Trust Your Gut

shutterstock_414254503.jpgIn every SLP’s career, there will be students who stand out in your mind for one reason or another. Some are success stories, some are students you just click with, and some help you grow as a therapist.  Megan falls into the latter category for me. Even though I had her on my caseload nearly 20 years ago, the lessons I learned from working with her remain fresh in my mind.

Megan was a kindergartener in our young life skills class.  She was a cutie:  long golden hair, bright blue eyes, engaging smile.  But Megan had some issues, too.  Learning disabilities were evident in delayed academic milestones.  Megan was overweight;  not obese, but definitely chubby.  As a result, or perhaps this was the cause, she was not fond of physical activity, although she did enjoy the weekly “dance party” with our PT.  By far, her greatest challenge was speech.  Megan’s speech was severely disordered, consisting mostly of nasalized vowels and a few consonants.  Her parents had taken her to several doctors from infancy through age 4 due to difficulty nursing, then delayed and disordered speech development, even traveling out of state to a pediatric specialist who declared that she likely had her own unique syndrome (he called it “Megan’s syndrome”) and told her parents she would “always sound like Tarzan!”  Yes, he really said that.  Parents were devastated.  I was incensed when I read that in her preschool records.

To enable Megan to communicate more effectively, we used a variety of communication boards and then a speech-generating device.  She learned to use these in daily routines, but it was evident that she wanted to be, first and foremost, a verbal communicator.  And that’s what I wanted for her, too, in part, I’ll admit, because I wanted to prove that horrible doctor wrong.  In weekly individual therapy sessions, we worked on consonants following the developmental progression.  Megan had good imitation skills, but her nasality affected production so that cognate pairs were often indistinguishable.  I also noted nasal snorting on /s,z/ and in her laugh. An oral motor exam didn’t reveal anything unusual — certainly not the submucous cleft that I initially suspected.

To build up oral pressure and air flow, I used (with parent permission) a swimmer’s nose clip as we worked on repetitive sounds.  Repetition with the clip produced better sounds, but when the clip was removed, production quickly reverted to nasality.  As low tone was evident throughout her system, we added squeezing stress balls and standing.  These efforts yielded some improvement in drill, but there was little carryover when the nose clip and stress balls were removed.

One day I read a journal article about velo-cardio-facial syndrome.  As I read through the list of possible characteristics, I realized that Megan fit a whole bunch of them:  almond-shaped eyes, short stature, dysmorphic body shape, tapered fingers, a heart condition, learning disabilities, and nasalized speech.  Of course, I could not make this diagnosis, but my gut told me that this needed to be explored.

When I met with Megan’s parents, I told them of the progress Megan was making under controlled drills but that I really felt there was an underlying physical problem that was impeding her progress without the supports.  My recommendation was a visit to a cleft palate clinic.  Her parents agreed and made the appointment at a facility nearly 2 hours away.  As the day approached, Megan’s mom asked if I would accompany them to the appointment, as I could better explain what I had observed and would better understand what the team reported.

During the long drive to the clinic, I found myself having strange, conflicting thoughts. On one hand, I didn’t want anything to be wrong with Megan;  on the other, I was afraid the team would look at her and then at me like I had lost my mind in making the referral.  Long story short, the members of the team (SLP, orthodontist, ENT) each examined Megan and immediately agreed that she had come to the right place.  Whew.  Tests showed insufficient tissue and mobility in her palate.  A series of orthodontic interventions were recommended to spread Megan’s palate.  She would also undergo pharyngeal flap surgery.  Follow-up with a geneticist was recommended.

With this medical intervention and continued speech therapy, Megan became a verbal communicator.  Although it wasn’t easy, I’m so glad I trusted my gut.  The fact that we proved that doctor wrong was just icing on the cake!

