Collaboration Corner: Developing an IEP with C.A.R.E.

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How can we make goal-writing and individualized education programs less daunting?  Recently I wrote an article for the upcoming March volume of SIG 16 Perspectives. I took the literature and combined it with what, in my experience working in public schools, makes the process collaborative.  Since I’m a visual person, I drew a model:

 

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So as you sit down as a team to write your next IEP, you may want to consider these four parts:

Context:

I apologize to those of you who have heard this from me before, but I can’t stress enough how important it is to remember that language is everywhere. Aside from basic artic goals, we really can embed our goals under most curriculum areas. Look to see how your speech and language targets may actually fit across other areas such as math (descriptive/comparative language), history (explain/describe/narrate), and science (using temporal language to order steps in a process, vocabulary).  If our ultimate goal is generalization, then it is logical to think broadly, holistically.

 

Assessment

Assessment doesn’t happen just at IEP time, it should be ongoing. If an IEP is collaborative, then data can be collected from a variety of general education activities and speech and language activities. Don’t reinvent the wheel; look at the assessments the general education teacher is giving your students and either analyze their findings or offer to provide the assessment. This is not extra work; it helps to inform your intervention. Recently I helped a Kindergarten teacher with a dictation assessment, and was it ever so enlightening!

Review & Reflect

Review your approach honestly; reflection is how we, as practitioners, learn and grow (Tagg, 2007). Since we have very little time in our crazy professional lives, this often falls by the wayside. As related service providers, we need to find time to discuss what we are seeing, and consult with teachers on how this can translate academically. In some cases, this may mean including in the IEP that the team will meet every certain number of weeks, to discuss and update one another on the student’s current performance.

Extend

Think about how to create goals that can extend beyond the immediate environment. For the majority of the students who I see, I am constantly looking for ways to connect academics with independence. A student learning math and money, for example, may need a trip to the store. A student working on following directions may bring a list to the store and come back to follow a recipe. These kinds of experiences make the abstract become concrete.

C.A.R.E is about creating a smooth, efficient and collaborative IEP process. This way we can move on from the paperwork part, and get back to the business of intervention and academic success. For more detailed information, please keep an eye out for my article entitled, “Autism in the schools: IEP best practices at work,” coming out in the next SIG 16 Perspectives issue.

Kerry Davis, EdD, CCC-SLP, is a city-wide speech-language pathologist in the Boston area. Her areas of interest include working with children with multiple disabilities, inclusion in education and professional development. The views on this blog are her own and do not represent those of her employer. Dr. Davis can be followed on Twitter at @DrKDavisslp.

Tips to Wrangle Your Most Unruly Speechies

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At the beginning of each school year, I have great expectations that this year is the year that all my little speechies are going to manage their behavior well in my treatment room with minimal incentives on my end. So much for great expectations. Because, of course, every year, I’m presented with new challenging behaviors to tackle because we educators know that “all kids are unique and different.”

Just when I think I have mastered all that I need to know about behavior management, one my little sweet speechies decides to bring a new unpleasant behavior into my speech room.

The good news is, I have learned much about managing these behaviors, both in the school setting and at home—from raising two little ones! These are my tips for keeping your therapy room calm and productive:

  • Say what you mean and mean what you say. Set the behavior expectations for your speech room at the beginning of the year and explain the consequences for not following your expectations. Each session, review these with students who need frequent reminders about their behavior. Visually post your rules and consequences, so they can see and hear them. Don’t be afraid to snap the whip and follow through with your consequences because it sends the message to the whole group that you mean business.
  • Bring on the visuals. Use visuals to remind students who struggle with transitions about the start and end of activities. I use a Time Timer and two to three warnings to let my students know when the activity will end. I am also creating a visual necklace that displays prompts to help show students what I want them to do. Visuals such as “all done,” “sit,” “clean up,” and “calm down” are on my list. I also use visual scheduling in treatment. For example, I might draw a chair with the child sitting down, then playdoh, cards for artic, and then clean up or a good-bye visual. As we complete each task, the child marks an X on it.
  • Empower students. We all want to be in control of our lives even when we can’t control our circumstances. This is the same for children. And although they cannot dictate the session, we can still give them choices, such as “You can sit in your chair or you can stand behind your chair,” or, “You can work for Legos or stickers,” or “You can finish your worksheet and earn your speech bucks, or sit in your chair and lose your speech bucks for the day.”
  • Encourage sensory integration. Some of your kids may struggle with focusing, staying still and controlling impulsiveness because their sensory regulation is off. Having fidget tools such as squishy balls available upon request may help your student. I explain that the squishy ball is a “tool” and if used as a toy, it will be taken away. Also, incorporating movement breaks or activities that infuse movement help keep our little speechies focused and in control of their body.
  • Abandon ship when necessary. We all plan wonderful, amazing treatment sessions filled with activities that we “think” all kids will love. Sometimes your most ideal therapy activities may not work for certain children. Don’t hesitate to abandon a toy or activity when a child does not appear interested in your fabulous board game! You will get more meaningful interactions with toys and activities that your students prefer, rather than trying to force them to like what you want to do. I always try to reintroduce an activity a couple weeks later to see if they may want to try it out again.

