Pragmatic Language Intervention for Adults with Autism

autism

 

A man enters the room, apparently comfortable with his surroundings and with those around him. Despite his large physique, he exudes a gentle demeanor and a genuine kindness as he approaches the other adults in the room. He curtly nods to a few people in the room, and then takes a seat in his usual spot. As he scans the papers in front of him, his face lights up and he points to a picture representing the day’s refreshments. He smiles at the woman sitting next to him and carefully produces the words, “Want…snack.” He nods again and smiles with noticeable satisfaction.

This man’s name is Jim, and he is an adult with autism. Jim attends one of the two Adult Language and Pragmatics Skills (ALPS) programs offered at Towson University’s Hussman Center for Adults with Autism. Like many other individuals on the autism spectrum, Jim struggles to communicate verbally and to engage in meaningful social relationships. These difficulties represent unique challenges for Jim and other adults on the spectrum. To address these challenges, Jim attends the ALPS group each week and participates in meaningful activities designed to explicitly address areas of need. The activities target communication in a variety of social contexts, and participants show subsequent improvements areas of need.

In addition to the positive changes observed with group participants, the ALPS programs also are gaining positive attention from families in the greater Baltimore community. Jim’s mother recently expressed her appreciation for the ALPS group and for the noticeable improvements she sees in her son’s communication. She wrote, “There are not enough words to express my gratitude to you and your team. Jim’s communication did significantly increase with the Fall session. I know that your program is critical to Jim’s continued progress.”

So what makes the ALPS programs at Towson University effective and attractive? Some would say the impressive amenities available at Towson University’s Institute for Well Being facilitate the programs’ success. Admittedly, the rooms equipped with multi-media technology and the fully furnished apartment in which adults can practice skills are indeed helpful. But the ALPS groups also offer experiences purposefully designed to incorporate evidence-based practice techniques for optimal success:

  1. Mentor/Peer Role Models – The use of peer role models is well-supported in the literature as an evidence-based practice intervention (Llaneza, DeLuke, Batista, Crawley & Frye, 2010; McGee, Almeida, Sulzer-Azaroff & Feldman, 1992; Orsmond, Krauss & Seltzer, 2004). Mentors from the ALPS groups include graduate student clinicians earning clinical hours in the speech-language pathology program, as well as undergraduate mentors earning service learning hours. Mentors plan the group sessions as well as individualized activities to target specific goals agreed upon by mentors and participants. The mentor-participant relationship emerges as a mutually-beneficial partnership in which each party experiences growth and personal satisfaction. Participants learn from the mentors through direct modeling experiences, and the mentors gain invaluable experience with adults on the spectrum. Often, the student mentors indicate that their perceptions of autism significantly change as a result.
  1. Relevant Topics – To foster meaningful learning experiences relevant to the unique challenges that adults with autism face, topics are selected that directly relate to participants’ everyday lives. Topics vary from semester to semester, but generally include practical themes such as nonverbal communication, managing emotions in moments of conflict, dating and relationships, self-advocacy, communication in the workplace, and increasing independence. Many participants suggest ideas for topics, and sessions are planned with the participants’ specific needs in mind.
  1. Universal Design for Learning Standards – To target specific strengths and needs of participants in the group and to incorporate learning style preferences, sessions are planned utilizing Universal Design for Learning (UDL) guidelines. The UDL approach asserts that to best meet the individual needs of diverse groups of learners, clinicians should offer (a) multiple means of presentation, (b) multiple means of response and (c) multiple means of engagement (Rose & Gravel, 2010). The ALPS groups at Towson University incorporate UDL standards in several specific ways:
    • Technology Tools – to increase engagement and to provide additional visual representation, ALPS groups routinely incorporate multi-media videos, interactive whiteboard activities, iPads, smartphones, and personal communication devices into learning experiences.
    • Response systems – to facilitate and maintain engagement of the group and to include nonverbal responders, discussions are often supplemented with systems that allow all participants to answer questions and express opinions simultaneously. Pinch cards, signs, color-coded paddles and gestures are all used to facilitate each participant’s communication of ideas and opinions.
    • Kinesthetic and tactile experiences – to include kinesthetic/tactile learning styles and to address participants’ need for movement for regulating sensory input, all sessions include activities requiring the participants to move. Sometimes the movement also serves as a mode of response (e.g., moving to a designated location in the room to indicate a choice), further integrating UDL guidelines.
    • Differentiated supports – to meet the needs of individual learners in a diverse group, activities are adapted specifically for each participant. Student mentors often create and implement visual supports, and provide hierarchical prompts to promote the highest levels of success and independence.
  1. Experiential Learning Opportunities – to address multiple learning styles and to provide hands-on practice, sessions often include functional activities that utilize social communication skills. Group members participate in role play activities, everything from acting out scripted dyadic communication to real-world experiences like ordering food in a restaurant. Participants do not simply listen to an instructor talking about strategies for successful communication; rather, participants engage in direct and relevant experiences that target effective communication and self-advocacy.
  1. Social Connection Opportunities – ALPS sessions are comprised of a variety of social experiences, encouraging participants to connect with others through structured practice. Whole group, small group and individual experiences are offered weekly as group members discuss ideas and opinions relevant to the session topic. Activities that foster partnership and cooperation are also utilized, encouraging participants to step out of their comfort zone as they practice social skills.
  1. Reflection and Review Experiences – All participants are encouraged to reflect on their experiences and to review important strategies. Each week, participants and mentors discuss progress and identify goals for the participant to consider in the week ahead.
  1. FUN – As one participant freely offered, “I don’t learn much when I’m bored. But I always remember the fun parts!” A preference for fun is certainly not unique to the autism population. Don’t we all remember the fun parts? To maintain an enjoyable and social atmosphere, sessions are planned using central themes. Activities, snacks, and even attire may revolve around the designated theme. Past selections include favorite movie, sport, travel and holiday themes. To further the fun, ALPS groups end each semester with a celebration party in which each group member is recognized for personal achievements.

