Connected speech and reading fluency take practice! Witty illustrations draw kids in. Humor, rhythm and rhymes help speech to flow. Children's experiences with frustration, self-regulation, word retrieval and homework are mixed in with the fun. Engaging and challenging!
There's a lot of discussion among SLPs about unreasonable, I would say INSANE, caseloads. Compounding the problem of too many clients are excessive documentation requirements.
I don't believe you can do your best work when you can barely make it through your schedule. So what do SLPs do? The best they can, considering the circumstances. However when productivity refers to billing hours as opposed to client progress, it's obvious the circumstances don't serve clients' needs.
SLPs are caught up in systems that manage human needs purely in terms of dollars. It's not surprising that clinician burn out is on the rise.
SLPs in private practice have a different experience. We decide how our time should be prioritized. We see fewer clients for longer sessions. I see the little ones for thirty minutes, the older ones for forty-five or sixty minutes.
Parents, siblings or grandparents often attend sessions. I have time to talk to them and, more importantly, time to listen.
A schedule with room to breathe leaves room to think. A valuable part of my work week is devoted to wondering: "Why isn't that kid...?"... "How can I make this task sharper?" ... "What's the clearest, and positive, way to say this to the parents?".
Part of my time is devoted to cleaning the bathroom. Yes, wondering and disinfecting are essential parts of my work day. It's my choice. I bill sessions and manage the rest of my time as I need to.
It has been deeply fulfilling, but not without cost. Office rent. No pension. I pay my own health insurance, all of it. (I belong to a group, Freelancers' Union). Every CEU, online or with airline and hotel, comes out of my pocket. And I have the same documentation load as anyone.
So that's my trade off: It costs me money to work in the way I think is best but I've never felt burnt out. I do need my recovery Saturdays. But I'm always happily engrossed when doing speech therapy.
I ran my first 10K in Central Park. About half way through I came to a hill. Eyes fixed on the top, I held my pace. As I reached it, a bend in the road revealed it wasn't the top at all. My heart faltered a little as I continued the climb. You guessed it, as I rounded the next curve, the hill continued it's relentless ascent. Desperation flooded my breath and my thinking. I struggled with all my might to keep plodding upward.
I recognize that look of desperation in children with dyslexia. It happens when they turn the page. Another expanse of text stretches before them.
When I turn the page I don't see a wall of hard words. I'm engrossed in images and ideas. I have a facility for reading. It's not smarts and I didn't earn it with prodigious discipline. It just came to me.
My brother told me there are no hills in Central Park. I pointed out the enormous one going down the West Side. He called it a slope. He's a guy who runs up Mt. Whitney. He is tremendously disciplined but he had tremendous motivation as well. He won. He set records.
There's no amount of discipline that could make me the runner he is. He was born to run. I was born to read. (I have a reader's physique). But I was a runner for twenty years. I ran for health and well being.
My dyslexic clients read the way I run. It takes tremendous discipline just to get by. Reading is an essential skill so I encourage them to continue up that hill. I also encourage them to pursue what they were born to do.
I once had a teenager list her strengths. Number one was, "I have good ideas". Her struggle with reading was monumental. So, therefore, was her struggle with school. She was failed, scolded, put down and laughed at. But she did have great ideas.
Many who go into teaching and speech therapy have that natural facility for reading I was blessed with. We seemed like the "smart" kids in school and we'd like to keep it that way. I worry about the barriers we put up for students who struggle to read.
My teenaged client wanted to work with preschoolers with special needs. We read an article on behavioral techniques for preschoolers. Getting through the article was excruciating. Once she understood it, I had her describe how she would deal with specific situations and explain her rationale. Her solutions were ingenious, her rationale surprisingly sophisticated.
The obstacles in her path are daunting. Her mountain makes my slope look silly. I'm rooting for her. I think she'll be (her favorite word) amazing.
Every now and then I hear a parent referred to as "crazy". Or eyes are rolled when parents are mentioned. Either the parent is disengaged or the parent's expectations are unrealistic. SLPs who have the least contact with parents have these reactions. Unfortunately, the basic model of providing speech therapy in the schools exacerbates the communication divide between SLPs and parents.
The parents are outside of the process. Practice sheets may be sent home but the purpose of that specific exercise may not be understood. The SLP's expectations of how it should be utilized are not communicated. When parents are out of the loop, they feel less capable of carrying the work over in the home and less motivated.