All in all, behavior management is an ongoing process that takes time, trial and error, and a willing SLP to dive in and try new techniques!

Felice Clark, CCC-SLP, is a school-based speech-language pathologist in Sacramento, Calif., and author of the blog, The Dabbling Speechie. 

How Can You Tell if Childhood Stuttering is the Real Deal?

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One of the more challenging clinical decisions that confront speech-language pathologists is what to do with a young child who stutters. Do we recommend intervention? Do we wait and see if the child recovers without formal therapy? A recent study published in Pediatrics by Reilly and colleagues has generated a significant amount of press, with headlines declaring that preschool children who stutter will “do just fine.”

Even though this message does not appear to be the intent of the authors (as per their more detailed podcast on StutterTalk), it is the message the media chose to run with in their headlines. There are several key points about the Reilly article, preschool stuttering, and our current research base that need to be evaluated before we make claims such as those put forward by the media.

First, the Reilly et al. study used temperament and behavior scales, which were not designed to assess reactions to stuttering or communication. In fact, of the three scales used, only one had a question relating to communication, and it was not about stuttering. So, while it certainly may be true that young children who stutter may exhibit normal temperament and behavior (a finding we should not be surprised by), this study did not actually assess reactions to stuttering or communication, as the misleading media headlines have suggested.

This brings us to the second point of discussion, which is the difference between early stuttering and normal disfluencies. For a child with normal disfluencies, a “wait and see” approach is much more acceptable than for a child with early stuttering. We often use the term “emergent” to describe skills that are developing, but have not fully emerged. Children with normal disfluencies have emergent fluency. Their skills are developing in this area. Children who exhibit signs of early stuttering are much more at risk for continued stuttering, without proper intervention. As such, the question for parents, physicians, SLPs and others, is “How do we know the difference?”

The chart below describes some characteristics of “normal disfluency” and “stuttering.”
Normal Disfluency (less risk)                               Stuttering (higher risk)
Phrase Repetitions Sound                                                Syllable Repetitions
Interjections                                                                          Prolongations
Revisions                                                                                 Blocks
Multi-syllabic Whole Word Repetitions                     Tension/Struggle
No tension or struggle                                                       Changes in pitch/loudness
No secondary behaviors                                                   Secondary behaviors
No negative reaction or frustration                             Negative reaction/frustration
No family history of stuttering                                       Family History of stuttering

 

 

This can be a starting point to help determine risk. In addition, the child’s gender (boys are at a higher risk), time since onset (greater than 6 to 12 months is higher risk), age of onset (children who start stuttering at age 3 ½ or later are at higher risk), overall speech and language skills (it is important to assess all areas of speech and language), and level of parent concern also need to be considered.

Third, much of the problem that persists in our understanding the risk of early stuttering lies in the difference between population studies and clinical studies. Studies that have looked at recovery rate have been population studies, and thus likely captured many children who were experiencing “emergent fluency” rather than “stuttering.” The research does not translate well into clinical settings. While up to 80 percent of children in population studies may outgrow their “stuttering,” that number is far lower in a clinical setting.

Of the children seen in a clinical setting, many have several of the above risk factors that would put them at higher risk for continued stuttering without proper intervention. Children in a clinical setting are not a random sample of the population, but a specific subgroup with an identified concern (usually on the part of the parents) about stuttering. As such, speech-language pathologists need to be careful about discussing recovery rates with parents that may not apply to their child.

Finally, a “gold-standard” that allows us to predict with 100 percent accuracy which children need intervention does not currently exist. As such, we have to rely on current best practice: the integration of research evidence, clinical experience, and client values. Even if we assume that waiting to intervene will result in a similar outcome later, the reality is we do not know if waiting has a negative impact on social skills, self-confidence, and peer relationships.

Given the above information, what do we recommend to parents, physicians and SLPs? Parents are often the most reliable judge of their children. When they come to us with concern, it is warranted in most cases. Parents should trust their instincts. If they are concerned about their child’s stuttering, they should discuss those concerns with the child’s pediatrician and advocate for a consultation with a speech-language pathologist. Parents do not need a referral for an SLP. They can contact an SLP on their own (go to ASHA’s ProSearch directory of clinicians to find one in their area) or go through their public school or Child Find.

Pediatricians should refer to an SLP when any of the following are present in a child who is stuttering:

  • A family history of stuttering
  • Child has been stuttering for more than six months
  • Child exhibits any negative reactions toward stuttering
  • Child exhibits physical tension or secondary behaviors (e.g., eye blinking, head nodding, etc.) associated with stuttering
  • Other speech/language concerns are also present
  • Parents are concerned
  • Child is experiencing negative reactions from other family members or peers

Through a collaborative effort between the parents, physicians, SLPs and others in the child’s community, we can make a significant difference for children who stutter.

 

Craig Coleman, CCC-SLP, BRS-FD, is assistant professor at Marshall University and president of the Pennsylvania Speech-Language-Hearing Association. He is an affiliate of ASHA Special Interest Groups 4, Fluency and Fluency Disorders, and 18, Telepractice. 

The School Cafeteria: Hurry Up and EAT!