All of these techniques are integrated into meaningful ALPS sessions for the advancement of pragmatic language and social skills. Future projects at the center include studies to objectively evaluate treatment efficacy and functional outcomes of the participants and mentors. While the ALPS groups continue to adapt and improve, the current success of the programs remains readily apparent. As we work to document improvements and successes, we are continually inspired by the adults who come to our center. Adults like Jim, entering our rooms with nods and smiles, looking for fun and friendly faces. Our hope is that these special adults feel equally inspired, and that they leave our rooms feeling successfully connected.

 

Lisa Geary, M.S., CCC-SLP, serves as Clinical Assistant Professor in the Department of Audiology, Speech-Language Pathology and Deaf Studies at Towson University. In addition to teaching and supervising graduate students in the on-campus Speech-Language Center, Lisa serves as program facilitator for the Adult Language and Pragmatic Skills Groups at Towson’s Hussman Center for Adults with Autism. Her teaching and research interests include Universal Design for Learning, Autism through the Lifespan, Augmentative and Alternative Communication (AAC), and Instructional Technology. Lisa can be reached at lgeary@towson.edu

 

References

Orsmond GI, Krauss MW, Seltzer MM. Peer relationships and social and recreational activities among adolescents and adults with autism. Journal of Autism Dev elopmental Disorders, 2004; 34:245–256.

LLaneza DC, DeLuke SV, Batista M, Crawley JN, Christodulu KV, Frye CA. Communications, interventions and scientific advances in autism: a commentary. Physiol Behav. 2010;100:268–276.

McGee, G. G., Almeida, M. C., Sulzer-Azaroff, B., Feldman, R. S. (1992). Promoting reciprocal interactions via peer incidental teaching. Journal of Applied Behavioral Analysis. 25 117–126.

Rose, D.H. & Gravel, J.W. (2010). Universal design for learning. In E. Baker, P. Peterson, & B. McGaw (Eds.). International Encyclopedia of Education, 3rd Ed. Oxford: Elsevier.

 

 

 

Are You Ready for Better Speech and Hearing Month?

bhsm

Better Hearing and Speech Month is a mere week away, and ASHA is gearing up for an exciting month! By now, we hope you’ve seen some of the resources we developed specifically for members—press release and media advisory templates, our 2014 poster, a Facebook cover photo, a letter to parents, our 2014 product line, and much more. We also encourage members to utilize the Identify the Signs member toolkit during May, as the campaign will be front and center for this year’s BHSM. The campaign’s message of early detection is a great tie-in to the 2014 BHSM theme of “Communication disorders are treatable.”

If you’re still looking for ideas on ways to celebrate, it’s not too late to plan something. We’ve got a list of suggestions here, and you can check out our new interactive map featuring stories of how your fellow ASHA members have recognized the month.

If you do have a fabulous event or activity in store, we want to see it! Take a photo and post to Instagram with the hashtag #BHSM. One winner will be randomly selected to receive a package of 2014 BHSM products. More details can be found on the BHSM member resource page. The contest will run from May 1st – 12th.

In addition to member resources and contests, ASHA will be conducting a lot of public outreach during the month to raise the profile of communication disorders and the role of ASHA members in treating them. Some highlights this May include:

  • Google Hangout—A live, online Google Hangout to mark BHSM will be held on May 6th from 1:30 – 2:30 p.m. ET. Moderated by ASHA CEO Arlene Pietranton, the event will convene experts from a wide range of backgrounds to discuss the critical role that communication plays in daily life—and the importance of early detection of any speech, language, or hearing difficulties in children to allow them to reach their full potential academically and socially. Guests will include Elizabeth McCrea, ASHA’s 2014 President; Libby Doggett, deputy assistant secretary for policy and early learning at the U.S. Department of Education; Sara Weinkauf, an autism expert from Easter Seals North Texas; Patti Martin, an ASHA-certified audiologist from Arkansas Children Hospital; and Perry Flynn, an ASHA-certified speech-language pathologist at the University of North Carolina – Greensboro. The panel will take questions from the public, and members are encouraged to participate. Questions can be posted to ASHA’s Google+ page, or use the hashtag #BHSM on Twitter. You can RSVP for the event here.
  • Twitter Party—A Twitter party hosted by lifestyle technology and parenting blogger Michele McGraw (@scrappinmichele), and co-hosted by five other leading parenting bloggers, will be held on May 20th from 12 – 1 p.m. ET. During the party, parents and other interested parties will have the opportunity to learn, and ask and answer questions, about speech, language, and hearing disorders. No RSVP is required; members who are interested in joining in should just follow the hashtag #BHSMChat at that time.
  • New Infographic—A new infographic illustrating the prevalence and cost of communication disorders, as well as the benefits of early intervention, will be posted online at www.asha.org/bhsm and http://IdentifytheSigns.org, and distributed widely to traditional and new media.
  • Podcast Series—Four new topical podcasts featuring ASHA members will be rolled out weekly during the month. These are: Newborn Hearing Screening—In the Hospital and Beyond (May 1); Noise-Induced Hearing Loss in Children: A Preventable Problem (May 12); Autism Diagnosis and Treatment of Today and Tomorrow (May 19); and Building Language and Literacy Skills During the Lazy Days of Summer (May 27). These will be available at http://IdentifytheSigns.org.
  • International Communication Project 2014—During May, ASHA is going to be disseminating digital messaging that relates to the International Communication Project 2014 that was launched earlier this year—and promoting signatories to the Universal Declaration of Communication Rights. Members are encouraged to sign the Declaration and invite others to do so to show their support for people with communication disorders. Watch the February Google Hangout to learn more and hear from the participating countries.

