Tuesday, April 22, 2014

Therapy Gone Wrong for a "Type A" SLP

Every Speech-Language Pathologist dreams of the day when they will have back-to-back perfect treatment sessions. Imagine finding that perfect game, having all three of your patient’s brothers and sisters sitting quietly off to the side as you and your patient work without interruption; or imagine zero behavioral outbursts, despite challenging your patient with more difficult tasks.
More often than not, this “perfect” treatment session is not what my treatment session looks like! 

During a treatment session or an assessment my telephone will ring or a colleague will knock on the door.  Shoes and socks are not just slipped off, but are thrown into the air for an unknown reason. The special reinforcement snack (that I bought especially for my patient) is now considered “yucky” and inevitably the bubbles, which are my back up for when all goes wrong, are spilled everywhere. The toy or game that I imagined the patient requesting, describing, or problem solving with, just goes awry!
As a Speech-Language Pathologist who admittedly has a Type A personality, these scenarios left me frustrated, overwhelmed and exhausted. Frustrated, because I couldn’t get this treatment right.  Overwhelmed, because I personally felt embarrassed that my therapy plan was not playing out the way I wanted in front my of patient’s parents. Exhausted, because I spent countless hours revisiting the treatment session in my mind, trying to pin point the moment where I lost control of the appointment, thinking of reasons why the toy wasn’t the right fit, and contemplating the possibility of having the wrong room. In reality the problem wasn’t any of that. It was myself, and dare I say it was my very own Type A personality traits, getting in the way!

When I took a step back, and pushed my Type A personality traits aside, I realized all of the amazing therapy opportunities that I was letting just slip through my fingers! The telephone ringing, people knocking on my door, toys breaking, shoes flying, yucky snacks… yes all of it could be used in treatment with benefit! I started to ask myself questions such as: “Did my patient attend to the telephone ringing? Could they localize the sound? Did they label the telephone or imitate the sound? Did they ask a “wh” question? Did they relate a personal experience regarding the phone? For my older patients, were they able to return to task? Was the ringing a distraction? Could my patient continue to attend to their first given task despite the background noise?” I found that a plethora of analysis and treatment options just opened up all in a natural opportunity!

You may be thinking, alright the telephone rang, I can overcome that, what about a toy breaking, shoes flying, a yucky snack, or bubbles dumped over my head? All of these seemingly problematic scenarios present with equal and unique opportunities for treatment. Broken toy or a toy with missing pieces? Go on a scavenger hunt! Model asking to fix the toy, “mommy fix please?” Talk about the disaster, “Oh no, toy broken!” Take the opportunity to teach how to trade it in for a new toy! Yucky snack? One-by-one throw pieces of it away telling each piece goodbye or emphasize the appropriate pragmatics of “no thank you!” Bubbles spilled everywhere? Let’s practice learning how to take turns, practice saying “sorry,” model cleaning up with the clean up song, or teach new vocabulary such as, “oh no!” “gross!” or “sticky bubbles!”

Learning to let go of “the plan” can sometimes be the most beneficial and fun part of your treatment or assessment. So push those Type A tendencies aside and let the creative juices flow. Look for the hidden speech and language treasures that can come out of a “therapy gone wrong” session!

Sunday, April 13, 2014

Stars in Her Eyes by Dr. Linda Barboa with Elizabeth Obrey

In graduate school, I always enjoyed going to Dr. Linda Barboa's class. I enjoyed her classes because she provided theory/evidence within her teachings and she provided real life experiences. When I found out that Dr. Barboa and Elizabeth Obrey were writing a book about Autism, I was thrilled!

Stars in Her Eyes provides an informative look into Autism Spectrum Disorder (ASD). This book gives a unique perspective from a Speech-Language Pathologist, an educator, and a mother of two children with ASD. This collaboration may have been my favorite part of this book! To have the opportunity to not only hear what an SLP would say about a topic but also see the perspective of a mother and an educator was incredibly helpful. It serves as a reminder that a multitude of perspectives can add value to treating a child with Autism.

Though I am not a mother, I imagined myself as a parent who discovered her child has Autism. From this view, I felt validated that my child is not the only one, that the sleep issues my child had been experiencing are common, and that there is hope! This book is a great place to start, with all of the literature and different treatment options available it is nice to have a book where you can review it all and then make a decision. Another benefit of this book is that the language is easy to understand. You are not reading a journal article where you have to look up what Pearson R Coefficient means! You are able to get the information you need, reflect on it and move on to what you feel you need to do for your family.

As a Speech-Language Pathologist all I can say is "I want more!" The wide variety of challenges and interventions that can help with those challenges for children with Autism are extensive! In order to dive deeper into communication, sensory issues or social skills this would warrant an entire text book dedicated to any of the aforementioned skills. Dr. Barboa, how about those additional text books? :-)

Since I am an Outpatient Speech-Language Pathologist and I do not work within the school system I appreciated the overview of the school system guidelines and how to advocate for a child with ASD. I also appreciated insight into sensory issues, various interventions and resources provided in the book.

I feel confident in recommending this book to several of the parents that I work with as well as fellow Speech-Language Pathologists who work with our plan to work with children with Autism. 

Monday, February 24, 2014

Stranger Danger

Stranger Danger Material
Recently in Springfield, Missouri a horrific crime was committed against a ten year old girl Hailey Owens. I created this free Stranger Danger material in her memory. In this activity there is a board game provided where each student has the change to race home to win. Depending on the color they land on will determine if they do one of the following:
    1. Tell you if the scenario read aloud is a Safe Idea or a Stranger Danger situation. Cards are also provided to hold up for the answer.

    2. Explain what they would do in a given situation.

    3. Sort a given character into the stranger, familiar person, or friend/family section.
With this game all you will need to provide are token pieces for each player and a set of dice. I encourage all of you to download, make copies and share. Talk about methods to ward off strangers or to help identify if the person is a stranger such as having a buddy system or creating a family password.

This activity provides opportunity for several language goals to be addressed such as: reasoning, problem solving, sentence formulation, pragmatic language skills, etc. This activity can be found on my teachers pay teachers store at http://www.teacherspayteachs.com/product/stranger-danger-in-memory-of-hailey-Owens-1131322 


Friday, January 17, 2014

The Flu Won't Get Me Down!

For the past couple of days I have been home with the flu. Yuck.  Below is me in a nutshell...

But I won't let the flu get me down! The past couple of days I have been working diligently on getting this project done. I started this project probably a year ago! Crazy it took me that long to finish it but it is great quality!

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

The Power of WAIT!

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 Systems

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
SpeechEasy - $2,500 - $4,500
Janus Development Group, Inc.
112 Staton Road
Greenville, NC 27834
Toll-free (877) 4-Fluency
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)
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)
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!
7.     Resources

Have you used a DAF system before? What is your experience?