What’s in my bag?

I’m sorry but I just have to say that writing about “my bag” makes me think of Austin Powers. (Warning: that link is NSFW).

Now that we’ve got that out of the way: my therapy bag. What is in it? How do I decide? As many of you know, I’m doing some home health for kids 0-3 (mostly in the two-three range). My car and home are filled with toys, but I abhor taking the same toys into homes every week – I get bored, the kids are bored, the parents are bored. It’s like “Yeah, we know, you knock the blocks down and say, ‘UH OH’ – message and vocabulary received.” I like to keep things fresh and exciting. However, I also have to be realistic regarding my time and energy, and the children’s…everything.

When I’m considering what toys are going into my bag, I have to think about my kids. Some kids are age-level in terms of play. They have strong fine motor skills, strong attention, strong cognition: everything is age appropriate with the exception of their language. The toys I take into these houses are a little more complex and require more imagination: baby dolls with food and cups and plates, Little People paraphernalia, high-level puzzles, high level books.

On the other hand, I have some kiddos who do not yet shake musical toys or bang two objects together. Some of my kids have rather limited attention. Some need a lot of sensory breaks. The toys I take into these houses are more cause-and-effect, texture-based,  noisy, etc.

As a result of all of these factors, I keep some good ol’ stand-bys in the trunk of my car. My employer has a few cabinets of “Community Materials” so those, combined with my own toys, give me enough material to change it up once a week. That doesn’t mean that kids don’t frequently play with the same toys, it just means that something new or something they haven’t seen in awhile gets thrown in the mix pretty regularly.

When I pack my bag to go into a house I try to ensure I have: one book, one fine motor oriented toy, one sensory-something, something with pieces for receptive language,   something for turn-taking and social games, and my phone so I have some language-apps as back up.  Some therapists may think this is a lot but frankly, my sessions are one hour long with two year olds. Five or six toys doesn’t seem like that much to me.

Toys from my personal collection that I have a lot of success with? I share them with you now:

BOOKS!

I like books that have manipulative features for the EI population.

 

Puzzles!

Think of the different skill sets required to complete each of these puzzles. Something as simple as taking a puzzle to a kid’s house takes a lot more thought than you would ever think.

Sensory!

Bean Box! I like these but holy smokes get ready for a mess.

 

This stuff is called “Gazz it” – it’s 99 cents at Walgreens and it’s a weird alternative if you’re sick of play-doh

 

Fine motor!

Kids love to bang on things.

Shape sorter ball is always a hit. Wooden stacker is a personal fave. And that other ball thing is just something different.

Social fun times

I just want to bang on my drum all day.
And shake shake shake. And pat. And tap. And clap. And imitate motor movement. And sing songs using baby signs. Yay!

Cause-and-effect

These poppers are always fun. For early players you can do a simple “POP” and for more advanced kids you can do some receptive “Who is in the trash can? Push the boat. Where’d he go?” prompts.

 

These are just some of my favorites right now, DEFINITELY not a be-all-end-all list. And as an FYI – I get nearly all of my toys at Goodwill. Don’t feel like you have to spend a fortune to get some nice materials. And if you don’t have a lot that is okay, my supervisor always says you should be more interesting than the toy. If you can get a kid engaged and playing with YOU then you are all good in the hood.

NP: Love Somebody – Maroon 5

The NSSLHA discount brain explosion!

I’m writing this because I was misinformed and I want to make sure new SLP students get the correct info!

When I was in undergrad, my CMDS program encouraged us to join NSSLHA – for the support, for the resources, and because of this great program: 2 years in NSSLHA and you get a discount for your first ASHA membership. It’s that simple! Join NSSLHA – it’s $60 a year and it is TOTALLY worth it. I joined (I think) my junior year and continued to renew my membership through my first year of grad school. By my second year of grad school I thought, “I got no money and I’ve met my ‘Two Years’ so it will be okay for my membership to lapse.”