 

Many of these resources won’t be available until May 1 or later, when they are debuted to the public. We encourage you to visit our member resource page www.asha.org/bhsm frequently to see the latest, and hope you can share the information with your networks. These resources will also be posted to http://ldentifytheSigns.org, the home of the Identify the Signs campaign and a site designed for consumers to easily find information tailored to them.

We hope this year’s BHSM will be one of the best yet, and look forward to hearing how you’re celebrating the month. Send us any stories, questions, or comments to bhsm@asha.org.

 

Francine Pierson is the public relations manager at ASHA. She can be reached at fpierson@asha.org.

Rockin’ the ASHA Health Care & Business Institute

gary blog 2


Where the heck is everyone? Oh. I get it.

So…here’s a tale to share, OK? Yours truly, this intrepid, Down Easterner editor-in-chief for the ASHA Leader news magazine, is attending his first ASHA Health Care & Business Institute. It’s Vegas (baby!), glistening with probabilities and paradox: palm-tree-lined streets press against yellow-brown desert; a chiming, smoke-filled casino perches an escalator-ride above a bustling, professional conference. And there’s me, all nimble-like, sprinting the gauntlet of one-armed bandits, dashing down the escalator, caught up in a dizzying quest to nab an interview or two. It’s the perfect time, ay-uh. Sessions are running now, but—if my experience at hundreds of other professional conferences holds true—there’ll also be a fair number of folks milling and networking outside the meeting rooms or chatting up the exhibitors.

Nope. The hallway stands silent. I duck into the exhibit hall.

Nada. There be tumbleweeds a’ blowin’. Heck, even a fair number of exhibitors are nowhere to be found.

My goodness—everyone’s in the meeting rooms. Yes, folks, the sessions at the ASHA Health Care & Business Institute are that darn good.

Packed with more sessions and CEU opportunities than ever (hey, check out the awesomely convenient and affordable PLUS Package recorded courses CE option), the 11th ASHA Health Care & Business Institute attracted a near-record-breaking crowd from April 11—13. It’s not difficult to understand why.

  • Tons and tons of practical advice. Interested in the most effective strategies for contracting with employees and third parties? How about the six principles of influence to best leverage yourself and your brand? The impact of using mainstream versus less mainstream speech on your career? Tips for reading the body language of your clients and colleagues? Want candid advice from an entrepreneur on how to build your own practice? The sessions on business management and strategies were packed!
  • Up-to-the-minute coverage and tips. Want to learn the best way that your program or practice can thrive under the Affordable Care Act? What about the latest, greatest apps for pediatric populations and adults? Need to know about Medicaid for children in 2014 or this year’s billing procedures and codes for SLPs? What about the newest requirements for securing health information? Attendees had at their fingertips the most recent goings on affecting communication sciences and disorders at these popular sessions!
  • The latest advances from the frontlines of treatment. Session after session, many featuring legendary CSD researchers and clinicians, showcased the latest approaches to assessment and treatment for clients affected by a wide range of communication disorders—aphasia, dementia, dysphagia, childhood apraxia of speech, and autism spectrum disorder, among others. Some of these sessions were so well attended that folks were sitting in the aisles and on the floor in the hallway outside—I gave up my chair many times…

1HCBI1

So, with such a gang buster conference going on, what was this editor-in-chief supposed to do? When in Rome….I immediately jettisoned the interview-heavy approach to coverage and swore a courageous but ultimately foolhardy vow to cover the sessions as completely as possible through the Leader’s social media channels.

Picture this: It’s early Friday morning, and I begin hopping like a killer rabbit (beloved Holy Grail reference required) from one session to another, tweeting and posting photos at #ashaigers on Instagram. Listen, snap and tweet; listen, snap and tweet. Whew! By lunch I was stretched rather thin, and then I had to do it all again that afternoon, the next day, and the morning of the third day. I didn’t waver. My grandmother was right—when a notion takes my noggin’, I get as set and fixed-purposed as an old New England stone wall.

And now it’s time for a slice of humble pie. In the end, I must admit that the Great Social Media Effort was nobly conceived but executed imperfectly, because 1.) there were so many wonderful sessions going on that I simply could not do justice to all of them; and 2.) in many cases, I found myself so drawn in by a presenter, subject, and/or an audience’s enthusiasm and engagement that it was very difficult to leave the room. Grrrr. I. Just. Couldn’t. Cover. It. All.

At long last, with the Luxor and its Strip kin fading behind, I had time on the flight back to reflect on an outstanding conference. The attendees LOVED it and learned much. Those I spoke with were uniformly excited about the sessions; many pronounced the meeting as the best yet. They’ll be back next year, I reckon. Come hell or high water, I’ll be there, too. Perhaps leading an army of Leader editors to help cover it ALL next time. Ay-uh.

