Collaboration Corner: 5 Take-Aways to Support AAC, Apps and Language

TEchnology and augmentative and alternative communication

This past month, my colleague Sean Sweeney (AKA @speechtechie) and I had the opportunity to join forces and write about AAC, apps and literacy development. Our article will be in the next issue of SIG 12: Perspectives in Augmentative and Alternative Communication.

This gave us a great opportunity to discuss how AAC users can benefit from apps to enhance treatment outcomes. Here are five highlights:

Feature matching is important: When choosing AAC or apps for learning, the tool must meet the needs of the user. For AAC, this includes the size, layout and physical accessibility of features to maximize independent use. For apps, this includes Sean’s FIVES criteria, which examines the context, appropriateness, accessibility and therapeutic considerations for learning. Just like any other tool in your kit, if it isn’t a good match then opportunities for communication or learning are potentially lost.

Make CORE align with the CORE: Using generative language formats, including core and fringe word vocabulary, benefits the student two-fold: building in opportunities for language growth throughout the day, while also meeting those pesky Common Core Standards. For example, a first grade ELA standard CCSS.ELA-Literacy.L.1.1.c, “Use singular and plural nouns with matching verbs in basic sentences.” Using core vocabulary allows the student to meet this standard through basic sentence construction activities. A first grader may enjoy learning this through the “Collins Big Cat” series, a free app that reads stories out loud and then has the option of the student recording his voice (or in this case, synthesized voice). The app also has a more interactive component, which allows the student to build scenes and narrate his own version of the story.

Apps and AAC are powerful together: Students love the interactive nature of apps. “Toca Hair Salon” is a highly interactive hair salon studio allowing students to describe how they are going to cut, color or otherwise coif the animal or person of choice. Another simple app, “Pogg,” is a cute alien that hops, sings and performs other actions, all at your student’s direction during a session. Beyond paper flashcards, the apps give students immediate reinforcement, so then work feels less like work.

Separate communication tools from other tools: If you are going to use apps and AAC at the same time, one practical solution is to use separate tools. Toggling between apps and AAC is cumbersome, and slow session momentum. In addition, having separate systems prevents the user from confusing a communication device with other technology, which is an important distinction. If your tools look the same, change the colors of the cases. If you have students that like to surf and press that home key, enable guided access so that only the AAC app is available.

Model, model, model through apps and AAC: Finally, apps provide the opportunity to model AAC live, and in unpredictable ways. You have more opportunities to explore and learn together. Don’t have curling iron as a fringe vocabulary item when using your “Toca Hair Salon” app (it’s not there, believe me)? Show your student how you can give clues to what you mean and talk it through using what is available on your AAC: “Let’s see, it’s a tool, it’s hot and it makes your hair curly…what is it?

There’s your abridged version and takeaways…log in to your SIG 12 portal for more info, and to get CEUs….ASHA renewal is right around the corner!

 

 

Reference

Sweeney, S. & Davis, K. (2014). In press. Reading, writing and AAC: Mobile technology strategies for literacy and language development. SIG 12: Perspectives in Augmentative and Alternative Communication. American Speech Language and Hearing Association.

 

 

Kerry J. Davis, EdD, CCC/SLP is a speech-language pathologist in the Boston area. She holds a special interest providing services to children and adolescents with complex communication profiles, including AAC. Davis is a volunteer SLP and consultant to Step by Step Guyana, a school for children with Autism in South America.

 

“Use Your Speech Tools!” Why Your Child Who Stutters May Not Be Using His Strategies

Stuttering Tools

When a child who stutters demonstrates the ability to change his speech during a treatment session, it seems obvious that he’d want to use the same strategies to improve speech outside the session as well.  Children, especially teenagers, rarely want to stand out in a way that stigmatizes them, provokes questions or increases the chances of teasing.   So the question arises, “Why aren’t they using their tools?!”

Speech and stuttering modification techniques are often learned quickly and easily within the treatment setting.  However, SLPs and parents often feel discouraged when these tools seem to disappear as soon as the client gets to his car.  Is it laziness on the part of the child?  Is it the fault of the family for not following through with home assignments?  Is the SLP not teaching the best strategies?

Instead of placing blame, consider the following three reasons a child may have difficulty generalizing his skills:

Reason # 1: These Techniques Are Too Hard! 

