Apps with Elders

elderapps

I am a tech savvy person. Use of technology is integrated into my life, and I am always learning something new. Currently, I am learning basic coding and web design to help private practice owners with their websites. Your website should tell your story and technology can make that happen. Perhaps I was a little naive, but it never occurred to me that maybe I should not use an iPad in my work with my geriatric patients in the SNF setting.

In the SLP social media communities I saw many SLPs using iPads or other tablets with their school or pediatric clinic caseloads. I saw what they were doing and thought, “Hey, I could do that with my patients.” And so I did. A few years ago when I got my CCC’s I gifted an iPad to myself.

And then I started using my iPad in therapy. There were a few bumps along the way, but I am still using it today. The iPad will by no means do therapy for you, but it is an excellent tool.

Five Tips to make using an iPad in therapy easier

Be confident to reduce the intimidation of technology. I start by asking if a patient has used an iPad. Then I briefly explain that it is a “little computer”, and we are going to use it to have a little fun in therapy. I gloss over the technology aspect and go straight to the fun. And then I choose an easy but interesting game, so they will have success when they are learning to use the tablet.

Use a stylus. A stylus is a pen-like instrument that the tablet will recognize similar to a fingertip. I pick them up for super cheap at stores like Marshalls or Ross. Some of the ladies I work with have gorgeously lacquered long fingernails. This almost always causes a problem, since tablets respond to fingertip taps rather than fingernail taps. A stylus will solve this problem.

Make it fun. Some of the games and apps can be quite challenging (just as any other task). When frustration starts to rise, I remind my higher level patients that we are just experimenting. If the solution or answer is not correct, we just figure out why and try something else. This approach seems to ease frustration. With my lower level patients, I do not allow that point of frustration to be reached. I use errorless learning and vanishing cues to increase success rate.

Keep your client relaxed. Because it is an unfamiliar technology there can be some anxiety about using it. I watch my patient’s body language. Is their brow furrowing, are their shoulders creeping up, are they tapping the stylus with great force? Sometimes I use subtle cues to help them improve insight into how they are feeling. Other times overt. These are great moments to talk about the effect of emotions (including anxiety) on cognitive function. Then I teach the strategy of doing something less taxing during these moments and moving back to more challenging tasks when they are feeling calmer.

Get a case. Get a case that allows you to prop up the tablet at different angles. This is really helpful for reducing the glare caused by different patient positions as well as making the tablet more accessible to those with mobility impairments.

Favorite Adult SLP Apps

Memory Match: If you are looking for an app to exercise use of memory strategies (visualization, association, verbalization) then Memory Match might be an app to check out. It’s $0.99 and available for iPad and Android. This is only suitable for clients that are able to generalize memory strategies and need activities to learn strategies.

ThinkFun Apps: Rush Hour and Chocolate Fix are great problem solving brain teaser apps that require use of deductive reasoning and logic for visual tasks. First, we identify the problem. Then, we work backward to solve it.

Tactus Therapy: This company makes some great apps. I have several, but my favorite is Conversation TherAppy. It is so versatile. I seldom use the scoring function of the app. The app has picture stimuli and a variety of prompts to target specific skills. I love not having to carry around a deck of picture cards. Have you dumped a box of stimuli cards on the floor? I have, too many times to count.

Google: Access the Google search engine via Chrome or Safari for endless possibilities. Do you have a client working on word finding tasks and needs a visual cue? Google it. Need a restaurant menu or a prescription label as a stimulus for functional questions? Google it. And I’ve been known to use it as a task motivator. Do your dysphagia exercises, then we’ll look up information about moose. (True story.)

Dropbox: Scan those 3-inch binders full of worksheets, protocols, and other information. Create PDFs and put them into Dropbox and have them anywhere you go with your iPad.  If you buy digital versions of books or tests to use on your iPad you will resolve the problem of original documents getting raggedy.

If you have an iPad or another tablet at home and haven’t used it for therapy, I recommend checking out what it can do. You might be pleasantly surprised.

Rachel Wynn, MS CCC-SLP, is speech-language pathologist specializing in geriatric care. She blogs at Gray Matter Therapy, which strives to provide information about geriatric care including functional treatment ideas, recent research, and ethical care. Rachel’s projects include: Gray Matter Therapy newsletter, Research Tuesday, and Patient Education Handouts. Find her on FacebookTwitter, or hiking with her dog in Boulder, Colo.

Avoidance Reduction Therapy: A Success Story

true colors

I was interviewing for assistant positions at our summer speech and language camp when I first met Ben Goldstein.  Ben is a graduate of the University of Maryland and was in the midst of taking his pre-requisite courses to apply for graduate school to become a speech-language pathologist.  Ben also happened to be a person who stutters (PWS).    As the interview continued he shared that he was introduced to avoidance reduction therapy by Vivian Sisskin at the College Park campus of UMD.  I had already been applying aspects of avoidance reduction therapy with my clients,  however Ben helped solidify my feelings on this approach.  Ben was kind enough to answer some questions and walk me through his experience with avoidance reduction therapy, which is included below.

Avoidance reduction therapy is an approach to stuttering therapy that can be used with both school-aged and adult clients.  This approach views stuttering as an approach-avoidance conflict; a theory that states that a PWS experiences the desire to speak and interact with others while simultaneously experiencing an urge to hide their stuttering.   The result of these competing desires culminates in the maladaptive secondary behaviors that interfere with communication (ex. eye blinking, leaning forward, use of fillers, etc.).  These competing desires also result in a feeling that one can not partake in certain activities and situations due to their speech.

Avoidance reduction therapy works toward reducing these maladaptive behaviors, leaving in its place a more comfortable, forward moving form of stuttering.  It also works toward reducing the handicap of stuttering, whereby increasing a person’s willingness to participate in various activities and situations, whether or not they show some stuttering.   Unlike other approaches that focus on fluency, this particular approach views a person’s strong desire to be fluent as perpetuating the problem and ultimately what contributes to their word and situational avoidances, as well as much of the struggle behaviors you see in their speech.  Avoidance reduction therapy does not put an emphasis on fluency, but rather on improving a person’s ability to successfully communicate in the “real” world.