Fast forward to my application for my CCCs: I call ASHA’s Action Center to get my NSSLHA number and was told to not expect my discount because too much time had elapsed between my last year in NSSLHA and my ASHA membership.

And I was like, “UHHH HUH? WHAT?”

As far as I knew – there was no expiration date on my two+ years in NSSLHA. No one ever mentioned that I basically had to be in NSSLHA at the time I graduated from grad school in order to get my discount. When I was in grad school no one ever even talked about NSSLHA – it was what the undergrads did. Right? Right.

HOWEVER, I was wrong! (As were a majority of my peers it turns out.) Everyone I’ve talked to thought you just had to be in NSSLHA for two years…at SOME point. After talking to an Exec NSSLHA member I was told that INDEED: you are SUPPOSED to be a NSSLHA member for the two years directly prior to applying for your CCCs!

Who knew?! Not me. I mean it says it directly on the website but I never even looked because why would I? Professors are never wrong! (Right? Hahaha.) (Also I’m not the brightest crayon in the box.)

So grad students – JOIN UP (like, yesterday). And grad schools – TELL YOUR STUDENTS. Encourage your students! Don’t just make NSSLHA about undergrads! This is important, yo.

And don’t forget about Gift to the Grad!

NP: Lisa Loeb – Stay

Learning about Deaf culture

I owe Liza a post!

To start at the beginning, I took “sign language” as an undergrad. It was pretty much a VERY BASIC sign course where we talked a little about grammar and Deaf culture and learned a lot of nouns. I never used it functionally and lost most of it pretty quickly. As of July I had retained toddler signs, and that was about it.  I’m currently enrolled in a legit ASL course taught by a Deaf woman and it’s bad ass. But still, I’m learning a lot and by no means think that I can “sign.”

Anyway, things got interesting as my caseload expanded and I started seeing adults for AAC. A majority of my adults have developmental disabilities and three of them are Deaf. They had sign language interpreters attend evaluations as well as therapy

Undergrad – What to look for!

Howdy. It’s four AM and I’m wiiiiiide awake. I went to bed weirdly early because I felt crappy and now here I am, blogging and answering emails because…what else is there to do? (Eat.)

I got an email from a high school junior (Melissa) this week, asking me what to look for in an undergraduate speech therapy program. (Which may be known as any number of things: communication disorders, communication sciences and disorders…who knows?)

GOOD QUESTION! Never really thought about it since I sort of…fell into my program. But if I was specifically looking for a program, I came up with some things that I really liked about my program (Or didn’t like…though there wasn’t much to dislike.)

1) Class size! My undergrad was teensy. We had about 30-40 girls in my program. And consider, that’s 30-40 girls that I saw every day. For four years. So depending on your personality a small class size or a big one might make more sense. To me, small was better than other state schools that had 60-100+ students in the comm dis program. I got to know the girls in my class, some of them are my best friends. But also, small means cliquey. Small means getting to know EVERYONE (even the people that make you INSANE. You may sit by your best friend for four years, but you may also sit by someone you want to judo chop for four years.) In a bigger program there’s more of a buffer.

Another benefit to a small class size is getting to know the professors more personally. These are people you’re going to be asking for references and recommendation letters in three years. If they don’t know you, your letters may be rather impersonal and vague. I got to know my professors, I’m friends with them on Facebook, I give them big hugs at state conferences. If your class size is humungous you’re going to have to work very hard to stand out.

Yuck. Can you image a class this big? No thanks!

2) Do they have a NSSLHA chapter? We had one at my undergrad but it was sort of…disorganized. It was affiliated, but involvement was rather willy nilly and professors didn’t really push you to be in it. If you were in it, it was likely just because you wanted it to be on your resume. We did community projects and that kind of thing intermittently. But some programs have really cool NSSLHA programs! They have a lot to offer students, they support students, and they push students to get involved early. NSSLHA is awesome too, because if you’re in it for …two consecutive years (?) you get a discount when you become a grown up ASHA member. Which is sweet. So yeah, ask about NSSLHA. If they don’t have one or it isn’t well-organized, and you really like the program, get in there quick and help organize it yourself! I’m pretty sure National NSSLHA has resources to help students put together their local chapter.