Oldies but Goodies

I once saw a t-shirt that said “I get paid to play board games.”  Well, we all know that we do WAY more than that, but there is no question that games keep the kids engaged in therapy.  The challenge is always making sure that the game doesn’t take up valuable therapy time.  Because I need to get as many repetitions as possible in a session, I am always looking for games that are super quick but also engaging.  In previous posts, I have described the stick game (an all-time favorite that’s dirt cheap and easy to make), commercially-available Feed the Kitty and Cookie Crumble, and the sound-specific games I’ve made based on old childhood favorites, Jump! and Square Off!  Pop-Up Pirate is another game that appeals even to my 4th graders. Lots of SLPs have blogged about the creative ways to use Ned’s Head, Guess Who, and Jenga — google or check Pinterest for those ideas.  And, of course, we all know about Go Fish and Memory games with therapy cards. A fun twist on using those cards is described in my post about “Hide the Sticker.”

A recent report from the American Academy of Pediatrics states that there is not much proof that tablet-based toys and games benefit brain development in toddlers, and concludes that hands-on toys like blocks and puzzles are far more beneficial for hand-eye coordination, problem-solving, creativity, and interactive play with adults and peers.  While there is certainly a place in therapy for some of the great speech/language apps, such as those by SmartyEars, I’ve come to realize that some of our students today, who are of the “digital generation,” don’t even know how to play with games and toys that we all grew up with.  And that got me to thinking about how to use other free or cheap toys and games to build brain power, concentration, social skills, and language.  Here are some suggestions, based on games and activities I’ve used in therapy.  Of course, you will want to modify the games to build language and social skills and meet IEP goals and work in AAC for those with low verbal skills.

  • Checkers, Chinese Checkers, Connect 4, Battleship — all require some strategy
  • Pick up Sticks (a lot quieter than Jenga!) — good for patience and hand-eye coordination
  • Games like Cootie, Don’t Break the Ice, and Operation — also good for hand-eye coordination
  • LEGOs, Duplos, magnetic shapes, plastic gears — all good for cooperative creating, requesting, describing
  • Yahtzee! — scorekeeping and math
  • Card games like Hearts, Crazy Eights, and Uno –lots of interaction with peers
  • Jigsaw puzzles — have a 100 piece puzzle out on a table for kids to work on — lots of language as they look for and describe pieces.
  • For kiddos who need to build auditory skills and following directions, favorite old games like Red Light/Green Light, Simon Says, and Mother May I? will get them listening and moving, making these good warm-up or end-of-session reward activities.
  • Toss Across or a DYI beanbag toss game will also incorporate movement in therapy.

What oldies but goodies do you use in therapy??

 

 

 

Selective Mutism

Screen Shot 2018-11-27 at 3.09.18 PMYears ago I was assigned as a short-term sub for a colleague who had been injured in a fall.  When I entered a 4th grade learning support classroom, the teacher introduced me to each student.  When she came to a girl I’ll call Tara, she said, “This one doesn’t talk at school.  Come on, Tara! Say something for the new speech teacher!”  Then the teacher shook her head with a scowl and said, “She’ll never talk.”   Tara looked at the floor in silence as the other students giggled.  As for me, my jaw hit the floor.  Horrified, I returned to the speech room to look up Tara’s records.  The narrative on her IEP stated that Tara talked a lot at home with family and friends, and her articulation was good, according to her mother.  However, since entering kindergarten, Tara increasingly refused to speak on the bus or in school.  Clearly, she fit the definition of a selective mute.

Through conversation with her teacher and observation of Tara in various locations in the school, it became apparent that nearly everyone in the school badgered Tara to talk:  the teaching assistants, the art/music/gym teachers, the librarian, the cafeteria lady, even the bus driver and principal.  Perhaps they thought they were giving her encouragement.  What they were really doing is bullying her, making her stand out in front of her peers, and setting up a situation in which, if she WOULD ever say a word, one might expect fireworks, a brass band, and a ticker-tape parade to break out.  Talk about pressure!

I had a phone conference with Tara’s mother to verify that mom didn’t detect any problems with Tara’s speech or language.  Indeed, her mom reported that Tara talked up a storm at home. She wasn’t able to shed any light on why Tara refused to speak in school, but did say it had been a growing problem since kindergarten.  I shared some information about selective mutism during our conversation and followed up by sending an article home for her mother to read.

