A Little About Me and This Blog

I have been a licensed Speech-Language Pathologist (SLP) since 1987. I am a member of the American Speech and Hearing Association. I have worked in the states of New York, Hawaii and Florida. I am currently in New York State. I have worked in settings that include public schools, special education preschools, hospitals, adult day treatment programs, home health rehabilitation, early intervention and preschool homebased therapy. I have provided evaluation and therapy to people ranging in age from 6 months to 100 years. I have worked with a wide range of conditions and treatments including fluency, aphasia, apraxia, voice disorders, dysphagia, cleft palate, hearing impairment, articulation delay, language delay, augmentative/alternative communication, autism, and many others through the years.
The purpose of this Blog is to share information and answer questions that you may have. I will strive to provide the correct information to the best of my professional knowledge. I may not share the same professional opinion as other licensed speech pathologists and I encourage second opinions if you want to be as informed as possible.

Thursday, December 31, 2009

Techniques to Encourage Language Development

     If a child is not told the name of an object, he can not learn to say it. If an action is never labeled, a child can not follow a direction to do it. Think about what it would be like if you were suddenly placed in a foreign country with absolutely no idea of the language.  If people are constantly talking but not helping you learn to place meaning on words, you will not ever be able to understand or use their language.  It does not come naturally for all people to think of this with a baby or toddler.  All babies will naturally make sounds and try to communicate, but it takes specific methods of interaction to reinforce their attempts and encourage more from them.  Children can have delayed speech and language skills for many reasons.  Parents can help be sure that their child's  language environment is as rich as possible to avoid lack of stimulation as a reason for any delay. 

     Most parents use the following techniques while interacting with their babies and toddlers without realizing that what they are doing has a name.  Some of these techniques are indirect methods of stimulating language.  By indirect, I mean that there is no specific requesting of a response from the child. The parent or therapist will perform these methods in a natural way during the child's day.  Direct methods of encouraging language are requesting that the child try to imitate words and phrases or answer questions that we ask.  These are important to do in combination with the indirect methods in order to check for understanding and encourage the use of words that the children are learning. It is not always natural to focus on one of these methods at a time, use them together and in various combinations to provide the most well-rounded language stimulation experiences.


     Self Talk:  This  method is just what it says. YOU talk out loud about what YOU are seeing, doing, or hearing as you do it.  The child should be nearby or at least in hearing range when you are talking so that he can make connections between what you say and what is happening. Use single words and short simple phrases.  A running commentary of non-stop talking in long sentences will not provide the same effect. An example of a natural activity to use this method is folding laundry.  With the child playing nearby or involved in the activity, some of the self talk might go like this:  "Mommy's folding clothes....shirt....fold shirt...sock....one...two...two  socks."  "Big shirt...Daddy's shirt....fold Daddy's shirt." "Pants....blue pants...fold blue pants...." 

     Parallel Talk:  With this method, YOU talk out loud about what your CHILD is seeing, doing or hearing. A great way, but not the only way, to use this method is to sit near your child while he is playing with something.  In this example, a child is playing with a toy farm set. "Cow....cow eat....yum, yum, yum.....cow says moo...moo cow...uh-oh...cow fall down.  You picked cow up...walk, walk, walk..."   This parallel talk can happen throughout the day as the child is doing all activities:  "Roll ball...weee....get ball...you got ball....bounce, bounce...you gave Mommy ball..."

     Description: This method is partly used in the above methods as well.  This method uses words and statements to describe, label and explain objects.  This introduces adjectives in addition to the noun and verb labels you started with.  Examples are "Big ball"  "Hot coffee" "My blue shirt."  "The juice is cold."

     Repetition: To use this technique, your child must now be talking in single words and some phrases but will still have sounds that they can not say correctly.  Although it is developmentally expected that they will make errors on sounds, learning them is partly trial and error. If their productions are always accepted and never modeled differently, their brain will register this as being correct. With this method, you repeat what they say but produce your words with correct sound production as a model for them to hear how you say it.  Do not expect them to repeat yours back or correct it the next time they say it.  An example might be if he says "Boo Baw" you say "Blue ball"  just the way he said the phrase, but with a model of correct sound.  Another example of the child's phrase may be "mow gink" Repeat what he says correctly: "More drink."

     Expansion: With this technique, you repeat the child's phrase, but in an adult form.  This reinforces that you understand what they said, but it models the more advanced forms of their early language.  They may say "Moo eat." You would reply back "Yes, the cow is eating."  If your child says "Shoe"  You say "I'm putting your shoe on."