How do you incorporate avoidance reduction therapy into your sessions?  Start by helping your client to identify their own stuttering patterns and assist them in recognizing how much of their pattern is “true” stuttering and how much of what we see is actually habits they formed in an attempt to mask stuttering.  Challenge clients to allow themselves to show true stuttering (or perhaps use voluntary stuttering), beginning in the safety of the therapy room and eventually branching out to different “real-life” situations.  As you work through these challenges, clients will often discover ways in which their stuttering was holding them back that they may not have realized before.   Read on to learn about Ben Goldstein’s first-hand experience with avoidance reduction therapy.

Before jumping into avoidance reduction therapy, how would you describe your speech intervention experience leading up to it?

Ben: Prior to avoidance reduction therapy, I saw two SLPs as a private client. Both focused primarily on common fluency shaping techniques (easy onset, breath control, continuous phonation). My parents felt that the therapy helped me sound better, but I don’t remember sounding better. I also don’t remember feeling better about myself or my stuttering through therapy.

Can you describe your stuttering pattern prior to beginning avoidance reduction therapy?  Do you feel like stuttering impacted your quality of life?   

Ben: When I showed my stuttering I usually blocked for long periods of time, contorted my lips and mouth, tapped my leg to release a block, used fillers such as “umm” and “you know,” and closed my eyes. There was little actual stuttering going on. It was mostly secondary behaviors.

In particularly scary situations, I would avoid talking altogether if I felt that I was going to stutter.  If somebody asked me a question and I felt a disfluency coming on, I would often pretend that I didn’t hear the person. I would constantly change words that I thought I was going to stutter on. I would not go to parties and avoid hanging out with friends sometimes.

All of that avoiding had a huge impact on my life. For one, I never showed my real personality. If I had a joke I wanted to tell or a comment I wanted to say, I usually wouldn’t say it. My mindset everyday was “Let’s get through today without showing stuttering. Say only what you absolutely have to say.” That kind of mindset suppresses one’s personality and it can lead to a lot of feelings of shame, guilt and feeling less than others.

How were you introduced to avoidance reduction therapy?  

Ben:  After my first semester freshman year at the University of Maryland, I found my way to the on-campus Hearing and Speech Clinic.  It was there that I was introduced to avoidance reduction therapy.

How would you define avoidance reduction therapy and the rationale behind this approach?  

Ben: I think the most basic definition of avoidance reduction therapy is to reduce one’s avoidances related to stuttering, speaking, and really, in life.  In other words, the goal is to reduce how often one actively avoids stuttering, avoids various speaking situations, and avoids different opportunities in life. The rationale behind the therapy is that stuttering is perpetuated by habit and fear.  If I have a fear of speaking in class, every time I keep silent in class, I reinforce that behavior and the fear of speaking in class grows. Avoidance reduction therapy is about reversing that process.  If you face your fear head on and with a different attitude of what is a success and what is a failure, the fear eventually dissipates, and once the fear of speaking weakens, you can start to make choices to stutter in a more comfortable and effective way.

Most clients seek therapy to try and reduce or eliminate stuttering and may be initially concerned with the premise of avoidance reduction therapy. How long did it take for you to “buy in” to this approach?  

Ben:  Great question. For me, I bought in pretty quickly. No one before in my life had explained to me the cycle of avoiding stuttering, the feelings and thoughts that I had, and how those feelings and thoughts perpetuated and worsened my speech.  Once these ideas were laid out for me it was almost like a lightbulb went off in my head. “Yes, finally what I’ve experienced my entire life makes a little sense.”

Can you explain what a typical therapy session would look like?

Ben:  A typical therapy session usually begins with the client talking a bit about how their week went. The client might talk about a speaking-related success they had the previous week (talking about my successes helped me feel good about myself as a communicator), a situation that is really bothering them (these always helped me relieve some anxiety and develop a plan), or a topic unrelated to speech altogether. While the client is speaking, the SLP is taking note of the client’s speaking pattern and assessing how successfully they are hitting their target from the previous week.

After the client has spoken for a bit, he or she usually receives feedback from the SLP. This feedback can be related to the thoughts and feelings of the client (dependent on what the client was saying) and/or his /her motor pattern (dependent on how the client was saying it.) Following feedback, the client and SLP engage in some specific practice where the client has the opportunity to put the SLP’s suggestions into action in a safe speaking environment. This allows the client to play around with the new assignment (whether motor-based or cognitive-based) and allows the client to begin to reinforce the new behavior.

Following target practice, the client and SLP finalize the client’s assignment or plan for the week. The client is told what the rationale behind the assignment is, and how that target or goal fits into the client’s longer-term plan.

What aspects of avoidance reduction therapy do you think are most beneficial to you and to the individuals in your group? 

Ben:  I can’t speak for everyone in my group, but to me, the lessons I’ve taken from avoidance reduction therapy are that it’s OK to stutter, it’s OK to be vulnerable and it’s OK to not be perfect everyday. Contrary to what I used to think, stuttering is not some giant, evil monster that I need to run away from for the rest of my life. It’s a part of me and not a negative thing. Perhaps most importantly, my goals have changed since starting avoidance reduction therapy. In the past, my priority was to avoid stuttering at all costs regardless of how it affected the way I connected with others and how I felt about myself. Today, my goal is to be true to myself, connect with other people, say what I want to say, and enjoy life as much as I can. If stuttering wants to come along for the ride, that’s OK.

How do you think your stuttering has changed?  Does stuttering affect your life in the same way it did prior to receiving avoidance reduction therapy?

Ben:  A lot has changed since starting avoidance reduction therapy. For one, my stuttering pattern has definitely changed. Now, I keep eye contact during disfluencies. The habit of tapping my knee is gone. I no longer use interjections with the same degree of frequency. I still contort my lips and mouth sometimes, but hey, it’s my next goal to tackle.

In terms of life impact, it’s night and day. Now, I say most of what I want to say. I show my personality. I also have a completely different perspective of what constitutes a success for me at this point and time and what is a failure. I recently gave a short talk in front of 600 people and stuttered a great deal. Four years ago, I wouldn’t have even thought of doing it, and if I had been forced to, I would have viewed my immense amount of stuttering as a failure. Today, I recognize what an accomplishment it is for me to voluntarily speak in front of that many people. I’m slowly chipping away at avoidances and those are my successes.

Do you think that there are individuals who would not benefit from this approach?  

Ben:  I think one really has to be motivated to change to undertake avoidance reduction therapy. It’s not easy work. Doing things that petrify us is so counterintuitive. If one has never talked in class before, talking in class that first time is going to be really scary. But talking the second time is going to be a little easier.

