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

brownie

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

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

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

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

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

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

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

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

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

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

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

 

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

10 Trillion Microorganisms versus Your Toothbrush

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“The mouth is dirty,” Dr Kenneth Shay stated frankly; AND, it is “the biggest hole in your body!”

Warning: You may want to finish eating, brush your teeth, floss, use mouthwash, and then come back…

OR

If it is early morning, and you haven’t brushed your teeth yet: then scrape the gunk off your teeth with your fingernail. You may have found 10 billion microorganisms in that cubic millimeter.

There are 1 trillion to 10 trillion microorganisms in your mouth. Simply brushing your teeth can get rid of that nasty bacteria film in your mouth. It can also prevent “some of that schmutz” from getting into your lungs. If you are having trace aspiration (saliva, food, and/or liquids getting into your lungs), try to make what gets into your lungs less nasty. You can prevent pneumonia. Pneumonia due to poor oral care is a major avoidable infection, per Shay.

Ross & Crumpler (2006) noted that despite strong evidence in the literature on the role of brushing the teeth in preventing pneumonia, medical staff continue to view oral care as a comfort measure and only use foam swabs.

“Toothette sponges are wimpy,” stressed Shay. They don’t get the gunk (plaque) off the teeth. Plaque is sticky. If not removed, it hardens into tarter (also known as calculus). Then a visit to the dentist is needed to get it off (debridement).

Why is the mouth forgotten in healthcare? We help the dependent elder go to the bathroom many times a day. So why don’t we help brush his teeth?I’ve heard some nurses say they are squeamish about the mouth! It makes them gag! Well, we should be gagging over the costs of neglecting the mouth.

This simple prevention technique of brushing costs pennies a day against the cost of a pneumonia. Based on CDC numbers from 2011, there were 157,500 Hospital Acquired Pneumonia infections that year. CDC states the average extra cost of that hospital acquired infection is $22,875. This equals over 3 billion dollars!

Why are we not protecting this wide open gateway to the body? Imagine your gingival space between the tooth and gum as a huge parking lot. Germs love these 1-3 millimeter deep parking spaces. If germs park in the gingival space for more than 24 hours, they become calcified into plaques. Bacterial loves to stick to plaque. Only brushing removes it. No brushing leads to a build-up of plaque in the gingival space and inflammation (gingivitis).

It only takes 48 hours of hospitalization in a critically ill patient to change this bacteria from the usual gram-positive streptococci to gram-negative microorganisms (the nasty pathogenic bacteria that cause pneumonia).
Maybe we don’t brush our patients teeth because the gums bleed? Blood is okay, per Shay, even if you are on a blood thinner. Shay stated that bleeding is a sign that you need to brush more. It is due to the inflammation, and regular brushing will prevent bleeding. Shay warned that bleeding is only risky if the patient has a blood disorder or disease that causes excessive bleeding.

Most cases of gingivitis do not progress to the more serious periodontitis, but…Immune-compromising events can cause an autoimmune response that can lead to periodontitis, per Shay. Examples of immunocompromising events are not only hospitalization and critical illness; they could also be the following:

• life stressors
• flu
• depression, and
• pregnancy

Periodontitis is inflammation caused by bacteria that affects the attachment between the tooth and the bone. It is an irreversible destruction of the supporting tissues (i.e., the periodontal ligament to alveolar bone). Then bone-absorbing cells eat away at the bone. The bone will not be regenerated. Additionally, with the gums receding, “there is more surface area to collect gunk,” said Shay. The periodontal pocket that is formed creates a larger “parking garage” of 6-8 millimeters deep. Lots of gram-negative anaerobic bacteria can park there! Pathogenic microorganisms. “These are the same things that cause aspiration pneumonia,” stated Shay.

See the full blog post at www.swallowstudy.com.

