Trick or Treating Voice Disorders: 3 Reasons Why It’s Not So Scary

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Hopefully the least scary thing to happen to you this Halloween season is getting a voice client on your caseload. (You think, I had a class on voice disorders once…maybe? You pull out your voice resources. Ew–that’s what the vocal folds look like? Ew–that’s what a vocal fold lesion looks like? Those are TEP’s? Yikes. I’ll stick with my articulation and language clients thank you very much.)

I hear from clinicians all the time, in person and on the web, that they are frightened to even attempt providing therapy to a voice client. Even with all the wonderful new technology and apps available, is it really as bad as walking through a haunted house while clowns lunge towards you?

Taking a step back, I remember that every person with a CCC-SLP trailing his or her signature was not thrust into this profession in the same way I was. I already knew a thing or two (or so I thought) about the voice and was ready to begin my college career as a singer. Alas, this was not in the stars for me as I had a vocal cyst requiring voice therapy and surgical removal. There was no way I was catching up to my same-aged peers with vocal performance degree aspirations to graduate on time. My voice teacher sat me down (I think I may have actually been standing in a voice lesson) and told me the words that would (for the next few years at least) be as frightening as that haunted house clown…”You have to find a new career path.” I was shocked, hurt and lost.

After lifting my chin and changing majors, I decided I wanted to help others in the same situation as me. I would use my vocal upbringing, my musical skills and my unique perspective to become a go-to voice clinician. It wasn’t until graduate school that I actually began to understand how my vocal mechanism worked. I studied video after picture after diagram of the larynx, its muscles, and the vocal folds. Slowly, and after 2 years of singing rehabilitation, I began to learn to love singing again and I now am thankful for that seemingly harsh (but necessary) redirection. My dream had changed,  but I became a better performer because of it.

Treating clients suffering from voice disorders requires just as much creativity as treating any language or articulation disorder. It requires out-of-the-box thinking when a particular technique doesn’t work. Which brings me to my first reason voice therapy is not so scary.

REASON NUMBER 1: You are allowed to change your strategy mid-session. I change techniques all the time when I sense the client is frustrated or if the client is unable to achieve a target sound production after a good amount of trying. This is a learned skill and requires humility. I learned this lesson the hard way back in school as I prepared a therapy lesson for one of my first few child clients. I spent hours preparing the “perfect” board game on the computer only to get to therapy the next day and the child was bored to tears playing it. Ego-0, Kid-1. But really, if coordinating respiration, phonation and resonance with Stone & Casteel’s Stretch and Flow or Confidential Voice Therapy (techniques that require increased airflow as the main component in unloading the vocal mechanism) is too difficult for the patient, switch to Resonant Voice Therapy (a technique that uses forward-focused feeling and sound to improve subsystem coordination). If it is not working with the patient seated, have the patient stand and bend over into rag-doll. Use a mirror. Use a tissue. Use a hand. Use your IPHONE to record. Any of this feedback could be the ticket to a successful intervention, so here is the second gem.

REASON NUMBER 2: Odd and strange techniques are encouraged. Sometimes, the weirdest one results in a break-through. If you are confident in your techniques, the patient will be too. As I continue to provide voice therapy to patients, they look at me less and less as though I have 3 heads when I ask them to put a straw in their mouths, bend over and hum Yankee-Doodle. This is because I have seen the outcomes and know that the seemingly silly activities I have patients do in session really provide tangible improvement. This confidence is translated in how I present a task. Some say, “Fake it till you make it.” I say fake it, but make sure you know what you’re faking. You are going to have to feel uncomfortable to make yourself great. Just remember to include the 3 main components of voice therapy in your treatment planning: “Improving Vocal Hygiene, Decreasing Phonotrauma, Coordinating Subsystems.” That’s it. Voice disorders seemed so much more complicated at one time, didn’t it? As a community of SLP’s and AuD’s, we support each other with therapy ideas. I witness daily on my social media perusals where a weary SLP is calling an SOS for a difficult case. We help each other out, so here is the final tidbit.

REASON NUMBER 3: Community means community resources. There is never a dumb question on any list-serv or forum I have ever been a part of. I witness graduate students getting answers from seasoned professionals. I once was scared of the “greats,” but they are people just like me and just like you who just want patients and clients to improve. It is humbling to step back and admit you need to “use a lifeline.” I think this is not a sign of weakness, but of strength as a resourceful clinician. If we can expect honest feedback, we can provide the best care, and isn’t that what it’s all about? See, not so scary!

And in lieu of trick-or-treat candy, here are a few resources that are just as yummy:

Improving Vocal Hygiene

Eliminating Vocal Abuse/Misuse

Coordinating Vocal Subsystems

Hopefully now you are armed with some new information on the voice. Don’t be afraid to make mistakes and get messy. (Magic School Bus anyone?) Voice therapy is not nearly as scary as that large pile of paperwork on your desk…(That deserves a Halloween costume…)

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.

