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An Open Letter: The Clinical Fellowship and Early Intervention

1 Apr

Even though I find myself irked on the regular, I continue to follow a few SLP boards on Facebook. Recently a graduate student (presumably) asked about doing her clinical fellowship in an early intervention setting. And I was really bothered by so many negative responses – most people seemed to feel that a CF would not get the support they needed in an EI position. So I wanted a chance to express my point of view as a fairly recent EI CF (without having to unsubscribe myself after posting on her question because notifications for days.) Continue reading

Going bag-free

20 Mar

I’ve sensed something. I can feel it coming. On the horizon it looms.

Going bag-free.

I was speaking with another SLP at the PALSS conference this week who said being “bagless” in early intervention has been “a thing” for “a long time.” You hear this sort of thing often – core vocabulary was identified in the 80s and 90s, NSOMEs were noted as an issue in the 80s, etc etc – but no one listened until 2008 or whenever. “Oh that’s nothing new! We’ve known about that forever!” What is with that? Is it that with social media we’re connected now and we can make sure everyone is on the same page? Or were we too bull-headed in 1986 to listen the first time?

I’ve seen talk about going into the home for early intervention and bringing nothing with you but the shirt on your back on Facebook for about a year now. But APPARENTLY it’s been best practice for awhile. WHY DIDN’T I KNOW HOW COME YOU DIDN’T TELL ME UNTIL NOW? We have really got to work on being accountable to ourselves and each other for best practice. Don’t hand me an article from 2003 about natural environments and routines and the negative effect of bringing toys into the home and say “tsk tsk” and slap my wrists in 2015. Tell me about it in 2003. I’ve only had my bag for 2 years! This whole thing could have been avoided if I didn’t have my damn bag in the first place.


OKAY. Now that I’ve got that out of my system. Going bag-free. Nothing has been written in stone for my clinic yet about getting rid of the toy bag, but I’ve been preparing. As I said, I’ve seen a lot of talk on social media, and I know in southern DE the therapists haven’t been bringing their toy bag for maybe 9 months now. So I know it is headed my way. I’ve been transitioning my bag out of the houses I usually go to by only bringing a few toys, or only bringing books or puzzles, and letting families now that we’ll be playing with their toys soon. Any new houses I’m going into I’m not bringing my bag in the first place. I’ve taken most of the toys out of my car (so now I look like a real freak with an apartment full of toys and no children.)

And honestly, it isn’t a big deal most of the time. A majority of the children I see are lucky and privileged enough to have toys and books in their homes. So it isn’t changing anything except for the clamoring to get into my bag. Really it is kind of nice – I feel a lot less like Santa.

But what about those homes that there isn’t much by way of toys? I’ve thought a lot about this too. And again I don’t see the problem – we’ll use routines, we’ll use the great outdoors, we can make toys, we can make fun. I can say to a family “What would you normally be doing right now – and how can I be a part of it?” As my CF supervisor always told me, “Be the toy” and as Lindsey Cargill at the PALSS conference said, “Be the fun.” I can do that. We can sing. We can listen to the radio. We can dance. We can meet at the library. I can give away my toys to less fortunate families. I can give away my books.

And the research makes sense. How crappy am I making families feel by bringing a bag of toys? Am I not saying, “Your stuff. that your child has access to the 167 hours a week that I’m not here, isn’t good enough?” Am I not saying, “Therapy only happens when I’m here with my bag-o-fun?

HOWEVER, I do have one question for you SLPs who have gone bag-free (sounds a bit like going green, no?):

How are you addressing really specific goals that you’ve gleaned off the PLS that require pictures? Such as “identifies actions in images,” “identifies line drawings,” “identifies photos,” “identifies object function.”

Are you still bringing a book or puzzle now and then? Are you digging through the mail or the newspapers that families have to use their natural environment? Are you drawing pictures with crayons and markers? Using apps on Mom’s phone? Talking about what we see on TV? Talking about family photos on the walls? Drawing with chalk on the sidewalk? Yes to all of the above? Are you even writing these goals anymore, or are you writing goals based on the routines of the family?

I’m ready for a new challenge and I see this as a chance to improve my coaching skills and become more comfortable with getting involved with routines-based therapy. I’m interested to hear your point of view and get some fresh ideas!

