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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


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

I adore fluency therapy

26 Sep

This semester I have a fluency client. I am LOVING it and I thought I’d share some of what is working and what isn’t with you.

Let me preface this by saying my client is a teenager and getting them to do ANYTHING is a chore but I love being able to say “Nanny nanny naaaanny” when something works that they didn’t want to do because it was “stupid” or embarrassing.

Okay so we start our sessions with some facilitating techniques – systemic relaxation, rote speech (ABCs, 123s), and discussing techniques we’re going to use. This kind of gets the ball rolling on the “feeling” of fluency. If your client can do something fluently, start the session with it. That way you’re getting a kind of errorless learning – the client can be successful right away and if they can’t do something you can always take a few steps backwards.

My goals for the semester are to establish fluency in structured speech tasks but my client has already surpassed that so I’m going to have to start working on fluency in connected speech/conversation.

Anyway, so I use word lists for one word, two word, three word, four word phrases and then sentences. Usually I use those right after we do rote speech tasks to keep up the fluent speech. We quickly practice the techniques we’ve seen success with on these word lists (thoracic breathing, reduced rate, low pitch, easy onset). Then we read an article from Missouri Conservationist for Kids, and I parse the article before the session so I know how many syllables my client will be reading (makes for easier tracking later). Each paragraph we read we use a different technique and record it so that my client can listen to them and count the stuttering moments for themself (not a word but I don’t want to say he or she).

The techniques we use: first we use DAF – not because it is a technique but because my client thinks it is cool and I use it as a reward. Also, my client does BETTER with fluency when using targeted techniques so I can say “Hey you know what – DAF is cool but you got this on your own, you can physically be fluent without any technology.” I think with teenagers who stutter this is a big deal – it’d be soooo nice to just have some earbuds in that look like an iPod that would make them fluent, but it doesn’t work that way, and even if it did – they can do better without them.

Then we read with thoracic breathing and practice inspiratory checking and conversational breathing. This is a hard one to monitor but I’ve seen a lot of progress with some coaching prior to speech acts.

Usually then we work on reducing rate. To reduce rate I taped a tongue depressor to the table and the client is prompted to read each word but not finish the word before finishing running his hand over the length of the depressor. Now we’re working on staying slow without the tactile cue (usually there’s a lot of me making  crazy “slow down” hand motions). Reducing rate has a HUGE effect on my client’s fluency – which is likely why the DAF works.

To target disfluent moments, we do easy onset and cancellation. My client really seems to hate easy onset, but it works. If you’re working with a teenager, expect a lot of ‘splainin – they want to know what they’re doing, why they’re doing it, and when they can leave. At least once a session I have to say “This isn’t something you would do in real life, I just want you to feel control over your speech.” Sometimes we’ll do things like negative practice or speaking at a ridiculously low pitch and my client HATES it but, it works (that’s when the “nanny nannying” comes in).

If you’re working with a teen, be relaxed and really make them feel like this is a team effort. Being different is not cool, so make sure they know they aren’t alone. Before you make them do something, do it yourself! At least then if they think what they’re doing is stupid they’ll feel like you both look stupid rather than them looking stupid alone.

If anyone has any tips for working on stuttering at the connected speech level please let me know! I’ve noticed with my client that when reading or speaking at a reduced rate, the naturalness of speech goes out the window. It becomes very robotic, but when prompted to add intonation to a reduced rate the dysfluency comes right back. We do a lot of modeling right now, any input is appreciated.

NP: The Rascals – Good Lovin



21 Sep

Hey guys,

I’m watching this video to prepare for a presentation and I think it is really interesting so I thought I’d share:

PROMPT can be used for phono, artic, CAS, AOS, fluency, ASD, dysarthria, HI, DD, aphasia, foreign language – so it is definitely worth taking a look-see!

I hope everyone has noted and appreciated my new skill: embedding video directly into my post. Why did this take me so long to figure out? I have no clue.


I like to move it move it

9 Sep

I was just reading a post on ASHAsphere about ASD and gymnastics and dontcha know – it got me to thinkin’.

I think therapy and movement should go hand-in-hand as much as possible – not only for kids on the spectrum but for kids with all sorts of disorders. Children are active by nature and they learn through exploration. You can’t stick a kid at a table and tell them to make the /s/ sound. There needs to be more and I’ve found that by utilizing the whole body I see better results.