 

A Misleading Account of Research on Stuttering Treatment for Young Children

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A recent ASHA Leader article by Peter Reitzes on treatment for preschoolers who stutter makes claims to the efficacy of some treatments that are both misleading and not evidence based – at least as far as published research is concerned.  Reitzes refers readers to a study by Franken, Kielstra-Van der Schalk and Boelens (2005) that claims to have shown no difference between the results or outcome of the Lidcombe Program and a Demands and Capacities treatment approach.  That study, as Bothe, Davidow, Bramlett and Ingham (2006) reported in their systematic review of research on the treatment of stuttering, is fundamentally flawed, making the results uninterpretable.

A study by Jones et al. (2005) evaluating the Lidcombe Program, did so by comparing children who stutter that were treated by Lidcombe with a control group that did not receive treatment. Another study by Yairi, Ambrose, Paden and Throneburg (1996) made it clear that preschool children (especially those who have been stuttering for less than 15 months) have a very high rate of untreated recovery. Consequently, any treatment evaluation using that age group needs to be compared with an untreated control group so as to show that its beneficial effects exceed those that would occur without treatment.  In the case of the Franken et al. (2005) study there was no untreated control group.  Hence, Bothe, et al. (2006) concluded that “Franken et al.’s data are difficult to interpret without a no-treatment control group to confirm that their application of either treatment was actually effective” (2005, p. 331).  In fact, that is a very charitable comment because the data are not just “difficult to interpret” – they are impossible to interpret! There is nothing in this study that would show that any speech performance improvements (from Lidcombe or Demands and Capacities) exceeded those that might have occurred without treatment.

There is even more to be concerned about in the Reitzes article.  He describes a presentation by Franken at the 2013 NSA conference of another study that also compared Lidcombe Program with a Demands and Capacities treatments. This study (Franken, 2013) used a larger cohort (n =199; 3-6 years) and reported findings similar to those reported by Franken et al. (2005).  It was claimed that after 18 months there was no significant difference between the groups in terms of stuttering frequency and percentage of children recovered.  But this study simply repeats the design error identified by Bothe et al. (2006): yet again there was no untreated control group.  The importance of controlling for a natural rate of recovery is also underscored by the report that many of the study’s children may have been stuttering for between 6 and 15 months when they entered the study. It is now almost indisputable that a high rate of untreated recovery characterizes children in this bracket (Ingham & Cordes, 1999). The argument that some might raise that running an untreated control group would amount to unethically withholding treatment is not an excuse or defense. There are many alternative research designs that can offset this problem (see Kazdin, 1998). And if one is concerned about ethics in research, how can it be argued that it’s ethical to draw unwarranted conclusions about the effects of treatments for preschool children who stutter that are based on research designs that cannot support those conclusions?

The fact that the Bothe et al. (2006) review was not mentioned among the sources or references for this article is puzzling.  Either Reitzes was unaware of this critique of the Franken et al. (2005) study, or for some reason chose to ignore it. Or perhaps he is unaware of the high rate of natural recovery in this population and thus did not understand the threat that that fact posed to the usefulness of the Franken and colleagues’ findings. Nonetheless, readers should not be ignorant of the deceptive message conveyed within his article.

Roger J. Ingham and Janis Costello Ingham are professors in the Department of Speech and Hearing Sciences at the University of California, Santa Barbara. Roger Ingham is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders.

 

References

Bothe, A.K., Davidow, J.H., Bramlett, R.E., & Ingham, R.J. (2006).  Stuttering treatment research, 1970 – 2005: I. Systematic review incorporating trial quality assessment of behavioral, cognitive, and related approaches.  American Journal of Speech-Language Pathology, 15, 321-341.

Franken, M-C. (2013). Comparing a Demands and Capacities Model approach and the Lidcombe Program for preschool stuttering children: The RESTART randomized trial (Abstract). NSA Conference Presentation, Scottsdale, AZ.

Franken, M-C., Kielstra-Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study. Journal of Fluency Disorders, 30, 189-199.

Ingham, R.J., & Cordes, A.K. (1999). On watching a discipline shoot itself in the foot: Some observations on current trends in stuttering treatment research. In N. Bernstein Ratner and E.C. Healey (Eds.), Stuttering Research and Practice: Bridging the Gap (pp. 211-230). Mahwah, New Jersey: Lawrence Erlbaum.

Jones, M., Onslow, M., Packman, A.,Williams, S., Ormond, T., Schwartz, I., et al. (2005). Randomized controlled trial of the Lidcombe Programme of early stuttering intervention [Electronic version]. British Medical Journal, 331(7518), 659.

Kazdin, A.E.  (1998). Research design in clinical psychology (3rd ed).  Boston MA: Allyn and Bacon.

Reitzes, P. (2014). The powered-up parent. The ASHA Leader, 19, 50-56.

Yairi, E., Ambrose, N.G., Paden, E.P., & Throneburg, R.N.  (1996). Predictive factors persistence and recovery: Pathways of childhood stuttering.  Journal of Communication Disorders, 29, 51-77.