NP: Conor Maynard

PS: If you want to look at the routines based research it is Robin McWilliams starting circa 2003 and he has a ton of great stuff out there on the world wide web

PPS: Does anyone have a link to a good video of typical 2 year old language? One where Mom or therapist isn’t asking 60 bajillion questions? Just a 2 year old talking.

A question for you

5 Mar

Okay so I’m having this trouble in my life and I need some SLP input. Actually it’s not just me with this particular trouble, it’s all the EI SLPs I know.

Imagine you get a referral for a late-talker. 18-24 months, little to no verbal output. And you and the family work and work and play and play and teach and teach and tada! – the child is almost three, and they’re jib jabbing up a storm. Oh man, they have a ton of great, functional one-three word utterances. Maybe they have 100, even 200 functional phrases. Wow! What great progress!

Now it’s time for a transition evaluation to see if they qualify for school services. Obviously you administer whatever assessment your state recommends for qualifying children for skilled SLP services. And they come out WNL right? Somewhere between 85-100 standard score. And their receptive language is strong – they can identify all sorts of good stuff, and they might even be a bit advanced with the colors, shapes, numbers, letters.

However, you feel something is just not right. Because you know that between 30-36 months a child should have between 450-1,000 words, and your kiddo is not quite there yet. ( Linguisystems Communication Milestones – page 18).

You would maybe even describe this child’s language as “rote.” Practiced. Routine. Reliant. Known. Structured. It’s functional, and they use the vocabulary they have very appropriately, because you are an excellent SLP and you’ve taught the child and the family all about modeling functional and useful words. But what does their spontaneous language look like? Can they answer basic Wh- questions? Are they asking basic questions? Are they using pronouns, possessives, present progressive -ing, plurals? Can they participate in “conversational” dialogue?

Chances are they are probably not doing these things unless these grammatical structures are part of a word or phrases that has been taught to them to use within a specific structure or routine. Their spontaneous output consists of those 100-200 words and phrases, over and over and over and over. Very limited novel output.

You guys know these kids right? You have a picture in your mind of a child or ten children on your caseload who fits this description?

I want to know, how are you expressing your concerns to the schools? Are you just hoping clinical judgment and qualitative explanation will help you make your point? Are you using an assessment? A language sample with type-token ratio? I was recently told about the Language Use Inventory, but I’m wondering if there are any other assessments you are using for this age group. My concern with the LUI is that it’s a parent questionnaire, so it may not really help our case despite the fact that it is standardized.

I hate to see my little guys who I know need the support lose services until they’re re-identified in Kindergarten at age 5. How can we prevent these kids from slipping through the early intervention cracks?

NP: Lana Del Rey – American

Strategies for EI – Says WHO?

8 Apr

Research Tuesday Numero Tres!

When “Simon Says” Doesn’t Work: Alternatives to Imitation for Facilitating Early Speech Development

Citation: Laura S. DeThorne, Cynthia J. Johnson, Louise Walder, Jamie Mahurin-Smith; When “Simon Says” Doesn’t Work: Alternatives to Imitation for Facilitating Early Speech Development. Am J Speech Lang Pathol 2009;18(2):133-145. doi: 10.1044/1058-0360(2008/07-0090).

 

As you know, I work with children 0-3 (I’d say the average age I get referrals is probably 26 months) in group center-based, individual center-based, and home-based therapy. I often make suggestions to parents on the very first day I see a child, maybe even in the evaluation – but I’ve often wondered …where do I get this stuff? Says who?

I saw this article while I was trying to find an article that supports the notion of putting an object near the face when you label it to gain attention and encourage imitation. I found a variety of sources that make the same suggestion but I have not seen any studies (if you know of one throw it my way). I seriously make this suggestion like three times a week but WHY? Who says it actually does anything? Somebody out there has to know.

ANYWAY, this literature review focused on six strategies that SLPs recommend and utilize for early speech imitation and language development. The review’s goal is to provide SLPs with evidence based strategies (rather than strategies that are anecdotal and maybe outdated and things that we just do because we see other therapists do it.) I have this dream that one day I’ll have a citation for every strategy I suggest to families. Which sounds alarming but really, I wouldn’t want a medication that hasn’t been proven to work.

What are these six strategies that SLPs frequently utilize to elicit speech imitation?

  1. Provide AAC access
  2. Minimize the pressure to speak
  3. Imitate the child
  4. Utilize exaggerated intonation and decrease rate
  5. Augment auditory, visual, tactile, and proprioceptive feedback
  6. Avoid emphasis on nonspeech-like articulator movements: focus on function

How did researchers pick these strategies?