Gary Dunham, PhD, is ASHA publications director and editor-in-chief of The ASHA Leader.

 

How to Begin or Reignite Your Career in Schools

school

One of the best things about being a speech-language pathologist is the variety of work settings to choose from. Holding the CCC affords SLPs the flexibility to carve out a niche many settings such as schools, hospitals, skilled nursing facilities; private practice, academia and corporate.  You can reinvent yourself just by changing where you work.

As an SLP who has worked in many settings.  I can attest to the value of change and honing new skills. However, change is always easier when you’re equipped with the right information.

If you’re making a change to schools, here are ten things to know to help you get started:

  1. The federal IDEA law and regulations governs special education and related services to all children with disabilities. This includes children with speech and communication disorders. It is important to understand the law and regulations in order to follow the special education process in schools.
  2. IDEA requires that all students who receive special education have an Individual Education Program or IEP. The IEP is the blueprint for the services that each child receives and should include a statement of the child’s present level of performance, measurable annual goals, including academic and functional goals that will help the child to benefit from the educational curriculum.
  3. It’s important to know that there are qualifications for eligibility for speech language services in schools. Check with your local district or state for guidelines outlining eligibility criteria for speech-language services.
  4. Service delivery in schools is typically conducted through individual or small group sessions, and/or  in collaboration with teachers and other education professionals. Tracking goals and collecting data for multiple students in one session is accomplished with preplanning and organization. It is important to develop a method of tracking data for each student goal in order to report progress throughout the year.
  5. The average student Caseload  across the country is 47 according the 2012 Schools Survey. That number will fluctuate throughout the school year. Scheduling and service delivery are key to managing your caseload.
  6. Response to Intervention (RTI) is a process in which struggling students are provided with alternative interventions in areas of need to determine if their performance is due learning difficulties or faulty instruction. Some schools fully embrace the RTI model while others do not. IDEA allows for RTI but does not require it.  SLPs often play a role in the RTI process in their schools.
  7. The Common Core State Standards have been adopted by 45 states thus far and is an initiative to prepare students for college programs or to enter the workforce.  The standards include the areas of reading, writing, speaking and listening, language and mathematics. SLPs should be familiar with the standards in their state to develop IEP goals that complement and integrate the Common Core curriculum for the students they serve.
  8. Speech-language pathology assistants (SLPAs) typically work in the school setting under the supervision of an SLP. The scope of practice for an SLPA is narrower than that of an SLP and is designed to support, not supplant the work of the SLP. ASHA recommends that SLPs supervise no more than 2 SLPAs at a time.
  9. SLPs in schools may be subject to state teacher requirements. ASHA’s state by state webpage outlines teaching requirements from each state across the country. Learn in advance what you’ll need to work in the public schools in your state.
  10. Salaries in schools vary widely across the country. ASHA’s 2012 School Survey provides salary data for public school SLPs in every state. Opportunities to earn additional income may be available by working in after school and summer school programs. Salary supplements may be available to SLPs who hold CCC credential.  Schools also offer excellent retirement plans, health benefits and favorable schedules.  Read more about the rewards of working in schools.

Of course, there’s much more to school based practice than just these ten points, but it’s a start.  ASHA is committed to serving school based SLPs by offering clinical and professional resources as well as professional development opportunities. One of the most popular professional development events is ASHA’s annual  Schools Conference. The Conference features the best speakers in the field on a variety of topics.  In fact, early bird registration is open now!
These resources and opportunities for learning will help to make your transition to schools a smooth one.  If you’d like to connect with us about school based practice, please contact us: schools@asha.org. We’d love to hear from you.

 

Lisa Rai Mabry-Price M.S. CCC-SLP, is the associate director of School Services for ASHA. She can be reached at lmabry-price@asha.org.

Beyond Skype for Online Therapy: Protecting Student Privacy

Privacy

 

The trend for kids online is sharing more, not less. Today’s kids consciously and unconsciously share so many aspects of their life using Facebook, Skype or even newer tech tools like Snapchat. But, as educators, we hold ourselves to a much higher legal and professional standard for protecting the information of these very same students. We’ve all heard about the laws—FERPA, HIPAA, COPPA— that set the standards for privacy of student records and personally identifiable information, but what do the laws mean in the context of delivering speech-language therapy online?

HIPAA: Protecting Individually Identifiable Health Information

Created by the Department of Health and Human Services in 1996, The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects patient medical records. HIPAA specifically protects “individually identifiable health information,” which includes:

  • the individual’s name, address, birth date and Social Security number.
  • the individual’s past, present or future physical or mental health or condition.
  • the provision of health care to the individual.
  • the past, present or future payment for the provision of health care to the individual.

HIPAA gives patients a variety of rights regarding individually identifiable health information. With consent, HIPAA permits the disclosure of health information needed for patient care, such as speech therapy.

FERPA: Protecting Education Records

The Family Educational Rights and Privacy Act (FERPA) is a federal law that protects student education records. FERPA gives parents certain rights with respect to their children’s education records until they turn 18 or transfer to a school higher than the high school level, thus making them “eligible students.” The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. Under FERPA, parents or eligible students have the right to:

  • Inspect and review the student’s education records.
  • Request a school to correct records they believe to be inaccurate or misleading.
  • Prevent a school from releasing information from the student’s education record without written permission (with some exceptions).

