Today I did a webinar on
Improving Social Skills in Children with Psychiatric Disturbances
click below for the initial reviews of my live webinar
Today I did a webinar on
click below for the initial reviews of my live webinar
Will be presenting a webinar via speechpathology.com on July 2nd 2012 at 12pm EDT entitled
Several months ago I had dinner with two of my colleagues, a pediatrician and a clinical social worker, to iron out the details of our upcoming conference presentation. As time went by we managed to discuss every topic under the sun, yet still the subject of our presentation was sadly not on the agenda. Exhausted from working at the hospital a full day and seeing private clients afterwards, I was getting distinctly antsy as the hand clock kept climbing closer to midnight.
The conversation began to feel more productive when we started to touch base on our mutual clients. Mostly they wanted to hear from me, since they both share an office suite and I was the only one located off-site. So, even though we all individually frequently conferred via phone regarding clients, that was the first time all three of us got together in the same room to discuss them. Quickly, I rattled off each of my clients’ progress in therapy, until I got to D, and paused. Oh, don’t get me wrong I am very proud of my work with D, whom I’ve been working with for several years, and who went from being limitedly verbal, severely echolalic, and “autistic like” at the age of 4-5 to fluent complex sentence speaker, fledgling problem solver, and a little charmer by the age of 6-5. Yet something was still bothering me regarding D’s performance that I couldn’t put my finger on. Despite the absence of a particular diagnosis (e.g., ASD) and significant gains, his issues with attention and cognition persisted, and his progress was still halting and inconsistent, even with rigorous language therapy and supplementary academic instruction at home 4 times a week.
In my desperation I have already considered and mentally rejected a number of referrals (“No it doesn’t seem to be a psychiatric issue”, “Yes he can benefit from a neurological but should I refer him to a psychological assessment first, could it be an IQ issue?” I pondered out loud as I shared my concerns with my colleagues. Both of them haven’t seen him for about 6 months so the clinical social worker immediately whipped out his chart busily looking for appropriate information, while the pediatrician started to frown, searching her memory for an “appropriate entry.” “Wait a second”, she said, “when I last saw him, during his physical exam I saw brown café au lait spots on his skin that I didn’t like at all, so I referred mom to get some blood work done but I haven’t heard from her since that time. Since you see her every week, can you please ask her to call me ASAP so I could remind her to do the blood test, as the information you are telling me makes it even more imperative that she follow up with the lab work.”
Right away, I became alert. Though the pediatrician was not stating her suspicious explicitly, through years of working with medical professionals I was familiar with the implications of what café au lait spots can potentially represent and that is neurofibromatosis. It is a neurocutaneous syndrome that leads to benign tumor growths in various parts of the body and can affect the brain, spinal cord, nerves, skin, and other body systems. In additional to all the medical implications of this syndrome (e.g., tumors becoming cancerous), it can also cause cognitive deficits and subsequent learning disabilities that affect appropriate knowledge acquisition and retention.
To me the situation was clear, no matter what the outcome, as the only team professional in contact with the parent at the time, it was my job to counsel the parent that she get in touch with the pediatrician so she can successfully pursue the recommended course of action. It may not have been the position I wanted to be in but unfortunately I knew that if this matter was left unpursued, I was left with a whole host of unanswered questions regarding further treatment options for this child.
I use the above example to emphasize the value and importance of working as part of a team to treat the “whole” child. Therapists specializing in working with children on the spectrum are most familiar with being part of a team, since they are just one of many professionals such as behaviorists, OT’s, psychologists or neurologists who are working with a child. Being part of a team is also a much more acceptable practice when a child is treated in a hospital or a rehab setting and presents with a complex disorder (e.g., is medically fragile, has a genetic syndrome, etc).
However, in our field, even outside of specialty settings (hospital/rehab) we are frequently confronted with speech or language disordered clients who stump our thinking processes, and who require the team approach (including the involvement of specialized medical professionals). Yet oftentimes that creates a significant challenge for many clinicians who are working contractually (through an agency) in school settings or in private practice. Being part of a team when one is contractor or a sole practitioner in a private practice is a much more difficult feat, especially when the clinicians are just striking out on their own for the first time.
