Tuesday, October 8, 2019

Floortime Examples for the Sensory Seeking Child {GUEST POST WITH SARA ROBERTS}

Recently, a picture caught my eye on Instagram that inspired me to contact the photographer and invite her to write a detailed guest post.  She provided an exceptional example of following a child's lead in play, so I humbly requested she enlighten us with more
information!  Sara Roberts is an ASHA certified Speech-Language Pathologist based in New York. She received training in Floortime while in graduate school at Queens College. The foundations of Floortime have been beneficial in her experience working with children on the Autism Spectrum in Early Intervention, preschool and elementary school settings. You can follow her on Instagram: https://www.instagram.com/slptree/and Teachers Pay Teachers: https://www.teacherspayteachers.com/Store/Slp-Tree

Do you know how to play with children on the spectrum? 

Playing with a child that barely or doesn’t at all acknowledge your presence can be intimidating. It can make you feel lost. 

I’ve seen many adults (myself included at one time) try to interact by asking questions and get absolutely no where. 

“You’re playing with the animals?” ... No response. 
“Which one is your favorite?” ... No response. 
“Can I have a lion?” ... No response. 

Strategies such as Following the Child’s Lead, Parallel and Self Talk, and Expansion are KEY to working on joint attention, engagement, as well as language and play development.  

Here’s an example of what this looks like in action: 

A child was playing with toy animal figures by silently standing the animals up and knocking them down repeatedly. I copied what he was doing while I modeled the words “up” and “down” both verbally and on his Augmentative and Alternative Communication Device (AAC). He didn’t pay too much attention to me but he let me do it and he was being exposed to language (win!). Then I added to his play idea by getting really animated when I said “down” and crashed the animals all over the table. This made him smirk and look up at me. We did the routine again and this time he imitated my crashing motion. After a few repetitions, I added the idea of the animals jumping over each other and he imitated that too! My hope is that he remembers this expanded play idea the next time the animal bin comes out and he will use the language I modeled for him. 

Now what do you do with a child that doesn’t play with toys? 

These children take a little more creativity. Here’s an example: 

A child was wandering the room and spinning around in circles. I copied him by spinning too while I modeled the word “spin.” After a few moments, I said “stop” loudly while I stopped spinning and put my arms up in the air. I kept repeating this, hoping that the child would establish eye contact with me and/or copy my action. He didn’t, so I copied his spinning and then fell to the floor while I said the word “down.” He never looked at me directly, but eventually he fell to the floor too! We kept repeating this until he let me hold his hands and we were playing a modified version of Ring Around the Rosie.

What about children who tend to focus on tactile stimulation? Here are some suggestions:

Let’s say a child is running his fingers along window blinds. First, copy his action by running your own fingers along the blinds next to him. Then narrate what you’re doing with simple language such as “up, down” or “open, close.” After a few repetitions, expand on this idea by adding one new idea. For example, when the blinds close, you can say, “Goodnight!” and pretend to sleep. When the blinds open, you can say, “Good morning!” with an exaggerated stretch and yawn. 

Let’s say another child is running his fingers over a bumpy surface. Copy the action then narrate such as exclaiming, “Bump!” or saying, “bumpy, bumpy, bumpy” in a sing song voice.  Then add a new idea such as introducing a toy car and having it drive over the bump. 

These strategies may not give you results every single time, but you’re exposing the child to language and different play ideas and that’s always a success! 

Here’s the bottom line when playing with children on the spectrum: copy what the child is already doing and then add to it! 

Sara Roberts, MA CCC-SLP

Friday, September 6, 2019

Language Literacy Planning

Language Literacy Planning for Simplicity: that is my tag line for planning my teletherapy language lessons this coming school year. I’m venturing into my fourth year as a part time telepractitoner and increasing hours at a new company: Lighthouse Therapy, so that means rebuilding my virtual library. This is a welcome change for me working with someone knowledgeable, trustworthy, and an all around decent human being: Janet Courtney. However, I’m a type A+++ person and it makes me anxious thinking about building therapy queues as the ones I previously used will remain with that dormant therapy room. That’s OK, I have a plan and it will force me to develop more treatment sessions rather than rely on planning games and flipping through flashcards. 

My plan isn’t anything new or ground breaking, in fact, I’m sure SLPs all over the world follow the same format. I’m going to structure my language sessions around books. See, I told you that it wasn’t anything earth shattering, but let’s get back to my type A+++ personality. I spent some time over the last couple weeks planning my language sessions from September through May appropriate for children with reading comprehension levels from kindergarten to third grade.  Follow this link to view my language excel sheet.