COPPA: Protecting Children’s Personal Information

The Federal Trade Commission instituted COPPA (Children’s Online Privacy Protection Act) in April, 2000 to protect children’s personal information on websites and applications that target children under the age of 13. Under the legislation, websites and apps that collect this information must notify parents directly and get their approval prior to the collection, use or disclosure of a child’s personal information. The FTC describes personal information as:

  • A child’s name, contact information (address, phone number or email address.
  • A child’s physical whereabouts.
  • Photos, videos and audio recordings of the child.
  • A child’s “persistent identifiers,” like IP addresses, that can be used to track a child’s activities over time and across different websites and online services.

Recommendations for Online Therapy

Clinicians and educators often focus on the capabilities of individual pieces of technology, and, indeed, a secure therapy platform is highly recommended both to ensure the privacy of sessions as well as student data. However, it is the information, and the sharing of that information by the adults responsible for the care of each child, that these laws focus on. So educators need to focus on a systems approach that considers the end-to-end process of handling and securing student data.

While clinicians are trained in student identity protection, non-disclosure methods and the maintenance of student record confidentiality, it is ultimately the school’s responsibility to ensure agreements they have in place with online therapy service providers support them in protecting student privacy. So what are the practical considerations in this end-to-end approach to protecting the privacy of students receiving online therapy?

  1. Ask what type of security is in place. Solutions with bank-level security offer the strongest protection of data. This includes 256-bit encryption using TLS 1.0, restricted physical access to the servers on which data is stored, and 24/7 on-site security personnel.
  2. Use a secure platform for therapy. Secure platforms use an invite-only, encrypted, secure connection. In this model, only the online clinician and the student assigned to that particular appointment time are permitted to enter the password-protected “therapy room.” Parents may also view a session with a prior written request.
  3. Use a secure server to store data. Make sure all student files containing individually identifiable health information and education records are stored on a secure server using industry-leading security.
  4. Restrict access. Only online clinicians, authorized school administrators and parents should have access to this password-protected information, thus further protecting student privacy.

This “big picture” thinking will let educators take advantage of new online delivery models for therapy services AND stay compliant with privacy laws. And leave Snapchat to the students.

Melissa Jakubowitz, MA, CCC-SLP, is the Vice President of SLP Clinical Services at PresenceLearning. She is a Board Recognized Specialist in Child Language with more than with more than 20 years of clinical and managerial experience. She is the past-president of the California Speech-Language-Hearing Association and is active in ASHA, serving as a Legislative Counselor for 12 years.

Can Speech-Language Pathologists Diagnose Autism?

Posted response

On February, as part of its Posted series, the ASHA Leader asked on Facebook, “Do you, as an SLP, diagnose autism spectrum disorder independently or as a team?” The response we received was varied and indicated there is some confusion in the profession about what is proper, expected, or even legal. The biggest question that appeared over and over was, “How can an SLP diagnose independently?” The answer bears some explanation.

When it comes to assessing and diagnosing ASD, interdisciplinary collaboration is important due to the complexity of the disorder, the varied aspects of functioning affected, and the need to distinguish ASD from other disorders or medical conditions. Ideally, the SLP plays a key role on an interdisciplinary team, whose members possess expertise in diagnosing ASD.  In cases when there is no appropriate team available, however, an SLP who has been trained in the clinical criteria for ASD and who is experienced in the diagnosis of developmental disorders, may be qualified to diagnose these disorders as an independent professional. For more information check out ASHA’s new Practice Portal and/or position statement on autism.

In most cases, a stable diagnosis of ASD is possible before or around a child’s second birthday (Chawarska, Klin, Paul, Macari & Volkmar, 2009). An early, accurate diagnosis can help families access appropriate services, provide a common language across interdisciplinary teams, and establish a framework for families and caregivers within which to understand their child’s difficulties. Any diagnosis of ASD, particularly of young children, should be periodically reviewed, as diagnostic categories and conclusions may change as the child develops. Interdisciplinary collaboration and family involvement is essential in assessing and diagnosing ASD.

Assessment, intervention, and support for individuals receiving speech and language services should be consistent with the World Health Organization’s International Classification of Functioning, Disability, and Health (2001) framework. This framework considers impairments in body structures/functions; the individual’s communication activities and participation; and contextual factors, including environmental barriers/facilitators and personal identity. There are recommended knowledge and skills for SLPs who are planning on working with individuals with autism spectrum disorder:

Knowledge required:

  • Federal and state laws and regulations regarding scope of practice, referral, and placement procedures.
  • Diagnostic criteria for ASD and related conditions (e.g., DSM-5).
  • Prevalence.
  • How to obtain information regarding etiology and related medical conditions.
  • Importance of early diagnosis and the role of the speech-language pathologis.t
  • How to evaluate the validity of diagnostic tools.
  • The necessary information to gather in a diagnostic evaluation about the child’s health, developmental and behavioral history, past intervention and academic history, and medical history of the family.
  • Other related diagnostic categories and when to make appropriate referrals to identify or rule out related conditions
  • How to rule out or confirm hearing loss while working with an audiologist.
  • The types of speech and language impairments that can co-occur with ASD, including features of language disorders, apraxia, and dysarthria.
  • How to share information about diagnosis with parents.
  • The challenges of determining eligibility for services for individuals with ASD, especially high-functioning individuals.
  • The needs of culturally and linguistically diverse populations, including the selection and/or adaptations of diagnostic instruments (ASHA, 2004b).