3) Can you be a clinician as an undergrad? This was one my most favorite things about my undergrad program and such a bragging point for me in grad school! I was a clinician as a senior. And as a junior I was an “assistant” clinician. It was awesome! I had clients! Three to be exact. It was so nice to go into grad school with clinical hours already and clinical experience under my belt. I felt so much more confident and secure than many of my peers. And God knows, I love feeling confident and secure.

4) How else can you get involved in your department? I knew as an undergrad that I needed to get in there, get to know the professors, get to know our department administrators. I wanted them to know my face, know my name, and to like me. So I worked for the department – I started working for our admin assistant shredding confidential papers 2 hours a morning, 3 days a week, for a whole summer. Then I moved up in the world and started working for our professor who was in charge of the alumni files, so I spent a lot of time filing, inputting data, sending out surveys, etc. Then I started working for another professor just doing her general bidding (seriously, one time I vacuumed bugs from under her desk. I also opened her mail for her. WHATEVER. I’LL DO IT.) I spent so much time in our department it was ridiculous. But guess what — they knew my name, they knew my face, they knew I was a hard worker. And I made some excellent friends/colleagues/mentors.

5) WHAT ELSE CAN YOU DO FOR THEM? My undergrad program had a lot of opportunities for research. Which is rare for an undergrad program so ask about it. As a junior I did research in a group setting – there was five or six of us. We picked a research project, put it all together with the guidance of a professor, and presented it at our university’s undergrad research conference. Then senior year my best friend and I did an independent research study, so the two of us picked a topic, did the project, and presented it at a local and state wide conference. It was awesome. And it gave me great experience for when I went to do my thesis in my Master’s program.

6) MELISSA! – I forgot something important: do they have an onsite clinic? Some schools don’t! And that means you have to go out in the world to do your 25 observation hours. Which might be good because it is more realistic. But it might also be super inconvenient. I honestly had ENOUGH going on as an undergrad without worrying about driving all over creation trying to do my observation hours.

7) @goldstein25 pointed out that undergrad programs don’t have to be accredited so I deleted this. But in its place I’m replacing it with this tid bit: if the school you’re looking at doesn’t have an undergrad SLP program, but you want to go to SLP grad school – you’ll have to “level“. Which means that you’ll have to take both the undergrad SLP courses as well as the grad courses. So you DEFINITELY want to find a university with a CMDS major for undergrads. Otherwise you might as well slap at least another year onto the 2 years for your Masters.

If anyone can think of anything else, please comment and share your ideas. This is just what my brain produced with minimal sleep.

NP: Brandi Carlile – Heart’s Content

Receptive Language….huh?

Once again I have to point out that during my time in the higher education system, I learned the definitions and the textbook information and other sorts of useless stuff, BUT I didn’t really learn quite how to specifically address disorders. When I got out in the world for internships and you know, MY JOB, that proved to be a problem since I do speech THERAPY.

What disorder do I speak of today? Receptive language delays and disorder.

As I had been taught, receptive language abilities and skills enable a child to understand the meaning of sound and spoken language.

Yeaaaah….so…..about that?

After a few weeks at my CF I finally asked my supervisor, “Um, so, this is really embarrassing but…if a kid has receptive language delay…what do you DO for that?”

She, luckily, is a kind and non-judgmental human and gave me some tips. Which I now pass onto you!

