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??

 

 

 

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!!

Sticks and Stones

Screen Shot 2018-11-10 at 9.45.31 AM“Sticks and stones may break my bones, but words will never hurt me.”  Baloney!  As experts in the field of communication, we all know the powerful effect — positive and negative — that words can have.  In fact, bullying (verbal and written) is a leading cause of depression and suicide.  Clearly, words hurt, but they can help, too.  One of the best unintended perks to come out of creating Speaking of Speech.com has been the personal connections that have formed with SLPs all over the world.  There have been times (especially the two times when I had to recreate the entire site from scratch — ugh, the memory still makes me shudder) that I’ve been tempted to pull the plug on the website.  After all, the costs in time, energy, and money to keep it going for nearly 20 years add up, and I start to wonder if the site is really worth the effort.  Without fail, I’ll get an email out of the blue from a faithful follower or someone who is new to the site, telling me just how much the site has enhanced their practice and benefited their students.  Or the emails will be a personal response to something I’ve shared about my life in my newsletter.  Those words of encouragement, gratitude, and personal connection touch me deeply, and I can honestly say that this positive feedback is the reason the site still exists.  Words are that powerful.

I recently received a message from Jeanne Kleinman Williams, M.A.CCC- SLP about the power of words, and that inspired this post.  Jeanne is a long-time follower of Speaking of Speech.com, and, although we’ve never met, she has become a dear friend through emails, messages, and Facebook posts — a relationship forged solely by the power of words.  Jeanne has acquired much wisdom and experience in her 44-year career.  Her message to me, in part, was this:  “I am committed to making children feel safe, cared for, and nurtured. It is my responsibility to establish guidelines that help them to develop confidence in themselves, respect for themselves, and to be their advocate. If along the way I also help close that achievement gap, I’ve made a real difference. We are the ones who love the children who come to school with dirty clothes, mismatched socks, who look a little bit different from others, may act a little different, and definitely have communication deficits. When you can make a middle school student feel like they are a winner, it makes me emotional. It’s all in the little nuances of how and what we say to the children, the students. When they walk out with their head held a little higher, then I, a down-to-earth woman, will advocate to the end of time, for my students. I think this is to make a point that it takes little, small words sprinkled with kindness and compassion, to make others feel like a winner.”

Jeanne makes an excellent point:  “the little nuances of how and what we say” are so critical to relationships, not only with our students, but also with their teachers, peers, and even family members, and can have influence far beyond the moment.  I’d like to believe that, as caring SLPs, we are always supportive and encouraging to our students, and that all of our students leave therapy sessions with a good feeling about themselves.  After all, “establish rapport” is the first lesson in Speech 101.  So let’s go with that assumption and think instead about the words of others and how they impact our students.  Are we doing enough to protect our students from unkind comments and even bullying related to their speech/language disorder?  Here are some eye-opening experiences I’ve had that touch on this question.

I was once pulled from my assistive tech assignment to be a short-term sub for an SLP who was out on medical leave.  When I walked into one of the special education classes, the teacher introduced me to the students and said of one girl, “this one doesn’t talk at all.  She can but she refuses to.  Come on, Susie, say something to the speech teacher.”  I don’t know whose expression was more horrified, mine or Susie’s.  This 8 year-old girl was a selective mute, and I quickly discovered that everyone in the school — specialists, the school secretary, the recess aids, and even the principal — badgered this child every day, “come on, you can talk, say something!”  Clearly, nothing had been done to educate the staff about selective mutism and to make them aware that their words were only making the situation worse.  I’d like to think the inservicing I immediately did made a difference for that little girl, but I left that position after a month and didn’t have the opportunity to follow up with the SLP, except to let her know what I had observed and what I did to help her.

An elementary Life Skills teacher with years of experience suddenly had 3 students in her class who used iPads with communication apps  — a new development in AAC at that time.  She observed that the boys stayed together and didn’t interact with their regular ed peers when included in specials, recess, etc.  We took a good look at the vocabulary on the devices and realized that (1) the vocab didn’t really lend itself to age-appropriate social interactions and (2) the boys needed to be taught how to engage with their peers.  Creative juices flowed and the devices were made much more conversational.  The teacher created dialogues and word games that got the kids talking, and even elicited suggestions on topics and expressions from the regular ed peers, which immediately invested them in the AAC.  She invited each 4th grade class to visit her room for a demonstration of the AAC;  she explained how and why the boys used this technology, then had the boys answer questions from their peers.   It didn’t take long before new friendships were formed and the boys were viewed by their peers (and other staff) in an entirely different light.  Again, the power of words — the words the boys used on their speech-generating devices, the words the teacher used to educate their peers.