 

ASHA 2014, Here I Come! It’s GO Time!

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Usually, the word scheduling elicits shivers down my spine. Usually that means scheduling 60 kids into speech therapy slots without interrupting ELA, math, lunch, recess, music, PE, art, intervention, OT or PT. It’s an astronomical feat when SLPs complete schedules every year. In contrast, scheduling for ASHA 2014 in Orlando has been a breeze. I’m scheduling lunch dates, meet ups, pool time, and my favorite CEU opportunities! Scheduling for #ASHA14 in Orlando is very different from scheduling therapy clients.

 

I’ve booked my flight. I’ve texted friends and worked out transportation. I’ve got a place to stay! I’ve joined up with some of my blogging buddies and reserved a booth for the exhibitor hall. Most importantly, I’ve started picking out a schedule for the courses I will take in November. I am so looking forward to downloading the mobile app this year. Since most SLPs don’t have time to wait in line for three days for the new iPhone 6, I’m hoping my dinosaur 4s phone will make it until November. The app should make managing my conference schedule a snap.

 

The Program Planner has been an easy way to browse for courses. It’s more user-friendly than my IEP writing program and my Medicaid billing programs. You can browse through courses by keyword, author, title, etc. So far I’ve searched for topics that apply directly to my caseload. My search terms were “school,” “autism,” “evaluation,” “preschool,” “apraxia” and “AAC.” Here are seven sessions that I’ve chosen so far:

 

  1. I really think research is valuable and there is just so much to choose from. I am trying to pick courses that relate directly to me or courses that really excite and interest me. In my current job I’m doing two preschool evaluations per week. I’m having the ‘articulation, phonology, and apraxia’ conversation with parents every week as I explain characteristics of each and their differences. The presentation “Differential Diagnosis of Severe Phonological Disorder & Childhood Apraxia of Speech” by Matthews and Rvachew sounds like a great refresher. I’m hoping to find some more evaluation-specific courses before November.
  2. I’m thinking the Phillips, Soto, & Sullivan presentation called “Strategies for SLPs Working with Students with AAC Needs in Schools” sounds perfect for a lot of my caseload. I need strategies for AAC students so this should be a big help.
  3. I can’t wait to see “iPad to iPlay 2: Teaching Play to preschoolers through Apps” from Tara Roehl. I love my iPad so I can’t wait to see how she is using it to teach play in preschoolers. This is really a skill I’d love to pass on to my teachers and parents.
  4. On the other hand I’m always careful to limit screen time with my students. There is a presentation called “The Impact of Technology on Play Behaviors in Early Childhood“ from Hagstrom, Smith, Witherspoon. Hopefully once I listen to both presentations I’ll feel good about balance and not leave feeling conflicted!
  5. Michelle Garica Winner is presenting four times. I’m hoping to catch “ASD Treatment: Cognitive Behavioral Therapy & Mental Health Problems Associated With Social Learning Challenges” and “Implementation Science & Social Thinking®: Discovering Evidence in Our Own Backyard”. I love her work and just can’t wait to finally see her present in person.
  6. Barbara Fernandez from Smarty Ears is presenting about one of her apps for data collection and caseloads. I can’t wait to talk to her about all the new Smarty Ears apps coming out in the future so I’ll be hitting up the Smarty Ears booth.
  7. Lastly, I decided to search my schools to check out what the faculty at Ohio University and The Ohio State University are presenting. “Skiing, Horseback Riding, & Communication With Individuals With Complex Communication Needs: Experiences From Community Volunteers” sounds really interesting from McCarthy, Benigno, and Hajjar at Ohio University. They are presenting information on recreational activities for individuals with complex communication needs. Interviews were conducted with volunteers in adaptive sport programs in New England.

 

I don’t think we will have any typical celebrities at ASHA. At least not the kind you see on entertainment television every night. There will however be some #SLPcelebrities to be found! I searched two of my favorites to check when they will be presenting. Hopefully you’ll see me posting a #slpselfie with some of my favorites SLPs over the weekend in Orlando.

That initial scheduling took about 30 minutes and I didn’t have to email 20 different teachers. Scheduling for ASHA is way more fun than making a therapy schedule. Now the countdown begins!

 

 

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 Facebook, Twitter, Instagram, and Pinterest. Jenna is one of four guest bloggers for ASHA’s convention in Orlando.

Collaboration Corner: AAC & AT: 5 Tips, Myths and Truisms

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Look around at every stop light and you will see the soft addictive glow of smartphones. Minivans off for a family vacation are burgeoning with tablets and some other thumb-numbing form of entertainment.  For more particular consumers, any technology prefaced with an “i” will do.

For people with complex communication needs, tools for learning and speaking have become more affordable and accessible.  But this easy access is not without its challenges.

It’s true that augmentative and alternative communication (AAC) platforms have made it into the cool kid circles, but this can make it more confusing for families and therapists to make informed decisions. Beyond You Tube and Candy Crush, it is important to remember the why and how of AAC and assistive technology (AT). Here are some points to ponder before getting too bedazzled.