Both interdisciplinary and multidisciplinary teamwork is oftentimes so crucial in our field. Working as part of a team allows us to collectively pursue common goals, combine our selective expertise, initiate a discussion to solve difficult problems, as well as to have professional lifelines when working on difficult cases. Different providers (neurologist, SLP, OT) see different symptoms as well as different aspects of the patient’s disorder. Consequently, different providers bring different perspectives to the table, which ultimately positively contributes to the treatment of the whole child.
Interestingly, many private speech language practitioners have wide referral networks (e.g., pediatricians, OT’s, PT’s and others who refer clients to them) yet when asked regarding frequency of contact with respect to conferences/discussions about the progress of specific clients, many clinicians draw a blank.
So how can we develop productive professional relationships with other service providers which go beyond the initial referral? I’ll be the first one to admit that it is not an easy accomplishment especially which it comes to physicians such as psychiatrists, neurologists, geneticists, or developmental pediatricians. I can tell you that while some of my professional relationships came easy, others took years to attain and refine.
In my hospital setting I work as part of a team. However, when I first started out in private practice, in a fairly short period of time I ended up having a number of clients with complex diagnoses and no one to refer them to. What complicated matters further that in contrast to them being referred to me by a pediatrician, these clients came to me first, since their most “visible issues” at the time were speech language deficits. I had to be the one to initiate the referral process to suggest to their parents relevant medical professionals, which needed to be visited in order to figure out why their children were having such complex language difficulties (among other symptoms) in the first place.
So here are a few suggestions on how to initiate and maintain professional relationships with medical service providers.
Start with doing a little research. You have worked hard to build your practice and your clients deserve the best, so locate the best medical service providers in your area. In the past I’ve had some excellent recommendations from locally based colleagues who were active on the ASHA discussion forums, other client’s parents who already did the necessary legwork, or hospital based colleagues who recommended peers in private practice. Several times I actually liked the initial medical reports I’ve received on a client so much – that I’ve referred other clients to the same doctor.
When word of mouth fails to do the trick, I turn to “Google” to provide me with desired results. Surprisingly, simply typing in “best _______in _____(name of state)” frequently does the trick and allows me to locate relevant professionals, after browsing through the multitude of web reviews.
Of course depending on the length of client treatment, you will have different relationships with different medical providers. I have collaborated for years with some (e.g., pediatrician, psychiatrist), and only infrequently spoken with others (geneticist, otolaryngologist, pediatric ophthalmologist).
Typically, when I refer a client for additional testing or consultation, in my referral letter to the physician, I request to receive the results in writing, asking the physician to also include relevant recommendations (if needed). Oftentimes, I also try to set some time to discuss the findings in a phone call in case I have any additional questions or concerns. Of course, I also send the physician (and other providers working with the child) the information from my end (progress reports, evaluations) so all of us can have a more comprehensive profile of the client’s disorder/deficit.
After all, ST’s, OT’s and PT’s are not the only ones who are dependent on information from doctors in order to do our work better. There are times when physicians need information from us in order to move further in treatment such as order specific tests. For example, just recently a pediatrician used my therapy progress report in conjunction with another provider’s, to order an MRI on our mutual client. The pediatrician had significant concerns over client’s development and presenting symptomatology, and needed to gather additional reports supporting her cause for concern in order to justify her course of action (ordering an MRI) to the HMO.
As mentioned previously there are numerous benefits to teamwork including the fact that it allows for appreciation of other disciplines, creation of functional goals for the child, integration of interventions as well as “brings together diverse knowledge and skills and can result in quicker decision making” (Catlett & Halper, 1992).
Given the above, it is important that speech language pathologists help to coordinate care and maintain relationships with other medical and related professionals who are treating the child. This will improve decision making, allow the professionals to address the child’s deficits in a holistic manner, an even potentially expedite the child’s length of stay in therapy.
Catlett, C & Halper, A (1992) Team Approaches: Working Together to Improve Quality. ASHA: Quality Improvement Digest. http://www.asha.org/uploadedFiles/aud/TeamApproaches.pdf
National Institute of Neurological Disorders and Stroke (NINDS) Neurofibromatosis Information Page http://www.ninds.nih.gov/disorders/neurofibromatosis/neurofibromatosis.htm
As speech language pathologist part of my job is to play! Since play assessment is a routine part of speech language evaluations for preschool and early school-aged children, I often find myself on the carpet in my office racing cars, making sure that all the “Little People” get their turn on the toy Ferris Wheel, and “cooking” elaborate meals in complete absence of electrical appliances. In fact, I’ve heard the phrase “I want toy” so many times that I actually began to worry that I might accidentally use it in polite company myself.