Making changes to one’s speech becomes exponentially harder when you introduce factors that often are not present in the session, such as interruptions, time pressure and feelings of embarrassment or shame associated with stuttering. Learned escape/avoidance behaviors and increased language demands may make it very difficult to use these tools.  Suddenly, what felt like an easy decision to use a new technique, becomes complicated by the person’s desire to be heard in a large group of chatty peers or by the need to formulate an excuse about why he doesn’t have his homework.

How Can I Help?

Children will be more likely to use speech/stuttering strategies if they are first introduced in safe and supportive environments (i.e. home, session room).  To help with this, create a hierarchy of speaking situations and use it to guide where the client practices the strategies.  If a child who stutters is not yet using speech tools in certain situations such as the classroom, it is probably because of where that situation is on his hierarchy. Work with your clients to determine where they would like to use their strategies , while also identifying those situations where they would prefer to concentrate on things other than using their tools.

Reason #2: These Techniques Make Me Sound Weird! 

There are several techniques that may be taught to a child who stutters. Some strategies involve prolonging the initial sound to ease into or out of a word with less physical tension or struggle.  Other techniques include inserting more pauses into speech.   All speech tools require a child to alter their speech in a way that is still different from how his friends sound.  Children may report that they have similar negative thoughts and feelings about using these strategies as they do about their stuttering.  This may play a role in why they are choosing not to use speech strategies outside their sessions.

How Can I Help?

Just as you might spend time trying to help reduce negative reactions to stuttering, you might also spend time desensitizing clients to hearing themselves use strategies through voluntary stuttering assignments.  Children can also benefit from improving their ability to handle listener reactions. This can be addressed by participating in role-playing activities that help the child create “scripts” for responding to curiosity/teasing.  For example: “Why do you sound like that?” “Sometimes I stretch my sounds like that to help me get out of a stutter.”  The more comfortable the child feels with his strategies and ability to respond to questions about his speech, the more prepared he will be to use these techniques outside the session.

Reason #3: These Techniques Aren’t Worth it!  

A cost-benefit analysis can be useful when trying to understand why a child may choose not to use speech/stuttering strategies.  At the surface, it may appear that there are many benefits of using strategies which include increased fluency and improved overall communication. However, SLPs and parents must be careful to consider the costs, as well.  Costs may include increased effort, difficulty concentrating on the content of message, the risk of showing more stuttering and the potential that the strategy doesn’t work.

How Can I Help?

Have discussions with clients about what they perceive as potential costs versus benefits of using strategies in a variety of different speaking situations.  As the child becomes more accepting of stuttering and is better able to tolerate both his feelings about stuttering and listener reactions, physical tension and struggles associated with speaking will decrease.  As this happens, tools become easier to use and costs may not feel so high.

The bottom line 

There are several strategies that may help reduce stuttering frequency and severity.  However, you often can’t offer these tools without first considering and incorporating goals that target how the client thinks and feels about his speech both while stuttering and while using tools.

Brooke Leiman, MA, CCC-SLP, is the Director of the Stuttering Clinic at the National Speech/Language Therapy Center in Bethesda, Md. She is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. This blog post is adapted from a post on her blog, www.stutteringsource.com, which focuses on fluency disorders and their treatment.

 

 

Tales From Apraxia Boot Camp

bootcamp
In August of this year, I was selected to be a part of The Childhood Apraxia of Speech Association of North America’s 2014 Intensive Training Institute, otherwise known as “Apraxia Boot Camp.” Twenty-four speech-language pathologists, including myself, trained with three mentors–Ruth Stoeckel, Kathy Jakielski, and Dave Hammer–at Duquesne University over four days. In its third year, the goal of the boot camp is to spread a high level of knowledge about Childhood Apraxia of Speech (CAS) assessment and treatment throughout the United States and Canada. This conference accomplished that and so much more.

This experience was different than any other continuing education seminars that I have attended. We did not listen to speakers discuss CAS. Instead, Ruth, Kathy and Dave became our mentors. This was powerful. They moderated discussions on evaluation and treatment approaches. We reviewed research papers and had long debates on the principles of motor learning. We highlighted and critiqued therapy methods for those brave enough to show videos of themselves. We problem solved and brought up more questions than we knew were possible.