  1. “AT and AAC are the same thing.” Not so much. While AAC falls under the umbrella of assistive technology, it requires a specific skill-set. Just as “related service provider” or “allied health services” includes SLP services, I would not assume the job of my physical therapy colleagues and start recommending orthotic devices. Same with AAC and AT; both tools aid and assist, and include low tech (such as a pencil grip, picture schedules) and high-tech interventions (anything that plugs in). The difference here is who is involved: AT includes a wide range of professionals well-versed in making recommendations, from special education teachers to AT certificate holders. AAC does not. In AAC, the “C” stands for communication. It is within our scope of practice per ASHA guidelines. As far as I know, it’s not under the domain of other disciplines. Period.
  2. “I don’t get it, he has an ipad, he should be able to (fill in your random ability here).” A large reason for device “abandonment” is a mismatch between the tool and the user. As SLPs your job is to consult with other experts to make sure it fits the child’s needs in terms of accessibility; fine motor, vision, and positioning are just a few considerations. AT, particularly high-tech AT, requires additional considerations, with the primary focus being, does it aide and assist?
  3. “Everybody has one.” ‘Nuff said. Social pressure should not guide recommendations. AAC is prescriptive. I know it can be difficult, but stay strong and focused on what is appropriate and effective.
  4. “He is so good at using technology, so then why can’t he…?”  My 10 year-old can use keys to unlock the door, but I wouldn’t give him the keys to drive to the store and pick up milk. Technology is a tool. AAC is a tool that requires explicit teaching. SLPs and parents are teachers that guide the process. Here is where it is important for us to educate, model and educate some more. As evidence-based practitioners, we need to take data. Data guides us on what’s working to guide what needs to be changed. For my students with autism spectrum disorder, it has been so helpful working with, and learning from, certified behavioral specialists, and come up with a system that everyone can use.
  5. “She uses it at school, and home is a time to relax, not work.” Consider the social circles of communication partners described by Deanna Wagner and colleagues (2003):
    diagram(adopted from Wagner, Daswick & Musselwhite, 2003)

    Becoming a confident communicator means practice: practice at home, practice with friends and friendly acquaintances, familiar and unfamiliar people, and within the context of different places. Don’t aim for perfection. Just aim for opportunities to practice!

Kerry Davis EdD, 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.

How to Prepare to Speak at ASHA Convention for the First Time

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This year I will be presenting at the ASHA Convention for the first time. The first time I attended an ASHA convention was last year in 2013. I enjoyed the sessions I attended and set a goal to speak at an ASHA convention sometime during my career. Thanks to partnering with amazing SLPs across the country I was able to  propose five sessions for the 2014 convention. Even though I felt that each proposal was an exciting topic, I did not expect all five to be accepted as talks (or get accepted at all). But that is exactly what happened. My first time speaking at the ASHA convention, I will be involved in five sessions. Due to scheduling conflicts, I will be speaking at only four of the sessions (see below for details). So how am I going to prepare for this? Here are three things:

 

1. Stay organized. Juggling the preparation for five sessions is not easy, so organization is key. I am reducing repetitive and inefficient work by only working on presentations at specific times. To respect my fellow presenters, I am communicating when I will be able to complete individual tasks. I schedule my presentation work sessions based on established deadlines.

Working with many co-presenters (all across the country) means many emails about our presentations. I created a file folder in my email for each presentation. I file each email in the presentation’s folder. This keeps everything together in case I need to refer back to details such as deadlines, ideas, to-do lists, and plans.

I have coordinating file folders in Google Drive for document storage (e.g. proposals, slide deck drafts, my presentation notes, etc). All the documents for each presentation are kept together. Since it’s all in the cloud, I won’t leave it behind.

 

2. Reduce inconveniences. The worst part about conventions and traveling for training for me is food. I have Celiac disease and other food allergies. Convention halls aren’t the best venue for finding gluten free, healthy food. Last year I spent $20+ on lunch, when I bought a sandwich with no bread or fries (because they were fried in the same fryer as gluten) and put the meat on top of a salad. I essentially bought 2 lunches to create one lunch (and I was still hungry).

So this time, I am doing myself a favor and anticipating a busy schedule and poor food options. I found a company that will make premade meals and deliver them to my hotel (for a lot less than $20). My hotel room has a fridge, so I will keep the premade meals in the fridge and bring lunch with me. I will not waste time on long lines or risk  getting sick.

 

3. Prepare for fun. The ASHA convention isn’t my first speaking engagement as an SLP. I have been speaking about dementia and ethics in healthcare to my fellow SLPs, other healthcare professionals, students, and family members via webinars, courses, video conferences, etc. I keep doing it because it’s fun! I thoroughly enjoy creating a presentation for a specific audience to help them reach their goals. My career has evolved into spending the majority of my time in an education role. For a former teacher, this is a very welcome evolution.