More crucially, the parents' expectations are not communicated to the SLP on a regular basis. When a parent expresses something she has been concerned about, or perhaps misunderstood, in a twice yearly meeting, it seems to come out of the blue. The SLP may perceive the parents' expectations as unrealistic or unreasonable because there's no context.
Working closely with parents complicates the process. There are two therapeutic relationships. And, it turns out, parents have other issues and priorities besides speech therapy!
They have other children. The kids who are "fine" need and deserve their parents' time and attention. Families who have multiple children with special needs are not uncommon. People with extraordinary parenting demands often need both partners to work or are single parents.
Parents can have the same or similar issues as their children. They may or may not be aware of this. I've worked with many parents who had ADHD and/or dyslexia.
Marriage is hard. Sometimes a child with special needs becomes the focus of division and opposition between partners.
I've worked with parents who are caring for their own parent with Alzheimer's as well as their child with special needs.
Less common, some parents are struggling with their own illnesses. I've worked with parents with heart disease, kidney disease, bi-polar disorder and depression.
Some parents carry guilt about their children's challenges. Guilt is deeply painful and never reasonable. It has a way of compelling the worst decisions. I've never seen positive actions emerge from guilt. Yet a well-placed word here and there can go far to alleviate it.
Many parents are just very young and young is young. They need support, not judgement.
Finally, some parents are resentful. It's a long and difficult road. They may blame children's issues for marriage conflicts or for holding back their own development. Many parents of children with special needs dream of going back to college themselves, or finding a better job, or going back to work.
There are no difficult parents. Life is difficult. Life is complex. Speech therapists, of all people should realize the road through complexity is ongoing communication.
There Once Was A kid Who... is a bridge for kids who struggle with reading.
Each limerick is embedded in a vivid illustration. The image draws kids in. The humor and intensity of the event doesn't have to be decoded, it's conveyed immediately. The illustrations are a hook, but they're more than that. They provide a strong visual image which struggling readers are often missing.
On the sw- page, for example, when the child is tasked with swing, swoop, swoosh and sweet, the vibrant image of a child soaring on a swing fills two thirds of the page. The strong visual image and familiar sensation are paired with the decoding target, sw-. The meaning of the words is clear and the retrieval strength of the target blend is fortified.
The best thing about limericks is they're short. This lowers the threat level. No pages turned to another vast expanse of text.
Present one limerick at a time. Don't LET your reader turn the page. Each limerick gets at least three practice sessions. Practice the words with the target sound separately. Segment multi-syllable words and practice them separately. Put the practiced words back into the text and work on the flow. Exaggerate the rhythm.
Getting good at something feels good. As you move on to new limericks, use the old ones as warm ups. When frustration erupts, remind the child they've conquered before.
A famous parable tells of six blind men who endeavor to describe an elephant. One feels a leg and says an elephant is like a pillar. Another touches the tail and says an elephant is like a rope. The man who feels the trunk is reminded of a tree, the ear seems like a fan, the belly, a wall, and a tusk like a pipe. Each man is convinced he knows what an elephant is yet each definition of elephant is completely different.
As a CFY, I was very attracted to the idea of becoming a certified auditory verbal therapist. I would be a specialist, an expert! As I went along though, I realized that a third of my hearing impaired clients had other issues as well: autism, apraxia, dysarthria, ADHD and anxiety all showed up in that first crop of kids with cochlear implants.
Once my supervisor sent me with a client to consult with two different specialists who reigned in their fields of auditory verbal therapy and oral motor therapy. The client didn't have a /k/. Each was absolutely certain why. Auditory development said one, motor function said the other, unequivocally. They both had valuable information but neither considered other areas of speech development.
I began to doubt the wisdom of specializing. A client came who'd been kicked out of an auditory verbal program because of behaviors related to autism. Hearing impaired clients whose auditory needs went unattended in special ed preschools arrived at my door. School aged kids with cochlear implants showed up with language impairments or learning disabilities.
Some kids, whose parents were in the know, went to three different speech therapists, specializing in different areas. Other kids, in settings designed for one particular issue, were seen as baffling failures.
I decided I didn't want to be a blind man touching an elephant. I didn't become a specialist, I'm an ordinary SLP. My clients shouldn't have to fit into my sphere of knowledge. I'm required to serve my client. When something shows up that I don't understand, I learn about it. We're all capable of doing that. It's our job.
