeter the atmosphere at the table.  Seems ironic, given this article is focused is on food, but, the strategies noted above all include time together.  That’s what family mealtimes are meant to be: a time to share our day.  Becoming an adventurous eater is part of that process over time.

And the #1 strategy for preventing food jags?  Seek help early.  If mealtimes become stressful or the strategies above seem especially challenging, that’s the time to ask a feeding therapist for help.  Feeding therapy is more than just the immediate assessment and treatment of feeding disorders – the long term goal is creating joyful mealtimes for the whole family.  The sooner you seek advice, the closer you are to that goal.   I hope you’ll visit me at My Munch Bug.com for articles and advice on raising adventurous eaters and solving picky eating issues.  Plus, here are just a few of my favorite resources:

Websites & Blogs

Doctor Yum.com

Spectrum Speech and Feeding.com

Picky Tots BlogSpot

Books

Getting to Yum

Fearless Feeding

Nobody Ever Told Me (or My Mother) THAT!

Facebook

Food Smart Kids

Feeding Matters

Feeding Tube Awareness

 

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.