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Getting Started: Non-English EI Referrals

12 Oct

Hey ya’ll.

If you were an early intervention speech therapist, and you got a referral for a child who does not speak a language that you speak – what would you do?

@liselschwartz and I discussed the other day and I wanted to share some of our ideas. I see a lot of Spanish-speaking children, but I don’t get too many referrals for other languages. Even though I speak some Spanish, my sessions can be a little disjointed. Early intervention is about coaching and guiding parents so they can provide therapy services all week long when you aren’t there. If you can’t talk to them during your sessions how can you make this happen? Here are some ideas!

Figure out how to get an interpreter in there. Our child-find program typically schedules an interpreter for at the least the first session, and then once a month following for non-English speaking families. If you don’t get an interpreter scheduled off the bat, ask your supervisor about what the protocol is for requesting one. When/if you get someone who can interpret for you, try to get some basic vocab words  in THEIR language written down for your knowledge and use. For early intervention my top ten in no particular order are usually:

1. More (some therapists aren’t into this being a first word but it’s quick and easy so I’m sticking with it)
2. Give me/my turn
3. All done
4. Open
5. Help
6. Eat
7. Drink
8. Cookie – or cracker, or apple, or whatever the child eats a lot of
9. Milk – or water, or juice, or whatever the child drinks a lot of
10. Play

– If you can’t get a list from someone who can interpret, trying Googling the words you want – if it’s the wrong word the family will likely know what you MEANT and will tell you the correct word (for example, I didn’t know the Spanish word for “marble” so I just called it “pelota” until a Mom told me “canica.”) If you put into Google “German for ball” it will give you several options, so I just pick the one that sounds closest and the families correct me if I picked the wrong concept. I also LOVE wordreference.com for colloquial definitions.

Put those words to signs for the family. In our center we even make a little sign language book with a picture of the sign and the word below. I know each language has its own corresponding sign language – but this is hard enough without adding extra sign languages to the picture so I just stick with ASL.

mas

de plusmehr

And so on and so forth.

– Do what you can to provide services in their native language. This can hard for a number of reasons (the main being that YOU do not speak Twi or Cantonese or Hmong or whatever). But also sometimes families know that the child is going to be exposed to English in the school system, and so they just want you to speak English to the child. But the two year old should really keep being exposed to their native language so they can communicate with their family members when you aren’t there. This is why it’s vital to get the family playing and doing the therapy, while you coach.

– If caregiver knows someone who can read English, who isn’t there at the time of your sessions, see if you can write down ideas to have translated later. Sometimes Dad or cousin or sister reads English, and so I’ll write down my “ideas” for the week, and then they’ll have that person read later. If you can find something like “Handy Handouts” from SuperDuper (which is in both English and Spanish) that’s ever better – you want to provide resources as much in the native language as you can. As the languages get more “obscure,” the harder this becomes.

– Sometimes families will have a little English in the home, or siblings will speak English, so families will ask, “If the English word is easier to say, can I just model the English word?” (think “ball” instead of “pelota” or “shoe” instead of “zapato.”) I usually try to steer clear of this unless that really is their preferred word that they’d typically use (I see a lot of Spanglish so some families really do just say “apple” instead of “manzana.”) I typically recommend in this circumstance to model approximations of the native language word, rather than modeling the English.

– If there are older siblings in the home who speak English try getting them involved, they can be a huge help for you, and they always love teaching the “teacher” their language and words. 🙂

 

Any other ideas out there? What do you do with kiddos and parents who don’t share your language? What if you can’t get an interpreter, or the family resists an interpreter? Please share!

NP: Florence + the Machine – Blinding

 

tricks of the trade

16 Sep

I just had my 2 year workiversary! (At the end of July.) As such I thought I’d celebrate two months late by sharing some of my early intervention tips!

1. Put it on your head. I don’t know why, but kids think hats are hilarious. Whenever a kid is not looking at me, is about to cry, is crying, is about to bail on a toy, is distracted – whatever – I just put something on my head. 60% of the time this works every time.

2. Bubbles freeze in the winter and crayons melt in the summer. Plan accordingly.

3. Also on bubbles: blow UP not out. When you blow up, you have time to draw attention to the bubbles, talk about the bubbles, sing about the bubbles, and generally enjoy the bubbles. When you blow out they just fall down and suck.

4. Get yourself pants with a strong knee. I’ve gone through three pairs of pants in less than two years. Double duty knees. Support knees. Worker knees.  Utility knees. Or maybe buy one of those gardening squishy rectangles.

5. In addition, get yourself a poker face. You can’t buy this but I highly recommend obtaining one. Poker face has been something I’ve been working on for years, but now that I’ve sort of got my face under control I find my life is a lot easier. When a kid does something that grosses me out, annoys me, makes me mad, makes me laugh (when I shouldn’t), makes me sad, or shocks me – you would never know. I’m like Mona Lisa MS, CCC-SLP over here. You don’t want parents or children feeding into your emotions during therapy sessions so lock it up!