In the years since, the AG Bell Academy developed the Listening and Spoken Language Specialist certification, open to educators as well as SLPs and audiologists, that covers 9 domains of competency.
If you miss this diagnosis, the consequences for the child can be severe. Last week I discussed the case of a deaf child who started out in an auditory oral preschool then was placed in a school for children with autism. This child didn't have autism. The child had childhood apraxia of speech (CAS).
The majority of deaf children, who are implanted early and remediated in an auditory oral framework, develop normal speech rapidly. There is one caveat. 40% of children with hearing impairment have some concomitant disorder. That's a large number.
The incidence of CAS in the hearing impaired population is unknown. It's thought to occur in less than 1% of the general population and to comprise 3-5% of children with speech delay. Estimates of the prevalence of CAS among children with autism range as high as 13%.
In a practice devoted to hearing impaired children with concomitant disorders, I've treated just 3 kids with cochlear implants who also had CAS. All had motor apraxia throughout their bodies and two had mild to moderate dysarthria.
I've also treated 3 kids with Down's Syndrome and moderate hearing loss who had CAS. I missed the diagnosis in one of them for longer than I should have because I was so focused on the impact of ongoing ear infections on hearing aid use and the dysarthria, which was mild. Those are the issues I expected.
When a client has multiple issues we need to treat each issue specifically. Often, when a child has multiple issues, there is an assumption made about intelligence. In my practice of children with severe speech and language delays, there are rarely more than 2 at any given time with cognitive impairment. Learning disorders, however, are common.
We all miss things sometimes. When the client isn't making progress we need to be curious. Never assume it's an issue of intelligence. Never say that a kid can't speak. Ask why not.
Here are some great parent resources that discuss apraxia and hearing impairment:
www.srsdeaf.org St. Rita School for the Deaf, Cincinnati, OH
Deaf children who are implanted early and educated in an auditory oral setting are generally verbal. Those who are not are generally fluent signers. So when I met the adolescent sketched in last week's blog I was shocked.
Did you make the diagnosis? This client had childhood apraxia of speech, (CAS). As far as I can ascertain, it was never diagnosed, much less, treated.
The diagnosis of CAS can be complicated in itself and is more so in hearing impaired children but an ongoing diagnostic approach will sort it out. That didn't happen in this case. Instead, assumptions were made.
What's the difference between an assumption and a hypothesis? Testing. No formal test exists for this situation. This diagnosis can only be made through ongoing diagnostic therapy.
We work in systems that demand we see a kid a couple of times, give some formal tests and slap a diagnosis into a report. That's not always possible. What fills the void? Assumptions. Assumptions written in a report are often received as facts. They can influence everything that follows.
When a formal test is given to a population it hasn’t been normed for the results are not only skewed, they can be insane. The psychologist gave a battery of formal intelligence tests to a nonverbal deaf person.
If he had hung out with the kid and observed sibling interaction it would have been obvious that the child was not autistic.
And intelligence? Can’t be measured! There is no intelligence test that has been normed on a population of profoundly deaf, implanted at 18 months, adolescents, with or without motor speech impairments.
"Intermittent explosive disorder"? Think about an adolescent with no functional verbal skills.
How about the speech-language progress report? If you are writing reports like that, please, stop it. The purpose of that report was to meet a requirement, not to inform or facilitate therapy.
Didn’t that clinician ever wonder what exactly was going on? Were the assumptions so intimidating they ruled out further hypotheses? Or does that clinician never engage in active hypothesizing?
The most distressing part of the SLP piece in this case is that many SLPs must have worked with this client over the years. Understand, they were working in an overwhelming, dysfunctional system. Still, it's deeply unsettling and disheartening that the diagnosis was never made. Or if made, never properly communicated.
An adolescent with a cochlear implant arrived in my office with little functional language. Implanted at 18 months this person responded to me with severely limited speech, gestures and a few signs. On the phone, the mother had reported clear speech, language delay, behind in school. Nothing I had prepared for an initial assessment was remotely doable.
I asked the mother background questions: delayed developmental milestones, balance problems, clumsy; consistent use of implant; auditory-oral preschool, followed by placement in a school for autistic children, removed after 5 years because of lack of progress; public mainstream school followed, 2 years, no progress; recently placed in a school for the deaf that uses ASL, responding well, mother opposed to sign language.