 

The pre-presentation nervousness comes, but reminding myself that each speaking opportunity is an opportunity for fun and to inspire better dementia treatment and elder care relieves my jitters quickly. I am thankful for each and every opportunity, including the several at ASHA’s convention this year. See you there!

 

Rachel Wynn is one of four guest bloggers for ASHA’s convention in Orlando and will be speaking at the following sessions:

 

Friday, November 21, 2014

  • Clients at risk for suicide: Our experiences and responsibilities (Session Code 1310) 8:00-10:00 a.m.
  • Get out of that box! Four creative mold-breaking models of private practice (Session Code 1441) 3:30-4:30 p.m.

 

Saturday, November 22, 2014

  • Social media for SLPs: Leveraging online platforms to connect and advance your practice (Session Code 1704) 1:00-2:00 p.m. (Not presenting due to scheduling)
  • Dementia 101 for students and new clinicians: Changing lives through a functional approach (Session Code 1720) 1:00-2:00 p.m.
  • Productivity pressures in SNFs: Bottom up and top down advocacy (Session Code 1755) 2:30-3:30pm

 

Rachel Wynn, MS, CCC-SLP, specializes in eldercare, and, as the owner of Gray Matter Therapy, provides education to therapists, healthcare professionals, and families regarding dementia and elder care. She is an affiliate of ASHA Special Interest Group 15 (Gerontology) and an advocate for ethical elder care and improving workplace environments, including clinical autonomy, for clinicians.

Finding Strength, Resilience and Speech-Language Pathology—as a Future Clinician and Current Client

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Life is full of challenges; age does not play favorites. I think the key is how we handle those challenges. That is where courage, resilience and strength come into play.

Since starting undergraduate courses at the University of Central Missouri, Warrensburg, in August 2012, I faced a number of challenges—residence changes, job changes, health challenges, and school challenges. I remember rolling into the fall semester in 2013 feeling exhausted, stressed and wondering if I would make it. I was trying to put some space between my long-time boyfriend and myself. He moved across the street from me after a fire where we used to live.

I was still working about 30 hours a week, attending school full time, and preparing to start graduate school in January. The final challenge was his unexpected death from a heart attack the day before the last week of fall classes in 2013. Over the next two weeks, I made it through classes, finals and a funeral.

At 52, I have experienced my share of obstacles and stressful events, but this put me into a tailspin. I am one of the strongest women I know and my obstacles are usually short walls. I made it through the spring semester, but that first summer semester knocked me back onto my heels, mentally and physically, and I could not climb over that wall. I learned then how much support I had in the school faculty, staff and my classmates.

During that summer semester, I lost my focus. I felt buried under the mountains of clinic paperwork, a research paper and challenging coursework. My clinical evaluations were not positive, and I was floundering. That is where I pulled my courage from deep inside myself and turned to the faculty and my friends for help.

Reaching for help is hard, because sometimes the answers are not what we want to hear. My supervisors got me back on track and helped me stand up on my own two feet. I had to take a long, hard look in the mirror and face the person they saw. At the final case conferences, I asked them some direct questions, which is how I not only became a clinician this fall, but also a client. As a former U.S. Army sergeant, and as someone with a strong personality, I fit in well in some venues, but I needed help to be successful in other venues—like the speech-language pathology field. That is where the strength came in. I am self-aware, and willing to look at myself, but I had to admit I needed help with my pragmatic skills.

My clinician is wonderful, and together, we are discovering how to work on my pragmatic skills. My clinician created a scaled list of questions about how I communicate, and we used that to get feedback from my teachers and supervisors. The answers knocked me back a bit, but I accepted their feedback with grace and maturity.

We are working on my personal interaction skills, my resume, and even my social media postings. The interventions are working as my teachers and supervisors notice a difference in how I communicate. I am having a successful semester and my mid-semester conferences resulted in two A’s and a B.

Being a client is different from being a clinician. I am convinced it takes courage and strength to come into a professional clinic and lay oneself open to change. Change is hard. Change is not always fun. Sometimes change is painful.
While attending graduate school, I turned 52, and in November my first grandchild will be born. So many changes, so many opportunities lie ahead for me. This field of speech-language pathology is ripe with opportunities for older students. As nontraditional students, we have faced challenges and experienced things that younger students will not experience for a while.

Sometimes our life experiences mirror those of our clients, giving us the ability to be empathetic and genuine in our care. I am looking forward to this next chapter in my life. I will face any other challenges with courage, resilience and strength, because that is what I do.

Teresa Shane is a speech-language pathology graduate student at the University of Central Missouri in Warrensburg, Missouri.

Is There a Heffalump in the Room? Learning to Be a Leader, Part 1

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In Pooh’s “Huffalump” movie, Roo asks, “’Scuse me, what’s a heffalump?” Pooh, Tigger, Rabbit, Piglet, and Eeyore sing a song about the horrible qualities that they believe heffalumps possess (three heads, fiery eyes, spiked tails, etc.).