My experience of diving right into the therapy isn’t the common one. (And my initial experiences with avoidance reduction therapy probably weren’t as smooth as I’m remembering them). It takes time to truly change one’s attitudes and beliefs. This isn’t an intensive, short-term kind of therapy. But in my experience, and the experience of many of my peers, it’s a therapy that leads to real, meaningful, long-term change.  The motto “short-term pain, long-term gain” really applies here. I do think everyone is capable of receiving meaningful benefits from it, but they’ve got to put a lot in as well.

If you want to learn more about Avoidance Reduction therapy, I highly suggest Vivian Sisskin’s video Avoidance Reduction Therapy in a Group Setting, available through the Stuttering Foundation of America.

Brooke Leiman, MA, CCC-SLPis the fluency clinic supervisor 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

 

Ben Goldstein is a graduate of the University of Maryland. He will begin work toward a master’s degree in Speech Pathology in the Fall of 2014.  Ben is a member of the Rockville Chapter of the National Stuttering Association and formerly served as it’s co-chapter leader.  He can be reached at bagoldstein@gmail.com.

On Becoming an Interprofessional

teamwork

According the authors of “The Interprofessional Healthcare Team: Leadership and Development,” interprofessionalism refers to the active participation of different professionals, which may include persons with professional licensure or certification in nursing, occupational therapy, physical therapy, speech-language pathology, social work, and other health-related professions who are collaborating to provide quality services to the patients they serve. Through a steadfast commitment to collaboration, interprofessional practice among healthcare professionals seeks to enhance the quality of health and medical services, which lead to improved patient outcomes. Developing synergy between through shared knowledge and decision-making promotes positive change in work settings and builds meaningful relationships with patients and their families. But, say the authors, shaping efficacious teams depends upon fundamental knowledge of the represented field, the use of evidence-based practice, interprofessional leadership, and members who are prepared to collaborate effectively in a team, which we believe can be accomplished through interprofessional education (IPE).

 
The Institute of Medicine Committee on Health Professions Education provides recommendations for developing a strong team: “health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.” Because of ongoing changes to the U.S. healthcare system, including insurance policy initiatives, technological advances, and innovative service delivery models, it is imperative for all professionals, including speech-language pathologists and audiologists, to embrace a new spirit of interprofessional collaboration and cooperation. Leading health organizations, such as the Pew Health Professions Commission, the Institutes of Medicine, and the World Health Organization, support the concept that health professionals have received adequate education to work in healthcare settings only if it includes experience participating in interdisciplinary teams to collaboratively solve complex problems.

 
Due to changes in service delivery models that have resulted in an increase of members within healthcare teams, interprofessional practice is rapidly becoming an expectation in most healthcare settings. Universities and training programs in speech-language pathology and audiology are only recently beginning to embrace models of IPE. In some universities, students from several disciplines are enrolled in the same courses, teamed for practicum experiences, participate in field-based experiences, and ultimately learn to work as effective, interprofessional teams. A unique way for IPE to be learned has recently occurred though simulation-based education in the College of Health Professions at The University of Akron.

 
Simulation-based education is an innovative process for creating authentic situations in which groups of IPE students learn to collaborate. Specifically, this technique can assist in overcoming some of the challenges that exist in healthcare: inadequate communication among professionals, focusing on specific needs rather than the whole patient, lack of knowledge of other professionals’ roles, the inability to work as an effective team member, and a lack of conflict-resolution skills. IPE conducted as a simulation activity may supplement traditional classroom strategies to enhance the performance of healthcare providers, ultimately resulting in reduction of errors in the workplace and an increase in the quality of care provided to patients. Although this strategy has been recognized by various international professional societies, including the World Health Organization and Institute of Medicine, as foundational to achieving safe, high-quality, accessible patient-centered care, not many healthcare training programs are on board.

Fortunately, as graduate students in speech-language pathology at The University of Akron, we were given the opportunity to participate in an IPE simulation activity. It included more than 90 students studying in the fields of nursing, nutrition/dietetics, social work, medicine, and pharmacy. Groups of five or six students from each discipline worked together to treat a specific, simulated patient. This particular simulation portrayed a young female combat veteran primarily diagnosed with a traumatic brain injury, with secondary diagnoses of depression, binge eating, insomnia, post-traumatic stress-syndrome, and cognitive deficits. Working as a team, our goal was to assess, diagnose and create a treatment plan for this patient to help alleviate her daily struggles, such as her inability to maintain a healthy diet, pay attention during class, and communicate effectively with loved ones. To develop an effective treatment plan, these challenges needed the knowledge and skills of each of the disciplines that participated in the simulation activity.

As the simulation began, we quickly recognized the need for strong interpersonal skills. It was a challenge figuring out when to speak, when to listen, and how to deliver opinions appropriately. Common observations of group dynamics included students promptly stating their opinions on how the patient should be treated before discussing a rationale or their role; students aggressively prioritizing needs of the patient without consultation; and many students reported they were unaware or had misconceived ideas about the roles of other professionals, especially speech-language pathologists. From these experiences, the need for this type of training was even more apparent. We learned that professional roles, especially speech-language pathologists, may be unclear to others, and we found ourselves advocating for our field and its importance in making treatment decisions. We also found that many students were very knowledgeable about their discipline but lacked good communication skills. This challenge resulted in a struggle to connect constructively with other students in other courses of study. We now recognize how vital  interpersonal skills are to delivering optimum patient-centered care.

 
From this exercise we now believe an IPE approach to teaching and training can have a tremendous impact on the preparation of speech-language pathologists and audiologists. With this training, students will enter the workforce with experience collaborating with other professionals and will understand the power of teamwork to accomplish a task. When students practice interprofessionalism and see the power in collaborating with other professionals, greater progress can be achieved in the workplace. Participating in the IPE simulation has boosted our confidence by showing us how to apply our clinical knowledge and skills in a safe but functional learning environment, but most importantly, it has given us a sense of how to work as a team to improve the life of our patient, which is the essence of patient-centered care. We have definitely taken our first critical steps toward becoming truly interprofessional!

Crystal Sirl, BA, is a graduate student in the School of Speech-Language Pathology and Audiology at The University of Akron.
Grace Bosze, BA, is a graduate student in the School of Speech-Language Pathology and Audiology at The University of Akron.