Skills required:

  • Observation, recognition, and interpretation of diagnostic characteristics of ASD.
  • Selection and correct use of valid diagnostic tools for ASD.
  • Appropriate referrals to other professionals to identify or rule out related conditions.
  • Diagnosis of the types of speech and language impairments that can co-occur with ASD, including features of language disorders, apraxia, and dysarthria.
  • Integration of findings from diagnostic tools for ASD, diagnostic evaluation, and information from other professionals or members of an interdisciplinary team, to determine diagnosis.
  • Documentation and communication of findings about diagnosis to family members, individually or in conjunction with a collaborative team.
  • Effective, delicate, and empathic communication when informing family members that the child has ASD.
  • Decision making about eligibility for services.
  • Appropriate recommendations and referrals for services and assistance to families in navigating the educational and health care systems, as well as promotion of self-advocacy.

Some state laws or regulations may restrict the scope of practice of licensees, however, and prohibit the SLP from providing such diagnoses. SLPs should check with their state licensure board and/or departments of education for specific requirements.

 

Understanding Autism: Restaurant Meltdowns

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I sat in a popular restaurant chain and watched an 8 year old boy have a major meltdown at his table.  His mother cringed as lunch time patrons stared.  An irritated couple at a nearby booth got up and moved, but only after glaring at the mother.  I’ll be honest, the child was disrupting my lunch too, but one thing I suspected was that this child had autism.  He appeared to be just like any other child, but the intensity of his outburst was out of proportion to the issue he was yelling about: The waiter had served him waffle fries and he had expected “skinny fries” just like the french fries served at home.

April is National Autism Awareness Month.  The U.S. Centers for Disease Control and Prevention (CDC) reports that 1 in 68 children are reported to have autism (ASD) and most are boys. Chances are, you know someone with autism.

What distinctive characteristics of ASD can affect a child’s ability to adjust to unexpected life events, even something as incidental as waffle fries?  Let’s look very briefly at some of the central features of ASD, while keeping in mind that this a spectrum disorder, with symptoms ranging from mild to severe and this list does not encompass all of the elements of a diagnosis. Just some of the central features that kids with ASD have difficulty with are:

  1. Social interaction, often including social reciprocity or that back and forth communication exchange known as conversation.
  2. Restricted behaviors and the need for “sameness” or the inability to be flexible with change.
  3. Hypersensitive and/or hyposensitive “to sensory aspects of the environment” which can hinder their ability to tolerate different tastes, temperature and/or textures of food and deal with change in general.

As a pediatric therapist,  I assess and treat a child’s ability to allocate specific cognitive resources in the brain to manage day-to-day life.  As adults, we too have to utilize many different parts of our brains throughout the day.  But what happens when we are bombarded with sensory input and suddenly, we have to adjust to unfamiliar stimuli? To understand what it’s like, consider this example:

You are driving the minivan full of kids to soccer practice, radio blaring, kids chattering.  Your brain is operating relatively smoothly, filtering auditory, visual, tactile and other sensations, while remembering to use your turn signal, maintain the speed limit, etc.  Suddenly, the weather changes and it starts to hail.  What’s the first thing you do?  Turn off the radio and tell the kids “Shush…Mommy needs to concentrate on the road.”  Perhaps you even slow down so that you can focus on the sudden change in driving conditions.  You have eliminated as much sensory input as possible so that you can concentrate on the task at hand – driving safely.  Isn’t it interesting that  you were driving perfectly fine until one unpredictable event changed in your environment?

Now consider the child with autism as he attempts to engage in mealtimes.  The reality is that daily life changes as easily as the daily weather report and for him, some days are just like driving through a hailstorm.  This child is already challenged by poor sensory processing; he has limited ability to take in information through all of the senses, process it and filter out the unimportant info, and then act upon only the relevant sensory input.

Now, bring that child to the family dinner table, which is all about social interaction and conversation.  Put a plate of food in front of him which looks and smells completely different from the last meal he was served.   Then, tell him to try that steamed broccoli for the very first time.  He doesn’t get to turn down the sensory input bombarding him at the table and focus just on the broccoli.  Because he has autism, he can’t always filter out which stimuli might be inconsequential and it feels so much safer to follow rigid behavior patterns and never try anything new.  Life for a child with autism is all about sticking to sameness. My role as a therapist is to help the child learn to deal with change.

A 2013 study from the Department of Pediatrics at Emory University indicated that kids with ASD are five times more likely to have feeding problems compared to their peers.  Once feeding difficulties are addressed in the home, restaurants are the next step for their families.  Here, the visual input is completely different and it changes constantly, the inconsistent auditory input can be overwhelming, the fluctuating smells may be interpreted as noxious, etc.   Every input to every sense has changed.   Once again, the child with autism is encountering a hailstorm and has to learn to tune out the distractions and focus on the task at hand – in this case, eating a meal away from home.  In this young man’s case, waffle fries were just too much to handle after managing all of the other sensory stimuli at the restaurant.

Perhaps you are a parent of a child with ASD.  Perhaps you have observed a child whom you suspect may be dealing with the daily challenges  of autism.  Thank you for considering what mealtimes feel like for him and his family.  It does get better, but it is a journey that requires patience from family, friends and the community.

Please share this article with a friend so that we can continue to raise awareness of autism spectrum disorder and if you know someone who loves a child with ASD, do something special for them this month in honor of National Autism Awareness Month – 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.