When I say the “whole body” I really mean it. In a university clinic setting you’re often in teensy rooms full of other furniture and equipment, but that doesn’t mean you have to sit in tiny chairs with both feet on the floor. Implementing a wide variety of sensory input during therapy can make a world of difference. Using gestures and tactile cues is more intuitive and natural than you might think.

I discovered that this sort of whole-body cueing and feedback works really well with children with apraxia of speech, but it also works well with kids who have less involved developmental speech disorders as well. It is so easy to add a visual component to a model of a sound – think of how you might “act out” a /p/ or a /k/. Beside verbally telling a child how to make a /n/ and showing them in a mirror, what kind of visual cue might be appropriate? What works for each kid is different but what is often the same is that they want and need to MOVE. Make that natural desire work to your advantage. Clap or jump on stops, move your hands like a fricative, SHOW them plosion. And make them do it with you. Not only can this be fun but it adds that extra sensory-kinesthetic-proprioceptive feedback. Instead of using movement as a reward, implement it right into the actual teaching and then you’re not wasting therapy time shooting hoops every time little Timmy says his /r/ accurately. Plus it doesn’t really hurt anything so why not?

Get those kiddos up and out of their seats. They are ninos! They need to release their wiggles. (Oh but seriously I’ve have kids fall down and crash into things so, uh, be careful)

This seems appropriate

NP: Natasha Bedingfield – Strip Me


how much scope is too much scope?

6 Sep

As you may have noticed, I’m in my course on dysphagia this semester. Dysphagia interests me greatly but I have to admit that part of me thinks, “Is this really what I signed up to do?”

I took on speech path as a major because speech and language interest me. I’ve taken a lot of classes on linguistics, communication, the English language, and obviously – communicative disorders. I absolutely adore therapy, especially that of early childhood artic/phono and adult cognition. For the most part I always envisioned myself in a long term acute setting or a SNF, though lately I have more and more considered ECSE as a potential path.

Previously, when I thought of myself working with adults I imagined speech and language therapy with dysarthria, apraxia, aphasia, executive functioning, cognitive-communicative skills, and the like. However, as I’ve gotten further into my graduate school program and talked more with people who work in the settings I always wanted I’ve noticed that they all say the same thing.

“A major part of my caseload is dysphagia.”

As I said before, I find dysphagia fascinating, but sometimes I don’t fully understand why I would be doing it. I get the logic – the aerodigestive tract is also the vocal tract and as SLPs we know about all of those muscles and structures and functions and so on and so forth.

But. I’m a speech. and language. pathologist. Even that name we’ve discussed in class as questionable at best because we aren’t just pathologists, we’re also therapists. So a better title might be speech-language clinician.  Or should we be called Speech-Language-Swallowing Clinicians? (That’s another post for another day. The semantics of our field is enough to make a person crazy.)

Dysphagia is scary. Trachs. Vents. Scary. I know I can do it – it isn’t a matter of possessing the skill set. I can do whatever I need to do, I’m a big girl. I have to wonder though, are there other people in other fields more qualified to deal with something that could be life threatening like a dysphagia? There are nurses, doctors, dieticians, ENTs, dentists, respiratory therapists – the list goes on. Obviously all of these professionals are on a team with us and we’re working towards the same goal but are we the best for the job? Are we stepping on toes? Who had dysphagia before we did?

Why is there not a specialty certificate for SLPs working with dysphagia? I feel this is such a specialized area of our field that there should be more specialized training than just a class. Don’t get me wrong – the clinicians that work with dysphagia know their stuff. They aren’t messing around, but most of their training is experience based rather than classroom or clinic based. We don’t go to externship sites with any REAL dysphagia work. Perhaps this is a case where an elective clinical doctorate might be more practical – it could provide more coursework, more clinical experience, and more specialized training for people wanting to go in the medical direction.

A professor I had once referred to the “tentacles” of ASHA – reaching out and grabbing up things like dysphagia. I don’t know that I agree or disagree with that, but with the seriousness of disorders relating to dyphagia I think it is an important conversation to have with colleagues, and with ourselves. How much is too much? When is it time to demand further education for our expanding medical scope? Can we hold our client’s welfare paramount in the case of dysphagia without more knowledge?