First, they created a list of strategies that already had some theoretical framework which were supported by the big wigs of speech pathology. Then they used a variety of search methods to track down associated intervention studies. Then they narrowed down the list to these strategies with Level Two empirical evidence (supported by at least one experimental or quasi-experimental study on a relevant population).

You guys remember about empirical evidence right? Let’s review friends:

ebp

What is something cool that this literature review told me about each of these strategies?

  1. Provide AAC: The authors identified SIX studies which support providing AAC to children who do not easily imitate. Within those six studies, 89% of the children showed an increase in verbal output, and 11% showed no change. AAC had no detrimental impact on speech production in any of the children.
  2. Minimize pressure: In a study with 29 late-talking preschoolers, using mands and prompted imitation increased imitation within a speech session, however showed no carryover to the natural environment. The study indicated that directly prompting an imitation does not increase word-learning any more than low-pressure imitation.
  3. Imitate the child: Recent studies have shown that when you see someone perform a familiar action, neurons fire in YOUR brain too as though you’re doing the action. So when a child sees a clinician perform an action it may incite neurons in their brain which acts as an involuntary rehearsal. How neat is that? Super neat.
  4. Exaggerated intonation and slowed rate: This one is kind of weird because they call it exaggerated intonation and slow rate but they talk about singing – which I think are two separate things but nobody asked me. The research for singing and speech is extensive for adults. However, one study showed that melodic intonation therapy for children was more effective at increasing phoneme imitation versus oral motor therapy (which makes sense because we all know non-speech oral motor therapy does nothing for speech right? WE ALL KNOW THIS RIGHT?)
  5. Enhance sensory feedback: There’s a pretty small amount of literature on use of auditory and visual feedback for small children. However, tactile and proprioceptive information has shown promise for eliciting imitation in children via the PROMPT program. The idea of using enhanced sensory feedback is that we’re helping the child develop internal models for speech sound production (i.e. motor planning has a sensory result)
  6. Focus on function: Oral motor therapy is not effective based on a number of unpublished studies. If you feel the need to recommended non-speech oral motor exercises, do it only when a child is genuinely not imitating speech at all, and the activity should match as closely as possible in the areas of position, movement, and function of the target sounds.

So now when you recommend a speech imitation strategy to a family or caregiver you can at least rest easy knowing these six strategies do have an evidence base. There are numerous other suggestions we make as clinicians that don’t have a Level 2 evidence rating – we should strive to increase our EBP for early language imitation and development. Don’t you think?

Classification Accuracy of Brief Parent Report Measures of Language Development in Spanish-Speaking Toddlers

11 Mar

Mark Guiberson, Barbara L. Rodríguez, Philip S. Dale; Classification Accuracy of Brief Parent Report Measures of Language Development in Spanish-Speaking Toddlers. Lang Speech Hear Serv Sch 2011;42(4):536-549. doi: 10.1044/0161-1461(2011/10-0076).

RT image

As a follow up to last month’s Research Tuesday article, I chose this research article as my second topic. Also in my workplace, we use the SPLS as our qualifying assessment for Spanish-speaking children, so I was curious to see what these researchers had to say.

The goal in this project was to evaluate the classification accuracy of three different parent report measures as they assess they language development of Spanish-speaking toddlers. The three parent report measures chosen were the Ages and Stages Questionnaire (Spanish ASQ; Squires, Potter, & Bricker, 1999), he short-form of the Inventarios del Desarrollo de Habilidades Comunicativas Palabras y Enunciados (INV–II; Jackson-Maldonado, Bates, & Thal, 1992; Jackson-Maldonado et al., 2003), and reported children’s 3 longest utterances (M3L–W). The children were also administered the Spanish Preschool Language Scale-4 (SPLS–4; Zimmerman, Steiner, & Pond, 2002) to assess concurrent validity of the parent report measures in comparison to the Expressive Language Subtest.

Who took part in this study? 45 Spanish-speaking families and their 2 year olds. 22 of the children had expressive language delays (ELD), and 23 of the children were typically developing in their language development (TD.)

What’s going on with these parent measures? Well, the Communication Subscale of the ASQ is six questions long. The short-form INV-II is a 100 word checklist with a question regarding combining words. The M3L-W is assessed by asking parents to write down the three longest utterances their child has produced (To calculate a score you add the number of words and then divide by three.)

