Stranger Danger Material
Friday, January 17, 2014
For the past couple of days I have been home with the flu. Yuck. Below is me in a nutshell...
The two links below will lead you to my teachers pay teachers store. There I have added two confrontation naming materials, a lite version and a full version. In the lite version there are 10 confrontation naming tasks that include a hierarchy of cues for the patient. In the full version there are over 90 confrontation naming tasks, a hierarchy of cues for each task and a way to track progress for the patient! I hope you enjoy it, I know that I am super excited to use it personally in acute care, long term acute care and my outpatient facility!
Friday, December 27, 2013
This past summer I had the opportunity to go to the Level 1 PECS course. PECS stands for Picture Exchange Communication System. It is an augmentative and alternative mode of communication for a wide variety of patients.
One topic that was briefly covered was “wait time.” I am so thankful that I was able to begin implementing this into my practice. I can’t tell you how many children I have on my caseload that will grab toys without permission (which I typically like to turn into a language opportunity). Out of these children that want things immediately there are several that will begin to have a behavioral breakdown due to not receiving their desired item/object/attention immediately.
How often have you seen this scenario occur?
Child: (Going to the slide unsupervised while mom and therapist talks).
Mom: “No no you need to wait until we are done talking”
Child: (Continues to go to slide).
Mom: “No no you need to wait.” (Mom begins to approach child).
Child: (Anticipates his/her mother stopping him/her from going down the slide and more aggressively climbs up the slide and/or goes down the slide anyway).
Mom/Therapist: (Trying to stop situation and takes child by hand).
Child: (Begins to tantrum characterized by yelling, screaming, etc.).
End Result: Child being carried out of therapy by patient’s mother or mother caving in and allowing child to slide despite child having tantrum.
What did the child learn in either end result? One, they learned that when mom or therapist says, “wait” they will most likely not get their reinforcement. Or two, if they throw a tempter tantrum despite mom or therapist saying, “wait” they will still get what they want. Either way this is not the lesson we want to teach our children. We want to teach that when you wait for a set amount of time you will get a positive reinforcement. This reinforcement could be an object, action, or some sort of social reinforcement. We have to give our children the opportunity to learn what a positive waiting experience feels like!
As you can see above this is the wait card that I created for my patients. I try to make the wait card in the child’s favorite color to automatically reinforce a positive emotion. My wait cards are made out of a cut out circle of foam with bold writing.
I start with purposefully putting out toys that the patient may have interest in. When the child reaches for the toy I quickly give them the “wait card” and state “please wait,” a half of a second later I reinforce the patient with their desired object, praising them for waiting. Each child is different and you will have to feel out how much you can increase the wait time for each child. You may do several trials at a half of a second or you may decide to try 5 seconds, then 10 seconds, 30 seconds, etc.… The most important thing about this process is to create the act of waiting into a positive experience and with reassurance that their desired object, action, or social reinforcement will be available to them.
For my children that are up to a minute wait time or above I personally use a timer that looks like the picture below. The red slowly decreases as the time passes, this gives a great visual reinforcement and expectation to how long the wait time will last, wait time is not this unknown time that could feel like eternity, wait time has an end with a positive result. I have also found that all of my children that I work with enjoy holding their wait time card. When they have finished their wait time they turn it back into me and they receive their reinforcement for waiting along with praise.
With my extended trials I am sure to set out my entire expectation such as,
“You want the toy car? I would like you to please wait for five minutes. During these five minutes you will sit calmly in the chair with still and safe feet. Your mother and I may be speaking during this time. When wait time is over you will get to play with the car.”
During a child’s wait time (after they have had several successful trials at a particular set time) then I like to either talk with their parent, play on the iPad or try to talk on the phone. I do this because it is simulating the real world. When they are waiting at school, in line at a restaurant, or at home for a reinforcement from their teachers, mothers, fathers, and playmates that communication partner will most likely be finishing a project or a conversation they were already doing before the child requested to do the new activity. They need the real life practice of the attention not focused directly on them.
So far, with the patients that I have started this with I have seen and heard wonderful results. One mother told me that she is now able to use the restroom independently. Her child now waits just outside the door until she has finished. This mother hasn’t been able to do this for four years.
The ability to wait is such a critical skills for our children. They need to be able to wait to listen to all of directions, to learn if an activity is safe or not, to wait there turn in social games, etc.… Now I am sure there are several methods to teach waiting, this is just one that I have personally found effective. What techniques have you used to teach wait time?
Tuesday, December 3, 2013
Delayed Auditory Feedback
Recently, I have had the opportunity to work with a patient that has neurogenic stuttering. We have attempted easy onset and using continuous voicing to improve the dysfluency. We have seen some gains with both of these therapy techniques and I plan to continue to utilize both of them but this patient has a goal to be back to work in a relatively short period of time. So, I decided to try a delayed auditory feedback (DAF) system with my patient. We have seen great results! Now there are several approaches to providing treatment for patients who stutter and this blog post is only discussing one of them, delayed auditory feedback.