In smaller groups, our mentors provided insights and personal perspectives on how they work. In this intimate setting, we felt comfortable asking questions and sharing our experiences. The mentors shared constructive criticism along with thoughtful suggestions. In all, they made me think, reflect and question everything I do. Why do I give that test? Why do I treat that way? What is the research behind it? They encouraged us to become critical thinkers.

As therapists, we often get used to using the same materials and therapy techniques we learned in graduate school or during our early experiences. Those methods are not always effective with every child we treat nor are they all proven effective with evidence based-research. Specifically, children with CAS require different therapy techniques than other children with articulation or phonological delays.

Ruth, Kathy and Dave provided valuable information in a small, engaging setting. Their mentoring and passion for CAS has inspired me and I hope to pass along this valuable information to others through mentoring, improving my competency in treatment and diagnosis of CAS, and, in the end, helping children to communicate.

Based on my experience, I’d recommend asking yourself a few questions when selecting your next continuing education event:

  • What am I passionate about? Is there a child or an area of speech pathology that truly inspires me?
  • How will it improve my skill set?
  • How will it help me better serve my clients?
  • Who is doing the most current, researched-based evaluation or therapy techniques?
  • How will it further our profession?

 

Amanda Zimmerman, MA, CCC-SLP, is a pediatric speech-language pathologist in Columbus, OH. She can be reached at azimmerman@columbusspeech.org.

In Appreciation: Sylvia Onesti Richardson

Richardson SylviaSylvia Onesti Richardson, president of the American Speech-Language-Hearing Association in 1973-74  and a passionate advocate for children with language and learning disorders, died in her home on Friday, October 24. A Tampa resident since 1980, she was 94 years old.

Throughout her career, Richardson strongly advocated for children with learning disabilities and speech-language disorders: In 1949 she established at Boston Children’s Medical Center the first speech-language clinic in any children’s hospital in the United States. She also created the Child Study Center and became involved in the use of Montessori educational methods for children with learning disabilities while at the University of Oklahoma. In Cincinnati, she was a founding member of the Hamilton County Diagnostic Center for Children with Learning Disabilities and the founding editor of Children’s House magazine. In 1970, she was invited to the White House Conference on Children and in 1977, was appointed to the President’s Commission on Mental Health. She was also Chair of the National Joint Committee on Learning Disabilities from 1997 to 1999, and a member for 30 years.

Richardson received her training in pediatrics from the Montreal Children’s Hospital and the Boston Children’s Medical Center and was also an ASHA-certified speech-language pathologist  and certified Montessori primary teacher. Richardson had numerous academic appointments, culminating in Emeritus Clinical Professor of Pediatrics at the University of South Florida, where she began teaching in 1981.

Richardson has contributed much to the literature of her field with more than 100 publications including the book, “Something’s Wrong With My Child: A Parent’s Book About Children with Learning Disabilities,” 1973. She also received numerous honors, including the 1964 Oklahoma Woman of the Year.

Richardson’s professional accomplishments are only a part of her remarkable life. She was an active member of the Athena Society, and especially their Young Women of Promise Award program, which has been renamed in her honor. She was a strong supporter of the arts, especially the Straz Center for the Performing Arts, and she loved to attend performances there.

She is survived by her brother, Silvio Onesti; her sons William and Christopher; and her grandchildren: Lucas, Michael, Eva, Will, Anna and Sophia. These grandchildren were Richardson’s pride and joy. She attended many graduations from high schools and colleges, and this past June saw Lucas get married.

A memorial service was held Saturday, November 8, in Tampa.

In lieu of flowers, memorial contributions may be made to the International Dyslexia Association, 40 York Road, 4th Floor, Baltimore, MD 21204.

Cooking up the Perfect ASHA 2014

shutterstock_159814334

What’s the perfect recipe for ASHA 2014? Blend together science, learning and practice. Add a pinch of party and a heaping of gratitude. Watch it grow for generations.

Like many SLP swallowologists, I’m a foodie. Expand that: I’m a bilingual (Spanish-speaking)-Canadian-American-Salsa-dancing-foodie-mama-dysphagia nut, ready for a stimulating convention getaway in Florida. Good thing ASHA has cooked-up a feast for the body and mind.

Coming from Boston, I’ll feel right at home Wednesday night at Minus5º Ice Bar for the ASHA-PAC Party. Drinking a cocktail in a glass made out of ice may make you swallow faster! Watch out! The icy architecture will cool us down as we discuss the latest political action on Capitol Hill.