Make a word sandwich: Say it, Show it, SAY IT

Use a slow speech rate

Exaggerate key words and speech sounds

Support comprehension with signs, touch, vision, music and any other modalities/senses

Use simple language, give plenty of repetition and experience with new words

Model response expected then repeat the direction

Give visual cues when giving directions

And the part that I’m bad at: reduce cues to assess comprehension

How can someone be bad at that? It’s my natural inclination to point, or repeat myself WAY too many times. My supervisor and I were watching a video of me doing therapy last week and Lord Almighty if I told that kid to “Get the cup”  one more time he probably would have punched me.

I need to improve my scaffolding. To say the least. My supervisor gave me a way to kind of…think about what I’m doing.

Step One: Give child direction “Get the cup!”

If child does not respond, Step Two: Repeat yourself and give them an extended period of time to respond.

If child does not respond, Step Three: Point to the cup and say “Get the cup!”

If child does not respond, Step Four: Hand over hand, help the child get the cup, and say “You got the cup!”

Also consider things like, is the child doing something else when you prompt him? We noticed that I was telling my kiddo to get the cup while he was pretty focused on cleaning up. It would have been more beneficial for me to wait for him to finish what he was doing, then prompt him.

And don’t prompt the child to do something that hasn’t been the focus of play or isn’t in his line of vision (unless you’re testing object permanence which why would you be doing that? Get back in your scope!) I’ve been known to do this when trying to do the PLS (it’s all, “Get the child to identify a duck” and I’m like “Crap where is the duck? ‘Find the duck!‘” and the duck is over on the table behind a book and the kid is doing a puzzle or blowing bubbles.)

Also be thinking, is the child not responding to me because of a processing issue or because he doesn’t understand the language?

Hopefully since I just shared this with you, it will stick in my brain a little better. And Liza – I’ll write about Deaf culture after my ASL course on Thursday because that’s our last day talking about culture specifically!

NP: The Lumineers – Stubborn Love

 

I don’t even know where to start.

It has been a really, really long time. SO LONG. MONTHS. I wish I had a valid excuse but basically it is cold and I’m sleepy and I’m busy and I don’t wanna go to the library to blog. I’ve had so many things to share, and I can’t even begin to pick a topic. I think the last thing I blogged about was CFs and swallowing therapy and how I suck at dealing with behaviors. I still suck at dealing with behaviors. I’m working on it OKAY?!

But I’ve been doing so many new things and meeting so many people and I learn something new every day. I think my most challenging area since my last blog has been AAC! Oh yeah my friends. Can I just tell you – in grad school and undergrad I was all, “UGGGGH AAC.” Now I eat-sleep-breathe AAC. And I enjoy it! It still scares me and confuses me and and overwhelms me and I’m still learning an INCREDIBLE amount. It seems so daunting! AAC is changing every day and that stresses me out – how am I supposed to stay on top of it? How can I make sure my clients have the best system for them when I might discharge them and find out about a new system the next day? I DON’T LIKE THAT.

So currently, my caseload is right around 30 plus evals. Which feels kinda crazy-pants some weeks, so I feel really bad for people in schools and hospitals who have more than that. Don’t forget, my friends: ASHA says no more than 40 but I know you all are doing way more than 40. Average is 50ish. Max is 110ish. SCARY.

Anyway, so about half my caseload is adults. I see two adults with acquired disabilities, and the rest have developmental disabilities. I’m not seeing anyone for swallowing currently, and I see one adult for cognitive-communicative tx, and the REST are AAC. So I’m seeing like 12 adults for AAC. It is a LOT of work. My adult clients require way more planning than my kiddos. The kids are challenging, but in a very different way. I’m doing some AAC with a couple of my kiddos but it isn’t the ONLY thing we’re working on. Basically my desk looks like the birthplace of AAC on most days:

DESK EXPLOSION

So what am I doing with these clients? Some I’m working on developing low-tech communication books and wallets. So far I’ve successfully created two functional and effective communication books for clients who use ASL, but have difficulty communicating with hearing individuals (specifically group home staff and workshop employees.) I’m learning a lot about interacting with the Deaf community, and I’m taking a sign language course right now. It’s…interesting. We’ll get there one day once I catch up on this blogging business.