The benefits of play are well known and cataloged. Play allows children to use creativity and develop imagination. It facilitates cognition, physical and emotional development, language, and literacy. Play is great! However, not every culture values play as much as the Westerners do.
Cultural values affect how children play. Thus play interactions vary significantly across cultures. For instance, many Asian cultures prize education over play, so in these cultures children may engage in educational play activities vs. pretend play activities. To illustrate, Farver and colleagues have found that Korean preschool children engaged in greater parallel play (vs. pretend play), initiated play less frequently, as well as had less frequent social play episodes in contrast to Anglo-American peers. (Farver, Kim & Lee, 1995; Farver and Shinn 1997)
To continue, cultures focused on individualism stress independence and self-reliance. In such cultures, babies and toddlers are taught to be self sufficient when it comes to sleeping, feeding, dressing, grooming and playing from a very early age. (Schulze, Harwood, and Schoelmerich, 2001) Consequently, in these cultures parents would generally support and encourage child initiated and directed play. However, in many Latin American cultures, parents expect their children to master self-care abilities and function independently at later ages. Play in these cultures may be more parent directed vs. child directed. These children may receive more explicit directives from their caregivers with respect to how to act and speak and be more physically positioned or restrained during play. (Harwood, Schoelmerich, & Schulze, 2000)
In Western culture, early choice making is praised and encouraged. In contrast, traditional collective cultures encourage child obedience and respect over independence (Johnston & Wong, 2002). Choice making may not be as encouraged since it might seem like it’s giving the child too much power. It would not be uncommon for a child to be given a toy to play with which is deemed suitable for him/her, instead of being asked to choose. The children in these cultures may not be encouraged to narrate on their actions during play but expected to play quietly with their toy. Furthermore, if the parents do not consider play as an activity beneficial to their child’s cognitive and emotional development, but treat it as a leisure activity that helps pass the time, they may not ask the child questions regarding what he/she are doing and will not expect the child to narrate on their actions during play.
Consequently, in our assessments, it is very important to keep in mind that children’s play is affected by a number of variables including: cultural values, family relationships, child rearing practices, toy familiarity as well as developmental expectations (Hwa-Froelich, 2004). As such, in order to conduct balanced and objective play assessments, we as clinicians need to find a few moments in our busy schedules to interview the caregivers regarding their views on child rearing practices and play interactions, so we could objectively interpret our assessment findings (e.g., is it delay/disorder or lack of exposure and task unfamiliarity).
While the prevalence of stuttering varies according to age groups (preschool, school-age, etc), the incidence of stuttering is reported to be at approximately 5%, with the onset mainly occurring during the preschool years. Based on the above, it is estimated that approximately 2.5% of children under 5 years of age stutter (The Stuttering Foundation).
Despite the strides made by the current stuttering research, much confusion and misconceptions exist with respect to the treatment of stuttering in preschoolers. Many clinicians still continue to recommend that the parents ignore the child’s stuttering or use indirect environment modification approaches in the hopes that the child’s stuttering goes away. Further complicating this issue is that oftentimes many preschool children DO spontaneously recover from their stuttering several months post onset.
While oftentimes, it may be prudent to wait a few months to see how the onset of stuttering progresses, waiting too long may be quite problematic. This is especially true for those children who become increasingly frustrated with their stuttering or those who begin to develop secondary stuttering characteristics (reactions to stuttering such as gaze avoidance, facial grimaces, extraneous body movements, words avoidance, etc).
When it comes to preschool children one intervention approach which has been highly successful to date is The Lidcombe Program. Developed in Australia, the Lidcombe Program is a fluency shaping program, which is highly effective for children 2-6 years of age who stutter.
It’s goal is to eliminate stuttering. The program focuses on behavioral feedback provided in response to a child’s fluent speech. However, it’s not the therapist who provides the treatment but the PARENTS. The researchers who developed the program firmly believe that the intervention has to take place in natural environments, and there’s nothing natural regarding the therapist’s office!