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Most parents tell me that their elementary school child has 20 to 25 minutes to enter the school cafeteria,  search for her lunchbox buried in a portable tub, find a place to sit, open all the containers, eat (oh, right, eat), then clean and pack up before the bell rings.  In an effort to ensure that their kids eat anything at all, well-meaning parents pack lunchboxes filled to the brim with typically, 7 to 8 different options!

Picture this: Your little first grader searches for spot in a sea of tables, newly found lunchbox in hand.  She squeezes in between her best friends, climbing up onto the metal bench, feet dangling, with her  little elbows resting on the much too high table top, just below her chin.  Most school cafeterias provide the same size seating for the entire school, whether the kids are 3 feet tall or towering 5th graders, about to move on to middle school.  Ever try to eat a meal on a narrow bench, your feet dangling and no back-rest?  It’s not easy.  By the time your child gets  the plastic bags opened, the juice box straw unwrapped and poked hard enough into the box that it squirts her in the face, all while holding up her other hand  to signal the teacher “Can you please open this lid?” well, another 5 minutes have passed by.  Meanwhile,  she’s excited to get out to recess, now just 15 minutes away.

As a feeding therapist, I visit lots of school cafeterias and have learned that parents and teachers have one priority: Getting kids to eat a nutritious lunch.  In contrast, kids have this priority: Talking to their friends.  How then, does a parent pack a lunch, especially for a picky eater or perhaps a child with special needs, that still allows their child some much needed “down time” to chat with friends yet fill their bellies quickly and nutritiously? Here are 3 strategies to do just that:

  1. Send one easy open container plus a drink.  I recommend EasyLunchboxes® BPA-free system, because the lid is easy for little fingers to pop off and instantly reveal 3 to 4 yummy choices.  Another favorite is the Yumbox®, where the single tray is divided into ½ cup portions designed for the key food groups: Fruit, Veggies, Grains, Protein and Dairy.  Both options are quick to open and not as overwhelming as a lunchbox filled to the brim with individual plastic bags, containers and/or drippy fruit cups with tricky foil lids
  2. Pack “GRAB and GAB” food.  Cut fresh fruit, veggies, sandwiches, cheese, etc. into small enough pieces that kids can grab a piece without gazing down and continue to gab with their friend across the table.  My favorite speedy gadget is FunBites® which instantly creates grab and gab bites, yet has no sharp edges.  It’s a fun way to get  kids in the kitchen making their own lunch the night before – once again,  get them involved and they are more likely to eat it later.  For some kids, cutting a sandwich into a larger, fun shape like a dinosaur, keeps the conversation and the eating on the same track.  But, for those kids who tend to just eat a sandwich and skip the other items, try cutting the sandwich into small pieces with a  FunBite® so the child alternates “grabbing”  a variety of foods, much like a mini-smorgasbord.  Remember, you don’t need to send a whole sandwich when sending half leaves room in little bellies for other key food groups.
  3. Include a power- packed smoothie  that you made the night before.  Freeze it directly in the cup (with a lid, of course) and be sure to include a wide straw.  By the time your child opens her lunch, the smoothie will be the perfect consistency, plus it helped to keep the lunch cold.  For elementary school age kids, refillable pouches are another option for healthy smoothie or puree blends.  One of my favorites is the adorable 4.5 oz. Squooshi™, which is freezer and dishwasher safe and free of all the “bad-for-yous” like BPA, lead and phthalate.  Recipes for kids of all ages can be found on the Squooshi website.  Another terrific option is to fill a Sili Squeeze with Eeeze™ food pouch and freeze it with the cap on. Please note that the manufacturer does not recommend storing the Sili Squeeze™ in the freezer for an extended periods of time, but states on their website that “Sili Squeeze™ is the perfect lunch box addition to keep your child’s lunch cool and will be perfectly defrosted for lunch time!”

One elementary school that I visited was graciously flexible to help one little girl eat better.  They provided a smaller table that fit her so that her feet could be on the floor (or try a box underneath little feet as a footrest). The table should be at sternum-height so your child can see her food and rest her arms for stability.  Smaller tables also reduce cafeteria noise and foster social skills thanks to smaller groups of kids sitting together.

Here’s a picture of that sweet little girl.  Note the easy “grab and gab” food in one (and only one) container.  See the rest of the food on the table?  That belongs to the two other kids seated across from her.

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Tell me about your kids’ cafeterias – the good, the bad and the delicious!  What can we do to help kids in school get more time and more options for a healthy lunch?


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.

Why the Scarcity of Male SLPs—and What Can Be Done

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One could easily see the lack of males in our profession by walking into any elementary school, or even attending an ASHA conference. It’s no secret that males are a rarity in speech-language pathology, but the topic of conversation has now shifted to what we can do about this trend. The fact that I was a minority in our field was apparent to me immediately after attending my first articulation disorders course.

Unfortunately, efforts to attract more males to our profession have been generally unsuccessful. Not only that, but according to data presented in the article on this topic by Kellie Rowden-Racette in the August ASHA Leader, the number of males in our field, and related fields (for example, psychology), have actually declined.

At this time, we have to use the information gathered by ASHA about why males are not choosing speech-language pathology, and develop concrete solutions on how to address the dearth of males in this profession.