 

 

Pragmatics with Elephant and Piggie

piggie

Are you working on social skills and building appropriate conversation with children ages 4 and older? Are you looking for more playful and fun ways to teach pragmatic skills and engage a child’s attention during therapy sessions?

Mo Willems is one of my favorite children’s book authors. Some favorite titles of mine are Knuffle Bunny and That is Not A Good Idea, and of course the infamous Elephant and Piggie books, which include A Big Guy Took My Ball, Should I Share My Ice Cream? My Friend Is Sad and many more. Mo Willem’s collection of Elephant and Piggie’s books expand to more than 20 books.

The Elephant and Piggie books are witty, silly and excellent for teaching some important social skills to children with delays or deficits with their pragmatic language skills.  These books are also ideal to read in a classroom or with a small social skills group because they are naturally engaging and can facilitate language.

Elephant and Piggie are best friends and treat each other with love and respect, which is an excellent friendship model for any child. I’ve used Elephant and Piggie books to help teach the following pragmatic skills:

  1. Turn Taking in Conversation: Elephant and Piggie have simple and animated conversation with each other and in certain stories, other characters. The conversation flows naturally between the characters and is related to a specific topic (great for practicing maintaining conversation). Role play after reading the book! A role playing activity can be a fun activity in a social skills group.
  2. Interpreting Body Language: Elephant and Piggie are extremely animated and express themselves well through body language. When reading an Elephant and Piggie book, discuss how the character’s body language shows how he is feeling (e.g. Elephant is jumping up a down, he must be excited!, Piggie is crying, he must be sad)  This is an ideal opportunity to ask questions and model language.
  3. When and why to use intonation in conversation: Mo Willems uses many explanation points, bold and italic wording to express the emotions and feelings of Elephant and Piggie. For example, in the book, “We Are In A Book,” Elephant jumps up and down and says “THAT IS SO COOL!” Ask your client, “Is Elephant whispering or shouting? How do you know?” Discuss when and where it is appropriate to use a soft or loud voice. When you are reading the book, make sure to use appropriate intonation as related to the text. I recently wrote an article about using intonation when reading to a child. Another great carryover book to teach punctuation and facilitate language would be with the picture book, “Exclamation Mark” by Amy Rosenthal and Tom Lichtenheld.
  4. Discussing Emotions:  Elephant and Piggie have intensive feelings and emotions in this series which makes it really conducive to discussion within a group. Ask your client how the characters are feeling and why. In Should I Share My Ice Cream? Elephant is confused about whether he wants to share his ice cream with Piggie. Discuss what “confusion” means and relate to an experience you or your client has had recently.
  5. Expanding and maintaining a topic within a conversation: Elephant and Piggie have extensive conversation in each of their books. Discuss how the characters extend conversation, maintain a topic and keep the dialog going. Determine if it’s by question, comment, etc. This can be a great exercise that can easily be carried over to other conversations with peers.

Other goals can include answering “wh” questions, building literacy skills, expanding vocabulary, describing, commenting, improving narrative skills and recalling information. This series of Elephant and Piggie books are also available at most libraries, which make them accessible.

More information about the Elephant and Piggie series is available online. If you have any comments, please comment below!

Rebecca Eisenberg, MS, CCC-SLP, is a speech-language pathologist, author, instructor, and parent of two young children, who began her website www.gravitybread.com to create a resource for parents to help make mealtime an enriched learning experience . She discusses the benefits of reading to young children during mealtime, shares recipes with language tips and carryover activities, reviews children’s books for typical children and those with special needs as well as educational apps. She has worked for many years with both children and adults with developmental disabilities in a variety of settings including schools, day habilitation programs, home care and clinics. She can be reached at becca@gravitybread.com, or you can follow her on Facebook; on Twitter; or on Pinterest.

Our Perception of Taste: What’s Sound Got to Do with It?

music

My first love as a speech-language pathologist is pediatric feeding.  I spend lots of time talking to little kids about “carrot crunchies” and “pea-pops” and various silly names for the sounds that different foods make in our mouths as we explore all of the sensory components of food in weekly treatment sessions.

Is it possible that sound is a larger component of our eating experience than many of us realize? What’s sound got to do with eating, or more specifically, with taste? Discovering how the sound of a crunching potato chip affects flavor is more than just curiosity.  Prof. Charles Spence, who leads Oxford’s Crossmodal Research Laboratory, studied how the sound that food makes in our mouths influences our perception of freshness.  It’s an important point for potato chip manufacturers, who strive to create the “crunchiest crisp possible.”

Background sounds in the environment also influence our interpretation of taste.  Spence conducted an experiment where individuals were presented with 4 pieces of identical toffee.  Two pieces were eaten while the subjects listened to the lower pitch of brass instruments.  Two other pieces were eaten while listening to the higher pitch of a piano.  The pieces eaten during the higher pitched piano music were rated “sweet” by the subjects and the pieces eaten during the lower pitched music were rated “bitter.”

Chef Blumenthal, owner of The Fat Duck near London, has taken Spence’s research findings to the next level.  Order the “Sound of the Sea” and you’ll enjoy more than seafood delicacies  presented on “a sand of tapioca and fried panko, then topped with seafood foam.” The dish is accompanied by an iPod nestled in a seashell, “so that diners can listen to the sound of crashing waves as they eat.” Spence reports that diners experience stronger, saltier flavors with the sound of the ocean in the background.  Another London restaurant, the House of Wolf, serves a cake pop along with instructions to dial a phone number and then, before tasting,  press 1 for sweet and 2 for bitter.  Diners who listened to the first prompt heard a high pitched melody and those who pressed “two” heard a low brassy tones.   In an article for the Telegraph, Spence said,  “We have also looked at the crispiness of crisps and biscuits and found that by boosting certain high frequency sounds when volunteers bit into them we could make them taste crunchier, and they became softer if we dampened those frequencies.”  It’s not just diners across the pond who are experiencing the marriage of sound and taste. Major food companies in the United States also have consulted with Spence, who developed a soundtrack to “complement”  the coffee at Starbucks®.  Speaking of coffee, in a recent study, Spence found that humans can detect whether a liquid is hot or cold, just from listening to the sound of it being poured into a glass, porcelain, paper and/or plastic cup.  I’ll consider this the next time I’m waiting for my drink at the local coffee shop.  Perhaps, from now on,  I can just listen to the sound of the pour, grab my drink and avoid the barista announcing “Lite Iced Triple Venti Half-Pump Americano Skinny for High Maintenance Melanie” with that smirk on his face.  But, I digress…