You can read more about the role of the SLP in dysphagia HERE! And share your opinion, I’d love to hear from people who are out there! I’m just a baby-child so my real world experience is limited.


check-check-check it out

15 Jun

I decided for my first session with my kiddo with hypernasality I’m going to do a bit of an anatomy lesson with him and this is what I’ve created:

(Don’t judge my drawing.)

I just think kids are smarter than we give them credit for. They’re going to respond better if they understand the rationale. So if I can teach mine that the power for speech comes from the lungs, and the more power you use, the more accurate you’re going to be – then great. They need to understand the physiology and mechanism just as much as we do because we’re asking them to do it. Plus when they have a visual like this you can add things like gestures and cues.

Also, trying to get our game together for ASHAAAAA! Maybe staying in a hostel??? Should be exciting



14 Jun

Starting this Thursday with my new clients. One has mild hypernasality.

Where do I even start with that?

With a brother who has hypernasality I feel like I should sort of know what I’m doing, but frankly I just don’t! It’s not like I can say “okay kid, just you know, move your velum up.”

Doing a little ASHA journal research this morning but there is very little in the way of telling me how to teach someone to speak without nasality. Some are super old and suggest using NSOMEs and we know all about that.

So then what?

We don’t have any technology tools beside the See-Scape (which is rather gross) to give clients feedback. The best “holistic” treatment approaches seem to be along the LSVT-line of things – increasing effort, increasing volume, increasing articulatory precision. So I’m going to make this kid yell at me for eight weeks? Sounds like a great time.

I think I might draw/create a visual something-or-other depicting the naso-pharynx and what the kiddo is doing and what needs to be happening. Probably will be employing a lot of mirrors,  and tactile, kinesthetic feedback. I wonder if I could make a gigantic bite block to facilitate an open mouth while speaking? ‘

OOO I just found a good journal article on behavioral hypernasality treatment.

Anyway, if anyone has any suggestions, throw ’em my way because I don’t wanna waste this kid’s summer experimenting.

NP – Sia Breathe Me



decisions decisions

20 May

I was chatting with an SLP gal pal of mine today (who is super smart and happens to attend Gallaudet – kill me now please) and discussing the vast array of options we have in our professional lives.

Everytime we take a class, go to a conference, talk with a colleague – we are literally PLAGUED by this constantly growing, every changing field and the opportunities it presents to us.

First you’ve got environment to deal with.

There’s schools. But not just schools. You’ve got First Steps, Headstart, and Early Childhood Education Centers. You’ve got elementary, middle school, and highschool. Then you’ve got special school districts to contend with. Oh, and you could likely work for private schools as well. No big deal.

Then you’ve got the hospital setting. Do you want to do rehab? Acute care? Long term acute care? Skilled nursing? Long term/nursing home? Home care? NICU? Outpatient? Polytrauma/VA? Pediatrics/Children?

Don’t forget that you could just work for any private rehab company, you could have a private practice, you could outsource yourself, you could do telepractice, you could work in a university clinic, you could work for uniformed services, public health agencies, or even be a consultant for private companies.

OR you could teach, be a professor, do research, be a speech-hearing scientist. You can go get your Ph.D!

So that’s all fine and dandy. But then you gotta think in terms of population.

Do you want to work with babies, toddlers, preschoolers, school-age kids? Do you want to work with children who only have speech and language issues? Or do you want to work with children with special needs/multiple disabilities? How about middle-schoolers, high-schoolers? Maybe you’d prefer working with adults. Do you want to work with adults with developmental disabilities, accent modification, acquired disabilities? Heck you could even work with people who are transitioning/transgender. Do you want to work with the middle-aged? Maybe you’d like to work with the elderly!

Then again, maybe you think in terms of disorder.

Maybe you have an inclination towards voice. Or stuttering. Or maybe you only want to do phonology and articulation. You could really love AAC/AT! Or maybe you lean towards the neuro-motor side of things: dysarthria, dyspraxia, dysphagia. Some people are really into social communication, socio-linguistics, pragmatics. You could ONLY work with clients who have stroke, or dementia, or TBI. Maybe you’re really into oro-facial anomalies and you want to go live in Venezuela and help kiddos who have cleft palate and lip.

Once an SLP told me that she literally only worked with 2 year olds. THAT’S IT. Nothing else. 2 year olds. This field is INSANE. You can actually, genuinely do ANYTHING you want.

My problem is I want to do it all. And I can’t. Where do I even start? How could I possibly choose?