I was recently assigned to a new school and held my first preschool transition IEP with parents and a wonderful kindergarten teacher.  The incoming student had multiple articulation errors, not all of which were developmental.  I explained to the parents the nature and severity of the errors, described what the articulators needed to do to correct production, and gave examples of how I was going to cue the student to elicit those sounds.  When the parents left, the kindergarten teacher said that she learned more about speech production in that IEP meeting than she had in her 30+ years of teaching, and asked if I would please do an inservice for all K-1-2 teachers. It was clear that she gained a new respect for just how hard these speech students have to work to correct their sounds, and now felt more empowered to support them in the classroom.  I was happy to share with her a copy of my children’s book, “The Mouth With a Mind of Its Own,” which I had written several years ago to make this very point.

I could go on and on…..classroom presentations to acquaint peers with hearing aids, teaching sign language to peers of deaf students included in regular education classes, educating parents and teachers about voice disorders and speech dysfluency, creating a functional curriculum for high school students in Life Skills and Multiple Disability Support classes that built relationships about the school with peers and staff.  All exemplify the power of words to educate, enlighten, and encourage not just our students, but also the adults and peers with whom they interact.  Speaking to Jeanne’s point about how our words affect how our students feel about themselves, I was tagged on a Facebook post by the mother of a young boy who stuttered.  We had worked for a couple of years in elementary school on fluency-enhancing strategies and also on acceptance of stuttering.  Her post was a video of him in middle school giving a presentation to his class, proudly and confidently.  Her tag said “he never would have had the confidence to do this without your encouragement and instruction.”  Wow, my words made a difference in this young man’s life, and his mom’s words brought me to tears.

For a first-person account by a parent on struggles with words, read “My youngest isn’t just quiet, he has a serious speech disorder.”

Rapid Speech Therapy on the High Seas

Screen Shot 2018-11-01 at 6.33.23 PMA new feature on this blog is periodic interviews with SLPs that you really need to know about.  In September, the spotlight was on Char Boshart, SLP extraordinaire.  Now I want to introduce you to an SLP who is unique in many ways.  I first learned of Marcus Little last year when he sent me information about his new website, RapidSpeechTherapy.com.  If you read my post, Drill, Baby, Drill, you’ll know that I am all about maximizing repetitions in artic therapy.  Marcus takes this much further by providing resources that assist parents in effective home practice, with the emphasis on achieving automaticity ASAP.  These resources include awesome videos that illustrate techniques for /r, s, th/ production; 20 detailed, downloadable “essential tips for effectively developing speech sounds;” and a blog that, among other things, describes how Marcus elicits 500-600 target sound repetitions in just 15 minutes.  Now, THAT’S rapid speech therapy!

But rapid drill isn’t the only unique feature of Marcus’ speech therapy practice.  Just wait until you see WHERE he has done therapy!

How I Got Started and Why I Keep Going:  An Interview with Marcus Little

Education: M.Sc – SLP SUNY Fredonia

Current employment: Self-employed

Web address: rapidspeechtherapy.com

My passion is helping children (and adults) achieve their speaking potential. Results come quicker when “an optimized” homework program is done consistently on a daily basis.  This is the reason I have made training parents, caregivers, tutors, educational assistants, teachers, and volunteers a top priority.   The “Rapid Speech Therapy” method was born out of the necessity to provide  an easy to use yet powerful way to develop speech sounds in the hands of the “nonprofessional.”

What first got you interested in the field of speech/language pathology?  I was one of those people who spent years in University trying to figure out what I wanted to do with my life.  I had a friend who was an SLP and it looked interesting.

In what types of settings and with what populations have you worked? I have worked in Canadian Schools predominantly.

What is your area of specialty in the field?  I love intensive high repetition drills that focus on developing speed while maintaining accuracy. This is done in order to develop automaticity of speech.  The approach is success-based, meaning we immerse the individual in drills that we know they can already do but focus on doing it smoother, quicker, and faster.  If errors occur, then it is simply a matter of slowing down and reestablishing the accuracy. One of the key principles is establishing a solid foundation of pre-word level skills, this being sound, syllable, and especially double-syllable levels. I find time and again that when the foundation skills are drilled and mastered, it reduces the amount of time it takes for a sound to emerge consistently into conversation.  My biggest tip I can offer is to focus on the foundation skills with an emphasis on speed while maintaining accuracy.