The next step was to take the pressure off the student by educating the staff.  I gave a brief inservice at the next staff meeting, and provided everyone with the same article I had shared with Tara’s mom. I provided Tara with communication boards with core language and fringe words/phrases she would likely use in the classroom.  In her individual speech therapy sessions, we played board and card games, again using communication boards with game-related vocabulary so Tara could name, request, refuse, comment, and direct actions. I provided verbal models as I used the boards during the games, and considered it a very positive step when Tara started using the boards appropriately during her turn.  However, I reacted calmly as though this was commonplace, expected behavior, and didn’t put any pressure on her to also use her voice.  I also spent several sessions in her classroom, helping to facilitate communication there and modeling for the teacher the kinds of interactions that would be engaging but non-threatening.  Because SM is more of a psychological issue, I tried to engage the school psychologist in her case.  Unfortunately, the district only used the psychologists for testing and attending meetings, not for counseling the students, so this went nowhere.  Ugh.

I’d like to report that Tara eventually began speaking, but after a month of subbing, the regular SLP returned and I went back to my assignment on the assistive technology team.  Before I left, I shared all of this information with the SLP and hoped that it would be followed through.  Unfortunately, the student later moved out of the area so I have no idea whatever happened to her.

As I said, this all happened years ago before the Internet (yes, I’ve been an SLP for that long!), so information was much more limited.  Today, there are many resources on the topic of selective mutism that SLPs can share with parents and school staff.  Here are some you should know about:

The SMart Center:  loads of information in their newsletters (definitely sign up!), professional development trainings and webinars, CommuniCamp for group treatment, and lots of downloads of research and intervention strategies.

What Teachers Need to Know About Selective Mutism:  informative article by We Are Teachers that would be great to share with school staff.

Selective Mutism Association:  books, articles, newsletter, and other supports for parents and professionals

Gobble, Gobble, Talk!

Thanksgiving!  A time when families come together to share a delicious meal, renew connections, and watch some football.  We’d like to think that our holiday will be Norman Rockwell perfect, but that requires navigating a bunch of hurdles, especially with kids at the table.  Following are some tips for getting kids engaged and communicating that will, hopefully, make your holiday gathering more peaceful and pleasant. (How to overcome adult differences in politics and current events is beyond me — good luck with that!)

Screen Shot 2018-11-18 at 10.23.13 AMWhile you are busy getting the dinner together, engage the kids in making treats.  Already on my list are ice cream cone teepees.  I’m skipping the cupcake baked inside the cone because (1) we’ll have enough dessert with pies and (2) I don’t have the time or oven space for baking cone-filled cupcakes.  Just the creating and decorating will be enough fun and should keep little ones busy for a while.  Here are a couple of examples that I will be combining:  Teepees 1Teepees 2

Screen Shot 2018-11-18 at 10.27.48 AMAnother treat we will make:  pilgrim hat cookies.  Simple, fun, and yummy!  (Caution:  Contains peanut butter).   Click HERE for directions.  Both the teepees and pilgrim hats would make fun and easy therapy activities, too, that hit on a number of speech and language goals:  following directions, problem-solving, making choices, describing, to name a few.

 

 

Screen Shot 2018-11-18 at 11.04.39 AMAs long as you are in a creative mood, engage the kids in making decorations for the holiday.  Give them a supply of construction paper, glue sticks, scissors, markers & crayons, and let their imaginations run wild.  For those who need some guidance, you can print out samples of finished projects and coloring pages, especially good for very little kids. Simply google “kids Thanksgiving crafts” and you’ll have more than enough activities for all ages and ability levels.  The photo to the left is from https://iheartcraftythings.com/15-terrific-turkey-crafts-for-kids.html.

Screen Shot 2018-11-18 at 10.53.05 AMInvolve the kids in setting the table.  When I worked with students in Life Skills classes, we made placemats from large construction paper, on which the students glued paper images of a plate, napkin, utensils, and a cup.  This served as a guide for them when they set their place with the real objects.  Stamps, stickers, and markers were used to decorate.  Again, think of the IEP goals (speech/language and OT) that go into a project like this!  Pictured is a premade placemat available from Amazon. It’s more elaborate than the ones we made, but it illustrates the idea.