When I consider my little clients in feeding therapy, I wonder how this research might be expanded to detect possible differences in taste perception in children with sensory processing challenges, including kids with autism. Certainly, respecting the differences in a child’s sensory system is an integral part of feeding therapy for most clinicians.  Could it be that this hiccup in auditory, visual, gustatory or other sensory systems communicating efficiently with one another makes eating a variety of foods especially difficult for some children, more than we know at this time?  A recent article in The Journal of Neuroscience reported that kids with “autism spectrum disorders (ASD) have trouble integrating simultaneous information from their eyes and their ears” and discussed how this might affect their language skills. Wendy Chung, MD, PhD at Columbia University Medical Center explained in a recent video for parents how a poorly functioning pathway for simultaneous auditory and visual information (and the secondary problems of processing and responding to sensory signals) causes a child with ASD to be overwhelmed in environments that we find quite comfortable.  Perhaps future research may include Spence’s work and how it might apply to children in feeding therapy. Would certain tones be more soothing while eating?  Would certain music in the school cafeteria help children eat faster or even choose more nutritious foods? The common phrase “a feast for the eyes” may one day turn out to be “a feast for the eyes and ears” as we consider all the possibilities.

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.

Kid Confidential: Data Collection Using Thematic Therapy

data collection

In December’s Kid Confidential column, I discussed the advantage to using thematic lessons in speech therapy.  Last month, I explained how I write goals when using thematic lessons in therapy and the need for additional sources of data throughout the academic environment.  Today, I’m going to discuss how I record data during thematic therapy sessions as well as how I have gotten other school staff members on board to collect data.  Please note that the below information is based solely on my clinical experience.

Data Collection of SLP in Thematic Therapy Sessions

There are three main ways I can think of to collect data using thematic therapy.  The first of which is to do so throughout the entire therapy session.  The second way is to collect data for certain activities during each session.  The third option is to use periodic data collection among several therapy sessions.

Target goals throughout the entire session

Once you know exactly what skills you are targeting with each student you can determine how you will do this in thematic lessons.  One way to do this is to simply target at least one skill for each student in every thematic therapy activity.  I tend to use this technique most often when working with small groups of students who demonstrate emerging skills.  I will choose language rich thematic activities and incorporate ways to target at least one goal/objective for each student during each activity.  For example, if I have a student who is struggling with pronouns, I will be sure to ask questions during every activity that would require that student to label or expressively use pronouns in order to answer my questions.  This way I am targeting that one specific goal for the entire session for that student. This technique allows me to continue to take data throughout the session for each student and performance in this way tends to demonstrate generalization of skills to other activities as well.

Multiple Short Activities Targeting Different Goals

Now there are times when it is necessary to “drill and kill” a skill for students who have yet to demonstrate emergence of skills and who seem to require multiple trials in one session to facilitate learning.  When this is needed, I will choose to have my students participate in several different short thematic activities where each student is given time to repeatedly target an individual skill within an activity I created just for them centered on the theme and interest of their choosing.  In that manner, all students participate in each activity however data may not necessarily be collected for each student during every activity.  Time for each activity should be flexible depending on your goals, the time it takes to complete the activity and students’ interest.

For example, let’s use the recent holiday season as a possible theme for therapy.  In a small group of 5 students, I may have one that is working on understanding and using prepositions, another student working on increasing overall vocabulary skills, two students working on auditory comprehension skills and recalling details of a story and one student working on articulation skills.  What can I do?  Well I can have a quick craft in which my student working on articulation skills can read directions with different prepositional phrases.  This activity will allow me to collect data on the student who requires assistance in learning prepositions, the students who are working on improving auditory comprehension skills, as well as allowing me to tackle articulation skills of my fourth student.  The next activity could be a thematic book in which my students take turns reading the pages (or if I want to save some time, I may read the book).  Of course this allows me to ask WH questions about the book, possibly ask for synonyms, antonyms or even definitions of words within the book and finally have the students attempt to use a graphic organizer to “map the story” thus requiring them to recall details in sequential order.  Now I have targeted at least one goal for each of my students.  As the book activity would most likely take longer than the craft, this is an instance where my second thematic activity may have a longer duration as compared to my first activity.  By the end of the session, I should have data on at least one goal/objective for each student from at least one activity.

Periodic Data Collection Across Therapy Sessions

The third main option, I believe we have as SLPs is to periodically record data.  This may mean, as an SLP, data is not collected every session but periodically among a number of sessions.  Some colleagues prefer this method of data collection for a number of reasons explained to me previously such as periodic data collection allows for a therapist to focus on the therapy itself without the additional distraction of data collection.  Periodic data can aid in time-management skills particularly for those with extremely high caseloads.  Some therapists feel this is a better indicator of a student’s skills over time without needing to filter out the variability of performance on a daily basis.  Additionally, some therapists believe using the “pre- and post-teach/testing” method of collecting data reflects the academic environment more accurately than daily data.  With all that said, I do want to share a word of caution to those thinking about using periodic data.  The most important thing to remember is to be consistent in taking that data.  Know ahead of time when you are planning on data collection and ensure that you have enough data collection days within each marking period to target goals effectively.  Meaning, if you write your goals for a skill to be performed with a certain amount of accuracy across three data collections days, then you must at least have three data collection days to determine if the skills has been achieved.  Also be diligent.  If a student is absent during those days, be sure to take data regarding that student’s skills the next therapy session.  Periodic data can be helpful in looking at a child’s performance over time if collected consistently.

Data From Other Sources

There will be times when we write goals and target skills in therapy but would like to determine generalization to the academic environment as previously mentioned in last month’s column.  In an instance such as this, data may be collected in a different way and from a different source. Periodic data can be just as effective as daily data collection, as mentioned above, if done with consistency.

With the implementation of RTI, I have found teachers are much more willing and confident in their own ability to take data within the classroom setting, if I take time to train them on how to collect data and express realistic expectations that data will only be recorded at specific times during the day/week or during specific assignments.  This way, I have gotten reliable data collection from teachers regarding a child’s articulation skills for specific sounds during small reading groups, qualitative data on social skills in cooperative learning situations among classroom peers, data on a student’s ability to expressively answer WH’s in the classroom, information on a child’s ability to recall details of a story, and data on the accuracy of a student’s ability to follow classroom directions.