Based on theories of operant conditioning, the premise of the program is simple: parents praise stutter free speech and request for correction of stuttered speech. The Lidcombe focuses on raising the child’s awareness of stuttering and encourages verbal reactions to stutter free speech.
To start, child and parent/s attend therapy sessions once a week. The therapist teaches the parents the types of verbiage to use with their child in treatment as well as how to rate their child’s weekly stuttering incidence on a 10-point stuttering severity scale in order to obtain a percent of stuttered syllables (%SS). Parents and therapist compare severity ratings (SR) and discuss discrepancies, if any. Therapist then supervises as parent administers treatment in session. For the rest of the week parents administered treatment in structured home setting in short increments (10 to 15 minutes each) 1 to 2 times per day. As child’s awareness improves, parents’ switch from structured to unstructured settings in an effort to initiate generalization.
For more information about whether the Lidcombe Program is right for your child, visit their website or contact the speech language professionals specializing in this approach in your area.
Tatyana Elleseff MA CCC-SLP will be giving 2 presentations at the NJSHA 2012 Convention on April 19-20, 2012
1. Presentation Title: Behavior Management Strategies for School Based Speech Language Pathologists
Time: Thursday, April 19 8:15 AM – 10:15 AM
Summary: In recent years more and more school based speech-language pathologists have to work with children who present with behavioral deficits in conjunction to speech-language delays/impairments. A significant portion of work with these children in therapy sessions involves successful management of inappropriate behaviors such as excessive inattention, hyperactivity, aggression, opposition/non-compliance and/or apathy, which interferes with successful objective completion and goal attainment. This workshop will explain what type of common challenging behaviors can manifest in children with select communication, psychiatric, and neurological disorders. It will outline behavior management strategy hierarchy from most to least intrusive methods for students with differing levels of cognitive functioning (high-average IQ to varying levels of MR). It will list positive proactive behavior management strategies to: prevent inappropriate behaviors from occurring, increase students’ session participation as well as improve compliance and cooperation during therapy sessions.
2. Presentation Title: Social Pragmatic Assessment of Children Diagnosed with Emotional/Psychiatric Disturbances in the Schools
Time: Thursday, April 19 10:45 AM – 12:45 PM
Summary: The number of children who present with non-spectrum emotional, behavioral, and psychiatric disturbances (oppositional defiant disorder, reactive attachment disorder, mood disorder, etc) has been steadily increasing in recent years. Many of these children attend district schools and due to high incidence of communication issues associated with these conditions, speech language pathologists are frequently included on the team of professionals who treat them. This workshop is aimed at increasing the participants knowledge regarding aspects of social pragmatic language. By the end of the workshop participants will be able to list common pediatric psychiatric diagnoses, explain the impact of psychiatric disturbances on language development of children, summarize the role of SLP in assessment of pragmatic language and social cognitive abilities of school-age children, as well as utilize formal and informal assessment instruments to assess pragmatic language and social cognitive abilities of school age children.
My article entitled: Speech Language Strategies for Multisensory Stimulation of Internationally Adopted Children has been published in the January 2012 Issue of Adoption Today Magazine
Summary: The article introduces the concept of multisensory stimulation and explains its benefits for internationally adopted children of all ages. It also provides suggestions for parents and professionals on how to implement multisensory strategies in a variety of educational activities in order to stimulate interest, increase task participation as well as facilitate concept retention.
Doman, G & Wilkinson, R (1993) The effects of intense multi-sensory stimulation on coma arousal and recovery. Neuropsychological Rehabilitation. 3 (2): 203-212.
Johnson, D. E et al (1992) The health of children adopted from Romania. Journal of the American Medical Association. 268(24): 3446-3450
Ti, K, Shin YH, & White-Traut, RC (2003), Multisensory intervention improves physical growth and illness rates in Korean orphaned newborn infants. Research in Nursing Health. 26 (6): 424-33.
Milev et al (2008) Multisensory Stimulation for Elderly With Dementia: A 24-Week Single-Blind Randomized Controlled Pilot Study. American Journal of Alzheimer’s Disease and Other Dementias. 23 (4): 372-376.