And what did we learn? Tell me about the results!

  • All three parent measures were significantly correlated with the SPLS-4. They showed concurrent validity (a type of evidence that is demonstrated when a test elicits similar results to a test which has already been validated).
  • When researchers compared the test scores of the children with expressive language delays and those test scores of the children considered typically developing, children with ELD received significantly lower scores than the children considered TD. (…which makes perfect sense? I guess that’s good to know – probably wouldn’t be great if both groups scored similarly.) The biggest difference was noted on the M3L-W measure.
  •  The classification accuracy aspect of the project looked at sensitivity, specificity, negative predictive value, and positive predictive value. Sensitivity of the measures reveals how many of the children who had a dx of ELD, also tested as ELD. Specificity of the measures reveals the portion of children considered TD, who tested as TD. Negative predictive value (NPV) is the percentage of children with negative screening results who were accurately classified, and the positive predictive value (PPV) with positive screening results that were accurately classified. (This is all very confusing for me, I’m hoping as I read it becomes clearer.)
    • The ASQ showed low sensitivity and NPV, but strong specificity and PPV – the ASQ was determined to be inadequate at detecting children with ELD (Possibly due to the fact that the questions are direct translations from English, and the ASQ was developed specifically for parental styles typical for Europe and America.)
    • The INV-II had high sensitivity, specificity, NPV, and PPV – it “shows promise” for use as an expressive language screener
    • The M3L-W had high sensitivity, specificity, NPV, and PPV – promising in terms of “pass/fail” screenings to determine need for in-depth assessment
    • Since the INV-II and the M3L-W had similar results, the researchers performed another test called a “receiver operating characteristics” which revealed the M3L-W was “non-significantly” better and demonstrated stronger classification accuracy.

To sum it up, when screening toddler-age, Spanish-speaking children it is appropriate to use a vocabulary checklist as well as a parent report on MLU to gain clinical information prior to an in-depth evaluation. But don’t bother with the translated ASQ. 

Stay tuned kids, for Research Tuesday in April!

Works Cited

Jackson-Maldonado, D., Bates, E., Thal, D. (1992). Fundación MacArthur: Inventario del desarrollo de habilidades comunicativas. San Diego, CA San Diego State University

Jackson-Maldonado, D., Thal, D. J., Fenson, L., Marchman, V. A., Newton, T., Conboy, B. (2003). MacArthur Inventarios del Desarrollo de Habilidades Comunicativas user’s guide and technical manual. Baltimore, MD Brooke

Squires, J., Potter, L., Bricker, D. (1999). Ages and Stages Questionnaire user’s guide. Baltimore, MD Brookes

Zimmerman, I. L., Steiner, V. G., Pond, R. E. (2002). Preschool Language Scale, Fourth Edition, Spanish Edition. San Antonio, TX Harcourt Assessment

Okay now this is too funny

1 Mar

I had NO idea that this blog was being pinned on Pinterest (it’s all good, I’m glad not mad…I just didn’t think about it.)

So I was looking at the site stats and referral sites etc and I click on Pinterest. And this is what I see:

 

AHHHH oh my God. I cannot stop laughing. It's just too funny.

AHHHH oh my God. I cannot stop laughing. It’s just too funny.

 

Thank you all for reading and making me laugh. This is way awesome.

Coming Soon: Research Tuesday!

3 Feb

As some of you may know, many of the SLP Bloggers of the World (official title) have been participating in an undertaking known as Research Tuesday.

The purpose of Research Tuesday is to encourage awareness of current professional research! I know that for me since graduating, I haven’t put much oomph into reading research articles. Which is silly because access to ASHA Journals is part of what I pay ASHA for every year. But there you have it. Unless someone forces me to read an article I am probably not going to. If say, research articles weren’t a thousand years long and full of jargon-y jargon, maybe it wouldn’t be so painful!

SO, as a result of this being the case for everybody in the club, Research Tuesday was founded. “The goal is to increase accountability for reading the research, advocate for reading the research, and improving exposure to research.”

Since my blog is in a current state of transition and lackluster blandness, I decided I would participate. I’m hoping that (a) I’ll learn (and you! You’ll learn!) more about professional topics that I like and (b) I’ll be encouraged to blog more because I’m slacking.

Keep your eyes peeled boys and girls!