How can all of this work when the goal is to use thematic lessons in therapy?  Well, here is an example for you.  Remember my student working on vocabulary skills?  Well it would behoove me to target academic vocabulary in the school setting as a means to hopefully translate to improved classroom function.  Therefore, I may be given a list of vocabulary words from my students’ teachers and incorporate those words into stories I create using the theme on which we are currently focusing.  I may pre-teach the vocabulary, use context clues to have my students’ define the same vocabulary in my created story, then I may have my students participate in a vocabulary definitions match-up page post story.  This may occur over the span of several sessions.  Once this is completed and I have my data as to how my students performed with this particular list of vocabulary words, I can then compare their performance in my speech room to that of their classroom performance to determine if carryover has occurred.  This way, I am actually using teacher data (e.g. score on the students’ vocabulary sections of their language arts assignments each week) to determine generalization all while still using themes in therapy.

How do I get teachers on board and how can I ensure data collection is occurring?  Here are few tips:

  1. Keep things a simple as possible by providing all materials needed for tracking data.
  2. Let the staff member choose when to take data:  I ask the teacher/staff member what time of day or which classroom activity would be easiest for them to track a student’s performance.  Teachers are more likely to take data during activities or times of day which are easiest for them.
  3. Training goes a long way: Once a specific classroom activity or time of day is identified by the teacher, I will be sure to go to the classroom during that time and train the teacher on how to take data for the specific skill being targeted.  I keep it as simple as possible and very rarely do I have to do this more than once.
  4. Accountability:  I randomly check the data sheets during class time and ask the teacher every few days how my students are doing in the classroom.
  5. Show gratitude:  When teachers and staff members understand how genuinely grateful I am to them for taking time out of their day to help one of our students by recording data, they are much more willing and likely to continue to take data.

What does the data collection form look like for the school staff?  Here’s an example of what I have used in the school setting.

data collection

I usually provide a folder for the data collection sheets for students so the staff member can pull out the data collection sheet, re-read the goal being targeted, and simply take data on the student during the agreed upon time/activity.

For more functional goals that require data collection in real-time during the classroom, such as using appropriate pragmatic skills or using age-appropriate receptive and expressive skills for functional conversational, I will provide teachers with the data collection sheets as well as a page of blank labels.  The teacher can simply take data on the labels in real-time and stick them onto the data collection sheet later.  This way, he/she does not have to stop the lesson to take data.

The possible ways to record data by ourselves as SLPs or collect data from other school professionals is numerous if we are creative and work collaboratively with others.  I’m sure there are a number of school speech-language pathologists using the above techniques as well as a number of others not mentioned today.  As long as we remain flexible, open-minded and always focus on improving functional skills of our students, I believe the ways in which we can do this are infinite.

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

ASHAWire: A New Online Platform for ASHA’s Publications

ASHAWire-Cover-image (1) copy

So … you’re hip deep in a CSD search, frustrated because the results are thin and a bit cumbersome to get to—that’s because most online searches are based on actual text matching rather than true meaning and resonance among concepts and terms. For more relevant results with less searching, check out ASHAWire, the new online home for ASHA’s main publications. ASHA content from the scholarly journals, the Leader, and Perspectives have been tagged semantically, allowing for deeper, more intelligent searching of your favorite publications. Even better, your search will also pull up a whole host of related articles for you to pursue at your leisure.

Scenario 1:  An awesome article just appeared in LSHSS and you’re eager to share it with a colleague down the hall. No problem! ASHAWire gives you—wait for it, wait for it—five different ways to share ASHA content through social media. Now, there’s no excuse not to let others know about the ton of goings-on in the journals, Leader and Perspectives.

Scenario 2: You’re passionate about a CSD subject and are always on the lookout for new articles in that area. ASHAWire can help! The new online platform offers dozens of CSD topic collections featuring up-to-the-minute feeds of relevant articles just as they are published in the scholarly journals, Perspectives and The ASHA Leader. Furthermore, since all articles in ASHA’s journals are now published as they are received rather than waiting for the next issue to be assembled, the topic feeds will be more current than ever.

Scenario 3: On a pack-filled passenger train heading home, you suddenly receive a text from a colleague who’s super excited about an article citing your research she just read in AJA. Darn, will you have to wait another long, excruciating, nail-chewing hour to view your moment of glory on the PC at home? Nope…ASHAWire’s been responsively designed so that ASHA publications can be accessed through mobile devices and tablets. 24/7 content, anytime and anyplace (assuming you’re not spelunking, deep sea diving or wrestling a yak on some forsaken frozen tundra).

Robust in functionality and sporting a striking design, ASHAWire brings together for the first time on a single online platform ASHA’s newsmagazine, its peer-reviewed journals, and the 18 periodicals sponsored by the Special Interest Groups. (Please note that 2013-2014 issues of the Leader are currently on the platform; the Leader archive will be transferred to ASHAWire over the next few months.) Think of it … the diverse content of ASHA’s three main publications seamlessly integrated into searches, navigation, feeds of the latest articles and topic collections.

ASHAWire went live in late December, and is already becoming popular with readers. To be sure, like all new online initiatives, modifications and upgrades are ongoing. I encourage visitors to take advantage of all of the capabilities of the platform by using Google Chrome, FireFox, Safari or the later versions of Internet Explorer.

There’s much more to come. Over the next weeks and months, we’ll continue adding even more functionality to an already powerful platform. For example, there’s the new multimedia capability of the platform … slideshows, videos, you name it, all designed to enrich the reading and learning experiences of ASHA members. We’re now busily integrating video options into all of ASHA’s publications, including interviews with and/or demonstrations by authors of journal and Perspectives articles, video and slide supplements to journal articles, and regular video columns in future issues of the Leader.

The bottom line is this: Enjoy your one-stop-shopping, CSD-at-your-fingertips experience. It will just keep getting better. Have suggestions or other feedback? Feel free to drop us a line at journals@asha.org or perspectives@asha.org.

 Gary Dunham, PhDis the director of publications at ASHA. He can be reached at gdunham@asha.org.