     Expansion Plus: This method uses the above Expansion method plus an additional comment that is related. Expand the child's sentence to an adult form, then add something that will enhance the meaning of this to add concepts to what they relate to this sentence.  An example would be if the child said  "Car go" You would say "Yes, the car goes. It's going fast."   Another example is if the child says "Go out." You could say "You are going outside.  We can play ball."

     Questioning:  Ask you child questions such as "What's this?" "What is the boy doing?" "Where's the ball?"  If the child is unable to answer or does not yet have the vocabulary to answer, you tell him the answer right away.  An example is :"What's this? (brief pause)  It's a monkey. Can you say monkey?" Try to encourage imitation of the answer in this method.  This method works well when looking at books with a child. Ask your child what people in the book are doing, ask where something is on the page for them to point to. Combine this method with the above methods to make looking at a book a great language enhancing activity.

     Imitation Requesting: If your child is in an imitation phase of language development, you will see more participation with this method.  If they are not yet imitating on a reqular basis, this method will help to encourage more imitation.  An example of this would be if the child says "more" but holds out cup instead of saying "drink"  You would say to him "Tell me more drink"  If the child has the ability to say drink and you have heard it before, it is fine to require that he say it before you give him the drink.  If he has not used it before, simply request it...model it and then provide drink.  

     Reinforcing:  One of the best ways to encourage children to communicate is to respond to their communication attempts. Reinforcement encourages a behavior to continue.Responding to their communication encourages them to do it more.  If a baby babbles you should babble and chat back to them.  If a child tries to tell you something, take the time to try to figure it out.  If a child is incorrect with speech or language production...model the correct form.  Be sure to acknowledge their communication attempts and  provide time for communication with them.

Wednesday, December 30, 2009

Who Can Speech Pathologists Help?

     Many people do not realize how many disorders and conditions a speech pathologist can treat.  I will provide a list of general categories and some specific conditions that can benefit from therapy. I am mixing the medical conditions as well as the things they cause in the same categories at times. Some conditions fit in more than one category. This is not a complete list, but it should give you a good idea of the many people that can be helped by a speech pathologist.  The links on the terms will take you to the American Speech and Hearing Association Website (ASHA ) for definitions and specific ways a Speech Pathologist can be involved with each disorder. Feel free to go to this site to look up any disorders that I did not include links for. I know I am forgetting many conditions, but this is quite a few!

     These conditions affect the sound of the Voice in either pitch, volume or quality.  Speech Pathologists never treat voice disorders until a person has been evaluated by an ENT. Voice therapy alone or in combination with surgical treatment may be recommended for the following:
     Vocal Nodules, Cysts or Polyps; Laryngeal Cancer/Laryngectomee; Spasmodic Dysphonia; Vocal Fold (cord) Paralysis; Voice Quality Disorder (pitch, volume, nasal quality);Vocal fold nodules; Vocal Hyperfunction (misuse); ALS; Laryngeal Papillomas; Vocal Fold Scarring; Glottic (vocal fold) and Subglottic Web;

     Speech disorders affect the ability to produce speech through the correct placement and movement of the articulators. 
     Apraxia; Childhood Apraxia of Speech; Sound Disorders; Dysarthria; Oral Cancer; Huntington's, Down Syndrome; Stroke; Accent Modification; Cleft Lip and PalateSelective Mutism; Stuttering (dysfluency); Cerebral Palsy...

     Disorders of language affect a person's ability to understand or express words, ideas, vocabulary, grammar, directions.
     Developmental Language Delay; Aphasia; Traumatic Brain Injury; Stroke; English as a Second Language; Auditory Processing Disorder; Down syndrome; Autism...

     This category includes people who require augmentative or alternative methods of communication due to inability to use speech. Often uses low and high tech methods in combination. 
     Hearing Impairment;  Cerebral Palsy;  ALS; Ventilator & Tracheostomies; Stroke;

   This category includes people who have difficulty swallowing or eating orally for a variety of reasons. Dysphagia is the term for a disorder with swallowing.
     Infant feeding delays; Stroke;  ALS;