When presented with a difficult task or situation, we often find ourselves in conflict about how to deal with it. The Chinese word for conflict or crisis consists of two symbols: danger and opportunity. When we are faced with difficult moments, we must remember we have a choice. How we manage that choice often determines the outcome of the situation. In audiology, we are often faced with conflict ranging from difficult hearing aid fitting and counseling sessions to negotiating with vendors. Sometimes we have conflicts internally in our office or conflicts regarding professional issues in our membership organizations.

Conflict often makes us think of a negative experience that did not go well. We must remember, however, that conflict is not a bad thing but an opportunity for both personal and professional growth. Think about how boring meetings and conversations would be if people did not speak up and share their thoughts and ideas. If conflict is handled right, then there are benefits that you might not expect such as:
Better understanding of the issues and the opportunity to expand your awareness to the situation.
Increased trust among your team members and colleagues. People feel safe to express themselves, allowing an opportunity for growth.
Enhanced self-awareness due to being more aware of your goals and thoughts on how to be an effective leader and team member.

Handling conflict, however, does not necessarily come easily for most. Here are some key strategies that leaders use every day to help prevent and/or defuse conflict to allow for productive opportunities or engaged conversations.

When dealing with difficult moments:
Focus on the process. It is not about the people, it is about the system or process.
Go “below the line” for a collaborative approach for conflict resolution. Imagine an iceberg. You can only see the top, which is usually only 10 percent of it. To navigate the waters, you need to know what is below the sea line, the other 90 percent, to be safe.
Listen first and then ask questions for understanding. Remember restate, rephrase, and summarize when trying to gain understanding and trust.
• Create options collaboratively. Be open to ideas.
• Negotiate what options would solve the conflict.

When dealing with conflict, it is important to consider when do you take action and who should have the conversation. To answer when—the sooner the better. Addressing unprofessional behaviors, engaging with the dissatisfied patients, and/or intervening before people forget are essential to maintaining accountability, employee satisfaction and retention, and minimizing potential liabilities. To answer who—anyone in most cases. Regardless of the title, anyone should be able to talk to us and share ideas without feeling minimized or degraded. If the leaders blink or if the culture is of the mindset “it doesn’t matter, can’t change it…,” then it is important for the leadership to step in and be a role model on how to resolve conflict or better yet create a culture where conflict is considered to be an opportunity not a negative event.

To learn more about your conflict style, the Thomas-Kilmann Conflict Mode Instrument is a widely used instrument that provides helpful information on your conflict style. The conflict styles are Competitive, Collaborative, Compromising, Accommodating, and Avoiding. Different situations call for different conflict styles, so knowing what domains you typically prefer will be helpful.

I encourage you to take Roo’s direction and instead of being scared of conflict, look for the heffalump yourself and discover that often the many traits outlined are things that are not true or can be negotiated.

So, you ask, how do I negotiate these uncharted waters? Next, Leadership Realities Part II will provide you with your compass.

Tamala Selke Bradham, PhD, CCC-A, is a quality consultant in the Department of Quality, Safety, and Risk Prevention at Vanderbilt University Medical Center. She is an affiliate of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood.

A Student Information Tool to Help Itinerant Evaluators in Schools

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I remember attending a presentation by Dr. Wayne Secord at a conference at Stockton State College in New Jersey, back in the late 1980s or early 1990s. I couldn’t tell you the topic, however, I recall Dr. Secord saying something along the lines of “today ‘multidisciplinary’ means come together-go apart when it should mean come together-stay together.” That sentiment has remained with me all these years.

At the time the truth of this struck me like a lightening bolt. Twenty-five or so years later, this idea, by and large, still rings true. But despite our best efforts, the time we need for collaboration is sadly limited. We are overwhelmed by staggering caseload numbers, case management responsibilities, massive paperwork requirements, meetings, playground duty and more. In concert with our general duties come more and more highly involved students presenting with academic and medical challenges that require the need for continuing education and research. Never has the need for consistent collaboration been more crucial.

I am fortunate in that I work in one building. I have the luxury of having a quick conversation on the run. I also have the benefit of knowing the students in my building. However, the itinerant speech-language pathologist or evaluator does not have such luxuries of interprofessional access. Recently, several of my colleagues expressed concern that itinerant evaluators may not have the inside scoop on students, potentially posing challenges to testing accuracy.

As a result, I decided to create a document that could be completed by a classroom teacher or case manager and given to an evaluator to provide a better understanding of a student’s dynamics. I based some of the criteria on James Anderson’s Habits of Mind (HoM), but also included general information such as the types of prompting the student responds to best, preferred reinforcement, response speed, signs of fatigue or frustration, ways to redirect the student, whether breaks are needed and the preferred type of break. The document also includes demographic information and opportunities to incorporate work samples and class schedule.