The Frederick Schnieiders Research study conducted in 1997 revealed three common reasons males were less likely to pursue speech-language pathology compared with women: concerns about adequate income, concerns about advancement, and fears of limited opportunities for growth. Perry Flynn, an ASHA board member who blogged on this topic for ASHAsphere last week, shared an additional reason in the ASHA Leader article—lack of awareness:

“Men seem to have awareness and knowledge of many other related services—physical therapy, psychology, even occupational therapy, and certainly nursing—but no inkling of what a speech-language pathologist might do,” says Flynn, also associate professor at the University of North Carolina, Greensboro. Flynn’s insight holds true for me, as I knew very little about the scope of our profession before entering my junior year of undergraduate courses. However, as illustrated in the Leader article, there are issues beyond “awareness.”

Another explanation given of why men aren’t in the profession was that men are still unfairly viewed as less nurturing than women. I agree with Michael Maykish, an SLP in an elementary school in North Carolina, when he says, “You can’t generalize the notion that men aren’t nurturing.” Maykish goes on to say, “Successful SLPs are inherently nurturing, male or female. If you aren’t, you’re not going to enjoy being an SLP and probably shouldn’t be in this career.” We, as males, have an opportunity to promote our gender by directly showing we, too, can be nurturing.

Bringing awareness of CSD opportunities to the male population before they enter college will hopefully have a multi-pronged effect. This should give some insight and knowledge about the profession to some males who previously wouldn’t have considered going into our field, and possibly spark some interest. The male students who are now interested in CSD will act as a conduit, since, as history has shown, males influence other males regarding college major.

It is important that men in our field act as ambassadors, and take time to share the benefits of being in this profession with high school juniors and seniors. Word of mouth, coming directly from the source is a powerful tool.

Earning an adequate salary is obviously a concern for everyone, but, traditionally, it’s an even bigger one for males. Given the large numbers of SLPs employed in schools, developing ways to address this financial concern from a school-based perspective may be the best way to see the biggest return of male therapists. If we want to see the median income rise, I believe it is imperative we continue our efforts to separate ourselves, males and females, from teacher-related fields through continuing education and specialization. It is dispiriting to hear that SLPs are being offered entry level pay. We are highly qualified professionals who are in high demand. Consequently, negotiating a salary above entry level should always be an option, including when working with a school district.

Adding courses to your resume or becoming specialized in a particular area will only help school-based SLPs become more marketable and should result in higher incomes, which hopefully will attract more males to the profession. Providing treatment after school hours or during the summer are other ways to supplement a school salary, making the profession more appealing to salary-driven males.

I hope some of my suggestions are valid enough to spur even a small increase in the amount of males choosing CSD, as it is a remarkable field. A large section of my response focused on the financial aspect of our profession. I must admit the financial issue was not really relevant to me when I was considering the field. I guess I always felt if you work in a “helping” profession, you make some financial sacrifices. That said, I always felt my salary was fair, and if it wasn’t, it was my responsibility to change something.

Also, I realize much of this blog has been a testosterone-fueled rant, but I would be disappointed in myself if I didn’t thank all the wonderful female SLPs. When the demand of speech-language pathologists is still so high that I’m trying to convince more people to commit, regardless of gender, well, then the gender that has composed approximately 96 percent of our field for so long must be doing something right.

Kevin Maier II, MS, CCC-SLP, is an SLP in the Wyomissing Area School District in Pennsylvania.

Why the Gender Imbalance in the Schools?

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There is no one answer to the shortage of men in the communications sciences and disorders professions in general, and in school settings in particular. The article on this topic by Kellie Rowden-Racette in the August ASHA Leader presents several hypotheses—and elicits input from a variety of men who practice in school settings—to get at the root of the shortages.

Let me share my own story of why I became a school-based SLP. At Central Catholic High School in Pittsburgh in 1980 I took an aptitude test as part of the PSAT during my junior year. The test suggested that I had interests and strengths to become a priest, veterinarian or speech-language pathologist. I knew the pros and cons of the priesthood and veterinary medicine, so investigated speech-language pathology which I had never heard of before.

As I investigated that profession it seemed a perfect fit. Science and language were strengths for me. I loved helping people especially children and thought either a school or hospital environment working with kids would be ideal for me. I have to say I never once considered how much money I would make. My parents had always instilled in me the ideal of finding a career that I loved not just finding a job—and it seems this was also the experience of my friend Rob Dellinger and James Brinton, both mentioned in the Leader article. So with the help of Brother Clement Smith I further investigated the profession and where I might pursue a degree in communication sciences and disorders.

For a variety of reasons the University of North Carolina at Greensboro (where I now work) fit all my requirements and I thankfully was accepted there. In the 1980s I could begin taking classes in my major freshman year. As I searched for jobs at the time of my graduation, two pediatric hospitals and two school districts were my targets. I learned that the two hospitals did not accept clinical fellows and was offered both the school positions. I began work for the Rockingham County Schools in North Carolina. Initially I thought, “I will do my clinical fellowship year in the schools and then move to a pediatric hospital setting.” I loved my school job so much I remained there for 15 years rising to become the lead SLP as four districts, including mine, merged.