Tuesday, December 29, 2009

Using Toys in the Home vs. Bringing My Own

     When I first started doing home based speech therapy for children birth-age 5,  I always brought my  own bag of toys and "therapy materials" into the homes with me.  My large L.L.Bean Tote made a great bag to hold books, puzzles, farm sets, preschool toys and games. I brought things that I could use to encourage speech and language production.  The children loved seeing my bag and they couldn't wait to see what was in it each week.  They often had favorites and I made sure to bring those each time.  I was sure to search for toys that could be used to teach concepts and vocabulary. I found toys and books with current TV characters and  things that looked fun to even the parents. For the longest time, I thought this was the best way to run my therapy sessions.  What could be better?  I had the knowledge, the techniques to model and the best toys to do it with.
     The first time a child cried because I had to take the toy away with me I started to question this method.  I started to let kids borrow toys until the next time I came, in order to prevent meltdowns.  Parents started to go out and buy the same toys that were in my bag so their child didn't have to be sad when I would leave.  I also started thinking about how I was demonstrating great techniques with the toys I brought, but I could not be sure that the parents could take what they saw and generalize that to the toys and things they had available in their home already.  A new theory started spreading among therapists that connected with the natural language environment concept.  Since we would be providing therapy in the child's natural environment, we should also use only what is in that environment to do our sessions.  There is no better way to be sure the parents are able to carry over what I do in the sessions to their child's everyday life.
     It was around this time that I attended a workshop that asked the question "How comfortable would you be if you had to leave your bag behind?"  The workshop talked about using things in the child's home, even if they had no toys.  The idea of a child having no toys is not surprising to me.  I have been in many homes that had only a few infant toys for toddlers.  We were given grocery bags full of random household items and asked if we could plan a session around these items.  We were all more creative than we thought and we were able to work on just as many concepts with these everyday items as we were with our bag of the best toys. I was in complete agreement with this theory.
     Now the questions started popping into my head.  How could I now do this with families that were already used to me bringing my bag?  What will a parent think of a therapist who brings nothing to work with?  How open will a parent be with having me use their things?   I didn't think I could quit bringing my bag "cold turkey."  I would probably have to wean myself and my families slowly.  I wondered if I would be able to do this with 100% commitment.
     I was able to start this method with one family I started seeing the very next week.  This was easy to do because during the first session I explained the theory to the mom and she thought it was very logical.  The second benefit in this particular case was that I was not bringing in any toys that other children had played with and may contain germs.  This particular child had a compromised immune system due to chemotherapy.  So, I was on my way to trying this method in a very willing family.  This family also had more toys than any family I had ever worked with, so I was not being tested on my creativity too much yet.  This was going very well.
     My next challenge was to sell this idea to families and children that were used to my bag full of toys.  I started slowly with families that I knew would be willing.  I surprised them with the method one day by telling them that I had left my bag of toys home accidentally. I took the opportunity to explain the theory and they generally said that it was not a problem and we used toys and books that were in the home.  This also had a bonus benefit of the fact that I was no longer tied down to providing therapy in one little spot in the house.  We went to the child's room, a play room, outside etc. This made it easy to talk more about actions and different vocabulary.
     The hardest situations were in the families that had few toys and lived in homes that did not provide much in the way of space or opportunity to do a variety of activities. I used the shopping bag method I learned at the workshop.  A asked that each time I arrived, they would have chosen at least 10 items from around the house and placed them in a bag for us to use during the therapy session.  I was surprised at how this also encouraged the parents to think about finding things that could teach concepts. In these homes, we sat at the table and used all of the things in the bag. Some of these sessions turned out to be the most educational for parents.  They used creativity and realized that even if they could not afford the newest and best toys, they could still help their child with what they did have and with what they could do. 
     Today, I admit that I do use a combination of these methods.  In some situations, when I am confident that the parents understand the techniques I use, I will occasionally bring items that may introduce concepts that I could not do with their items.  I also bring things as examples for parents when they have asked what things they should try to get for their child.  I sometimes bring things to assess how a child is doing in an area and to see where we should focus next.  I think the best method is to use what is in the home, but there is still a place for us to bring in things that make therapy most beneficial to the child.      