Tarullo, A & Gunnar, M (2006). Child Maltreatment and Developing HPA Axis. Hormones and Behavior 50, 632-639.
White Traut (1999) Developmental Intervention for Preterm Infants Diagnosed with Periventricular Leukomalacia. Research in Nursing Health. 22: 131-143.
White Traut et al (2009) Salivary Cortisol and Behavioral State Responses of Healthy Newborn Infants to Tactile-Only and Multisensory Interventions. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 38(1): 22–34
“The importance of thorough pediatric orofacial assessments in speech pathology: It’s not just for speech sounds anymore” will be published in the online edition of Advance for Speech Language Pathologists and Audiologists on November 16, 2011.
Article Summary: This article explains the importance of documenting orofacial assessment findings for multidisciplinary referral and diagnosis purposes. It offers several personal clinical case examples of atypical orofacial findings, which let to subsequent medical diagnosis of neurological and genetic disorders. It also explains why in some select circumstances, SLP’s may be the first professionals to observe/record atypical findings.
In recent years the percentage of “at-risk children” has been steadily increasing across pediatric speech-language pathology caseloads. These include adopted and foster care children, medically fragile children (e.g., failure to thrive), abused and neglected children, children from low socioeconomic backgrounds or any children who for any reason lack the adequate support system to encourage them to function optimally socially, emotionally, intellectually, or physically.
At times speech-language pathologists encounter barriers when working with this population, which include low motivation, inconsistent knowledge retention, as well as halting or labored progress in therapy.
As a speech-language pathologist whose caseload consists entirely of at-children, I have spent countless of hours on attempting to enhance service delivery for my clients. One method that I have found to be highly effective for greater knowledge retention as well as for increasing the kids’ motivation is incorporating multisensory stimulation in speech and language activities.
To date, a number of studies have described the advantages of multisensory stimulation for various at risk populations. For example, in 2003 a study published in Journal of Research in Nursing and Health described the advantages of multisensory stimulation for 2 week old Korean orphans who received auditory, tactile, and visual stimulation twice a day, 5 days a week, for 4 weeks. This resulted in significantly fewer illnesses as well as significant gains in weight, length and head circumference, after the 4-week intervention period and at 6 months of age. Another 2009 study by White Traut and colleagues published in the Journal of Obstetric, Gynecologic, & Neonatal Nursing, found that multi sensory stimulation consisting of auditory, tactile, visual, and vestibular intervention contributed to a reduction of infant stress reactivity (steady decline in cortisol levels). Moreover, multisensory stimulation is not just beneficial for young children. Other studies found benefits of multisensory stimulation for dementia (Milev et al, 2008) and coma patients (Doman & Wilkinson, 1993), indicating the usefulness of multisensory stimulation for a variety of at risk populations of different age groups.
After reviewing some studies and successfully implementing a number of strategies I wanted to share with you some of my favorite multisensory activities for different age-groups.
Before initiating any activities please remember to obtain parental permissions as well as a clearance from the occupational therapist (if the child is receiving related services), particularly if the child presents with significant sensory issues. It is also very important to ensure that there are no food allergies, or nutritional restrictions, especially when it comes to working with new and unfamiliar clients on your caseload.
Multisensory stimulation for young children does not have to involve stimulation of all the senses at once. However, there are a number of activities which come quite close, especially when one combines “touch ‘n’ feel” books, musical puzzles as well as paper and edible crafts.
Here’s one of my favorite speech language therapy session activities for children 2-4 years of age. I use a board book called Percival Touch ‘n’ Feel Book to teach insect and animal related vocabulary words as well as talk about adjectives describing textures (furry, smooth, bumpy, sticky, etc). As I help the children navigate the book, they get to touch the pages and talk about various plant and animals parts such as furry caterpillar dots, shiny flower petals, bumpy frog skin, or sticky spider web. We also work on appropriately producing multisyllabic words and on combining the words into short sentences, depending of course, on the child’s age, skills, and abilities. With this activity I often use animal and insect musical puzzles so the children can hear and then imitate select animal and insect noises.