The Habits of Mind present a way to think about the way students learn and are, to a large extent, a determinant in academic success or failure. The HoM include persistence, managing impulsivity, listening with understanding and empathy, thinking flexibly, metacognition, striving for accuracy, questioning, applying past knowledge, thinking and communicating with clarity, gathering data through the senses, creating and imagining, responding with wonderment and awe, taking responsible risks, finding humor, thinking interdependently, and remaining open to continuous learning.

Having an understanding of a child’s ability to manage impulsivity perhaps, or task persistence paints a more complete picture for an evaluator. Such knowledge would allow an evaluator to say, schedule movement breaks or encourage a child to take risks when responding. The upshot is, the information obtained could yield more accurate test results. I am hoping that this document provides evaluators with greater insight when administering tests and interpreting test results.

Anne Doyle, MA, CCC-SLP, is a speech-language pathologist in Bridgewater, New Hampshire, who is in her 31st year of practice in the schools. She is a graduate of ASHA’s Leadership Development Program and is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education, and 16, School-Based Issues. This post is adapted from  the post “Help for Itinerant Evaluators” on her blog “Doyle Speech Works.”

When Social Media Turns Antisocial—and What We Can Do

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I really have fun with social media. My platform of preference is Instagram. It’s fun, it’s a quick share, and it doesn’t afford opportunities for ranting. I post to Facebook intermittently and I tweet infrequently. It all can be fairly overwhelming.
While on the surface, it seems social media has connected us, in my humble opinion, it has disconnected us. We’ve all seen it: a family out to dinner. The little one is watching a movie, as another is playing a game on the phone. The teen is texting a friend, and mom and dad aren’t talking.

In our family, we have an unstated rule when we are out to eat: no media! We talk and we laugh (Annie Doyle likes this).

I know I am not alone in being concerned that media, in particular social media is negatively affecting communication. I haven’t grown up with social media. In fact, I remember when we first went “online,” I was terrified. I recall chat rooms that could be pretty dicey. I also remember the thrill when I heard the classic “You have mail.” Who me? Today, I err on the side of caution. I make it a point not to have any online “friendships” with my students, their parents, the children of my friends, or my children’s friends, so I really don’t know what they are posting about.

I have heard tragic stories of social media run amok and it is disturbing. We, as parents of teens, have access to our children’s passwords and they know we DO check. We are steadfast in our roles as parents and know our children are not always happy about our “meddling,” but it’s a scary world.

I also am aware of the effect social media has had on me. I have made some wonderful connections via the Instagram and blogging world, and I am so grateful for that. I have reconnected with friends from 30 years ago. There also have been times I’ve been consumed with social networking. Never has this been more apparent than since I have started blogging. I have asked myself: “Do I really have 15 followers? Woohoo!!” “How many page views today?” “Why won’t so and so acknowledge my posts/efforts?” I have experienced emotional contagion whereby I have felt the emotions of others after viewing a posted video of the homeless or a mother singing to her dying daughter. I’ve read with disdain political rantings and ad hominem attacks made without the need for civilized discourse.

As an adult I can choose to ignore these posts, block the author, or unfriend individuals who use Facebook as a sounding board. Middle school and high school students, whose social life incorporates social networks, may not have the wherewithal to to do the same.

What follows is just a brainstorm of the possible problems our students might “face” when using social media.

  • Over-sharing: Many people become turned off by posts documenting every moment of everyday.
  • Impulsive posting: Posts that are written when hurt or angry.
  • Confidence killers: So many gauge their popularity by the number of friends they have or the number of likes a post receives.
  • Misinterpretation of posts: This happens so frequently. We can’t know the tone of voice without hearing it and we don’t know the intent with which posts are written.
  • Misperception of our posts: Likewise others don’t have the benefit of knowing our intent.
  • Bullying: The internet is rife with opportunities for harassment. Individuals are so often emboldened by the cover of anonymity.
  • Feeling alienated: What is it about that “like” button? We are all too aware of who likes our posts and who ignores them and many are easily hurt by the passive-aggressive nature of “not liking.”
  • Macy’s window: When a post is out there, it is out there forever. It’s like standing in Macy’s window for all to see.
  • FOMO (fear of missing out): Kids often feel left out and alienated when they see posts of friends doing fun things and they aren’t included. As a kid who wants to belong, there is often nothing worse than feeling excluded.
  • Ranting: Tirades are off-putting!
  • Attention-getting: Kids are needy and social media is the perfect outlet for posting for attention. Positive or negative, attention is attention and meets the same need.
  • Not being in the moment: I have seen more people stop enjoying the moment to post a picture to Facebook or Instagram (guilty).
  • Time blackhole: Why waste time texting, waiting for a response, texting again…?
  • Disingenuous posts: Kids can post without honoring what they are really feeling. There have been sad stories of kids who have shared seemingly happy posts all the while hiding deep sadness.
  • What’s missing: At least 80 percent of our communication is conveyed through tone of voice and body language, so while we may seem connected there is an awful lot we are missing.

As communication gurus, we can help our older students not get caught in the social media quagmire. Let’s collectively encourage our students to have a healthy relationship with social media. Let’s work toward being models who use social media to improve the world we live in, to disseminate quality information, to learn, and to spread joy.