Screen Shot 2018-11-18 at 10.58.35 AMHave a picky eater?  These plates, which my grandson calls his “course,” are fabulous for getting kids to try a little of this, a little of that, as they work toward a reward.  Amazon has them in a number of variations.  I’ve also seen them in kitchen specialty shops.

 

Screen Shot 2018-11-18 at 11.16.38 AMHave some shy guys who need some help in conversing with rarely-seen relatives?  There are a number of commercially-made conversation cards that introduce topics and questions, but you can make your own.  Be creative!  Print out the conversation starters from THIS SITE and glue them onto paper feathers or leaves.  An excellent post about this very topic for AAC users and children who need help with social skills can be found on PrAACticalAAC.org.

Screen Shot 2018-11-18 at 11.22.36 AMI hope this provides some ideas for therapy lessons and holiday prep activities that will keep the kiddos actively engaged.  Here’s one more, a freebie from my TPT store:  Fall Vocabulary Cards!  Print 2 copies on cardstock, cut apart, and use for Memory and Go Fish games.  All of the words contain the /r/ sound and the symbols are great for thematic vocabulary activities, as well!  Happy Thanksgiving!!

Lesson Pix

If you have followed this blog or the Speaking of Speech.com website for any length of time, you’ll know that I am a strong proponent of visual supports for all students.  I’ve presented on this topic at local, state, and national conferences, and have built up such a huge collection of materials created with Boardmaker that I’m running out of space to store it all.

Screen Shot 2018-10-18 at 10.25.16 PMRecently, though, I’ve been exploring the features of another symbol system, Lesson Pix.  Lesson Pix is a subscription-based, web-based tool for creating a wide variety of visual supports.  A single subscription is just $36 per year, and lower prices are available for multiple subscriptions.  Included in the subscription:  35,000 symbols accessed by an easy to use search engine, the ability to upload images from the Internet or your camera, tools to modify symbols, and a gazillion preprogrammed templates for all kinds of games and materials. In addition, you get tech support in the form of a large number of instructional videos on all features of Lesson Pix.  Looking for ways to use visual supports?  Check out the resources under “Articles.”

Screen Shot 2018-10-18 at 10.25.37 PMSymbols in Lesson Pix are available in color, outline (black/white), and stencil (no outline).  SLPs will love the SoundFinder feature, which lets you search for any speech sound in any position of words.  Making worksheets and cards for medial and final target sounds just got a whole lot easier!!  But that’s not all,  You can also search for patterns (CV, VC, CVCV, etc.), minimal pairs, and rhyming words!!  Wowzers!

If you are making theme-based materials, you’ll want to use the ClipArt library, which is arranged by category.  Click on the category to open the folder, drag all desired images to the “tray,” then use these symbols to populate your chosen template.  Edit to change text and alter the appearance of symbols.  You can also import clip art and photos to augment the 35,000 symbols built into the program.  A unique feature of Lesson Pix is that you can request a symbol;  just fill out the form with a description of what you need and they will draw it for you.

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Although an MS-Word Integration plug-in allows for creating your own unique materials, Lesson Pix is primarily a template-based tool.  Here is just a sample of the long list of available templates:

  • Picture cards
  • Picture schedules
  • First, then boards
  • Books and social stories
  • Certificates
  • Door hangers
  • Flashcards
  • Coloring, lacing, and cutting materials for fine motor practice
  • Loads of games, including Bingo, Dominoes, treasure hunt, fortune tellers, I have/Who has cards, and much more!
  • Menus
  • Voting ballots
  • Multiple Choice worksheets
  • Semantic maps
  • Writing pages
  • Stick puppets
  • Overlays for AAC books and devices

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If that isn’t enough, your $36 annual fee also provides you with access to the Sharing Center.  Upload your creations for others to use, and download loads of free materials that others have posted.  All materials created with Lesson Pix are saved as PDF.

Lesson Pix provides a free 30-day trial in which all features of the program are operational, but a watermark appears on materials when you print them.  For just $3/month, Lesson Pix is certainly worth exploring!