Karen Sheffler, MS, CCC-SLP, BCS-S, graduated from the University of Wisconsin-Madison in 1995 with her master’s degree. There, she was under the influence of the great mentors in the field of dysphagia like Dr. John (Jay) Rosenbek, Dr. JoAnne Robbins, and Dr. James L. Coyle. Once the “dysphagia bug” bit, she has never looked back. Karen has always enjoyed medical speech pathology, working in skilled nursing facilities and rehabilitation centers in the 1990s, and now in acute care in the Boston area for more than 14 years. She has trained graduate student clinicians during their acute care internships for more than 10 years. Special interests include neurological conditions, esophageal dysphagia, geriatrics, end-of-life considerations, and patient safety/risk management. She has lectured on various topics in dysphagia in the hospital setting, to dental students at the Tufts University Dental School, and on Lateral Medullary Syndrome at the 2011 ASHA convention. She is a member of the Dysphagia Research Society and the Special Interest Group 13: Swallowing and Swallowing Disorders. Karen obtained her BCS-S (Board Certified Specialist in Swallowing and Swallowing Disorders) in August of 2012. You can follow her blog, www.swallowstudy.com.

Kid Confidential: Parent Education and Training, Part 1

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This is part 1 of a three part blog series on the topic of parent education and training.  Look for part 2 and part 3 coming up over the next two months.

Parent education and training is not only an important part of our job as SLPs it is an essential part of our job.  Still, I’ve spoken to many SLPs over social media who still feel like they are lacking this particular skill for a number of reasons. For SLPs in the schools, their caseloads are so high and paperwork demands so daunting, they are left with little time to collaborate with school staff let alone contact parents on a regular basis. For private practitioners, speaking from experience, I think we are so focused on targeting the necessary skills and making gains with our clients, that we forget how important parent education can really be.

We know that parent involvement in general education is certainly beneficial. Children whose parents are involved in their school tend to have better academic performance and fewer behavior problems. It makes sense that parental involvement in speech services also would result in positive effects such as increased home practice of target skills and generalization of learned skills to the home environment.  In fact, there are whole therapy models (i.e. DIR/Floortime, Hanen, etc.) that incorporate parent education and involvement as key factors in their models and have the research to back it up.  The DIR/Floortime model’s portion of parent education and training has been tested and retested among various populations all resulting in positive effects, faster progress and improved generalization of social skills for children with ASD (see list of additional resources below).

So the question we need to ask ourselves is why we aren’t tapping into this wonderful resource and effectively educating and training parents of our clients?  For myself, I can tell you that it took some time to become effective in this manner. Initially it seemed as if I was more of a teacher explaining the rationale for various techniques however I was missing some very important steps. Over time, I have improved upon my ability to educate and train parents and I will share with you my tips for effective parent training:

  1.  Trial techniques:  The first thing I usually do is trial various techniques to determine which techniques the child responds successfully.
  2. Explain rationale:  Once I determine the most effect speech therapy techniques for the child (which we have to accept will change over time, maybe even at each session depending on the child’s ability and behavior), I will explain the rationale behind the techniques to the parent(s) present (either in my therapy room or in their homes when providing therapy).
  3. Model technique(s):  Modeling the technique(s) immediately after explaining the rationale will demonstrate the effectiveness of the technique(s) and make more sense to the parent(s).
  4. Parent’s turn: Allowing the parent(s) to take turns trying to eliciting the communication skill via the use of determined techniques will give them much needed practice in the safety of the therapy session.
  5. Give Feedback: Giving feedback is necessary to training.  It allows parents to feel successful with the skills they currently exhibit and provides additional ideas for the areas in which they are weaker.
  6. Follow up: I think it is so important to follow up with parents session to session to determine how well the techniques are working at home, how comfortable they feel using the techniques and if there are adjustments that need to be made for more effective use.

These are my basic tips for effective parent education and training.  Next time I’ll be talking about how I realistically incorporate parent education and training in my speech therapy sessions.

DIR/Floortime Resources:

  • Casenhiser, D., Shanker, S., & Stieben, J. (2011). Learning Through Interaction in Children with Autism: Preliminary Data from a Social-Communication-Based Intervention. Autism, 17 (2), 220-241.
  • Pajareya, K., & Nopmaneejumruslers, K. (2011). A pilot randomized controlled trial of DIR/Floortime™ parent training intervention for pre-school children with autistic spectrum disorders. Autism15 (5), 563-577. doi: DOI: 10.1177/1362361310386502
  • Solomon, R., J. Necheles, C. Ferch, and D. Bruckman. “Pilot study of a parent training program for young children with autism: The P.L.A.Y. Project Home Consultation program.” Autism, 2007, Vol 11 ( 3) 205-224.

 

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.

