Napolean Dynamite

Napoleon Dynamite.  Yes, I am writing about this movie!  I can hardly believe it either.  But, this movie can create some great opportunities for conversation with adolescents and young adults with social communication issues.  I used it with a teen who was making inappropriate comments at school.  I would show a scene and we would talk about what happened, if it was appropriate, why it was inappropriate and what the characters should have done instead.  Then, I had the young man consider being in a similar situation and tell me what he would/should do. It is a fun way to address some of the more sensitive issues.  Be sure to watch the movie ahead of time and know which parts you want to show based on the individual need of your client.

Building Rapport with Children

As I mentioned in a previous post, it is essential to build a good rapport with your clients/patients!  In this post I will discuss ways to build a good rapport with children.

Genuinely care about them.  Not just about their speech/language but about them as a child.

Know what they are talking about . . . watch the movies they like, read a few of the books they like, walk down the toy aisle at the store. 

Give them choices.  Even if the only choice you can give is "Do you want to play this game or that game?"  give them a choice.  It makes them feel like you care what they think.

Pay attention to them.  I try to do most of my charting with children after we are done, so that I'm not looking away constantly.  They do notice!

Remember what they told you in previous sessions and bring it up, they will realize you were really listening.

Follow through.  Follow through when you tell them you will do something or that they can have something. 

Just a few thoughts . . .

The office that I work for just relocated and here are a few things that I come away with.
1.  I love that in our new office the games are located in an area where the children cannot see them!  This cuts down on "I want to pick a game."  issues.
2.  I love that the new office has automatically locking doors.  This is awesome for evenings when one of us is there alone.  Much less worry about safety!
3.  I cont. to wish that each therapist had a computer/tablet for charting.  It would be awesome to be able to do my paperwork whenever I have downtime-rather than having to wait for an available computer.  A tablet would be awesome because I could use it to chart during the session as well as use it for speech apps.
4.  I really wish that each therapist could be assigned to a specific therapy room.  That way we could keep supplies for our clients in the closet and not have to haul them in each time we see them AND more importantly it would be ideal for our clients with autism or similar disorders that are thrown off when anything changes.
5.  I love that there is an observation room for parents.  However, I wish that this was available in all therapy rooms, not just the testing room.  I firmly believe that parents "buying into therapy" is essential.  When they can watch what we are doing they can implement things from therapy at home thus increase progress across multiple settings.
6.  I love that this company encourages the therapists to communicate with each other.  The OTs and SLPs all share an office space allowing us to discuss needs of shared clients and bounce ideas off of each other.  

Building Rapport with Elderly

It is important to establish a good rapport with all of your patients/clients.  In this post I will discuss ways to build a good rapport with the elderly.  It is important to help them feel that you genuinely care about them.

The most important step to doing that is to GENUINELY CARE.  I know that sounds simple but people (esp. adults) can tell when you are being genuine and when you are being fake.

Don't treat them like children.  They have lived a long life and could likely teach you a thing or two.

Ask about their lives.  Ask about pictures in the room, where they have lived, their family (of origin and that they raised), occupations, hobbies, etc.

When/if you hit a sensitive topic express genuine concern and quickly change the topic.

Look for common interests.

Tell them about you.  Don't get carried away with this but let them know you are human.  Let them connect with you as more than just a teacher/student relationship.

Greet them before you jump into therapy.

Be sure to focus exclusively on them while you are with them.  Don't get distracted by other people, phone calls, turn off the TV, etc.  This is their time!  If you NEED to be available for a phone call explain that you may be interrupted but that you will make it as brief as possible.

Remember what you talked about during the last session and bring some of those things up again.  For example, if they had an appointment coming up at your last appt.  ask how it went.

Remember be real with them.  I have learned a lot from the geriatric patients I have worked with and have truly enjoyed being with them.  Be in the moment and you will be able to build some real relationships of trust and caring.

Holiday ASL

It is always nice to be greeted with a "Merry Christmas" or "Happy Mother's day" but it means even more when it comes from a child who has never been able to say it before!  I love seeing the joy on a parent's face when their child uses a social phrase appropriately for the first time!  Often, I have seen parents tear up when their child says or signs "I love you!" or another similar phrase.  So, I have compiled a short list of links to holiday phrases in ASL.  Often when a child has a language delay or disorder sign language can help them communicate before they are able to verbalize. 

Merry Christmas:  http://www.youtube.com/watch?v=pxMiSZFxcTs
Happy Valentines day:  http://www.youtube.com/watch?v=hBhBB-K-vFgH
Happy Thanksgiving:  http://www.aslpro.com/phrases/holidays/happy_thanksgiving.swfH
Happy New Year: http://www.signingsavvy.com/sign/HAPPY%20NEW%20YEAR/8021/1
Happy Mother's day:  http://www.youtube.com/watch?v=zOIxtp6aoZc
Happy Father's day:  http://www.bing.com/videos/search?q=happy+fathers+day+asl&FORM=VIRE3#view=detail&mid=5DE6D9888E798E7E50DC5DE6D9888E798E7E50DC

Enjoy!

Puzzle Links

Chunky puzzles:
Melissa & Doug Jumbo ABC Chunky Puzzle
Melissa & Doug Shapes - Chunky Puzzle
Hape First Shapes Puzzle
Melissa & Doug Mix-Match-Stack Chunky Puzzle-Occupations
Fisher-Price Brilliant Basics Activity Puzzle
Sounds puzzles:
Melissa & Doug Vehicle Sound Puzzle
Melissa & Doug Farm Sound Puzzle
Melissa & Doug Shapes Sound Puzzle
Floor puzzles:
Melissa & Doug Going Places Floor Puzzle - 48 Piece
Melissa & Doug Search and Find Sunny Hill Farm 48 Piece Floor Puzzle
Alphabet Letters & Numbers Educational Foam Puzzle Floor Mat for Kids + 72 Interlocking Pieces, 6"x6" Squares Blocks, Covers 18 sq ft
These are just a few that I really like.  As I said in my post about puzzles, there are tons of good ones out there and you can even sometimes find a good puzzle at the dollar store.  Look around.  Find what would interest your clients the most!