In addition to watching/reading stories via You Tube, I also like using Storyline Online for read alouds.  While clients listen to the story, I will have them complete pages from the “Any Book Companion” packet that my colleague and friend, Maureen at the Speech Bubble so cleverly created years ago. For teletherapy purposes, I will likely need to email the applicable page to the parent or on-site assistant who helps clients log in for sessions. You can find this product in her Teachers Pay Teachers Store at this link

I’m assuming that writing down the speech and language targets will take all of 30 minutes, so we will use the next session to review the word list and drill practice targets in games while referencing the story. 

The following week, I will play the story from the previous week once more for listening purposes and then use my virtual materials library of board games and worksheets to supplement learning.  This way, clients still get a chance to “play” and I can maintain buy in for my services. 

After two weeks, I will start all over again with a new book. I’ll just peek at my spreadsheet and find the next title. As luck would have it, the ever-talented and bright, ray of sunshine, Jenn Alcorn of Crazy Speech World, has launched a virtual book club to share her suggestions for seasonal text throughout the school year.  It is a gift that she is sharing her knowledge and lesson plans with the world, so don't miss the opportunity to join the group for monthly emails at Book Club for Speech Therapy.  

Saturday, July 13, 2019

Top 5 Summer Toys to Enhance Communication

With warm temperatures and long summer days here in Illinois abound, I want to share some of my favorite summer time toys to support communication development for some fun in the sun.  You will find that my recommendations are free of noise, bells, and whistles, so no need to stock up on batteries or worry about recharging something.  Please note that this post contains affiliate links.  

1) This pretend play camping set by Learning Resources is most appropriate for children between 2-5 years old.  Here are some suggestions for building communication:

  • Expand your child's pretend play skills while "roasting" a hot dog and marshmallow and then blow on these as they get "hot".  
  • Pack up all the goodies in the carry bag and bring it outside the next time you are going to roast marshmallows to help your child build longer play sequences and imitate actions.
  • Build comprehension by asking "Get/Give me" for designated objects.  
  • Work on answering WH questions such as, "What do you do when you are hungry?"
  • Make comments about each item to model expanding speech development.

2) Here is another item from Learning Resources appropriate for children 2 years and older.  Match upper and lower case alphabet letters with this adorable Popsicle stick toy.  Build fine motor and speech/language communication with some of these techniques:
  • Pull apart all Popsicle sticks and hide them under dry beans, water beads, or any filling of your choice.  Then, have your child build hand skills by pushing the pieces together as he/she locates matches.  
  • Build phonemic awareness by asking your child to find the letters that make the sound "Buh".
  • Increase speech skills by modeling sounds.  
  • Talk about words that start with the targeted letter. 

3) This toy is suitable for 3 years and older as there are some small parts.  I typically incorporate a pirate-theme sometime in my summer speech and language lessons while we talk about the ocean and the beach.  
  • Build sharing and taking turns by having children use a gesture, sound, or word to make a request for "Me", "My turn", or "It's my turn."
  • Ask questions with "yes" or "no" answers such as: "Did the pirate pop?" or "Is that a red sword?"
  • Increase following directions with "Take two swords" or "Get a yellow sword."
  • Practice simple to complex speech by modeling "pop", "more pop", "I want more pop!"

4) This is a new, water play toy that I have been using in my speech and language pool group sessions this summer.  Recommended ages are for 5 years and older, but I have used it with supervision with children as young as 3 years old.  
  • Practice turn taking and sharing during pool play.
  • Model making appropriate comments when children make and/or miss baskets.
  • Build social comprehension by asking a child to throw the ball to another.
  • Role play initiating asking to join a game with others.

5) Ocean-colored water beads!  While the recommended age for these is 3 years and older, I have used them with children through 10 years.  These make a great filler for those sensory bins that I mentioned above.  Here are some suggestions for objects that you can hide in a container of these delightful beads:
  • miniature ocean animals
  • Learning Resources Alphabet Popsicles
  • seashells
  • colored fish

Wednesday, June 19, 2019

Diving into Pool Groups

It's time for all of you land lovers to get in the water and experience a sensory, social, and language-enriched adventure. The pool is the place to be, especially this summer!

I have been practicing speech and language pathology for nearly 25 years and implementing speech and language pool groups through an early intervention and my private practice: Naperville Therapediatrics for the last 15 years.  Last week, I launched my summer pool sessions with over seven children aged 3-15 years old and it rejuvenated me!!  We laughed, vocalized, sang, took turns, made comments, answered questions, socialized, and bonded all in the matter of 30 minutes.  Many of my pool group clients also work with me in my home office and I swear they skipped into clinic sessions following that pool group. 