A couple of clients I’m helping to obtain high-tech speech generating devices for. One client my goal is a Dynavox Maestro, the other a NovaChat7. I’m also trialing a Springboard Lite with a client.

Some clients I’m going more mid-tech with – Go Talk 20, 7 Level Communicator, Three Message Platform Communicator etc.

Some devices I’ve trialed include: Dynavox Xpress, Dynavox V+, Dynavox DV4, NovaChat7, Springboard Lite, Alt Chat, Tobii C12, ProxTalker, Go Talk 4, Go Talk 20, 7 Level Communicator, One Message Communicator, Three Message Platform, Four Message Communicator. The DV4 isn’t made anymore, but we have one in a cabinet and I like using it during evaluations because it has a large screen and “exploratory” pages that assist in evaluating category skills, access skills, identification skills etc. Someone today referred to it as a dinosaur, but I think this ol’ dinosaur still has a place.

communicative dinosaur. I’ve seen older.

Also of course, I’ve been working with the iPad and apps. I don’t LOVE the iPad the way everyone else does. Don’t get me wrong: it is awesome and there’s so many things that can be done with it in therapy and in terms of using it for a communication device. My main beef with it is that damn 60 minutes piece that focused on its use with people with autism. I think just about every person I see for AAC has asked if they can get an iPad. I’m like:

WELL, you certainly CAN but I can’t promise that insurance will pay for it or any apps on it (probably not). And I also can’t promise that using it will be successful or that it will be appropriate for the person using it. The iPad IS NOT a be all end all.

I’ve also been downloading free AAC apps for my Android phone and there are SO MANY. I think I want to start reviewing them and sharing what I think here on my blog. So get excited for that. I think it is a great idea especially for home-health therapists to be able to just pull out their phone and try an AAC app with a client.

You may be wondering how I get my hands on all this good stuff.  First of all, my workplace has an AWESOME Resource Center that has SO MANY AAC and AT products. It’s great. I just be-bop down there about a million times a week and borrow devices. Also, I utilize DATI a LOT.  In fact I’m on their wait list right now to borrow a Dynavox Maestro. DATI is a life-saver! They’re so incredibly knowledgeable and helpful. LOVE. And of course, if I need to I can always contact companies directly and ask them if they know of a device I can borrow in the area (I tweeted at Saltillo and they were so helpful in my hunt for a NovaChat. Thanks Cara at Saltillo!) I think I’m pretty in what is available to me.

I think one of the more frustrating things about AAC is actually GETTING a device. The process is so long. I wrote up an explanation for families for the steps it will take to get a device. I found that families were coming to the evaluation and expecting that their loved one would have a device by the next time I saw them. And while I don’t want to discourage anyone from coming to therapy to get a device, I also don’t want them to be surprised if it takes a long long lonnnnng time.

My letter to families and caregivers

I think overall, the learning curve for AAC is a little intense, but I’m getting there. I tell people that I’m learning just like they are and that it is definitely a trial-and-error process. If you have any questions, ideas, suggestions, stories – WHATEVER – about AAC, please share!

PS – I’m obsessed with the NovaChat7. OBSESSED.

addendum: my biggest struggle

I wrote post a few weeks ago about my difficulties with children who displayed elopement behaviors in my speech therapy sessions.

A lot of therapists shared a lot of great ideas with me! At that time I had seen a child I was having a good deal of trouble with about four times. I’ve seen him three times since then and I wanted to give a little update.

My supervisor came to observe me at that fourth session (which went horribly), and she came to observe me today, and she said there was a NOTABLE difference. So what happened?

First, I rearranged the setup to reduce the chance of him escaping. (Basically I cornered him.) Secondly, I offered him choices so I could better follow his lead (i.e. – “Do you want crayons or cars?”) Thirdly, I worked really hard at allowing his siblings to be a part of the play rather than trying to prevent them from wanting novel toys. This also allowed me to see what happened when my client had to take turns or share (not pretty.) Not going to lie, the first few sessions after that post were a LIIIIIITTLE wild. A lot of tantrums, a little aggression, and more elopement. But I had to create routine.

