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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

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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review’s goal is to provide SLPs with evidence based strategies (rather than strategies that are anecdotal and maybe outdated and things that we just do because we see other therapists do it.)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!

please someone just shoot me

17 Jul

Good grief. This is a cautionary tale.

Okay so early in June I mailed my application to get my temporary license. I sent my Praxis scores, a letter from my graduate program, my transcripts, and my license application. I did, I really did.

When the state of DE receives a license application, they hold onto it for ten business days and then they process it. Why? I don’t know.

My CF supervisors signed my application and mailed it to the board on June 22nd.

Since then and now I’ve emailed, and called, and emailed, and called, one million times. Yes. One million. They never told me anything was wrong with it, but they also wouldn’t enter me into the system.

YESTERDAY, my mom got my application in the mail. They sent it back because I missed ONE YES/NO question. And guess what? TODAY is the day they give out licenses. So, long story short, I won’t be getting my license until the end of August.

What does this mean for me? Luckily, my company is willing to hire me on as an “aide” for the month and then let me start as an SLP at the end of August. Which is good, but I have to pay rent and bills. So I’m also trying to find a part time job.

Please shoot me. Why is nothing simple?

OH and best part – the question I missed asked if I excessively use drugs. OHMYGOD. NO! Jeeeeez.

questions to ask a grad program

5 Jun

If you visit a graduate program I think it’s incredibly important to arrive with questions. It shows that you’re actively involved in the process and interested. Should you visit a graduate program? YES. It gives your name a face, it gives you contacts within a program, it gives you a chance to find out if you actually like the program as much as you think you do!

Do it.

So yes please bring questions. I think some of the most important questions you can ask are going to relate to clinical practicum. How long is practicum? How is it done? My program, for example, we had a year of on campus clinicals and one semester of externships. We have a longer medical externship than school based. Some schools however, you’re doing externships the whole time. You may have a semester or two of on campus placements and the rest of the time you’re off campus and taking night classes. I liked my program because I wasn’t taking courses while I did my externship. Also, I had the opportunity to go away. We had girls doing their clinicals all over the country. Other programs – if you’re taking classes you’ll have to do your externships in the same city. But with the extended off campus clinical time you really get the opportunity to try out many different settings and see a really wide variety of populations.

As I’ve said previously, ASHA mandates what sort of information you MUST be exposed to in a graduate program so that’s kind of predictable. Some programs offer EDHH focus or other extra classes for specific interests like AAC or craniofacial disorders. If you have a special interest ask if you’ll have an opportunity to take courses in that area. In my program we had no choice, we took all of the exact same classes. There were no electives.

It’s also important to know the set up of the program. How many people are in the program? My program was huge and I gotta say – I didn’t love it. I came from a small undergrad program and I just didn’t like so many people in my classes. Also if the program is large and you have a lot of on campus clinic you may see some panic for hours and available clients. It’s also good to know how many Ph.D.s will be teaching your courses and how available they are. Are they willing to supervise theses? Will they be gone for sabbatical? What are their research interests? These are the people who are guiding your education for the next two years so it’s good to know that they’ll be around.

I also like to just know little things about programs. Is their clinic set up on a sliding scale? How do patients get access to services in monetary terms? Do you spend time in the community doing screenings or volunteer work? Is the thesis required or an option? If it’s an option – how many students do it and is it supported/encouraged? Are students involved in NSSLHA nationally? Locally? State? Do students regularly attend conferences and is there funding for attendance? What sorts of clinic materials are available to clinicians? Is the clinic up to date in terms of technology support? Can you use iPad, Boardmaker, and AAC devices? Are there GAs and if so, how do you apply and get one? If you don’t get a GA, can you get a job? Where do students live most often?

This is a lot of information but you want to know the answers to these questions so you can make the best decision for yourself.

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.

Memory Therapy

21 May

I don’t know about you guys, but I felt like in many of my SLP classes I learned a lot of “textbook knowledge.” Meaning it’s good info to know and it’ll help me pass the Praxis, but beyond that it’s sort of useless. For example, in aphasia we learned the symptoms of aphasia and the different classifications of aphasia and how to evaluate aphasia. But three months ago if I was presented with a person with aphasia and someone said “TREAT THEM!” I’d be all, “Oh Dear Mother of God.” The knowledge isn’t super practical sometimes.