Unlocked

15 Oct

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.

my biggest struggle (so far)

29 Sep

As a CF, I’m not great at everything quite yet (as you may have noticed from the previous post.) But the thing I’m struggling MOST with is what to do about escape behaviors.

Let me give you an example: I’m working with a kid in his home, everything is going smoothly, and then he takes off. Runs away, down the hall, up the stairs, into another room…wherever. He’s gone. I’ve set up the environment to decrease the chance of his escape (I.E. I’ve trapped him with my body and furniture.) I’ve brought items that I know motivate him. Mom is in the room and playing. Or siblings are present and playing.

I’m not a bad therapist I swear. I know how to set the scene appropriately.

And I know to analyze the behavior. Why is he running? Sometimes it happens during transition between toys and tasks. Sometimes it happens because something better is going on elsewhere (crying baby, TV is on, Grandma is in there, food is in there). Sometimes he’s mad at me and wants to go away. Sometimes he needs a sensory break.

Once the kid has run away…what do you do? In early intervention we want to follow the child’s lead. We want the child to be engaged and interested in you. When a child elopes, what do you do? Do you follow him and do therapy in the hall or the kitchen? Do you ask the crying infant to come sit and be a part of therapy? Do you try to entice him back? Do you ignore the behavior and wait for the two year old to return? Do you comment on and describe what he’s doing? Do you go get him and bring him back to the task at hand? Do you look at Mom and hope that she’ll be a disciplinarian?

There are pros and cons to each thing you could possibly do, and it seems like no matter what I do it feels wrong. I want the kids to have SOME structure and follow directions, but I’m also supposed to take their lead. If I let them do their thing and ignore it they might never come back! And I can describe what they’re doing or seeing but if they aren’t engaged then my voice is white noise. If I become a part of what they’re doing or describe what they’re doing then they might get more amped up and run more, thinking it’s a game. Then I’m reinforcing the behavior by giving it my positive attention. And I’ve found you can’t really count on the caregiver to help corral them. Sometimes I’ll let them do their thing once – Okay check on the baby once. Turn on the TV once. Go find some carpet fuzz to play with ONCE. But then they’re likely to tantrum when they don’t get to do it again. Sometimes enticing them back works if you can get their attention, but usually going to get them and sitting them down just causes more running or a tantrum. And some kids I do squeezes or jumping or some other kind of sensory break and that’ll work for a little while.

Basically I have no clue. I know it’s a dance, it’s a balancing act, it’s finding a happy medium. But what IS that happy medium? How do I find it?

So what do YOU do with runners? Please help!

CF. Clinical fellowship? or major Charlie Foxtrot?

25 Sep

CFs are kind of clumsy and doofy and ridiculous and any number of other adjectives which indicate that we just don’t know what we’re doing.

We really don’t. You’d think after 6 years of #slpeep schooling we’d have it together but you’d think wrong. It’s not that we aren’t booksmart, and it’s not that we aren’t loving our new jobs. We are just trying to fine tune our lives and our CRAFT and it’s a little messy.

If you’ve pulled any of the following stunts (that my fellow CFs and I have pulled), you MIGHT be a CF:

1) You thought this would be easier than grad school! Silly goosey.

2) You drive to EI homes and come to find out they don’t live there! And they speak Spanish! Donde esta tu casa? So you’re 45 minutes late. And/or you just completely miss sessions!

3) A child calls you a real nasty name and hides under a table. You aren’t sure the correct behavior management technique so you just stand there and try to entice them back with an iPad.

4) You reschedule a client and are proud of yourself…until you come to find out that you’ve scheduled them in a way that is non-compliant with insurance. Whoops.

5) You’ve educated a cardiac patient on CVA information.

6) You keep forgetting to reserve a room for evals and then you have to mad dash scramble around to find a room for a patient arriving in mere moments. And THEN you pick the wrong room and get yourself into trouble.

7) A patient’s mom calls you a baby.

8) Your supervisor comes to observe you. You get performance anxiety. You freeze! Drat.

9) You volunteer to assist with office work and turn on Pandora on your phone. Your supervisor comes to talk with you and it appears you’re playing on the phone in the middle of the work day. What a Gen Y-er you are!

10) Your gung-ho, save the world, CF passion can’t save you from the assault on your immune system. Sick sick sick all the time!

Feel free to share your ding-dong moments. I’m certain I’ll have more to share.