When I saw an increase in behaviors I got a chance to do some functional behavior assessment. Turn taking and sharing lead to the aggressive behaviors (pushing, hitting) and tantrums. I saw the elopement during transition between toys and tasks, and when he was told no, or that he had to wait (especially in regards to turning on the TV.)

So, to decrease the aggression and tantrums, I really encouraged mom to make turn taking and sharing a major part of play and home routine. If he only has to share once a week of course he’s going to be upset. It needed to be established that this was an expected behavior.

In terms of elopement I had to improve my transitioning. I realized what I was doing was letting him play with a toy, then saying “ALL DONE” and putting it away. That means all of the sudden his object of desire has been removed and he’s got nothing new to entertain him – OF COURSE he’s gonna run! So now I preface the transition “In a minute new toy. Soon it’s time to clean up.” Etc and I bring out the new toy before I take away the old one.

Also I’m increasing my affect, I’m working REALLY hard at taking center stage, and trying to make kids WANT to pay attention to me. It feels really stupid sometimes but that’s what these kids need! You need to be better than the toy they have.

Another factor in this kiddo’s behavior SEEMS to be sensory related. I noticed when he was eloping he was crashing, jumping, throwing himself around – more so than your average 2 year old boy. He’s a rough player. I spoke to one of our OTs and she gave me the run down on sensory processing and integration and he seemed to fit the profile. So the last few sessions I’ve been LETTING him take some sensory breaks, and I’ve been providing some sensory input. Deep pressure, squishes, squeezes etc. At first he did NOT like it and resisted, but today he allowed it for a few minutes and seemed to be seeking continuation of the deep pressure.

What it is really coming down to following the child’s lead and PLAYING. Watch behaviors and do your ABCs (antecedent, behavior, consequence.) Make changes as needed. Really look at what you’re doing and analyze how the kid is reacting to your actions. There is a reason for behaviors, you can figure it out!

NP: Mumford and Sons – I Will Wait

PS – when it comes to the TV, sometimes I let him turn it on and I’ll kind of narrate what he sees for a minute. Then I transition him back to play. If he continuously tries to turn it on I have to say “I’m sorry, not TV time” and prevent him from turning it on. Sometimes he’s okay with that and sometimes he does NOT like that and I see some elopement or tantrums, but I just say “I’m so sorry that you’re angry – let’s do XYZ.” He recovers either way. I play it by ear and how easy he is to redirect that day. The TV is a hard one when you’re in people’s homes, but it is OKAY to ask to turn it off or lower the volume.

PPS – I did all of the above in SPANISH. Booyeah.

Unlocked

So I’m interacting with some folks over at DATI regarding a device for one of my patients. My buddy over there who I’ve been chit-chatting up, referred to a device as “unlocked” earlier and I asked for an explanation. It was a pretty solid explanation so I thought I’d share:

“Well, all devices are computers. Maestro, Vantage Lite, AltChat. Every single one is a computer AND a dedicated device. It is dedicated to only run the communication program the company chooses for it. It would be like if you got an iPad that only had P2G or TouchChat on it. Since they only run the one program and nothing else, no YouTube or solitaire or anything like that, they are only capable of running the communication program, Medicare, Medicaid, and private insurance are typically cool with paying for them. If it was just an open system, they would not because you could use the system for much more than just communication.

So all of these dedicated systems that can be covered by insurance can be unlocked, meaning, the maker (DynaVox, PRC, Saltillo) can change the programming so that in addition to the communication software, the device can have full function like the computer it is. DynaVox charges like $55 to unlock devices, not sure how much PRC charges, and I’m sure Saltillo is also under $100. Typically, a family gets insurance to pay for the dedicated device and then the family or school will pay the “unlock fee” and then everyone’s happy.