 

 

 

Collaboration Corner: Love Your Librarians!

librarian

One of the best resources in my school is my librarian. I have an amazingly knowledgeable colleague who knows top to bottom, every resource on the shelf or online. Here are some things (online and off-line) that she taught me about my school library:

  • Libraries are an excellent resource for wordless picture books: I can never have enough wordless picture book resources to target narrative language, my kind librarian researched wordless picture books, and printed out a list of titles available throughout the district. The best part is I can check out books as I need to, which saves me from out-of-pocket costs for materials.
  • Libraries are a great place for pre-voc skills: One year I had a minimally verbal student with ASD who was so great when it came to sorting and shelving books in alphabetical order. I’ve had other students help with book check-in or check-out.
  • I have access to so many subscriptions purchased by my schools district, including curriculum-aligned resources, which includes my most recent favorite place, PebbleGo.
  • As we continue to help our students understand fact, fiction and other online places, there are a ton of resources for digital literacy and education, including cyber-bullying.

 

Finally, the library is a welcoming place for all kinds of learners. My generous colleague purchased multi-sensory books and curriculum which help my students connect with literacy in a way that is enjoyable. Whenever a student of mine is having a tough time, we can come to a place for quiet and a little bit of sunshine…there’s a spot right by the window whenever we need to beat a little bit of those winter blues!

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

 

Just Breathe. Really?

breathing

Easy for you and me to say.  But for 7.1 million U.S. school children it’s not. Childhood asthma rates continue to rise and from 2001 through 2009 those rates were the highest for African American children, almost a 50 percent increase. Asthma accounts for 10.5 million school absences each year. The main trigger of asthma in school children are the same contributors to poor indoor air quality. Yeah, that’s right … open a window.

Air is mostly composed of nitrogen (78 percent) and oxygen (20 percent), air also has about 1 percent of water vapor and tiny amounts of argon and other gases.  For most of us, air quietly passes through our nasal passages into our lungs and out again; taking in the oxygen needed for our blood supply during inhalation and disposing the carbon dioxide by-product during exhalation.  We do this without thought, without effort–unless you are a child with asthma.

Asthma is a chronic lung disease characterized by inflammation of the airways. Recurring symptoms include wheezing, shortness of breath, chest tightness, and coughing.  Asthma develops in childhood as early as 6 months of age and lasts a lifetime.  About one in 12 Americans are living with asthma and over one third of them are children. In adults women are more likely than men to have asthma and more boys than girls among children. Those with asthma pay a huge price, about $3,000 per year per person to be exact. This figure includes medical care, medications, lost work/school days and deaths.

Various triggers not easily controlled can cause an asthma attack such as changes in weather. However, there are other triggers that can be controlled such as the presence of dust mites, roaches, pets, and mold affecting indoor air quality.  Asthma is particularly more prevalent to those living in poor neighborhoods.  A recent episode of NBC Dateline revealed that the childhood asthma rates in East Harlem run at 19 percent compared to the adjoining Upper East Side neighborhood at 7 percent.  They breathe the same New York City air, so what accounts for the difference?

Water leaks, pest infestation and general contract repairs are the responsibility of a rental unit’s landlord. As economically disadvantaged families tend to reside in these units, they are at the mercy of their landlord. Water damage leads to mold; pest infestation carries allergens; both of these conditions create a significant trigger for asthma in children. Even a child without an asthma history may become asthmatic as a result of repeated and chronic exposure to such poor indoor air quality.

School absences are of particular concern; children who miss more than 18 school days are year are more likely to drop out of school. Children with asthma miss more days of school due to their disease compared to children without asthma.  The number of missed days rises with severity—on average a child with severe and persistent symptoms misses 11.5 days of school in a year.  That’s a lot of missed homework and make up speech sessions. Asthma also affects a child’s sleep quality, which in turn affects a child’s ability to pay attention in class and lowers their quality school work.

 What can you do? 

  • Know which children on your caseload have asthma and know how to deal with an asthma emergency, including the location of the child’s inhaler.
  • Take a look at your therapy treatment room or classroom. Are the floors hard wood or are they carpeted?  If hard wood, hooray! If carpeted, make sure they get vacuumed every day and shampooed at the end of the school week.
  • Got pets? If there are in your classroom, better to send them to another home. Animals carry dander that can trigger asthma. If you have a pet at home, make sure your work wardrobe is free of pet hair.
  • Are you working out of a trailer or portable classroom?  These type of environments generally trap moisture than can turn into nasty mold. Make sure spills and leaks are taken care of quickly.
  • Skip the perfume spritz and after shave before leaving the house for work. Fragrances can trigger an asthma episode.
  •  Refrain from fuzzy or scented materials, pillows or upholstered furniture; these can collect dust mites, which are (surprise!) asthma triggers. If the furniture must stay, vacuum it frequently.
  • No clutter!  Cockroaches and dust mites love clutter … and produce more asthma triggers.
  • If your room has a window that faces high volume vehicular traffic, keep it closed during the vulnerable morning hours and cold temperatures.
  • Stay away from phthalate-based toys  as phthalates are known triggers for asthma.
  • Don’t use pesticide sprays in your room.  Go for integrated pest management strategies instead.
  • Like team work?  Collaborate with your school nurse and district’s administration to develop an asthma management plan at your school if one does not exist.  Another excellent resource is to adopt ideas from the IAQ Tools for Schools Action Kit.  Work with your district’s transportation department to monitor school bus engine exhaust near open windows.

 

Although asthma is prevalent, with some forethought and preventive measures, it can be controlled. Now breathe a sigh of relief!

Anastasia Antoniadis is with the Tuscarora (PA) Intermediate Unit and works as a state consultant for Early Intervention Technical Assistance through the Pennsylvania Training and Technical Assistance Network. She earned a Master of Arts degree in speech pathology from City College of the City University of New York and a Master’s degree in public health from Temple University. She was a practicing pediatric SLP for 14 years before becoming an early childhood consultant for Pennsylvania’s early intervention system. Her public health studies have been in the area of environmental health and data mapping using geographic information system technology.  You can follow her on Twitter @SLPS4HlthySchools. 

 

 

 

Baby Led Weaning: A Developmental Perspective

blw

One of the things I like best about teaching courses on feeding to parents and professionals around the United States is learning what new trends are evolving around family mealtimes. Over the past year,  one of the common questions I’m asked is, “What about Baby Led Weaning?”

Baby Led Weaning (BLW) is a term coined by Ms. Gill Rapley, co-author of “Baby-led Weaning: The Essential Guide to Introducing Solid Foods.”  Rapley graciously chatted with me about her philosophy and explained that although she did not invent BLW, she found the method to be successful in her work as a former health visitor and midwife in the United Kingdom and continues to study the topic today while earning her PhD.