6. Patience is a virtue.  Learn to wait. I always tell the kids, “I know, waiting is so hard!” and I make them wait for everything…but it took me a long time to learn to wait for them. Waiting waiting waiting. I do it all day. Wait for them to reach, wait for them to vocalize, wait for them to calm down, wait for them to notice. Quit anticipating, quit assuming, quit rushing, quit pushing. COOL YOUR JETS.

7.  Embrace the germs. I mean, Clorox wipe everything and wear gloves when needed. Embrace that you are going to get sick a lot when you first start. Like, a LOT. Way more than you can possibly anticipate. Start stocking up now on all your favorite cold and cough meds, you’re gonna need them. I’m here to tell you that there is a light at the end of the tunnel…after two years I have the immune system of a feral mutt. I can withstand anything (A kid sneezed into my open mouth the other day and I lived to tell the tale.) And you will too. But you have to live through the first six months.

8. Get a mentor (or three). I have a lot of mentors. I have my mentor for picture exchange, I have my mentor for feeding, I have my mentor for behavior, I have my mentor for apraxia…the list goes on. I don’t harangue these people endlessly for lunch dates so we can discuss me and my progress in becoming a grown SLP like them. But I do say, “Hey can I pick your brain about this little guy?” when I need back up. Know when you need backup, and find strong resources. It’s okay to ask for help, and it’s okay to have lots of mentors. (I recommend reading Lean In’s chapter “Are You My Mentor?” if you’re looking to develop mentor-mentee relationships…it’s really very enlightening.)

9. Learn about the other disciplines as much as you can. In early intervention it is SO important to look at the whole child. And until you work with OT/PT/ECE regularly you’re going to have a harder time looking at the whole child (because what are you looking for!?) You’ll see so much improvement when you make adjustments based on those other disciplines. You’ll know when to make referrals, and when to just make a suggestion. It’s hard to help the whole child make major improvements when you’re just looking at his mouth. Cotreat. Observe. Ask. 

10. Be flexible. No two kids are alike. Seriously. None. What worked with one, will work again with none. It’s insane. You will see new things every single day. I always say, “Never a dull moment” with EI. It will keep you on your toes and keep you moving and thinking constantly.  As an early interventionist you’ve got to be open to new ideas – whatever you’ve got planned probably isn’t going to go as you imagined 🙂

 

If you’re just starting out in EI I hope some of these help you on your path. If you’re a seasoned EI Vet – share some of your tips and tricks, I’m always looking for new ideas!

NP: Ingrid Michaelson – Home

further details regarding my BAG

11 Nov

I was having mall and lunch time with MsSohanSLP on Sunday and she asked when the last time I blogged was.

Shame. I AM ASHAMED. It’s been a stupid long time. I have a wide variety of things I could blog about, and I choose not to because I’m a lazy, lazy SLP.

I thought the easiest way to return to the blogging was to segue from the previous post!

(lazy. i’m so lazy.)

As we know, I do home health with 0-3 about half my work week. As we also know, I have raging ADHD and can’t play with the same toys week after week after week like some kind of therapy zombie. So I *try* to change what I bring to homes each week. It can be a challenge and it requires some creativity, but it can be done, and if you’re a home therapist I encourage you to change it up when you can!

Anyway, since this “school” year started in September, I have been attempting to do THEMES! Yes, my bag is now themed! We do group therapy in my center and we do monthly themes so I thought, why not translate themes to home therapy as well?

So far I’ve done: farm animals, zoo animals, transportation, body parts, food, shapes/colors, letters/numbers, actions, and this week is SENSORY.

Since it’s sensory week I’ve got playdough, paint, shaving cream, crazy textured balls, a small bean box, touch and feel books, and so on and so forth. Also I have wipes and a table cloth because…I’m not dumb.

I’m kind of running out of ideas. I’ll probably do “home” as a theme, and “school” as a theme. Any suggestions are welcome! What are some concepts that you think 0-3 year olds should have under their belt by preschool?

Okay, that’s all for now. I’m going to be better, I swear! Well, I don’t swear but I’m making a sort of promise to be a better blogger. And give me theme ideas please and thank you!

 

NP: Lady Antebellum – Get to Me (this song gets me right in the feels).

What’s in my bag?

28 May

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

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

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

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

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

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

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

BOOKS!

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

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

 

Puzzles!

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

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

Sensory!

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

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

 

This stuff is called "Gazz it" - it's 99 cents at Walgreens and it's a weird alternative if you're sick of play-doh

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

 

Fine motor!

Kids love to bang on things.

Kids love to bang on things.

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

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

Social fun times

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

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

Cause-and-effect

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

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

 

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

NP: Love Somebody – Maroon 5

Receptive Language….huh?

25 Feb

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

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

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

Yeaaaah….so…..about that?

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

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

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

Use a slow speech rate

Exaggerate key words and speech sounds

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

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

Model response expected then repeat the direction

Give visual cues when giving directions

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

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

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

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

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

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

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

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

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

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

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

NP: The Lumineers – Stubborn Love

 

I don’t even know where to start.

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.

The Visual Swallow Study

15 Oct

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

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

So here’s how it goes:

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

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

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

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

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

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

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

7. I write!

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

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

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.