1. What is delayed auditory feedback and how does it work? DAF is a device that takes your voice and delays it by a set time. This set time can be predetermined by the speech-language pathologist or the patient. DAF systems are thought to best help patients who stutter that have an under activated auditory processing system.
Before I try this system with a patient I explain to them it’s like you have a poor connection with your phone and you keep hearing your voice echo. Instead of turning off the phone for a better connection we are going to be working through the delay, the best way to work through the delay is to slow your rate of speech and prolong syllable sets.
DAF systems have come a long way. I was first introduced to DAF systems with The Facilitator that, I believe, was made by Kay Elemetrics and Dr. Daniel Boone. I don’t think they even make it anymore but if you click on the link below you can find an article on The Facilitator. http://www.kayelemetrics.com/index.php?option=com_publication&Itemid=5&id=16&menu_id=46&subid=194
Now DAF systems are available on the VisiPitch (the system I have), apps, and various other forms. The constant with all of the DAF systems is that there is a microphone for you to speak into, a processor that alters your voice (in our case delays it) and an ear piece for you to hear your own voice at the selected delayed time.
2. Do we have evidence to support the use? In graduate school I was taught that a DAF system is like a one hit wonder, it only would work while the patient was wearing the device, once the patient removed it that there would be no carry over. I was pleasantly surprised when my colleague Kimberly Herrejon M.S. CCC-SLP provided me with this journal article, Delayed auditory feedback in the treatment of stuttering: clients as consumers. (Borsel, Reunes, and Bergh 2003). http://www.ncbi.nlm.nih.gov/pubmed/12745932. In short, they first assessed patients stuttering occurrences independently and with a DAF system. Over a three month time span they had the participants use the DAF system alone, when they brought them back for testing they found that the stuttering occurrences without a DAF declined significantly! So yes we do have some evidence out there to support this method!
I have also read that there is a method of using the DAF system in a weaning manner. Some have started a DAF system at an appropriate delayed setting and once their patient is fluent over several contexts they then reduce the delayed setting and continue to do so until there is no need for the DAF system. I find this so interesting and I can’t wait to find some more research on this!
3. Is it for everyone? I do not believe that a DAF system is a cure all for people who stutter. I do think the best way to find out though is to give it a try. Your patient will either have a reaction or no reaction. I had a patient in just the other day that had no reaction to the DAF system despite several trials and settings so we are not going to use it. We are going to move on and find what works best for the patient.
4. Video! This gentleman did a great job presenting his DAF system. And I think it is a true picture of what a basic DAF system looks like. With some of the other systems they have made it much more discrete.
5. Vendors. I was so fortunate to already come across a pre-made list by The Stuttering Foundation. It can be found below as well as a note from the foundation. I as well have no financial ties to any of the below organizations.
“Note: The Stuttering Foundation of America does not warrant the efficacy of these devices nor guarantee their treatment in any way. This page is here for your information only. Appearing on this page is NOT an endorsement by the Stuttering Foundation.
Speech Monitor Rick Arenas www.speechmonitor.org
SpeechEasy - $2,500 - $4,500 Janus Development Group, Inc. 112 Staton Road Greenville, NC 27834 252-551-9042 Toll-free (877) 4-Fluency www.speecheasy.com
These devices, worn like traditional hearing aids, use altered auditory feedback in the form of auditory delays & frequency shifts.
Casa Futura Technologies - $1,495 - $3,500 720 31st Street Boulder, CO 80303 888-FLUENCY or 888-358-3629 or 303-417-9752 303-413-0853 (Fax) www.casafuturatech.com
DAF, FAF, MAF, and stuttering bio feed back devices for clinical, home practice, telephone, and pocket use. 15 States (CA, MA, TX, WI and more) provide funding for anti-stuttering telephone devices to qualified consumers. Schools may inquire about special rates.
KayPentax - $4,000 2 Bridgewater Lane Lincoln Park, NJ 07035 800-289-5297 (toll-free USA & Canada) 973-628-6200 www.kayelemetrics.com email@example.com”
The Stuttering Foundation has also provided a list of apps and computer software available for DAF use. Again below is also a note from The Stuttering Foundation.
“Note: The Stuttering Foundation does not warrant the efficacy of these apps nor guarantee their treatment in any way. This page is here for your information only. Appearing on this page is NOT an endorsement by the Stuttering Foundation.
Apps for smart phones, tablets and iPad/IPhones etc…
Smarty Ears (Fluency Tracker and Disfluency Index Counter)
The Stammurai, a game created by teens who stutter
Software for Computers
Speech Monitor (free)
I believe these are all already hyperlinked for further exploring if you are interested! I also just wanted to take a short moment and say a big Thank You to The Stuttering Foundation and other organizations that support people who stutter. I am so impressed with their the time and dedication!