Which is why externships and clinic are important.

Anyway, I thought I’d take some time to break down some of my favorite areas to work on in the adult realm. Today I thought I’d go over,

MEMORY

As SLPs we address cognition which is an umbrella term for: orientation, memory, attention, problem solving, reasoning, initiation etc. Executive functioning overall. You’ll find often that OTs work on this as well.

Memory is an umbrella as well, since there are so many types of memory. Short term, long term, delayed, procedural, working, autobiographical, muscle, semantic and so forth. And memory has many steps. Your brain has to absorb the info, it has to code it, store it, and make it available for retrieval.

Generally, what I worked on most often was working memory and training patients to compensate for short term memory loss. There are a few agreed upon tricks of the trade and I’ll share them with you now.

1. Teach your patients to associate. This is most often used in the case of remembering new names. I always give my patients the example, “My name is Sam. I am a Speech therapist. And I’m a Student.” Lots of /s/. You could also use physical traits or personality. Like “Democratic Diana” or “Tall Tina.” You can make an association between new information and something you already know like, “My niece’s name is Sam and your name is Sam so I’ll remember you” (I never get how this works but patients always do this as their example.)

2. Repeat repeat repeat. If you want to memorize a list, a phone number, a poem, song lyrics – whatever – what do you do? You say it or do it over and over until you can do it without prompts. If a patient can’t remember what month it is – tell them during your session. A lot. And write it down. Several places. Repetition and rehearsal are great tools for committing something to memory.

3. Visualize it. This is good for prospective memory because you imagine yourself calling the doctor at 3 PM, or you imagine yourself turning on the TV to watch your favorite show. It’s like a little movie in your mind. A way to train visualization is to give a patient a list of words and have them make a story out of the words. Sometimes patients don’t really get it and will just combine a bunch of unrelated sentences. You want to encourage the story to have flow and be related, though it can be really silly. So if the list of words is:

Sock. Keys. Pink. Word. Chair.

They might say something like, “I’m wearing socks. I have keys in my purse. My favorite color is pink. Chair is a word.”

This is beneficial to no one. You want a story like, “I put on my sock but couldn’t find the other. So I got my keys and unlocked my pink car, so I could go buy a new pair. When I got home, I said a curse word because my sock was under the chair.

They’ll say the story to themselves a few times and then you remove the list from their line of vision. Ask them to verbalize or write the list immediately. Then ask again 20 minutes later.

4. Grouping. Which is one we all do a lot anyway – putting like things together. So if you’re making a grocery list, put the meats, dairy, dessert, veggies on the list together so it makes sense. Also then if you forget the list at home you have a better chance of remembering if you had categories.

5. Writing things down. Putting new activities into a planner. Writing notes on your day. Keeping a pad of paper by the phone. Reviewing the day with someone. Writing on a calendar. However you want to do it. But you’re more likely to retain something if you’ve put it on paper. A lot of patients physically can’t do this, so encourage their families or caregivers to help them.

You’ll also want to encourage your patients to make changes in their home environment so it’s more conducive to memory. Like keeping everything in a specific place everyday. Labeling drawers. Using a pill organizer. Using external aids like alarms and calendars. Whatever is going to make their life a little easier.

Working memory is something I really enjoy therapizing and that is just the retention and manipulation of information. So doing things like numbers reversed, or unscrambling letters into words when provided verbally. If you have a patient who has visual impairment these are good tasks to get them settled into therapy and get that brain moving. It’s a challenge for me too!

NP: Memory

I need to…

8 Jan

…drive to Bolivar, Missouri today to finish gathering thesis data. But you know, I went to a wedding yesterday and drank my body weight in vodka. As such, I just want to snooze.

BUT THE VODKA WON’T WIN. I’M GETTING UP. I’M DOING IT. IT IS HAPPENING. MOTIVATION.

I CAN DO ANYTHING GOOD.