I used an acoustic screen to informally assess the client's auditory language perception with the cochlear implant. Responses were much better than expected, given initial communitatve presentation: simple questions and simple two step directions were 83% correct. 77% of single words were repeated accurately, with consonants that hadn't appeared prior. No simple sentences were repeated accurately or fully attempted by the client.
Some 3 and 4 word sentences were elicited without the screen. No articles. I had subject read a portion of The Sentence Articulation Test. (Oral) decoding skills were were high 3rd to low 4th grade level. Articulation errors occurred in each sentence: all blends and clusters resulted in omissions, substitutions and reversals of target consonants and vowels in the vicinity were distorted. A maximum of 3 consecutive reduplicated syllables were repeated accurately, but only in 40% of attempts.
Out of time, we arranged for our next meeting and for the delivery of some reports the mother had forgotten to bring. Here is a brief summary of their findings.
A recent psychological evaluation from a "Center" provided this diagnosis:
Intermittent Explosive Disorder
Mental Retardation, Severity Unspecified
Cochlear Implant; severe Hearing Loss
A Speech and Language Progress Report from related service providers at the public school reported:
"structures adequate for speech and feeding purposes"
"several phonological processes"
"poor phonological awareness skills"
"severe delays in all areas of speech and language development subsequent to profound, bilateral hearing loss"
I think both reports are depressingly idiotic.
What do you think the correct diagnosis is?
Here is some empowering mom wisdom from Mari Nosal that I like to share with the parents of my clients.
"To parents with newly diagnosed children, I am here to emphatically implore you never to give up hope. "
"I have most definitely experienced a multitude of emotions in terms of parenting my son to adulthood...fear for my son's future, pain from the inevitable ostracism he endured...sadness for my son's struggles...uncertainty..."
"Each and every child can and does learn and develop."
"You know your child better than anyone...trust your instincts...you are your child's best advocate."
Ms. Nosal is the mother of a young man with Asperger's Syndrome who was inspired to get her Masters degree in special education. She shares her knowledge "to assist others who trod the path I have traveled as a parent experienced in disabilities."
In her book, Ten Commandments of Interacting With Kids On The Autism Spectrum, she has some particular advice for us:
Ten Commandments for Educators Who Teach Kids on the Autism Spectrum
1. Thou shalt not perceive me as a diagnosis.
2. Thou shalt not assume that I am defiant.
3. Thou shalt help me learn to socialize with my peers.
4. Thou shalt catch me being good.
5. Thou shalt not attempt to embarrass me.
6. Thou shalt practice reflective observation and remediation.
7. Thou shalt not attempt to fix me.
8. Thou shalt not say negative things about me.
9. Thou shalt differentiate instruction.
10. Thou shalt perceive me as a human being.
Timely progress in the treatment of articulation and voice disorders requires consistent, daily repetition. Vocabulary and syntactic development depend upon many repeated experiences. Auditory processing of language, either in the hearing impaired or those with CAPD, also requires intensive experience. SLPs see most clients for thirty minutes, twice a week. To see progress from one session to the next, there has to be something in between.
While practice increases skill, carryover incorporates these new skills into actual communicative contexts. The seeds of language function and social skills may be planted in the therapy room but they bloom in real life. Getting established behaviors into clients' lives begins with their interactions with their parents.
#3. Parent knowledge and insight
Parents often enlighten me about preferences, fears, talents, sibling conflicts and cultural differences that require adjustments or present opportunities. Families bring in wonderful ways and means strategies that they develop at home. I've learned many effective tricks and methods from parents.
#4. Information and Encouragement
I keep a folder of speech and language articles for parents and post more general articles, about the importance of sleep, diet, water, exercise and play, on the bulletin board. Having a child with special needs can feel overwhelming. Parents who are involved in the therapy process are aware of their children's steps forward and less apt to focus on what is still lacking. All parents feel guilty sometimes and the parents of children with big challenges can carry a heavy burden. Helping parents to put some of that down can make a huge difference to the process and outcome of speech language therapy.
Parents observe me then do it themselves. When they practice practicing in the session they feel confident in their understanding and ability. I give written instructions to refresh their memory during the week and there's always a notepad and pen handy if they want to jot something down. I also brainstorm with parents to come up with routines, timing and motivation that will support the work. I tell parents to keep practice to five minutes at a time. The more doable it is, the more it gets done.