Those of you who follow me on social media may have noticed some recent posts about my first book publication available on Amazon!  We Talk on Water is a guide book primarily for speech pathologists, but also useful for occupational/ physical therapists and parents/caregivers wanting to enhance overall communication with a pediatric population at the pool. 

If you're interested in learning more about stimulating your children in a water environment, take a peek at my newly released guide book (I just love saying that!) which is divided into four parts:

  1. Background information on finding the right location and asking the right questions; documenting sessions; advertising; and billing/ insurance for speech and language pool groups.  
  2. Seventeen lesson plans for 2-5 years old.
  3. Seven lesson plans for 6-9 years old.
  4. Sample documentation (SOAP note, augmentative communication board, list of developmental targets addressed at the pool, registration paperwork)
For more details, you can follow this link to the Table of Contents.  I will be back soon to talk about why pool group is such a great medium for speech, language, and social development and how it helps establish trust with my clients.

Thursday, June 13, 2019

Speech Therapy in an Aquatic Setting- Interview with Susan Nachimson

Over the last two decades, my innovative work in speech and language pool group sessions has connected me with therapists across the nation.  One of those providers, Susan Nachimson, emailed me after reading my "In the Limelight" interview Water Works in the 2015 ASHA Leader and we have spoken by phone and through emails a few times over the years.  Given her wealth of knowledge, I invited her to share her experiences providing speech therapy in an aquatic setting on my blog.  She was kind enough to take some time to answer questions that are often asked of me via email. 

Susan has been practicing speech and language therapy since August 1976.  She is a licensed Speech-Language Pathologist in California and a Neurodevelopmental Therapist NDT-C; Watsu Practitioner; and Certified Massage Therapist.  She currently lives in California where she continues to provide speech therapy in an aquatic setting as well as a variety of land and clinic settings.  If you would like to contact Susan about her dynamic career, then you can reach her via email at:  sbnslp@gmail.com  or on her website www.AquaSLP.com 

How did you become interested in providing speech therapy in an aquatic setting?
My first exposure to providing speech therapy in an aquatic setting began in 1987 after I completed the 8-week Neurodevelopmental Treatment (NDT) Course in Pediatrics.   At that time, I was treating a very unhappy and severely involved little one, 2 ½ years with spastic cerebral palsy that affected all limbs and voicing.  He and I were both frustrated and the land activities I had learned in NDT, although sound and logical, were not working.  This child, when spontaneously using voice, exhibited severe laryngeal blocking yielding strident harsh sounds.  He was not a happy camper.  One day during our speech therapy session on the floor of his living room, Mom entered, and I looked up at her and, out of desperation, asked, “How does he like his bath?”   This mom lit up like a Christmas tree!  She excitedly shared how he loved his bath and always laughed when he was in the water.  I was motivated to take him into a nearby, warm pool we were fortunate to have available for people with disabilities.  This little one, who I expected would play in the water with me on the double wheelchair ramp, headed straight into the water!   I followed him and he came up laughing, looked at me as I caught him, and then he dove right back under!  So, the mom and I set it up for him to swim between us and we took turns catching him when his head came up and turning him to repeat the sequence.  We did this the whole session and both of us were amazed!

Whom have you worked with in the water?
The types of clients I have treated include infants through adults with cerebral palsy, Down Syndrome, CVA, Parkinson’s, seizure disorders, Autism Spectrum Disorders, Hearing Impairment, and Attention Deficit Disorders.  In addition, I have treated children with delayed speech and language who overcome resistance when jumping in and out of the water using voicing and early speech!

What are the benefits in working with clients in the water?
In my experience in working with infants through geriatric patients with neuromotor disabilities, the water provides a medium in which these bodies would have less of a struggle to achieve more movement than working against gravity in a land-based practice.  The land then becomes the setting to follow through and facilitate the easy movements attained in water then onto the land setting.  It is a slow, direct, specific process that can have very good results.  And, the fun involved is a plus!

Can you share some information about the coursework you offer in California?
Originally, I taught a class for continuing education for Speech-Language Pathologists because a funding agency was having difficulty paying for SLP services in an aquatic setting as it was not a Standard of Practice for SLPs.   I asked the California Speech and Hearing Association to cover my course and after the first one, they suggested I get my own PDP (Professional Development Provider) number directly from the California Board of Speech Pathology as they had.  So, my courses are supported by the California Board of Speech Pathology for 16-18 continuing education units (PDP129) that are recognized by ASHA and State Licensing Boards as viable Professional Development Units.