Speech and Language Therapy in Natural Environments

     I have provided speech therapy for preschoolers in a variety of settings.  I have seen them in their pre-schools, in their homes and in clinic settings.  Of these settings, the clinic does not meet the criteria of natural environment. I no longer work in that setting with any child.  A natural environment is defined in IDEA Part C Regulations at 34 CFR Part 303 as: "To the maximum extent appropriate to the needs of the child, early intervention services must be provided in natural environments, including the home and community settings in which children without disabilities participate." (34 CFR 303.12 (b)). See the IDEA Regulations for Natural Environment for details.       All of my early intervention (birth-3 yrs) therapy sessions currently occur in the child's home.  The therapy in this setting allows the most opportunity for progress for several reasons.  In this setting I can include parents, siblings, friends and other caregivers in the sessions. I require at least one person to be an active participant during each session. I am not there to give the parents a break. I can provide support and models in the context of typical relationships and play.  I can adapt my plan to accomodate activities and routines to support full participation and learning. 
     As I tell parents, I am only in their home for a total of about 1 hour each week.  My job is not to provide therapy to the child to catch them up developmentally all by myself.  They will make minimal progress and may not catch up with only my effort one hour per week.  My job is to educate the family through explaining and modeling, so that they can provide the same quality speech and language stimulation techniques throughout the child's day when I am not there. I am a resource for them.  I am available to them for the hour each week to share my knowledge and help them provide the best interactions they can.  I have them be active participants in the sessions and demonstrate to me that they have an understanding of the techniques that I use.
     Another benefit to this natural environment setting is that I can help parents learn how to teach vocabulary that is relevant to their child.  We use toys and activities that are in the home. I teach basic signs to the parents as I teach them to the child. We use a variety of items in several ways to stimulate speech and language development. I provide ideas and activities for parents to use. I make suggestions to them of experiences to try to encorporate into their child's life. There are times that I bring some of my own materials although it is usually best to use what is in the home.  I will address this in my next post since this topic deserves its own space. 
     At the ages of 3-5, I feel it is still most beneficial to see the child in the home with parents present to provide consistency in the way cues and models  are presented to the child.  At this age, they are often working on speech sound development and correction as well as language skill development.  I see many children at this age in their preschool classrooms.  I see the most progress from these children if there is also parent and teacher involvement.  Since the teachers are with these children for large parts of their day, I am sure to share what I am doing with these day care providers as well as progress reports and home activities sent to parents. I provide homework for children working on speech sounds so that the parents learn to help remind them of their sounds.
     Parent involvement is necessary and crucial in order for children with delayed speech and language skills to make consistent and substantial progress in the shortest time possible. This can be most effectively accomplished through provision of therapy in natural environments.

Monday, December 28, 2009

Using Sign Language With All Babies and Toddlers

   Think about the natural gestures we all use. We wave to say "Hi" and "Bye," nod our head for "Yes," shake our head for "No," shrug our shoulders for "I don't know," and clap or high-five when we like something.  These are a few of the universally understood natural gestures we use and even teach our babies. The reason we naturally teach these gestures to our babies is because we know they can imitate and attach meaning to these gestures before they are able to use the words. We are so proud when they wave or shake their head "Yes" for the first time around 9-12 months of age. The babies eventually learn the words that go with these gestures, but they are able to communicate with these gestures much earlier. This is the concept behind teaching your babies and toddlers sign language.  They can imitate hand gestures for patty-cake, peek-a-boo and the words mentioned above. If they can do this, let's give them even more words they can communicate with as they are learning speech. Trust me, a normally developing baby will not use signs learned instead of the spoken word. They will generally use the signs, pair them with the words as they are learning to speak, and eventually only use the signs when they can not be understood or when they are exaggerating their message. Wouldn't it be great and less frustrating to know what your baby wants  before he has the words to verbally express himself?
     You will not be trying to teach your baby to speak in fluent sign language using a sign for every word.  The idea is to choose words you are naturally teaching your baby as he grows.  Some of the first signs would be for the following words: eat, drink, wet, dry, nite-nite, mommy, daddy, help, more, done, out, ball, cookie, etc.  These are the words that have meaning to them and should be helpful to you if they can express it.  Other signs to teach would be for objects that are in your baby's world.  Favorite toys, people, pets, and activities are good ones to teach. Use books and label the pictures verbally and with a sign. As you expand your child's sign language vocabulary, you are naturally helping to develop their speech and language skills.  You are always using the spoken word at the same time you are teaching them a sign, using the sign yourself, or reinforcing their commuinication attempt when they sign by saying something like..."Oh, you want your ball...here's your ball," while you also sign "ball."
     The use of sign language and the spoken label at the same time is part of an approach often called Total Communication.  This approach is often used with hearing impaired children and children with special needs such as Down Syndrome, autism and other conditions that may include a delayed speech and language component.  It allows children to increase expressive communication as they grow and learn faster than their speech and expressive language can keep up.  It is also a way to provide children with a way to hear and see a message you are trying to get them to understand.  Some children learn more visually and may miss the message if it is only spoken to them. Some children with early delays will continue to use signs and speech in combination to make their communication more effective. These children will usually be receiving speech-language therapy if they have been identified with a delay as a preschooler.
   In the case of a normally developing child, they can understand things much earlier than they can express them verbally.  They express by crying, gestures, sounds,touching what they want or having a tantrum when they can't make you figure out their message.
   It is fine if you and your immediate family are the only people who understand your baby's signs.  It would be wise to let any babysitters know the basic signs the baby may use as well.  The general public may not understand what you baby is doing, but you will understand him and, after all, isn't that the goal?
     There are many books and programs for getting started teaching your baby sign language such as this one: Teach Your Baby to Sign: An Illustrated Guide to Simple Sign Language for Babies. I have included many of them  in the Communication Corner Store on this site.  Click on the banner above and go to the category titled Sign Language to check out ways to get you started.  You can learn along with them!