Collaboration Corner: 10 Easy Tips for Parents to Support Language

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As we make our way through the lazy days of summer, schedules change, and things relax. My usual theme is collaboration; parents can be one of our biggest assets in promoting language development. Parents of young children usually want to know what they can do to support their child’s language development in the absence of a structured day. Though I teach children with disabilities, I find I continually revisit the following tips with parents of young children regardless of whether a child is typically developing or needs a little more support. Here they are in no particular order of importance:

  1. Pay attention to body language, when a child is looking toward or reaching for something, they are communicating. Talk about what they are reaching for, “Oh, you want the bubbles!”
  2. Avoid the “say this” tendency. Don’t pressure the child to speak; keeping the experience positive is important. Instead, model what the child might say when he/she is ready.
  3. Take time to sit and read with your child every day. Label everything you see, and encourage them to point to the words and pictures as you talk about them. Books with repetitive lines are great.
  4. Be playful. Sing songs. Use lots of inflection. With familiar songs, leave some of the words out and see if your child will hum or sing the words.
  5. Provide limited choices when you aren’t sure what your child wants. Holding out 2 items, lessens the stress of having too many choices.
  6. Talk with your child about what you are doing, then provide the opportunity for your child to reciprocate. “I’m making some cookies, do you want to help?”
  7. Use first/then language to guide behavior, and then be consistent, “First you need to eat, then you can read.” Use this language even when moving between activities that are preferred or less preferred.
  8. Use pictures: Take pictures of your child’s day and talk about what is coming up next, or make a photo album of fun activities (vacation, going out for ice cream) to talk about.
  9. Remember language is everywhere, even if you child doesn’t understand everything you are saying, he or she needs the exposure. Car rides, walks outside, blowing bubbles are just a few examples. Describe what you see, and ask questions, e.g, “I see a cow. What does a cow say?”
  10. Simplify your props. Sometimes the simplest toys can bring out the best language. Summer is full of such opportunities: A spinning toy, taking a turn kicking a ball, bubbles…all can support your child’s development, simply by talking to them.

Kerry Davis Ed.D., CCC-SLP,is a speech-language pathologist in the Boston area, working with children who have significant communication challenges. She conducts trainings and workshops, and serves as a volunteer speech pathologist and consultant for Step by Step Guyana, a school for children with autism in South America. The opinions expressed in this blog are her own, and not those of her employer.

CFY (Coming For You)!

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I’m a big fan of musical theater (I was so excited Jessie Mueller won a Tony this year.  She was wonderful.). I’m in awe of the performers who seem to sing, dance and act with equal aplomb.  And then they go out and do it in front of a live audience.  Every day.  Twice on Wednesday and Saturday. Where do they find the endurance?

Well, baby, I’ve got news for you.  You’re about to star in your own show.

There is no denying the difficulty of grad school. You’re taking classes in everything, even the stuff that might not be your cup of tea.  Ideally, your clinical fellowship year is in an area you particularly enjoy and the everyday implementation of book learned skills will certainly give you many ah-ha moments. What can be difficult is the frequent observation, knowing, or maybe not knowing, that someone is on the other side of that two way mirror.  There is a feeling of being constantly “on.”  Even paperwork remains a performance. I would drop into bed at night, completely spent.

I actually had two CFY experiences.  The first was my dream job. I was a preschool therapist in a local school system and my job included home visits/evaluations, lessons within the preschool handicap classroom, individual pull-out therapy for many of those same kids, other children that came only for speech, and screenings–lots and lots of screenings.  I’d been working at my school practicum the previous spring in the same location so I knew the staff, some of the kids and had a relationship with my supervisor.

Then life intervened.  My husband and I married in early August which gave us time to honeymoon before the first day of school.  But as the saying goes, “the best laid plans of mice and men….”  Within the first month my husband was transferred to Atlanta, a five to six hour drive from where we were living, and needed to move immediately.  I gave notice that I would leave at the Christmas holiday, started packing our wedding gifts and began to look for a new placement.  (Yes, my husband left a couple months before I did.  Not an auspicious start to married life, but we made it work.)

My second placement was equally as dreamy–out-patient rehab for a large children’s hospital with lots of experienced therapists, including OT and PT, to learn from and watch. The experience I gained there truly shaped the clinician I am today.  So much so, that if I were to give one bit of advice to a new therapist starting out it would be to work where you have lots of interaction with more experienced clinicians. I know you’re sick of being watched, guided, and yearn to start doing your own thing, but…for me, it was the best possible thing that could have happened. (This is where I spent two years exhausted.  I was finally starting to get my feet under me, doing some mentoring myself, and feeling less stressed by the whole process when, guess what, transferred again.)