My course is an introduction for Speech-Language Pathologists to become acquainted with the various issues we experience and how we treat these or any issues in the aquatic setting.  After taking so many courses to prepare myself for treating clients and patients and teaching colleagues, I realized that I could offer an overview and hands on support for interested SLPs who then could decide to take more courses to address specific issues more oriented to physical and aquatic therapy, if still necessary.  My colleague, who teaches with me, and I have desired to create a manual with anecdotal information and explanations about how we work in water.  However, she is presently working on a PhD in treating Voice Disorders in an aquatic setting, thereby setting a precedence for working in water.  Our manual is on the back burner, so to speak!

Do you offer any online coursework?
I have considered creating a short presentation for basic information on a website and/or online lecture that offers credit for SLPs.  My hesitation is that the hands-on work is specific and serious.  I would not endorse anyone labeling themselves appropriate for treating in the aquatic setting without specific hands on experience.   I have witnessed medical professionals, who have only had a short course with limited experience, labeling themselves experts which has negatively affected patients.

Are there any graduate school programs or certification programs that teach aquatic therapy for SLPs?
My colleague, Rita Alegria, Professora at Universidade Francisco Pesoa, Porto, Portugal, teaches graduate SLP students in an aquatic setting.  It is the only university program that I am familiar with that has a formal program in aqua for SLPs.  I would recommend interested persons consider taking some of these courses at the Universidade. 

Rita enrolled in a speech pathology program in college after she had participated as a professional competitive swimmer from 8 through 22 years of age.  She saw a process for applying aqua principles in working with voicing issues in all aged patients.  Her orientation is totally different from mine where I needed to learn hands on treatment of little ones with cerebral palsy and Down Syndrome.

Many ask about certification for practicing in an aquatic setting and label this as Aquatic Therapy, but to my knowledge, a certification for SLPs is not yet available.  However, as a Speech-Language Pathologist, I, as all of you reading this who are SLPs, know that we practice and provide speech-language therapy in whatever setting we participate.  It seems that the aquatic atmosphere is a modality.  There are many aspects of being able to use that modality to enhance our work. 

In your opinion, can an SLP treat individuals in the water without any formal training?
It seems appropriate for SLPs desiring working in the water to invite a physical/occupational therapist with aqua training/experience to support the SLP program.  In 1984 there was very little support for this work.  Seems there are more choices now.  However, if you would rather work in individualized, direct therapy in the pool with those with a combination of severe physical, sensory, emotional and other limitations, then more specific training would be necessary.  

Saturday, May 11, 2019

PROMPT Therapy for Mild to Profound Speech Delays

PROMPT: One piece in the puzzle
What is PROMPT?

PROMPT is an acronym for Prompts for Restructuring Oral Muscular Phonetic Targets.  This is a dynamic, hands-on approach in which the trained clinician shapes a child's jaw, tongue, and lips through facial manipulation in support of sound production.  Some children that may benefit from PROMPT include those diagnosed with: apraxia, cerebral palsy, and autism.  In order to determine if PROMPT is appropriate for your child, your clinician will begin with an observation and evaluation.  

How long will my child need PROMPT services?

Typically, children are scheduled for weekly services for up to an hour.  Younger children may benefit from two, 30 minute sessions, while older clients may attend once a week for 45-60 minutes.  Depending on the degree of the speech delay, services may range anywhere from 3 months for mild impairments to 3 years if delays are severe to profound.  Other contributing factors that can impact longevity of services are cognitive, social/pragmatic, sensory/tactile defensiveness, and comprehension delays.

What does a PROMPT treatment session entail?

If a child has limited verbal skills or is nonverbal, then sessions will initially focus on attending to tasks while working on using vowel sounds to make needs known.  Attention, focus, and eye contact are all necessary foundation skills for speech communication, so these targets will be addressed according to the child's needs.  As attention improves, then PROMPT support increases for productions of consonant sounds/words/phrases/sentences. 

As with any articulation or phonological approach, we start at the level the child can accurately produce, which may be a sound syllable like "ma" and progress in gradual steps to words.  It is not realistic to assume that once a child can produce a single word, that he/she will leap to using that word in a sentence.  Rather, we would progress to phrases and then simple sentences following word level achievements.

Should I see one private speech pathologist for PROMPT and another for traditional speech therapy?