Ya follow?”

Yeah. I follow. Sassypants.

The CF

Okay I was GOING to blog about AAC assessment and device trialing but I am doing my first days of device trialing this week and I figure I should wait until that actually happens to have an opinion on it. (Don’t worry though – I already have opinions.)

The Clinical Fellowship. The ol’ CF. Ye olde CFY. (It isn’t a year anymore I HATE when people call it the CFY now. IT ISN’T A CFY STOP THAT STOP IT RIGHT NOW.) (STOP IT.)

What’s the deal with the CF? According to ASHA:

The Clinical Fellowship (CF) is a transition between being a student and being an independent provider of clinical services that involves a mentored professional experience after the completion of academic course work and clinical practicum.

Purpose of the Clinical Fellowship

• Integration and application of the theoretical knowledge from academic training
• Evaluation of strengths and identification of limitations
• Development and refinement of clinical skills consistent with the Scope of Practice
• Advancement from constant supervision to independent practitioner

It is 36 weeks of full-time clinical practice. You get paid don’t panic. It isn’t a continuation of an internship. You’re expected to do real work and you’re the SLP. You just don’t have your CCCs yet because probably you’re a screw up. Don’t worry – we all are. As my mom says, “YOUR PROFESSION HAS A CF FOR A REASON.” (And I’m all, “Yeaaah Mom but like, I like being perfect at everythiiiiiing.”)

What do you have to DO for a CF? Here, read this:

Clinical Fellowship Requirements

• 36 weeks of full-time (35 hours per week) experience (or the equivalent part-time experience), totaling a minimum of 1260 hours. Part-time work can be completed, as long as the CF works more than 5 hours per week. Working more than 35 hours per week will not shorten the minimum requirement of 36 weeks.
• Mentoring by an individual holding ASHA certification in speech-language pathology. It is the responsibility of the Clinical Fellow to verify certification of the mentoring SLP, and can do so by contacting the ASHA Action Center to verify at 1-800-498-2071.
• A score of “3″ or better on the core skills in the final segment of the experience, as rated by SLPCF Mentor using the SLP Clinical Fellowship Skills Inventory form.
• 80% of time must be spent in direct clinical contact (assessment/diagnosis/evaluation, screening, treatment, report writing, family/client consultation, and/or counseling) related to the management of disordered that fit within the ASHA Speech and Language Pathology Scope of Practice.
• Submission of an approvable CF Report and Rating Form.

I actually filled out my own rating scale the other day of how I think I’m doing. I mostly gave myself 3s and 4s. November 15th is the last day of Segment 1 for me and then my supervisor and I will compare and discuss.

Something you’ll also note on the CF Rating Form is:

A full-time SLPCF consists of a minimum of 35 hours worked per week and equals 1,260 hours throughout the 36-week SLPCF. The SLPCF must consist of at least 36 mentoring activities, including 18 hours of on-site direct client contact observations and 18 other monitoring activities.

Ew.

That equals 6 hours of direct supervision and 6 hours of “mentoring” per segment. THAT’S A LOT OF BONDING TIME. Sheesh ASHA, you’re killin’ me.

Overall I think the CF is going pretty well – I love my supervisors and I have wonderful support at my facility. I think for a CF it is SO important to have support – you NEED other SLPs, you SHOULD HAVE an onsite supervisor who you see regularly. A few jobs I interviewed for would have supervisors for me in other buildings, or I’d be doing only home health and wouldn’t really have a home base. It would have been a mistake for me to take one of those positions. I have a sounding board, I have people to observe, people to bounce ideas off, people to share/commiserate with.  I do group therapy twice a week where I get to see PTs, OTs, and Early Childhood Educators in action. My supervisor and I meet every Friday. There are SIX other SLPs for me to talk to and they’re such amazing resources. If you’re considering somewhere for your CF – please consider the support system your facility will have in place for you, it’s incredibly important.