Skyrocketing Autism Numbers a Call to Action for SLPs

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Last week the child-development community got a jolt from news of a jump in numbers of children diagnosed with autism spectrum disorder: an increase of 30 percent in just two years. One in 68 children had ASD in 2010, up from one in 88 children in 2008, according to data from the U.S. Centers for Disease Control and Prevention.

And that’s raised many questions among speech-language pathologists and other developmental experts. For one thing, what’s driving the increase? And what does it mean for ASD diagnosis and treatment? There are no clear answers or absolutes. But developmental expert Stephen Camarata is willing to speculate. We talked with the Vanderbilt University hearing and speech sciences professor about his take.

What is behind this increase? Is it really just an increase in identification?

There are three main factors. One is a real increase in incidence. Our technological ability to take preemies weighing less than a pound and have them survive has changed, and it’s not surprising that more of these kids might have challenges.
Second, there’s increased awareness, so more people are looking for ASD in kids. And third there’s the expansion of the definition of spectrum. The numbers of kids identified as high functioning and as having Asperger syndrome has skyrocketed.

What do the higher numbers mean for SLPs?

We’re the speaking profession, so we have a central role in assessing and treating these kids. Based on this, we’re obviously seeing a big increase in caseload, which as a field we need to develop ways to handle. But more basically than that, we need to figure out how to differentially diagnose these young kids, these 2-year-olds, distinguishing between ASD and the new DSM-5 [Diagnostic and Statistical Manual of Mental Disorders] category of social communication disorder.

We are the main profession driving identification and treatment of SCD, and we need to develop assessments and interventions in this area. It’s a huge opportunity and a huge challenge—and we need to be prepared to handle this demand.

The study suggests that there is a lag in identification, with most kids diagnosed at 4 and older when they could be diagnosed as early as age 2. What can SLPs do to help get these kids diagnosed earlier?

First I should point out that when the kids in this study were toddlers, in 2004 and 2005, we weren’t yet able to accurately diagnose autism at those young ages. Now, with the toddler module of the Autism Diagnostic Observation Schedule, we can. And given that with ASD comes late onset of speaking, SLPs are often doing the earliest assessments. Right now, we may be less inclined to put a late-speaker in the SCD category because we want to get these kids services but don’t yet have appropriate assessments, treatments or reimbursement for SCD. Our charge is to develop these. And it’s also to it’s also to continue to develop continuing education for our practitioners to diagnose autism, which we can do, typically as part of a team.

The study suggests that kids who are African American and Hispanic are being underdiagnosed relative to white kids—again, what can SLPs be doing to help close this gap?

It should be noted that, if you look at the report, there actually has been a dramatic increase in diagnosis in both those communities. But yes, the rates still lag behind those in white children a great deal, so there’s a need to close this gap. Part of this is an issue of cultural difference, but it’s also the well-known health-disparities story of lack of access to services. So we need to do more outreach and education in the African American and Hispanic communities about early intervention and their entitlement to public services.

What are the implications of these findings for the services SLPs provide to children on the spectrum?

This is my sense: Some SLPs feel like they’re not necessarily the primary interventionists in cases of autism but if a kid’s primary weakness is in the speech and language domain—which is the case in ASD, along with behavior—then they really have the role. Improved speech improves behavior. And parents want their kids to talk, so we are and should be primary clinicians involved in diagnosing and treating ASD.

As we go forward, we need to work on distinguishing SCD from autism. We need to own this, but to do that we need to provide data that make a difference and train others on what we know.

 Learn more about social communication disorders  and autism spectrum disorder on ASHA’s website. More information on both categories is available from ASHA—e-mail Diane Paul, ASHA director of clinical issues in speech-language pathology, at dpaul@asha.org.

Stephen Camarata, PhD, CCC-SLP, is a professor of hearing and speech sciences at the Bill Wilkerson Center at the Vanderbilt University School of Medicine. He is an affiliate of Special Interest Group 1, Language Learning and Education. Contact him at stephen.m.camarata@vanderbilt.edu.

Kid Confidential: The Latest on Treatment of Ear Infections

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For those of us speech-language pathologists who serve the birth-5 year old population (or have young children of our own), it is always important for us to know the most recent health and safety regulations that can affect our clients/students. Here are the newest regulations regarding the medical treatment of ear infections.

As otitis media affects three out of four children by the age of three, and there is a correlation between chornic otits media and communication delay, it is likely that we as SLPs will treat students with acute or chronic otitis media.  As a result we must understand the American Academy of Pediatrics (AAP) guidelines regarding the medical treatment of this condition.

Although, these regulations were initially released in 2004, it appears there is still much confusion among the medical community and, as a result, a second publication of the same AAP medical regulations for treating otitis media was released in 2013.

The regulations were written in response to antibiotic overuse and resistance in children.  Traditionally children are treated with antibiotics as the first line of defense for acute otitis media.  As there are a number of causes for ear pain, it is crucial that pediatricians firstly make an accurate diagnosis of otitis media prior to administration of antibiotics.  Doctors are urged to diagnose otitis media only when a moderate to severe bulging of the tympanic membrane (i.e. ear drum) is present.  Mild bulging and recent ear pain (i.e. meaning within 48 hours) exhibited along with other signs of ear infection (e.g. fever) also may be diagnosed appropriately.  Therefore, if the pediatrician is unsure of the diagnosis of otitis media he/she is discouraged t to prescribe antiobiotics.