PROMPT trained speech pathologists use this specialized approach along with many other strategies and cues, so it is not necessary to have more than one private speech pathologist on your treatment team.  As stated earlier, some children may not be suitable for PROMPT, while others could require time before they feel comfortable with a tactile approach.  In my experience, children typically benefit from a multi-modality approach to therapy that includes verbal, visual, and tactile cues.  As such, I would not choose just  a tactile approach like PROMPT in my treatment plan and solely focus on that one support.  Having said that, if you want to continue speech services with another private clinician with whom your child has established rapport, then collaboration between all professionals is considered best practice.  

Given the intensity of the PROMPT training, any speech pathologist interested in learning how to administer PROMPT would need to register for course work to both learn and demonstrate competence in PROMPT.  My level of training does not permit me to instruct another speech pathologist in PROMPT.  Therefore, as a PROMPT trained practitioner, I cannot model the supports for another speech pathologist to incorporate into his/her treatment sessions.

How do I locate a PROMPT trained speech pathologist?

If you want to find a speech pathologist in your area trained in PROMPT, then you can visit this link and conduct a search.

Will my speech pathologist train me in PROMPT for home practice with my child?

No, in fact the only professionals allowed to register for PROMPT intensive training are speech pathologists given the extensive foundation knowledge of anatomy and physiology of speech these individuals have completed at the graduate level.  The intent of PROMPT is to help develop a new motor plan for speech while eliminating error movement patterns.  Consistent attendance helps support that development and over time results in accurate motor movements for speech.  

Sunday, April 28, 2019

The Motor Speech Disorders: Apraxia and Dysarthria Defined

The late Pam Marshalla, a renowned Speech Pathologist, said it best in the opening to her book, Apraxia Uncovered- Seven Stages of Phoneme Development, "Children with apraxia and dysarthria do not respond well to traditional speech therapy methods and procedures, rather they need a therapy that actually teaches them how to make their speech mechanism function correctly." Let's take a more detailed look at the causes, theories, and characteristics that define apraxia and dysarthria.

Dysarthria is an impairment in muscle movements for speech caused by damage in the central or peripheral nervous system.  Speech productions may sound weak or breathy,
 or productions may sound strained; it all depends on the site of the lesion.  The articulators (lips, tongue) may be reduced in range of motion, speed, or coordination of movement.  Therapy sessions would be catered to the needs of the individual, be progressive in nature, and may involve oral motor activities.

Apraxia of speech is a condition that impacts one's ability to plan sequential movements for speech productions.  Like dysarthria, apraxia can be acquired or developmental.  Probably the most frustrating thing about a developmental apraxia diagnosis for some families is that it's cause is unknown.  Since there are no definitive answers in these idiopathic situations, there are a few theories for causation ranging from motor programming/planning theories to breakdowns in linguistic process theories.  The latter implies that language frameworks are inadequate and thus cannot support segmenting sounds into words.  Still another theory proposes that impairments in sensorimotor integration and/or sensory processing make it difficult for children to feel placements for articulators or interpret sensory feedback in the mouth.  While we can't always provide answers to causation questions, we can provide effective therapy by structuring programs that best meet your child's ability and needs.

Below is a list of characteristics common to many clients with apraxia of speech.  This information was adapted from an informative website, www.apraxia-kids.org:

  •  Errors on vowel productions
  •  Variety of errors for one sound target (For example, may produce "mat", "sat" or "hat" for the word "cat")
  •  Productions that are difficult to understand or distorted
  •  Increase in errors as length or complexity of words increases
  •  May be heard saying a target sound correct once, but not again 
  •  More successful with predictable, learned targets, like counting and reciting abc's, but not able to produce sounds in spontaneous conversations
  • Slower rates/speeds when talking because sequencing sounds/words is such a struggle
  • Awkward prosody with limited to no use of stress on words
  • Significant difficulty with repetitions
  • Clear, physical signs of difficulty talking
  • Age appropriate receptive/comprehension ability.  Your child knows what he or she wants to say, but can't sequence the complicated stages necessary for speech.

As speech pathologists it is within our scope of practice to diagnose and treat apraxia and there are several tools available for these purposes.  We also seek additional training to help us enhance our diagnostic and clinical skills in treating children with apraxia.  In addition to speech interventions, we may need to teach other effective means for communication, determine if there are comprehension needs, address social communicative concerns, and work at your child's level. 

In severe to profound motor speech disorders, speech pathologists support functional, effective communication for a child by finding the appropriate augmentative communication (i.e., pictures, voice output) that assist in making a child's needs known.  Once the method is identified, the next steps in therapy involve teaching both the child and caregivers how to communicate effectively with the new support system.

PROMPT therapy is an evidence-based option that may suitable for your child, but rigorous clinical training is necessary for this approach.  I will further discuss PROMPT in my next blog post.