I love sharing what I have learned.  My first website was thespeechpathway.com. I have neglected it, but it still contains some great information and ideas.  My current website, rapidspeechtherapy.com, focuses on helping parents learn how to maximize their efforts in working with their kids at home. The tools section has some great content for developing the /r/, /s/ and /th/ sounds.  Please share it, link to it, and help get it out there to anyone who you may feel would benefit from it.

How did you become interested in that specialty?  This is a bit of a story. In my first batch of clients, straight out of Graduate school, I inherited one who was a veteran of speech therapy. He was a grade eight student who had only an /r/ sound remaining. I was so impressed with this fellow because it appeared he had nearly achieved his /r/ sound. He could use it in sentences and monitored conversations during our sessions. I was ecstatic and wrote his parents about how well he was doing and that he was just about there.

Then it happened. I passed my client in the hall and overheard him speaking with his friends. What I heard shocked me.  He was speaking as if he had never been in speech therapy. All spoken /r/ sounds were in error. I had just written his parents a glowing note saying how well he is doing in conversation.  I am sure he was speaking the same way at home with his parents. I vowed to solve this. During our next session I paid extra attention to what was going on and found he was “pausing” before his /r/ targets and “emphasizing” his /r/ sounds.  My client was only able to produce his /r/ sound accurately when consciously attending to his speech. He had to do this to “override” his automatic way of speaking.

Ever since that time, I shifted my approach to facilitating automaticity of speech.  This is done through drills that focus on developing high repetition and speed. You have to get the individual in a zone where you are always pushing the speed of the productions while trying to hold on to the accuracy.  When the mistakes start to happen you just slow down and reconnect with the accuracy and then start pushing the speed again. It becomes a wonderful feedback loop that is easy to teach parents.

Where has that area of specialty taken you as an SLP?  I have a highly developed skill set for maximizing repetitions in clients in a way that does not frustrate the individual.  I have been successfully teaching parents and caregivers on how to perform these types of drills at home and it has been a great way to speed up the progress by sharing the workload.

Of all the things you learned in graduate school and in your externships, what stands out the most being most valuable to you now?  It was actually a cognitive psych course in my undergraduate degree that has the most impact.  It was a result of a paper I wrote on attention and automaticity. Speech is all about developing automaticity.  I have spent 19 years evolving how to do it more effectively.

If there was one thing you wished you learned before entering the field, what would it be? How to market myself better.  I love what I do but struggle to get clients at times. I am actually dedicating the next few months to really figuring this out and getting myself more visible.

How have you changed as an SLP over the span of your career?  I have worked virtually for the past 10 years.  The past two years I have worked exclusively part-time while traveling the world with my family.  We visited 28 countries and stayed last winter in Mexico, split between San Miguel de Allende and Playa del Carmen.  I am in love with the idea of being location-independent. Doing teletherapy while traveling has been a life highlight for me, but I would definitely do things differently going forward.  I would have the marketing automation in place to provide a more consistent stream of clients.   I am currently back in Canada and marketing automation is my current focus. I will definitely get this piece of the puzzle figured out, as I would love to travel again in the future.

My coolest moment as an SLP would be providing therapy sessions while at sea on Royal Caribbean’s “the Mariner of the Seas.”  That blew me away! I couldn’t believe I was able to do this. Their internet, called “Voom,” could handle my sessions as we sailed from Singapore to Shanghai.  How cool is that! Don’t try this on Norwegian Cruise lines. Their internet is terrible.

Check out my family’s travels at http://alittlebeyond.com.

 Have you received any awards or honors for your work?  One of my biggest honours was flying to Ethiopia in 2014 to offer a training bootcamp for a nonprofit there.  I met some amazing people that are really making a difference.  For instance, I met Zemi Yenus who is probably the most inspiring person I have ever met.  She is a woman who was told by professionals her child would never speak but refused to accept it.  She worked relentlessly with her child and others (starting the Joy school in 2002). Her persistence paid off and her son, Jojo, not only communicates verbally, but can read and count as well.  But here is the thing. He didn’t start putting words together until age 16. Her story is beyond inspiring.

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Well, Marcus, I’d say your story is quite inspiring, too!  Thank you for taking the time to participate in this interview.   To those reading this post, please be sure to check out the amazing resources offered by Marcus Little.  They just might change the way you approach articulation therapy.