Although pain is present, antibiotics are not necessarily to be considered the first course of action. In fact, in response to ear pain and/or low grade fevers, pain relievers are to be recommended initially as “about 70 percent of kids get better on their own within two or three days, and giving antibiotics when they aren’t necessary can lead to the development of superbugs over time” reports Dr. Richard M. Rosenfield, professor and chairman of otolaryngology at SUNY Downstate Medical Center, Brooklyn.

Antibiotics are only to be prescribed when the child is exhibiting several signs or symptoms of otitis media (e.g. pain, swelling for at least 48 hours, fever above 102.2 degrees Fahrenheit, etc.).  Immediate prescription of antibiotics should be recommended in the event a child’s tympanic membrane ruptures.

Although it is important to understand the medical treatment of otitis media, perhaps it is more important for us to understand the simple preventive measures a parent can take to help avoid the development of ear infections in the first place.  In addition to this medical treatment plan, the guidelines also stress avoidance of tobacco exposure, receiving the influenza vaccination, and breast feeding exclusively for the first 6 months (if possible) as additional ways to prevent infant ear infections.

Medial guidelines for “silent ear infections” (i.e. middle ear fluid without presence of other symptoms typically following acute otitis media or colds) consist of “watchful waiting.”  If a child is diagnosed with “silent ear infections” also known as otitis media with effusion the pediatrician should initially provide no medical treatment.  A follow up reexamination should take place three to six months later.  If fluid persists for more than three months, the pediatrician should recommend a speech/language and hearing assessment.  If middle ear fluid persists more than four months and signs of hearing loss are evident, a pediatrician may recommend placement of PE tubes or refer their patient to an ENT for further assessment.

I very much appreciate the AAP for adding in the guideline of further assessment in the areas of speech/language and hearing if fluid persists longer than three months.  This demonstrates the AAP’s understanding of the important of communication development and the need for a quick resolution to such delays rather than the typical “wait and see” attitude that parents often report to encounter particularly in instances of “late talkers.”  Now we, as SLPs, have guidance and support from the AAP for our clients/students with long-term persistent middle ear fluid.

Please refer to the resources below for further information.

Resources:

Jaslow, R. (2013, February 25). Antibiotics for ear infections: Pediatrician release new guidelinesCBS News.

New guidelines for treating ear infections. (2004). The Harvard Medical School Family Health Guide.

 

Maria Del Duca, M.S. CCC-SLP, is a pediatric speech-language pathologist in southern, Arizona.  She owns a private practice, Communication Station: Speech Therapy, PLLC, and has a speech and language blog under the same name.  Maria received her master’s degree from Bloomsburg University of Pennsylvania.  She has been practicing as an ASHA certified member since 2003 and is an affiliate of Special Interest Group 16, School-Based Issues.  She has experience in various settings such as private practice, hospital and school environments and has practiced speech pathology in NJ, MD, KS and now AZ.  Maria has a passion for early childhood, autism spectrum disorders, rare syndromes, and childhood Apraxia of speech.  For more information, visit her blog or find her on Facebook.

Collaboration Corner: In Defense of the Whole Child

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I treat children with autism. I’ve been doing it for a while now. As the numbers of children with autism peak a staggering 1:88 (Center for Disease Control, 2014), the demand for trained staff has gone through the roof. Many districts have specialized paraprofessionals whose primary job is to teach and support children with autism. In the Boston area, graduate and certificate programs related to ABA are cropping up everywhere, churning out new and enthusiastic graduates by the boatload.

Before I go on, there are three things you should know about me: 1) I have never been a diehard, one-shoe-fits-all clinician, 2) I embrace whole-heartedly the principals of ABA. It’s as an evidenced-based approach, and it works wonders for all sorts of kids, not just ones with autism, and, 3) If I couldn’t be silly with my students, I would just close up shop.

As an SLP, I know there are mountains of other kinds of research, and that child language and cognitive development that are important too. In this age of ABA, I find myself wanting to shout from the rooftops, “Wait! Stop! There’s more to this kid than just autism!”

Our role as SLPs and educators

Working with so many professionals “trained in autism” made me realize that, as SLPs, we bring to the table our knowledge of childhood language development, learning, motivation and context. Never before has this been more evident to me. We also bring the friendly reminder the importance of a playful approach and rapport building.

I’ve found myself shifting discussions to the whole child, and what we know about children and learning.

Here are some pointers I frequently share with staff:

  1. Appeal to the inner child first (yours and theirs). The individual comes before the label.
  2. Not every behavior can be attributed to one definitive cause. Environments, emotional state/regulation, personality, medical/biological components, all should be up for consideration.
  3. Assessment and intervention is a daily process, which is sometimes messy and dynamic (see #2). We won’t always get it right the first time. Or even the second time.
  4. It’s possible (and OK!)  to be structured and silly at the same time. Sometimes silliness increases engagement.
  5. Watch and learn from your kindergarten teachers (see #4). I’ve learned a lot from them about having fun while being structured, thoughtful and flexible.
  6. Use visuals even if the child is verbal or becoming verbal. We can model language through PECS, topic boards and Aided Language Stimulation techniques, within natural play activities.
  7. Strive to meet every child “where they are” in all aspects of learning: attention, behavior, communication and language development.
  8. We can’t make someone ready to learn or communicate; we simply lay the foundation.
  9. Learning can’t happen in a bubble. Context is just about everything. I know what a zoo is, because I’ve been in one, not because I’ve seen a flashcard of one.
  10. And finally, my favorite: Provide random acts of praise and compliments. Make daily deposits into that relationship bank. It’s a worthwhile investment.

 

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