Also, since all of Percival’s friends are garden insects and animals, it’s fairly easy to turn the book characters into paper crafts. Color paper templates are available from free websites such as www.dltk-kids.com, and range in complexity based on the child’s age (e.g., 2+, 3+ etc). While looking innocuously like simple paper cutouts, in reality these crafts are a linguistic treasure trove and can be used for teaching simple and complex directions (e.g., after you glue the frog’s arm, glue on his foot) as well as prepositional concepts (e.g., glue the eyes on top of the head; glue the mouth below the nose, etc).
So far we have combined the tactile with the auditory and the visual but we are still missing the stimulation of a few other senses such as the olfactory and the gustatory. For these we need a bit more creativity, and that’s where edible crafts come in (inspired by Janell Cannon’s ‘Crickwing’). The child and I begin by constructing and gluing together a large paper flower and dabbing it’s petals with various food extracts (almond, vanilla, raspberry, lemon, root beer, banana, cherry, coconut, etc). Then, using the paper flower as a model, we make an edible flower using various foods. Pretzel sticks serve as stems, snap peas become leaves while mango, tomato, apple, peach and orange slices can serve as petals. After our food craft is finished the child (and all other therapy participants) are encouraged to take it apart and eat it. The edible flower is not just useful to stimulate the visual, tactile, gustatory, and olfactory senses but it also encourages picky eaters to trial new foods with a variety of textures and tastes, as well as serves to develop symbolic play and early abstract thinking skills.
It is also important to emphasize that multisensory activities are not just for younger children; they can be useful for school-age children as well (including middle school and high school aged kids). In the past, I have incorporated multisensory activities into thematic language and vocabulary units for older children (see resources below) while working on the topics such as the senses (e.g., edible tasting plate), nutrition (e.g., edible food pyramid), the human body (e.g., computer games such as whack a bone by anatomy arcade), or even biology (building plant and animal cell structures out of jello and candy). From my personal clinical experience I have noticed that when I utilized the multisensory approach to learning vs. auditory and visual approaches alone (such as paper based or computer based tasks only), the children evidenced greater task participation, were able to understand the material much faster and were still able to recall learned information appropriately several therapy sessions later.
I find multisensory stimulation to be a fun and interactive way to increase the child’s learning potential, decrease stress levels, as well as increase retention of relevant concepts. Try it and let me know how it works for you!
· Doman, G & Wilkinson, R (1993) The effects of intense multi-sensory stimulation on coma arousal and recovery. Neuropsychological Rehabilitation. 3 (2): 203-212.
· Ti, K, Shin YH, & White-Traut, RC (2003), Multisensory intervention improves physical growth and illness rates in Korean orphaned newborn infants. Research in Nursing Health. 26 (6): 424-33.
· Milev et al (2008) Multisensory Stimulation for Elderly With Dementia: A 24-Week Single-Blind Randomized Controlled Pilot Study. American Journal of Alzheimer’s Disease and Other Dementias. 23 (4): 372-376.
· Tarullo, A & Gunnar, M (2006). Child Maltreatment and Developing HPA Axis. Hormones and Behavior 50, 632-639.
· White Traut et al (2009) Salivary Cortisol and Behavioral State Responses of Healthy Newborn Infants to Tactile-Only and Multisensory Interventions. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 38(1): 22–34
October 21, 2011: East Brunswick NJ
The Department of Children and Families and the New Jersey Task Force on Child Abuse and Neglect had a statewide child maltreatment prevention conference today and I had great fun doing today’s presentation:
“Differential Diagnosis of Inattention, Hyperactivity and Impulsivity in At-Risk Children” with our clinical team, Alla Gordina, MD, FAAP and Lydia Shifrin, LCSW.
We had a terrific crowd, who asked great questions and gave excellent feedback.
Attention Deficit/Hyperactivity Disorder is one of the most common and the most controversial neurobehavioral disorders in children diagnosed today
Core symptoms of ADHD include Inattention, Impulsivity and Hyperactivity
Some ADHD statistics:
However, numerous medical, psychiatric, neurological, psychological, speech-language and other disorders are frequently misdiagnosed as ADHD
Disorders frequently misdiagnosed as AD/HD :
My presentation focused on explaining that having select language based difficulties can cause the child to act as inattentive, hyperactive and impulsive without actually having ADHD
My examples included: