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forgot to tell anyone about this post

8 Jun

I wrote a blog post for PrAACtical AAC on motivating adult clients to utilize AAC systems. You may read it here if you so desire:

AACtual Therapy: On Motivation and AAC

 

Enjoy! Let me know if you have questions or comments or ideas or suggestions or if you just want to see more pictures of Simon (he is ultra-cute.)

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Disconnect de comunicacion

3 Mar

Currently in my caseload, I am working with approximately 13 Spanish-speaking families. Communication at times can be very tricky – not between the child and I, but rather between parents and me! I have enough Spanish to interact with a toddler, and I can generally express myself to parents, but when they ask me a question or tell me a story – not a chance. My receptive Spanish skills are pretty limited (in classes when a Spanish professor asked me a question I was always a deer in the headlights.) Oftentimes I’m working with a child in a daycare, so I’ve never even met the parents, or spoken to them on the phone. In this case I leave a carryover note in Spanish, but I’m constantly using wordrerefence.com (they need an app) to look up phrases and words.

I don’t love the disconnect, and I never know what the parents have questions about or concerns until their service coordinator comes to me after months of therapy and says, “Oh Mom thinks they aren’t making progress” or “Dad is worried about XYZ” and then I have to do this crazy tango between the coordinator and the parents. Plus I have no idea about what suggestions or techniques are being carried over.

I do get an interpreter once a month, when I specifically request one, but that’s pretty useless when I’m in a daycare since I don’t need an interpreter to play. We have a receptionist at work who speaks Spanish, so I can potentially use her to call families though scheduling this with the receptionist and the working parents and my schedule isn’t necessarily going smoothly.  For one child I’m developing a communication notebook to stay in the daycare cubby so Mom can ask questions and let me know her concerns, or tell me what is working at home and what isn’t. But I have no idea if Mom will actually use it or if I’m just going to be writing note after note with no sign of life on the other side.

I’m wondering what other strategies clinicians are using for parents interaction. I’m sure this happens in the schools frequently. How do you find out what is going on at home? Have you learned any tricks for communicating when the parents aren’t sitting inches away from you every week?

Ayudeme!

OH and does anyone happen to know student-friendly Spanish musical artists? I have a client who is highly motivated by Latino tunes but I don’t wanna download the Latino equivalent of Lil Wayne by accident.

Clinical self-discovery. It’s okay!

21 Jan

Hey 2014, great to see ya!

It’s been two (TWO!) years since I started my internships and I’ve been thinking quite a bit on the narrowing of my clinical interests.

When I started my internships, I had no idea what I liked and didn’t like. I mean, I THOUGHT I knew (but we all know that’s silly…you have no clue until you get experience under that very cute belt you’re wearing.) I THOUGHT I wanted adult and hospitals. I THOUGHT I hated AAC (now we have a love-hate relationship.) I THOUGHT I wanted middle school students with diagnoses of ED/BD.

Hahaha. Thoughts.

I knew after my first internship that I loved working with the little children – you know, the weensy ones with the munchkin voices. I knew after my second internship that I did not want to focus on ED/BD. I knew after my third internship that hospitals are not my scene. Even after that, we still have quite an elaborate scope of practice to choose from.

So I got my first job and started my CF with a great, big, wide open caseload. Early intervention, bilingual early intervention, adult dysphagia, adult AAC and cognitive communicative therapy, peds feeding. Behavior, family coaching, communication strategies, group homes, ASL. Lions, tigers, and bears, OH MY!

When I started I was all, “Ohmygod I loooove it allllllll.” Now, a year and a half in, I’m seeing that I have clientele that I get excited about and things I look forward to and enjoy learning about. In turn, there are clinical things I don’t get super thrilled to death about. (Don’t get me wrong. I love all of my patients, but as far as clinical interests go there are things that I just professionally am more intrigued by.) (Was that a fragmented sentence?)(Sorry.) Since I would like to pursue the Ph.D. at some point, figuring out those clinical interests is a really important thing! I can’t stroll into a Ph.D. program and say, “Hey ya’ll – I like everything!” I need to find out what I love so that I won’t mind studying it for the rest of the foreseeable future.

So what do I enjoy? I love working with my Latino babies and families for language therapy. I love working with adults with developmental disabilities. I love adult dysphagia. I just wanna do those things all day.  Is there some communicative disorder where all three happen at once? Oh and I weirdly enjoy evaluations. Can’t really explain that one.

What do I sorta enjoy-ish? AAC. But not high-tech. I enjoy helping families use no-tech, low-tech strategies for targeting critical communication acts. (High-tech AAC makes me want to crawl in a hole. My brain rejects it. And the process for obtaining any device is the worst thing that ever happened. And it is just getting harder. And it is terrible. Run away!)

What am I unsure about? Peds feeding. It makes me so nervous. I don’t have a lot of practical experience and my book-knowledge is useless because it’s book-knowledge. Observation is an option, but frankly every child is so different there isn’t a ton I can take away from watching someone else do it. I’m learning as I go. Progress is slow (for me, not the kids.)

What am I pretty certain I don’t find particularly intriguing? High tech AAC! Adult acquired communicative-cognitive deficits pooooooooost-onset. School aged ANYTHING.

Part of me feels bad, about not loving it all. I have to remember that we ALL have clinical interests. That’s how we grow and develop specified skill sets. I can’t, mentally, love it all and I can’t know it all. I do truly enjoy interacting with and getting to know all of my clients. However, when faced with a puzzle, some situations get me all excited and riled up and I want to learn more. And I’m finding out what those exciting things are! Woo woo! Self-discovery!

And for your viewing pleasure, here is a picture of Simon snuggling with his own tail:

He is sooooo cute

He is sooooo cute

I don’t even know where to start.

20 Feb

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

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.

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

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

18 Oct

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.

SCENARIO

30 Sep

My friend and fellow CF texted me earlier with this clinical dilemma and I bet it’s something a lot of us are dealing with. And it takes the heat off me and MY biggest struggle.

SCENARIO!
Place: School setting
Delivery: Autism group therapy
Grades: Anything K-8
# in Group: Three to Four
Severity: The whole spectrum. Nonverbal. Low cognition. High functioning. All over the place.
Goals: Expressive Language. Receptive Language. Pragmatic. The gamut.
Current status: Kids who are verbal are more focused on pragmatic USE of language. Kids who are non verbal have access to picture exchange or verbal output devices but have received no training.
Frequency: One hour a week

The breakdown:
UH what the heck do I do? Overwhelming much? None of these kids are on the same page. I have one hour with them. How do I maximize my time? How do I make sure they’re all benefiting? My caseload is nutty bananas – I can’t give them individual services even though some of these kids need them and that’s all I want to do.

Ideas:
Ok. So say two kids are verbal and their goals are more pragmatic. And two are nonverbal and their goals are more expressive. Here’s what you need: a craft. Or snack time/cooking. But more appropriately a craft. A craft that for all parties is going to require asking for school tools, commenting, rejecting, choice making, identifying, following directions, affirming etc – critical communication skills (per the Pyramid people). So you could do a letter home maybe once a month. Letter home might be a good thing to try. And you could do holiday themed crafts. You’ll have to make sure the kids with AAC have the appropriate access to vocabulary for the tasks (paper, scissors, glue, colors, more, paint, markers, stickers – anything they’d need to complete the task). You’ll be doing a LOT of hand over hand.

You might try work contracts for kids with completion difficulties or behaviors. Work contracts are AWESOME – find out what motivates a kid – they get a sticker every time they do something compliant and when they get five they get their thing – sensory break, their fav toy, their stimmy behavior.

I would get all my tools for the task and I’d put them in a clear container. I’d pull out the ones they’d need step by step, but also pull out the wrong things too. If they need to glue, pull out glue and scissors. That way they have to identify and make a choice. Hold things up near your face to encourage eye contact. Or hold two of the same thing – like a blue marker and a red marker. Or keep things in the box so they have to ask you to open, or ask for more. When they’re done ask for specific things back so they have to follow simple directions. And just follow their lead, if they need a break or something let them have it and then bring them back to the task. Make sure the kids with AAC have a way to ask for a break.

I’m always thinking in terms of critical communication skills. What do these kids need to express? How can I manipulate the situation to reach that goal? Just like in early intervention, I find it easier to squash goals into an activity rather than planning an activity around goals.

If your seventh grader, high functioning students are going to hate this, make theirs more complicated. Change the task so it suits their goals, but so that they’re still participating in the “same” task. Because while its important that they don’t think its dumb you can’t spend your whole life trying to think of “cool” things for them to do – you’ve got an hour to address their goals. Maybe they can paint rather than glue or color. Or they can write a haiku about the day’s theme. Or talk about what they like about your unit theme, they could categorize and list, compare/contrast, make a language web. Maybe there is an app or a website about your theme. Talk to the science teacher or the language arts teacher and find out the units in the classroom.

Anyway boys and girls. This is just one idea, if you have more ideas for what to do with a REALLY varied group therapy session please share! We all know that this setup is not ideal, but it IS real life.

NP: The Weepies – Twilight

Planning early intervention sessions: should you even try?!

29 Sep

I got an email from Emily, a new CF and an EI therapist asking how I plan my sessions. It seems like good info to share. If you guys have ideas or things you do please share! I always love hearing new ideas:

“I’ll tell ya, I have NOT been doing lesson plans like I did in grad school. How can I? Right now I’ve got, 6 kids I see in the center and 7 that I see in their homes – plus adult and child evals. There’s not a chance to do lesson plans unless I want to work a zillion hours of overtime!

Here’s what I do: before a session I make sure I have a data sheet with my client’s goals written on them. I bring a bag of items into the home. One bag, for the whole day. Every kid gets the same bag (except sometimes I take out the doll or the barbie coloring books for the boys – more for the parents than for the kid.) (Also I wash the toys between sessions!) I alternate the items every week or two so I’m not using the same toys every week. Then I offer choices, “Hey Timmy, I brought a puzzle and a car” and then follow their lead. That way I know whatever we’re using – they’re motivated by it.

With 0-3 you really CAN’T plan – you have no idea what this kid is going to want or how long they’ll be interested. My supervisor says make yourself the toy, you are the spectacle, you need to be in the spotlight. I’m not so great at that yet – but I’m working on it!

I take what interests the kids and I fit their speech-lang goals into their interests. If I don’t have a toy that I can see an obvious way to slip in /m/ words I make that toy make robot /m/ sounds or car /m/. It is way easier to squash goals into an activity rather than hoping that a kid will want to play with the MMMMMonkey or the M-soup you brought. In grad school I would try to plan a WHOLE 50 minute session around the sound /p/ but I had the time and energy to do that. Now it just isn’t realistic. And how badly does a two year old need to say “peach” or some other crazy initial p-word?

And you’re right: targeting functional language is a great thing to do! More, give me, mine, all done, go, up, down, in, out, wow, hi, help, no, etc. I do it in every session and there is a lot of functional language that targets those early sounds (p, b, m, n, w, h) and then (t, d, g, k) (at least according to the GFTA).”

NP: KT Tunstall – The Other Side of the World

Dear Musical Artists,

12 Jul

(An Open Letter)

Dear Musical Artists,

Quit abusing your voice. Your money is your voice (Well for some of you…this is actually addressed to MUSICAL artists…not boobie artists or auto-tune artists).

Here’s a list of artists who have called off concerts because they’ve abused their voices and require vocal rest in the last few years:

Adele. Justin Bieber. Miranda Lambert. Cyndi Lauper. Tom Gossin. Florence Welch. Eric Church. John Mayer. Keith Urban. Ozzy Osbourne. Bjork. Maxwell. Celine Dion.

REALLY guys? Every time I turn on the radio somebody is cancelling a concert because they’ve beat the hell out of their vocal folds. Don’t you people have vocal coaches? Don’t you have people that love you?

Somebody needs to tell these artists that in their demanding profession they have to take CARE of their voice.

And that, is why speech-language pathologists exist.

Vocal hygiene is a major issue for ANYONE who uses their voice a lot – so ESPECIALLY legitimate singers and other people who are on stage and projecting night and day for weeks at a time.

Here are some tips for you doofs who make millions of dollars off your voice but take it for granted:

1. HYDRATE. Drink that water. Then drink more. And when you’re done drinking water, drink some more water. Use a humidifier at night.

2. SHUSH. Give your voice a break. And I mean don’t whisper, don’t laugh, don’t cough, don’t clear your throat. No noise should issue from your face. Balance the time you spend using your voice and the time you aren’t. Use some common sense.

3. Stay away from: dairy products, caffeine, alcohol, smoke, and meds that dry you out for cold or allergy.

4. Avoid one time abuse. All it takes is a really intense one time, “WOO WOO” at a concert or a sporting event and oh there ya go, POLYP. Seriously, your vocal folds can hemorrhage. It’s a thing.

5. If you notice any lack of voice, hoarseness, gravellyness, pain – any change in the voice, consult a doctor right away! Don’t wait a thousand years and try to push through and be the cool guy. Just go get it taken care of.

6. Breathe through your nosey. Noses humidify and help prevent crap in the air from irritating your vocal folds.

7. Quit competing. If there is a lot of background noise at a party and you’ve been on stage all night and talking all day, MAYBE give it a rest. Don’t scream over the noise to be heard.

There are also vocal warm ups you can do and exercises for the voice and neck. When you abuse your voice you can develop inflammation (laryngitis) which may go away on its own. But you can also get nodules, cysts, polyps, and other structural pathologies that hinder the vocal folds’ ability to come together and make your voice sound pretty which helps you get paid. So for goodness sake, knock it off with the abuse!

LOVE,

Sam

Attention! Therapy

3 Jun

I’ve been posting about specific things you could try in therapy for specific deficits, but I wanted to make a little disclaimer: It is very unlikely that you’ll encounter patients who just have issues in one of these areas. Patients post-stroke or BI are going to make ALL sorts of things going on, both mentally and physically. They might have any combination of deficits including but not limited to speech, expressive language, expressive language, pragmatics, memory, attention, fatigue  – you have to treat EVERYTHING…TOGETHER. You’re treating the whole person and all of their deficits. So when you’re reading these little blurbs about therapy ideas – try to imagine what it’d be like to treat expressive aphasia in someone who also has difficulty with selective attention, or treating someone who has comprehension issues and also memory deficits. We need to be very holistic and take SO MANY things into account.

That being said, after brain trauma many people have difficulty paying ATTENTION. They’re easily distracted, tangential, can’t filter, can’t focus on details. We learn about different kinds of attention and the types that I saw people having the most difficulty with were: selective attention, alternating attention, and a general complaint of boredom, fatigue, disinterest.

These are very typical issues post stroke or TBI. When I talk about selective attention I mean that the person can’t filter. They can’t focus on what I’m saying to them and NOT pay attention to the sounds in the hallway. Easily distracted by noises and visual information. They need training in what is relevant and not relevant information in reading and listening. When I talk about alternating attention, I mean that they have trouble bouncing between tasks. For example, right now I’m writing this blog and my mom is watching TV behind me. Every now and then I’ll stop and watch the TV or say something to my mom. When I’m done doing that I can come back to writing and I’m able to pick right back up where I’ve left off. In terms of boredom – you’ll often find patients will state that they feel foggy, they get zoned out, they just can’t focus.

What to do with this stuff? Well. Usually you want to start with removing distracting stimuli from the environment and then slowly incorporating it back into therapy. There are tasks such as APT which has levels to move up in attention capabilities. For selective attention, tasks that require someone to filter out information such as errors in spelling or text or locating something specific in the text like the word “the”. I always encourage my patients to approach this sort of task in steps. First scan and read the text. Then go back through and highlight what we’re looking for. Then check your work. If it’s an actual story they’re reading, it is very easy to get caught up in the actual story and not pay attention to the task at had. So giving them an opportunity to read it once for content is a way to reduce that phenomenon.

In alternating attention you may want to do a “switch” task. This is where you give the person three things to do and then make them switch between the tasks every few minutes. They’ll need to compensate by re-reading directions, marking places they’ve left off, and completing something before moving onto the next and not just abandoning a prompt in the middle. You might also give them something to do during a task, like count how many times they hear an overhead page or how many people walk by.

Don’t forget to TEACH how to do these tasks. Don’t just give someone three worksheets and then make them switch, or hand them an article and tell the to count the “the’s”. Train your patients for success. Scaffold. TREAT. You’re intervening!

When a patient tells me they can’t follow a conversation or get zoned out, I usually recommend we work on functional note taking. I had a patient who absolutely COULD NOT listen to her mother (haha) so we worked on taking notes during a conversation. Writing down the Who/What/When/Where/Why. I told her you don’t have to write down every single word that anyone says but at least try to jot down some simple key words so that (a) you’re actively listening and (b) you have a record of the conversation in case you can’t remember it later. Just like in school.

Like I’ve said before, this is not a be all end all of ideas, but just some things to consider or things to try. Every patient is going to be different and will require different supports.

NP: Brass in Pocket

Aphasia therapy

26 May

APHASIA!

If you’re working with adults you’re PROBABLY working on aphasia. There are maaany types of aphasia. If you use the WAB, which there is a good case you will, then you will give your patients any one of eight aphasia diagnoses (Broca’s, Wernicke’s, Transcortical Motor, Transcortical Sensory, Global, Isolation, Conduction, Anomic). Most aphasias  be classified as fluent (receptive) or non-fluent (expressive). And there are other aphasias out there like primary progressive, alexia, agraphia etc. AND the way you classify aphasia will depend on your “theory” of aphasia.

I say all of this, but really you won’t see “pure” aphasias often – I would say many are mixed. You’ll see patients with a variety of difficulties that manifest themselves in all sorts of exciting ways.

AND QUITE FRANKLY – sometimes the diagnosis is SORTA irrelevant. To me – I’m not treating a diagnosis. I’m treating the issue. Just because someone has Broca’s aphasia doesn’t necessarily mean that the treatments typically used for Broca’s aphasia will work for this patient.

So what do you do with these patients – who may have difficulty speaking, understanding, reading, writing, spelling and a plethora of other troublesome word related tasks?

I’ll try to narrow it down a bit.

The patients I saw MOST OFTEN were having difficulty with word finding. I’ve had one patient with global aphasia and one patient with Wernicke’s. My externship had a very cool “Evidence Based Aphasia Clinic” which analyzed the aphasic characteristics of patients enrolled in the clinic, and then looked at EVIDENCE BASED protocols for treating aphasias. WHICH IS SO SMART. Everyone should do this. Not just with aphasia. With all things. One day I’d like to have at least one legit journal article printed off that explains why I do what I do with each kind of disorder that I focus on.

Back to what I was saying – What do we do with these patients? With a global aphasia you’ll likely be trying to find some kind of multi-modality communication system that will be consistently and appropriately utilized in the patient’s life. These are tough patients but you’ll find a way to communicate. One of my most favorite patients had global aphasia. She was the sassiest.

Wernicke’s? Wernicke’s aphasia is really cool. There is a Treatment for Wernicke’s Aphasia which works, but is extremely tedious and exhausting for EVERYBODY. Be sure to break up your sessions if you attempt it. The idea is you put out six photos (of 12 photos total) of everyday photos and first – hand the patient a card with a word on it. The patient matches the word to the picture. The patient then reads the word or verbally identifies the picture. The patient then repeats the word after you. Then you ask the patient to identify the picture with just a verbal cue. There is no scaffolding or cueing, but obviously for training purposes and for success purposes you’ll want to cue and prompt as necessary at the beginning. When I find the source for this I’ll share it – I’m not sure where I hid it. You can also do Response Elaboration Training, Cloze Procedures, Melodic Intonation Therapy, and I’m sure a number of other procedures.

And the biggie – word finding. This is going to change with each patient. I really enjoy category naming and teaching HOW to do this efficiently. I think often we say to a patient “Name all of the animals you can!” and then they have a hard time and we write down how many they got and then we tell them to name some other things. THIS IS NOT GOOD THERAPY.

Teach, don’t test, people.

So some ways we can deal with naming and word finding is to do semantic mapping tasks and semantic feature analysis. You can TEACH patients how to categorize by really thinking about how our brain works. How is our brain organized? Do we just have a jumble of animals in our brain all willy nilly? If someone asked YOU to name as many animals as you could what would you do? I often tell patients to subcategorize. Tell me animals, but first tell me farm animals, then zoo, pets, woodland, ocean, flying, etc. Tell me vegetables but envision yourself at the grocery store. And also consider – are you asking the patient to name CONCRETE items or ABSTRACT? Example time. Concrete: Animals. Abstract: Red things. Our brain is not organized by color.

Other tasks for word finding: synonym and antonym generation. And not just ONE word. Tell the patient to think of THREE antonyms. This gives you a good idea of where they are as far as what is difficult and what sorts of scaffolding is required. Can you give a patient a FIM score without really pushing them and figuring out what is hard? (No.)

Unscrambling tasks. Idiom defining.  Homonym explanation. Word defining. Seriously – ask a patient with a word finding disorder to define the word “tree”. Try that one. I really recommend the WALC books and Cognitive Reorganization if you work with aphasia often.

Now, I’m going to do the last edit of my thesis because I’ve been…not doing it.

NP: Anna Begins – Counting Crows

PS – if you Google just the word “WALC” you get this website. Lolz.