Enough of my personal story. Onto the more specific comment in the Leader article. I, like Tracy Ball, have many friends who have shared with me that while they may make a very good living, they just drone through their day at a job they in some cases dread. Some of my friends are in prominent positions on the national stage but still express envy at my job—one in which I feel I make a difference for kids and the greater good of our world on a daily bases. Every day I am thankful that I feel like this way about my career/ daily work.

In conversations with young men (and women) of college age, I am impressed by their interest in serving the greater good of humanity and the world at large. At least in our conversations they recognize the value of enjoying their work on a daily basis over the almighty dollar. I do realize that sometimes the reality of college loans and the pull of the American dream have some sway over their ideals.

As I mentioned in the article, my experience is that while this generation is interested in the related services, they typically have never heard of or had any experience with speech-language pathology. I believe all of us SLPs, both men and women, would do well to get the word out about our rewarding profession. We all need to cast a wide net to recruit men to the profession. Part of casting this wide net might mean to mention the other related service professions to help our occupational therapy, physical therapy, psychology and nursing brothers and sisters recruit men to all of those professions (but hopefully catch the cream of the crop for our own).

We all need to do a marketing blitz to recruit the next generation for our profession. We need to take time out from our jam-packed workload to get in high school classes, youth groups, Boy Scout troops and undergraduate classes to introduce our profession. Every young guy I talk to at the gym, in line for food at volunteer events, I seize the opportunity to mention what I do, talk it up and plant that seed. In a couple of cases, I know the seed has grown and my chat has paid off. We could all participate in a marketing campaign on a grass-roots basis.

Margaret Rogers, chief staff officer for science and research at ASHA, noted that cultural currents of gender roles are slowly changing, and I agree. We all need to be that change we hope for by both recruiting men and by contemplating “masculine friendly” conditions in schools. I also agree with Margaret in that we are “midstream” in this current change away from societal expectations toward assertion of individual preferences in choosing professions.

I can provide an example of my personal (inaccurate) gender expectations. When someone says to me the word nurse I still picture a woman in a white dress with a cap. I think that is a functional of my age/generation. When I take one more second to consider the word my vision opens to men in scrubs, as I have encountered many male nurses (who wear scrubs). In some ways the profession of speech-language pathology does not have to overcome that generational picture of an SLP because we do not have a historical “look.” Our marketing campaign can paint the “look” of an SLP however we want in promoting the profession to potential students. We have the opportunity to “sell” the profession at least initially as lacking a gender bias.

Tracy Ball noted that men have an intangible special something in working with boys. In many instances, behavior is easier for us to manage, boys are more attentive. Men in schools have a tremendous opportunity to influence the next generation, and that is a great privilege.

I will end with this thought. Membership in ASHA is like a cruise. I think many people see it as a luxury pleasure cruise involving deck chairs and endless buffets. I, however, see ASHA membership as more of a Windjammer cruise. While we are getting to enjoy the beautiful experiences of our profession, we all have to pitch in to contribute to and enhance the experience. Just as the crew of the Windjammer helps cook, clean and steer, all of us SLPs have to promote the profession, recruit for it and help change cultural currents. I hope all of you will join in helping to bring more men into our rewarding profession through recruiting efforts and affirmative marketing on a grass-roots level.

Perry Flynn, CCC-SLP, is an ASHA board member, associate professor at the University of North Carolina Greensboro and the consultant to the North Carolina Department of Public Instruction in the area of speech-language pathology. He is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education, and 16, School-Based Issues.

Kevin Maier, CCC-SLP, an SLP in the Wyomissing Area School District in Pennsylvania, will share his thoughts on this topic in next Tuesday’s post on ASHAsphere.

Social Skills and Theater—It’s Showtime!

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True story: One night in the summer of 2009, I had a dream that I took a group of actors with special needs to a high school arts competition. The next day I was offered the opportunity to start a collaborative speech-language/drama program that targeted social communication skills while the group worked to put on a play. That really happened.

Obviously, my answer was “yes.”

The Expanding Horizons: Broadway Kids program, a collaboration between the Loyola Clinical Centers of Loyola University Maryland and the Columbia Center for Theatrical Arts (CCTA), started in the fall of 2009 with five actors. First-year graduate students under the supervision of a licensed SLP planned weekly 1.25 hour group speech-language sessions that targeted the individual pragmatic needs of the “actors.” Traditional theater games (e.g. improvisational activities) were modified to teach skills needed to be both successful actors and successful communicators. Clinicians targeted using the voice and body to convey emotion, reading the non-verbal cues sent by a communication partner, as well as giving and receiving constructive feedback during small group sessions. Next, the whole gang joined together to practice selected songs and scenes from a musical, with a director and music director from CCTA running the show (pun intended). The graduate clinicians facilitated generalization of the goals targeted in the highly structured small groups into the larger, more informal, group setting (play rehearsal).

Since then, there have been nine performances. Cast sizes have tripled, peer buddies have been added, and the Howard County Public School System joined as a partner (a tear jerking story about that later). The original format described above has remained consistent, but we have learned many things. Here are just a few items from our long list of lessons learned.