In a nutshell, BLW centers on the philosophy that babies are developmentally capable of reaching for food and putting it in their mouths at about 6 months of age. As stated on the BLW website “You just hand them the food in a suitably-sized piece and if they like it they eat it and if they don’t they won’t.”  Please note that the word “wean” is not referring to weaning from breast or bottle, but instead refers to a term commonly used in the United Kingdom for adding complementary foods to the baby’s current diet of breast milk or formula.  According to the BLW website, ideas for first foods include “chip size” steamed vegetables such as a broccoli spear with the stem as a handle, roasted potato wedges, meat in large enough pieces for the baby to grasp and chew, rice cakes, cucumber, celery and dried apricots.

As a SLP who focuses on pediatric feeding, I view feeding as a developmental process.  Whether I’m working with a child experiencing delays in development or offering advice to a parent whose child is meeting milestones with ease, I always ask myself “How can I respect and support this family’s mealtime culture while guiding this child safely through the developmental course of learning to eat?”  Thus, for families who are interested in following the BLW method, whether their child is in feeding therapy or not, I try to support their wishes if the child is capable,  while offering the following BLW points to consider:

BLW encourages parents to eat with their children, since everyone is eating the same food. 

In today’s busy culture, it feels easier to many parents to feed the baby prior to the adult or family meal, and in BLW the thought is that jarred purees contribute to this habit and it’s important to include baby at the table at an early age.  Even in feeding therapy,  the ultimate goal is for families to be able to gather around the table at mealtimes with everyone enjoying the same foods.  Plus, Columbia University reports that consistent family dinners are an integral and valuable part of raising children.

BLW emphasizes that babies must be the ones to put the food in their mouths.

Feeding therapists encourage self-feeding  for all kids because it allows them to get messy.  Babies are programmed to explore the world with all of their senses, especially their hands and mouths, and often the two together!  BLW notes that the time to begin self-feeding is at 6 months when baby can sit upright on his/her own. I explain to parents that first, every child must have the gross motor stability to support fine motor skills, including reaching and raking for food and controlling their grasp to bring the food to the mouth to be chewed.  For children who have this capability, I feel comfortable with large pieces of food that will not snap off (or allow a solid chunk to fall into the mouth) in addition to short spoons and chewable toys for practicing the skills that will eventually lead to self-feeding.

BLW follows the baby’s cues rather than the parent controlling the feeding via the spoon.

I explain that whether presenting food to your child by placing it on the high chair tray in front of them, directly on a spoon or even mouth to mouth as done in some cultures, reading baby’s cues for readiness is crucial.  Like a beautiful, flowing conversation, feeding children is a reciprocal experience.

According to the BLW blog, BLW introduces chip-size foods (rather than purees or mashed foods) so that baby learns to chew first and then spit out if unable to swallow, noting that with purees on a spoon, babies learn to swallow first and then chew.

From a developmental perspective,  this doesn’t quite fit with my understanding of how infant reflexes integrate  and babies acquire oral motor skills. Babies can begin the process of BOTH spoon and finger feeding between the ages of 5 and 6 months using both purees and soft, safe foods.  Why?  Because this is when babies acquire better lip control and movement as they suck the puree off of a parent’s finger, their own hands or a spoon.  As noted in Diane Bahr’s book “Nobody Ever Told Me (or My Mother) That!” this is when babies use their rhythmic bite reflex to bite off soft pieces of safe, soft or meltable foods that they can hold in their tiny fists or when presented by a parent to their open mouths. If the food is placed onto the gums where we will one day see molars, a rotary chew pattern will begin to emerge over time, thanks to reflexive patterns that soon become purposeful movements.  It’s a developmental process and BOTH purees and finger feeding facilitate the progression of skills. It makes sense to me to transition gradually from thinner  liquids (breast milk/formula) to thicker (thus, a smooth puree) to consistently mashed or chopped  while introducing soft meltables over time.  Keep in mind that I also encounter families who are moving too slowly through graduation of textures, as noted in this article by Bahr.  But, jumping straight to only large pieces of foods to be chewed and then either swallowed or spit out feels like skipping crucial steps in the developmental process.  “Feels like” is the key phrase here: We need research to determine if children who follow this model eventually acquire skills traditionally learned prior to chewing chunks of food as listed in this article found in ASHA Perspectives.  Unlike my previous post on sippy cups, where therapists have raised concerns based on their professional experience over several years and observation of prolonged sippy cup use,  consistent BLW practices are a relatively new phenomenon in the United States.  So, when any parent asks “What about Baby Led Weaning?” I try to integrate my own practitioner expertise and knowledge of feeding development while honoring the family’s preferences and mealtime culture.  Still,  my biggest concern for any 6 month old child is choking.

BLW encourages parents to become comfortable with gagging episodes and understand the difference between gagging and choking. 

Gagging versus choking are two different experiences.  Typically, an infant’s gag reflex is triggered when the back three quarters of the tongue is stimulated, but by the time a child reaches  9 months of age, the reflex covers less area, lying on the back third of the tongue. Eventually, the gag reflex shifts posteriorly even more as the child learns to tolerate the stimulation. Gagging is nature’s way of protecting the airway, where true choking occurs.  Choking happens when food (or other substances) obstruct the airway and thus, often has no sound or intermittent, odd sounds.  Other signs of choking include but are not limited to: gasping for breath, turning blue around the lips and beneath the eyes and/or staring with an open mouth while drooling.

Gagging is an uncomfortable sensation where the soft palate suddenly elevates, the jaw thrusts forward and down, and the back of the tongue lifts up and forward.  It is not unusual for a child to vomit after gagging.  In between the gags, the child is still able to breathe, cry and make vocal noises.  The occasional gag is an important built-in safety mechanism, but frequent gags and/or vomiting can lead to an aversion to food.

In summary, when asked for advice from any family that would like to follow Baby Led Weaning principles, I stress the importance of reading baby’s cues and monitoring them closely for safe feeding while supporting them through the developmental process of learning to eat, no matter what age.  This includes proper positioning in the feeding chair for optimal stability and presenting only manageable pieces of safe, meltable and/or solid foods that do not pose a choking hazard.  For children in feeding therapy, incorporating some aspects of BLW is dependent on that child’s individual delays or challenges and where they are in the developmental process, regardless of chronological age.  My primary concern for any child is safety – be aware and be informed, while respecting each family’s mealtime culture.

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.