On Thursday, ASHA promises “hot, hot, hot” at the The ASHFoundation Latin Party at Cuba Libre Restaurant & Rum Bar. After we swallow liquids, we can test solids from the award-winning chef Guillermo Pernot. Salsa lessons anyone?

But of course we won’t just be there to party– relaxing and dancing will help us learn better.

 

Gratitude for opportunities in Science & Learning

I love seeing my heroes at conventions. This year we are deeply saddened to have lost our pioneer in dysphagia, Jerilyn Logemann.

As we remember Logemann, we also need to remember to thank all our mentors. Take time to reflect on how much they have influenced you and your career. Who would I be today without teachers like Jay Rosenbeck, Joanne Robbins, and James Coyle during my master’s studies years ago? Thank you!

And not just mentors who you know directly, but those who are influencing the profession, too. Thank you Catriona Steele, University of Toronto, for pushing us to go global. She suggests an international consensus for diet texture terminology. How many names do we have for that safe-ish dysphagia diet between puree and regular? Here are a few: mechanical soft, ground, moist ground, chopped, mechanically altered…

Thank you Tessa Goldsmith, Partners MGH, for the very important exploration of Human Papilloma Virus (HPV). SLPs are public health advocates. Michael Douglas was misdiagnosed three times, delaying his treatment by too many months. He said it started with a sore throat and sore gums behind his last molar. As rates of laryngeal cancer from smoking decline, HPV has emerged as the most common cause of oropharyngeal cancer. However, there are many differences between HPV-positive and HPV-negative cancers. Additionally, don’t miss a chance to see Katherine Hutcheson, of MD Anderson, who gave a fabulous series at the ASHA Healthcare & Business Institute this past April. Jeri Logemann co-authored a two-part series on Long-Term Dysphagia After Head & Neck Cancer. Thank you to her team for carrying the torch.

I appreciate how Dr James Coyle is like Socrates, probing with critical questions to seek the truth. His courses ask: Which side is up?; What’s wrong with my patient?; What are we doing and why?; and what can bedside swallowing examinations do and what can’t they do? Every SLP practicing in dysphagia has to take at least one of his courses. We will learn a lot of science that directly relates to our practice, while having fun! I try to capture his humor in my blogs.

Another thank you to the twilight session on Thursday, called “Eating is Not Just Swallowing.” Samantha Shune, University of Iowa, integrates “components of the broader mealtime process with our definition of swallowing.” I typically introduce my bedside swallowing evaluations with: “Your doctor wants me to evaluate your eating and swallowing.” However, I was once told at an old job to not say “eating,” because it was deemed unrelated to swallowing and swallowing impairment. I appreciate this session’s holistic perspective.

 

Generations of Discovery

ASHA conventions inspire growth. I have discovered that you can recreate your career at any age. After performing Modified Barium Swallow Studies for 15 years, I am beginning again in an extensive FEES training program.

This past April at the ASHA Healthcare & Business Institute, a group of us were sharing our dreams and goals for our careers. I realized that I love to constantly learn, synthesize, and share with others. One year ago, I never would have believed that I would start a dysphagia resource website and become an SLP blogger.

As us older generations teach the younger generations, we also need to thank the younger SLPs for inspiring us to keep it fresh. For me that meant finally embracing technology. It is technology that is helping ASHA members network and reach all corners of the globe.

Thank you, ASHA, for this feast!

 

Karen Sheffler, MS, CCC-SLP, BCS-S, graduated from the University of Wisconsin-Madison in 1995. Karen has enjoyed medical speech pathology for 20 years. 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. She has lectured on dysphagia in the hospital setting, to dental students at the Tufts University Dental School, and on Lateral Medullary Syndrome at the 2011 ASHA convention. Special interests include neurological conditions, geriatrics, oral hygiene, and patient safety/risk management. Karen continues to work in acute care and is a consultant for SEC Medical. She started the website and blog www.SwallowStudy.com in May 2014. She has blog posts on ASHAsphere and www.DysphagiaCafe.com. Sheffler is one of four invited bloggers for ASHA’s 2014 Convention in Orlando.

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

Making trying new foods fun for teens.

Making trying new foods fun for teens.

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

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

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

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

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

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

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

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

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

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

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

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

singingcloseup

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

stutter

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

AAC

 

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.