1. Not every kid wants to be on stage.

Shocking, right? As someone who has been performing since age 10, the fact that other people would not find the stage as amazing as I do was eye opening. Though, as a grown-up and a professional, I should have known better. Through the years, we have made good progress to ensure that all actors are going benefit from the program. Client selection factors include making sure the actors have shown interest in the arts in advance of being volunteered for our program. Trying to target social skills while an actor is hiding under a table suffering from a severe case of stage fight doesn’t work too well.

2. Don’t assume.

We all know what happens when we assume, but I still do it. This year I assumed that the middle school girl with selective mutism would benefit little (warning: here comes the tear jerking part). What I did not know was that this student had requested to be in the program. In September, there was limited to no verbal communication during rehearsals. Somewhere along the way, she was assigned a musical solo (our director was obviously a more optimistic person than myself, thank goodness). When this student performed the solo for her sixth-grade peers, the audience went wild. Again, I had assumed that the school audience would be polite, but would be more excited to be out of class than to support a peer. The reaction from the audience was genuine and supportive. They understood how much courage it took to be up on the stage, and recognized the huge accomplishment of their classmate who they had never heard speak. Of the adults present, there was not a dry eye in the house. Personally, I was sobbing.

3. Stakeholder buy in is a must.

School staff and leadership need to see the value in such a program for it to be a success. Our most successful school partnerships have been those where we were invited to a) perform for the general education students and b) easily partnered with the school SLP. Because of the level of collaboration between us, teachers, and the SLP at the second high school we were invited into, the program continued without Loyola involvement in the subsequent year. An integrated theater arts program at a public high school was born!

It’s been a tremendous four years and we are looking forward to many more. To learn more, visit Loyola’s Clinical Center’s website and  the Columbia Center for Theatrical Arts website for more information.

 

Erin Stauder, MS, CCC-SLP, is clinical faculty at Loyola University Maryland. She has worked in special education schools, early intervention, and in acute care pediatric settings. Currently, she supervises a diverse caseload that includes a social skills group that uses theater to teach pragmatic language skills. She can be reached at estauder@loyola.edu. 

ASHA Schools 2013: Putting Your Best Foot Forward

school shoes
I needed to find some bandages. Even though it was Friday morning of my fourth ASHA Schools Conference I had somehow conveniently forgotten how even the most seemingly comfortable shoes can feel like torture devices after a day of running and I had forgotten to bring bandages. Luckily the very nice concierge listened to my tale of woe and, instead of making me walk five blocks to the nearest drug store, gave me four bandages from the hotel’s super secret hidden first aid kit. Bingo—I was set.

I don’t wear fancy shoes very often (and usually new shoes for me means new running shoes) but every now and then I’ll splurge on a pair that promises pizzazz and comfort. Hence my silver platform pumps that were actually cleverly disguised “wellness shoes.” Yowza. Off I went to the Long Beach Convention Center.

In the ballroom for the opening plenary: So far so good. Everyone is busy getting their materials and buzzing around saying hi to friends and colleagues. The opening speaker, Murray Banks, infused the audience with his energy and passion for teaching. Once named the Teacher of the Year in Vermont and a recipient of the Outstanding Educator Award from the American Alliance for Health, Physical Recreation and Dance, Murray told the audience that they, as SLPs, were charged with a special mission for each student—to connect with them, no matter how difficult. “Each day,” he said, “remember to look in the mirror and tell yourself ‘It’s show time!’”

The morning sessions were good—really good. I wanted to go to both Sylvia Diehl’s presentation on autism and executive function where the audience learned why “visual supports are the bomb!” and Patti Prelock’s session where she helped the audience identify steps to make an effective integrated team to support students with severe disabilities. I had to divide my time and (of course) they were located at opposite ends of the conference center. I could feel my feet becoming one with my shoes but in a good way. Each speaker emphasized the importance of looking at each child and really learning what was behind the behaviors and to the goals.  In other words, improve a life one story at a time.

Meanwhile I was beginning to take note of the shoes conference attendees were wearing as they, too, ran from session to session. I had already fielded several questions about how comfortable my shoes were, so I was curious about others’ choices. If I had to say there was an overall theme, it was comfort. But that didn’t keep some from wearing heels, straps, and sometimes even flowers on their feet.

It was in Wayne Secord’s Friday afternoon session I gained some insight into the conference’s attendees’ shoe choices. Secord presented the results of a questionnaire that he had presented to each state’s top two speech-language pathologists (each state determined the qualifications and chose one from the schools and one from health care). The idea was for the answers to this questionnaire to illuminate what sets these great speech-language pathologists apart. The presentation was fascinating and some of the characteristics Secord pointed out resonated with me:

  • They remember their priorities
  • Not afraid to take risks
  • They understand the big picture
  • They never got too comfortable in their jobs

And then I started thinking about some of the shoes I was seeing.  They weren’t just comfortable, they were athletic and purposeful. They weren’t just fun, they were creative. They weren’t just borderline uncomfortable, they were a way to not get too comfortable. So, in fact, the very members who were attending this conference and racing to go to all the sessions they possibly could, were, in a way, embracing and displaying the characteristics identified to place them in the top in their profession. I met so many wonderful people at this conference and was reminded once again what a special breed it takes to be a school-based speech-language pathologist.