For instance, let’s all consider the following, and teach our students as well, to:

  • Read and reread posts, text messages, and emails and if there is a nagging feeling that says, “Don’t post,” trust those instincts.
  • Don’t put stock in the number of likes on a post; it really is meaningless and what counts is the sharing of a valuable moment or idea.
  • Don’t post controversial material: try to keep it happy, as social media is no place for political tirades. If feeling compelled to make a point, do it respectfully and without profanity and hurtfulness.
  • Turn off notifications. It can make you crazy.
  • Make efforts to engage in face to face conversation or at least the telephone. Allow yourself to key into tone of voice and body language. When firming up plans, how about a real conversation? Just pick up the phone for Pete’s sake!
  • Don’t over-share. People don’t really want a play by play of your day by day.
  • Be sure that what you post is a reflection of what you truly believe or feel. Be genuine and if you need help ask for it. In this day and age no one should suffer alone.
  • Learn to take posts at face value. Without a conversation you can only guess what the intent or motivation of another is.
  • Don’t post when you are emotionally charged, you will regret it.
  • Live in the moment: when doing something fun don’t stop what your doing to post. Wait until the activity is finished and then share.

I would love to hear your thoughts on social media and communication. Please share any of your awesome ideas for encouraging safe social media practices.

Anne Doyle, MA, CCC-SLP, is a speech-language pathologist in Bridgewater, New Hampshire, who is in her 31st year of practice in the schools. She is a graduate of ASHA’s Leadership Development Program and is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education, and 16, School-Based Issues. This post is adapted from  the post “Un-Social Media” on her blog “Doyle Speech Works.”

Changing the Clinical Question from ‘Can I?’ to ‘How Can I?’

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It’s always easy to discuss how things should be. We start sentences with:

“It’d be great if…”

“Ideally…”

“In a perfect world…”

But typically, when we discuss ideals, we quickly follow up with:

“But that’s not realistic.”

“Too bad that can’t actually happen.”

“Wish it could really be that way.”

When it comes to clinical practice, I think we default to the latter group of statements far too often. We significantly limit what we believe is actually possible, because the things we know are good in theory are just too hard to apply in the “real world.” It’s easy to sit through a graduate class or a continuing education session, but it’s another thing entirely to apply that information day-to-day in the therapy room. Think about some examples:

We learn about the importance of evidence-based practice, but “realistically,” there is not a vast amount of high-quality evidence for many of our practices in this relatively young field.

We discuss the necessity of being sensitive to culturally and linguistically diverse populations, but “realistically,” we can never learn to speak every language or understand every culture.

We understand that the Code of Ethics exists for the purpose of maintaining best practices, but “realistically,” ethical dilemmas are not always so black-and-white.

So what’s the point then? Why do we have standards that we can’t live up to in practice? Why are we taught things that we are doubtful we can ever actually apply?

That, right there, is the problem. It’s the question we’re asking. We look at a client or a situation, and we ask, “Can I do this?”

“Can I find any evidence to guide my clinical decisions with this unique and difficult case?”

“Can I effectively treat this client whose language I do not speak?

“Can I maintain my personal and professional ethical codes when a ‘sticky situation’ arises?”

The problem with these questions is that from the moment we decide to become speech-language pathologists, we have already answered all of them. In accepting the responsibilities that come with being a part of this field, we have already said a huge, resounding “Yes” to every ‘Can I?’ question. No matter how challenging the situation may be, yes, we can do it, because we must.

One of my professors recently challenged our class to change the question. When faced with difficult situations that make us uneasy, or cause us to doubt what we can handle, we have to start thinking of it differently. Instead of asking, “Can I do this?” we should ask, How will I do this?”

 How will I follow the levels-of-evidence hierarchy in order to implement EBP, even when the current existing evidence base is not extremely strong in this particular area?”

How will I be creative and use resources to effectively treat this client whose language I do not speak?”

How will I ensure that I maintain my personal and professional ethical codes and engage in best practices, even when a ‘sticky situation’ arises?”

 How will I do this?”

 Many people are familiar with the famous quote from Spider Man, “With great power comes great responsibility.” While a few ‘Cs’ behind your name may not seem like power to most of the world, as members of this field, we know differently. SLPs have the power to help others, facilitate communication, and cause change, and I would say that is great power. We have been given the power, and therefore we have accepted the responsibility. We have said, “Yes,” to every tricky situation and every obstacle, whatever it may be, no matter how challenging. We have said “Yes,” because it is our responsibility to do so, based on the power we have been given. We can, because we must.

The next time you are faced with a tough case and are tempted to ask, “Can I do this?,” remember that you have already answered yourself. Can you do this? Yes, you can, because you must.

So, start asking yourself and others something different. Start changing the question. Start asking, “How?”
Kelsey Roberts is a student in the master’s speech-language pathology program at Abilene Christian University in Abilene, Texas.