Shoot me questions! I’m happy to help.

NP: Lee Brice – Hard to Love

The Visual Swallow Study

As previously stated, I’ve been doing a LOT of visual swallow studies. Mostly with group home residents who have developmental disabilities.

What am I doing exactly? I don’t have access to FEES or MBS, so I’m basically doing a bedside evaluation. The outcome of which is USUALLY: refer for a FEES or MBS, refer for skilled speech language services to train in safe swallow strategies, diet modification, meal time modification, or no changes!

So here’s how it goes:

1. I generally start with an oral motor examination. This tends to be slightly difficult because this population of older adults (usually 50-60ish) with developmental disabilities didn’t HAVE access to early intervention – and in some cases any intervention at all. So the cognitive skills, the ability to follow simple one step directions with verbal, visual, and tactile cues: not really present. Sometimes they are able to imitate me and in some cases they are able to follow directions (but not always – I don’t count on it.) So at the least I try to get in and check out dentition and structure (size of tongue in relation to oral cavity, lip seal, tone etc.) It’s important to note whether the patient is able to follow directions because this is going to be a major factor in whether I think they’d benefit from skilled speech therapy services focusing on compensatory manuevers.

2. I check out language skills. As with the cognition – a lot of my patients don’t have strong receptive or expressive language. I want to be able to say in my report what their language is like, how do they communicate.

3. I chat with caregivers while the patient is eating. I want to know: Where do they eat their meals? What diet are they on? What kind of supervision do they receive? Have they had previous swallow studies? Previous swallow difficulties? Do they have special tools for eating? (Divided plate, cutlery with handles) Do they avoid giving this person any types of food and why? Is how they’re eating today comparable to their normal habits? What kind of prompts are given to this person and what is their response? Have they seen any signs/symptoms of aspirations/penetration?

Also in the group homes in Delaware the patients are given a “Choking Risk Assessment” – I like to get a copy of that report as well as their most recent nursing assessment. Often times what the nursing assessment says about the person’s diet is different than what the caregivers report and that is important to know.

4. While I’m chatting I’m also checking out the person eating their lunch. I note all foods and drinks trialed and response. Rate, signs/symptoms of asp/penetration, time to initiate swallow, prompts required and response to prompts, peri and inter oral residues, laryngeal excursion. Do they talk while they eat? How is their voice? How is respiration? Rotary chew? Tongue thrust/delayed swallow pattern?

5. Then if I see anything that concerns me, I try out some strategies. If they have the cognition I may try a superglottic swallow, chin tuck, head turn – whatever I think would work best. I might try to encourage small sips, small bites, alternating bites and sips. Here I also check comprehension – do they have a concept of “small” or “slow”? Or are we just saying “Small bites!” over and over to no avail? I’ll try out some different prompting strategies and see how they respond. I may try breaking their meals into smaller portions or bites.

6. I summarize my findings and discuss with caregiver. Generally I provide them with an outline of the National Dysphagia Diet (circling the one I recommend), a list of typical swallow function in older adults,  and I may give them something to try out like a visual pacer they could laminate.

7. I write!

Now, I have about an hour for an actual evaluation and it pretty much takes that entire time. Honestly the most common dysphagia I see with this population is RAPID stuffing of food and gulping of liquids. Very impulsive and highly motivated by food. I have never in my life seen this before so the first time it was a REAL SHOCKER. I try to avoid diet modifications because I think diet has a major effect on quality of life, but I will do it for the safety of the person. Usually with the rapid stuffing I recommended 1:1 supervision, with consistent prompts to slow, wait, stop, chew, etc. I also recommend that meals be presented in portions – just a little at a time! Liquids included! They don’t need their entire meal at once. And often cutting food into small bite sized pieces helps slow them down a little.

I’m really enjoying these evaluations so if you have any questions please feel free to ask! Or give me ideas! I love ideas!