Going forward into the conference on Saturday and Sunday, the race continued as there was so much to see. People were running to catch Vivian Siskin’s session on Avoidance Reduction Therapy for children who stutter; others clamored to see Bonnie Singer’s instructional strategies for academic writing; and there was practically a stampede of members vying to hear Judy Montgomery share vocabulary strategies to support the Common Core State Standards. I did notice, however, that the number of high heels had greatly diminished by Sunday.

After one of the afternoon sessions I decided to check out the exhibitors in the Exhibition Hall. Among the many vendors of books, speech software and literacy programs, I came upon Kathie Kenaston who was representing the Fairbanks, Alaska, school district and trying to recruit SLPs to come to Alaska. A former California girl, Kathie has lived in Alaska for more than 20 years and loves it. I asked her how recruitment was going and she said that it’s slow but steady.

“Going to Alaska isn’t for everyone, but it’s perfect for the right person. I’ve seen people embrace it but I’ve also seen people not be able to handle it,” she said. “When I’m talking to someone about it I can usually tell if they’d like it by their shoes.”

Look for more ASHA Schools Conference 2013 coverage online in the upcoming August issue of The ASHA Leader.

Kellie Rowden-Racette is the print and online editor for The ASHA Leader. She can be reached at krowden-racette@asha.org.

 

 

 

Kid Confidential: What Reactive Attachment Disorder Looks Like

July11

 

Over the last few years, I have become aware of an increase in the number of referrals to assess children diagnosed with Reactive Attachment Disorder. Whether this is a coincidence or an indication of statistical increase in incidence of RAD, I cannot say.  What I can tell you is how clinically interesting and extremely frustrating these cases can be.

What is RAD?  According to Nancy Thomas, author of “When Love is Not Enough: A Guide to Parenting Children with RAD-Reactive Attachment Disorder,” RAD,  originally termed “attachment disorder” prior to 1979, is defined as a condition where an individual has difficulty forming lasting relationships and lacks the ability to be genuinely affectionate toward others.  In addition, persons with RAD do not learn to trust others and do not appear to develop a conscience.  This is believed to be caused by abuse or separation (physical or emotional) from one’s primary caregiver during the first three years of life which translates to an internally suppressed rage.  If untreated, children with RAD grow up to be adults who cannot truly ever feel love.  It is suggested that many of these adults will eventually be labeled as sociopaths or psychopaths.

According to Thomas, the following are a list of some signs that put infants at high risk for RAD in the first year of life:

  • Constant crying or a weak crying response
  • Tactile defensiveness (after 8 weeks, flinching or startling)
  • Poor clinging or holding on
  • Resistant to cuddles (may seem “stiff as a board”)
  • Lacks strong sucking response
  • Lacks eye contact and tracking skills
  • Demonstrates developmental delays
  • Does not exhibit a reciprocal smile
  • Doe not demonstrate “stranger anxiety”; appears to be indifferent to strangers
  • Will exhibit self abusive behaviors (head banging, etc.)

 

What can parents do to facilitate bonding with their infant?  Thomas makes several suggestions in her book.  Here are just a few of them:

  • Breastfeed if at all possible; hold bottle, never prop it up
  • Use a sling or carrier to carry the infant front facing toward the child’s mother for 4-6 hours daily
  • Baby massage, 20 mins/daily while smiling and using a high voice
  • Rock and hold infant with good eye contact while singing and taking using “motherese”
  • Sleep with or near parents at night
  • Nap skin to skin on dad’s chest

As these infants may be referred to speech-language pathologists due to feeding problems, we may be the first professionals to see these children.  So I believe it is important for us as professionals and parents to learn the warning signs and make the appropriate referrals as needed.

The following are signs and symptoms of RAD in children found in Thomas’ book:

  • Child is superficially engaging and charming
  • Lacks eye contact on parents’ terms
  • Demonstrates affection with strangers indiscriminately
  • Not affectionate on parents’ terms (no cuddling, etc.)
  • Appears “accident prone” in that the child is destructive to self, others and objects
  • Exhibits cruelty to animals
  • Steals
  • Lies about obvious things (outlandish lies)
  • Lacks impulse control; hyperactive frequently
  • Developmental delays (“learning lags”) due to being in a state of anger and frustration affecting ability to learn
  • Lacks cause and effect thinking
  • Lacks conscience
  • Exhibits abnormal eating patterns (not eating and/or gorging)
  • Has poor peer relationships
  • Seems to be preoccupied with fire, blood/gore, violence
  • Persistent nonsense chattering and questioning
  • Very demanding or inappropriately clingy
  • Exhibits abnormal speech patterns for the purpose of controlling situation
  • Attempts to triangulate adults against each other
  • Tells of false allegations of abuse
  • Feel entitled
  • Parents appear angry/hostile

 

What type of therapy works for children with RAD?  According to Thomas’ attachment therapy is a must. A good attachment therapist will work with the parents and child to create an attachment.  He/she will NOT allow the child to manipulate and triangulate them against their parents.  Additional therapies that can be of use in conjunction with attachment therapy are:  holding therapy, Neurofeedback or EEG biofeedback, EMDR (eye movement desensitization and reprocessing), Theraplay, Therapeutic horseback riding, specialized art therapy, music and sound therapy (Tomatis, Somonis), massage, nutritional supplements, and Psychodrama.