I share this because I think we get so close to a situation we aren’t seeing it anymore. My situation was unique, but these things come up for lots of reasons.  Sometimes CFYs take place in more than one location or setting.  There might be a short “pause” right in the middle. It’s ok.  Show close and new ones open.  Break a leg!

 

Kim Lewis is a pediatric clinician in Greensboro, NC and blogs atActivityTailor.com.  Attendance at the ASHA convention this fall qualified her for an ACE award (7.0+ CEUs in a 36 month period).

 

Favorite Resources: Fiction and Non-Fiction Texts

reading

School based SLPs often look to align their intervention goals with academic content standards to increase student success in the classroom. Many of these goals align with English Language Arts standards. Goals for vocabulary, comprehension, and articulation can be targeted easily using fiction and non-fiction texts. Using reading passages is a perfect way to support reading skills and curriculum. It’s also an easy way to incorporate current events or seasonal information as well. I wanted to share four different resources I used for my caseload this year.

The

1. Newsela.com
Newsela is a site that takes regular news articles and changes the lexile level for a variety of readers. You can select the article, then pull it up on your screen. On the right side of the screen you can select a variety of lexile levels from 3rd grade up to the regular adult version.This is perfect for mixed groups.
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I love to use it for middle schoolers reading at lower lexile levels.
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We also use these in my articulation groups. This 7th grade student went through and highlighted each /r/ word.
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As he reads the page, I marked each sound with a +/-. Then we go back and work on the words he missed. This resource is free.
2. ReadWorks.org
ReadWorks is another fantastic free resource. I love their units for seasonal reading. Sign up for a free membership. You can search using the calendar at the bottom of the home page. There are resources for Kindergarten and up.
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They even have whole units for free for common books you already have on the shelf! Take time to search through and find units that are made to teach specific skills.
3. ReadingA-Z.com 
Many  districts pay for teachers and SLPs to have access to ReadingA-Z.com. I use it a lot and would recommend it to any SLP working with school aged students. I also have access to VocabularyA-Z. Let me show you some favorite resources within it.
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Leveled books used to be the meat of ReadingAZ. Lately they have added a whole lot more, but these are still my Go-To!
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Once you open a leveled book, you have many options. Print the book, share on a Smartboard, or print additional worksheets.
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I love the vocabulary connections most of all.  Since we have a subscription to VocabularyA-Z there are sets of  vocabulary lessons for EVERY BOOK!
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This is such a huge time saver for me. It takes the planning out of vocabulary practice!
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There are special lessons for ELL/ESL. These are great for language learners and for daily living skills units.  There are printable books that focus on feelings, vocabulary (vegetables, money, etc.), and places (neighborhood, school).
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The website also includes decodable books.  They are divided by sounds and even blends. These are  great for articulation practice.
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One section of ReadingAZ features comic books. Lots of my reluctant readers /language delayed  kids love comic books.
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The last feature I frequently use is the write your own story books. Most of the lower leveled books are available in the ‘write your own’ format. You can either print the regular book or print the wordless book. This is an easy way to progress monitor a variety of grammar and narrative skills. Of course it’s great for direct instruction, too! If you’re working on retell you can read the story with the words first and then use the ‘write your own’ version to support retell.
ReadingAZ is a paid subscription. Look into the free trial if you haven’t used it before.
4. N2Y.com
News-2-You is a symbol based weekly newspaper. It’s my ‘go-to’ for daily living skills classes and autism classrooms. I love the predictability and the symbol support. You can also download many levels of  instruction.
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This is the ‘regular version.
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The simplified version has less text.
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This is the ‘higher’ version (but still not the highest offered.)
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Did you know they have a spanish edition?
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I love the pre-made communication boards and the recipes included. I use the app frequently with my students.N2Y is a subscription based program. You would not be disappointed if you purchased it. I promise!
Those four resources are websites I use every week to support my instruction.  SLPs can use them as part of their instruction or as a way to provide homework, align their intervention goals with academic content standards in order to increase student success in the classroom.

Jenna Rayburn, MA, CCC-SLP. is a school based speech-language pathologist from Columbus, Ohio. She writes at her blog, Speech Room News. You can follow her on facebooktwitter, instragram and pinterest.