6. Real life Experience. Here is a review from a person who stutters and has used a DAF system. Some of his thoughts are positive and some are negative but I think it is important to see both sides!
Have you used a DAF system before? What is your experience?
Sunday, November 24, 2013
Have any of you moved before? If so, you know how hectic life can be during and after the move! So after a crazy couple of weeks of moving we finally have the Internet and I have my cozy office set up.
As I sip on a nice cup of tea this evening I find myself reflecting on some of my adult patients that I have been so fortunate to work with lately. Most of these patients have sustained traumatic brain injuries and/or a stroke. When an event like this occurs it can leave the patient with significant cognitive-linguistic deficits.
Often times these patients that I see will reflect upon what used to be. “I used to be able to read an entire book.” “I could go to the grocery store without a shopping list.” Etc.. This reflection is normal and can help drive treatment but when a patient becomes stuck or fixated in the world of “what used to be” then making gains in treatment can be challenging.
Though I have never experienced a traumatic brain injury or a stroke I do understand what it is like to be in the “what used to be” world. When I was in graduate school I played golf for Missouri State University. It was so easy to get stuck in the mindset of “why can’t I hit this pitching wedge…last week I was able to…maybe if I hold the club this way…no more club head speed, less club head speed…I used to be able to make that put.” I was lucky because my coach, Coach Kevin Kane, was able to recognize when I would get stuck. He would tell me to “get out of your own way.” Mentally I had to stop thinking about what I did but what I was going to do and what I was going to accomplish. Sometimes we have to help our patients get out of their own way.
When I identify a patient that is in the land of “what used to be” or they are “in their own way” and they can’t get out of it, I will have them do a simple exercise. I will have them make a list of the accomplishments they are proud of. This list can be long term or short term. I know it seems strange to have them reflect on the past but there is a method to my madness… After they make this I have them write what they now want to accomplish and what they will be proud to accomplish. Just because a patient has had a stroke or a traumatic brain injury does not mean that there past accomplishments are worthless or gone. They can still be proud of a past award, raising their children, writing a book or being a great grandmother or grandfather. It’s time to harness that feeling of pride and accomplishment and move it into treatment. It’s time to talk about the work that they put into previous accomplishments and how that same work ethic they possess is going to help them now. With every single patient that I have done this with, I have seen a fire light inside of him or her and then gains in treatment. This exercise is not only good for the patient but it has also been tremendously helpful for the treatment plan that I formulate for the patient. You may find that your current treatment plan is not reflective of what the patient wants to see the most gains in, you may find more functional day to day cognitive-linguistic skills that the patient would immediately gain from.
Have you tried something like this with your patients before? Have you seen positive gains? Do you have any other methods that help keep your adults motivated? Do you have a patient that may benefit from this technique? Please share!
Monday, October 28, 2013
I don't know about all of you but I have been having so much using Halloween materials in treatment this month! I thought tonight I would write out some of the items that I have been using.
First we have Spooky Speech by Sublime Speech - http://www.teacherspayteachers.com/Product/Spooky-Speech-Halloween-Articulation-Word-Lists-and-Activities-372036 This download is free and is full of various articulation targets. If you are working in groups there is a great opportunity to turn the articulation targets into language centered goals. Some language activities may include picking out 1-4 words and having your patient create a sentence, turning the words into an auditory memory task, having your patient draw a story from the words, giving definitions, etc., I also find the vocabulary in this appropriate for my adult population especially with word finding difficulty.
Another fun activity is Ms. Lane's Happy Halloween following directions download. I am having trouble finding the original link so here is a general link to her website - http://slpmaterials.blogspot.com/ she also has a new and festive story comprehension download available! Both for free!
Lets Talk Speech-Language Pathology has a Thanksgiving following directions download available as well. I haven't downloaded it yet but it is definitely on my list! https://docs.google.com/file/d/0B5wRO8_NbvC4TlJlTmJUeGNwWjQ/edit?usp=drive_web
The Slide and Find SPOOKY book is by Roger Priddy. I found this book last year at Gordmans on sale and I love it! It is a simple, yet interactive book for your younger patients. It includes basic concepts such as counting, early inferencing skills, and generally I feel this book is great for orientation to the Halloween holiday.
For my iPad I downloaded a neat pumpkin app complete with creepy music! I usually use this app as a reward for hard work in treatment. My patients get to decorate the pumpkin as they like. It takes a bit to get used to navigating to the different body parts you can add (eyes, nose, etc.,) so I like to see this as a great opportunity for my patients to request for help and give details for what they need. The app is called Pumpkin Creation and it is free!
Of course Halloween wouldn't be complete without fun stickers and a whole bunch of candy! What are you all doing to get your patients in the spirit? Have you picked out your costume?