 

As SLPs, we may have children who have been or have yet to be diagnosed with RAD referred to us due to the “abnormal speech patterns” they tend to use.  The difficulty is in determining the true communication abilities of these children.  According to Thomas, little research supports effectiveness of speech services for children with RAD as communication is often times not truly affected.  Therefore, our role becomes more of a referral source either to a child psychologist for diagnostic purposes or to an attachment therapist for possible treatment.

 

Case Study, “Johnny”, 3 years old, seen in early childhood special education classroom setting:

 

Speaking from personal experience, I too was duped with the first child I ever suspected to have RAD.  Although, he was not diagnosed prior to my evaluation, I had come believe RAD was a strong possibility after many, many hours of collaboration and consultation with his early childhood special educator.

 

For confidentiality purposes let’s call this child, Johnny.  Johnny was reported to be a “difficult” child at home, requiring his mother’s constant attention, exhibiting extreme anger during typical play and sharing situations, highly impulsive, and very much enjoyed using language for the purpose of interrupting the classroom and manipulating adults.  As I was not familiar with this child prior to the evaluation, the only information I had were parent complaints of behavior at home.  When speaking to his mother, I was surprised to see that as Johnny tried to snuggle up to his mom in front of me, she would roll her eyes and push him away.  I didn’t understand then, that this reaction was because she knew he was attempting to manipulate me, showing me he was the loving child and his mother was the “bad guy.”  I didn’t know then, that his mother had spent years with little to no sleep because he insisted on sleeping on a cot at the bottom of his parents’ bed at night and woke up every night pretending to sleep walk.  I didn’t know then that Johnny would use a very high pitch and what I can only describe as “baby talk” when he wanted to seem sweet and affectionate all while trying to get something he wanted from someone.  I didn’t know then that this child would demonstrate the most rage and anger I had ever seen in a 3-year-old.  I didn’t know then, that the language he was using during my evaluation was his way of manipulating me.

 

After a few months, it became quite clear that the expressive language deficits Johnny exhibited during the initial assessment were not an accurate view of his true abilities.  In fact, although considered typically developing, he appeared to have higher receptive language skills than he portrayed during testing as well.  Academically, when Johnny would slip up a bit and show us what he really knew, he demonstrated good rote counting skills, early identification of some letters, and understood concepts of sorting and patterning with ease.  However, he had significant difficulties with peer interactions.  At this time, I attempted to change my strategies and help with his social skills by focusing on verbal expression of feelings of anger/frustration and using cognitive problem solving skills to determine appropriate behaviors during peer interactions in order to reduce hitting, grabbing, and physical contact with peers.

 

Yet, it wasn’t until the day, during a school assembly, Johnny picked his nose so long that he was gushing blood, did I realize he did not seem to register pain like you and I do.  As his teacher was unable to leave the rest of the classroom in the assembly without her, I took Johnny back to the classroom bathroom to clean up. Of course this was a day the school nurse was not in so I was on my own.  As he approached the bathroom, I watched as he stood up on the stool, looked in to the mirror and proceeded to smear his blood all over his face and arms while smiling in the mirror.  He did not see me watching him.  I’ve never seen a 3-year-old act like this.  It was in that moment, I became a true believer that he could very well be a child with RAD.

 

Unfortunately, Johnny and his family moved out of state prior to ever getting an outside evaluation to determine or rule out RAD.  And as you can imagine, the therapy strategies I attempted failed to carryover to functional play situations, although in the therapy room, he seemed to say all the right things (incidentally another sign that he might have had RAD).

 

I share this story with you because I know how easily one can be mislead and manipulated by a child.  Although I know I cannot diagnose RAD but based on the above signs and symptoms, Johnny exhibited 15 out of 22 of them and in my humble opinion, RAD was a very good possibility.

 

As they say, hind sight is 20/20, and I feel I am still learning long after Johnny is no longer on my caseload.  If I could turn back the clock there are two things I would have done differently.  Firstly, once I knew Johnny and saw him for who he truly was, I would have told his mother with sincerity that I believed her when she was telling me about his behavior problems at home.  Secondly, I would have pushed harder for her to follow through with a psychological evaluation prior to their move out of state.

 

At the end of the day, for the few months that I worked with Johnny, I learned to question everything I thought I knew about child development and language acquisition.  I learned to keep looking, consulting, collaborating and never give up trying to find the source of the problem.  Even if clarity came to us as a multidisciplinary team too late, I find that I will always be grateful to Johnny for the lessons he taught me and how he has personally made me a better diagnostician, therapist, collaborator and yes, even a better parent to my own son.

 

RAD can be a very confusing and trying disorder to understand.  We as professionals can work with a child for a very long time before we realize all the signs and symptoms are really pointing to something other than communication deficits.  However, as long as we never give up trying to help, as long as we continue to consult, collaborate, and research we may just be able to help these children by referring them to the correct professional.

 

 

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.