Puzzles

I like to use simple puzzles in therapy.  Melissa & Doug have some really fun puzzles that are durable.  But, you can even get simple puzzles at the dollar store.  One thing that I use puzzles for is as a reward. The child earns pieces to the puzzle until they are able to complete it at the end of the session.  This is not only a good reward but allows that to target fine motor control too.

I also like to use the puzzles to target vocabulary.  I use chunky puzzles with basic concepts (shapes, colors, letters, numbers, etc).  They name the concept as they put it in.  If in earlier stages I model the word and give them the piece to put in.  You can also do this with vocabulary like animals, transportation, etc. 

I will add links to some that I like soon! 

Identifying Emotions (part 2)

The following ideas are intended to be used following the ideas presented in this post.

Once they can identify the emotions based on facial expressions and body posture it is time to begin perspective taking.  Ask the patient, "What is something that would make you feel that way?", "What else would make you feel that way?"  "Tell me about a time that you felt this way."  Have the patient answer these questions for a variety of emotions ex: sad, mad, happy, confused, bored, surprised, annoyed, etc.
Next, identify some important people in their lives and esp. those that they have problems getting along with.  (Parents, teachers, siblings, friends, classmates, etc).  Have the patient choose one of these people to focus on (you will work your way through the list over several sessions).
Hold up a picture and ask, "What might make (fill in out of the important people) feel this way?"  "Tell me about a time that you think (important person) felt this way."  Go through a variety of emotions.
At the next session hold up the pictures and ask "Have you felt this way since our last visit?"  "Tell me about it."
Choose another important person and ask the questions above.  Do this until the patient has identified plausible reasons for several people in their lives.  Assist as needed so that the patient is successful.



Once the person is able to identify possible causes of the feelings talk about what the patient could to do change the situation for themselves to work through the negative emotions.  Then, talk about what they could do to help others change negative feelings in a particular situation.

Example 1:  SLP holds up a picture of a person who is sad and asks, "Why might your mom feel sad?"
Patient: "She lost her shoe."
SLP: What could you do to help her not feel so sad is she lost her shoe?"

Example 2:  SLP holds up a picture of a person who is angry and asks, "Why might your brother feel mad?"
Patient: "He didn't win his video game."
SLP: What could you do to help him to not feel so mad?

If the patient struggles to thing of an appropriate answer, discuss several appropriate and helpful responses.  Then, ask the patient which one(s) they would try.

Early Vocabulary Development

There are two areas of vocabulary development-understanding words and then using words.  In this post I am only talking about using (producing) the words.  Here is a very basic overview of typical vocabulary, based on age.  Do not worry too much if your child is a little behind (each child is different) but if they are several months behind I would recommend having your child assessed for a possible language delay.
12 months: 2-3 words
18 months:  50 words
24 months: 200 words
Again, this is just a very basic standard and should be used only as a screen.  If you have concerns please see an SLP in your area for a language assessment. 

Emotional Dissemblance

Since this is my speech therapy blog I figure I can share my thesis on here.  It was a labor of love and took more time and devotion that I ever could have anticipated.  I was overjoyed when it was done.  But, am grateful that I had the opportunity to learn through the experience and provide some new understanding to the field of Speech Language Pathology.

My thesis has a very long (descriptive) title: Performance on Naturalistic Dissemblance Tasks in 7-11 Year Old Children with Language Impairment and Typically Developing Children. In essence the study was to see if children with language impairment presented with similar emotional dissemblance (hiding/limiting) skills compared to same age peers.  We presented the children with 4 natural opportunities for dissemblance and recorded their responses.  In my thesis the results are analyzed and presented.  If you want (what I think is) an interesting read, here it is.

Identifying Emotions

This is a very important part of social interactions.  Without recognizing others' emotions it is impossible to interact appropriately.  During a 10 minute conversation a person may experience a variety of emotions: anger, sadness, happiness, boredom, irritation, frustration, surprise, and on and on.  When we sense our conversation partner's feelings it impacts the way that we continue the conversation.  If they appear mad, we may apologize and change the topic.  If they appear happy, we may continue with the current topic.  If they appear to be bored, we may change topics or conclude the conversation.  Etc. 
Many children have difficulty with recognizing emotion.  This is a hallmark of persons with Aspergers Syndrome.  Recognizing emotions is an important part of social language therapy.
Start basic: sad, mad, and happy are the easiest emotions to recognize.  Get photos of persons with each emotion and have the pt identify the person's emotion.  If they have difficulty, prompt them.  Point out key features of their face like a smile for happy.  You can then add other emotions that are more difficult.  Once they can recognize emotions in pictures it is time to try in real life.  Have them encounter different people in the clinic, school, or other therapy setting that you have asked to appear to have different emotions when you bring your client by.  Then return to the room and have them tell you each person's emotion.  This is the first step in perspective taking-you have to recognize first!

/r/ remediation

These are some phrases that I like to use when working on the /r/ sound.  There are two ways to produce the /r/ sound.  Most people produce it by bunching their tongue at the back of the mouth, the tongue tip stays down.  Some people flip the tip of their tongue up to make the /r/ sound and don't really "bunch".  Before using these phrases make sure which type of production you want to target. 

During an the assessment for child who makes /r/ errors I like to see if they can make /r/ correctly in isolation or a variety of syllables (different vowels before and after).  I try to watch what their tongue is doing.  This helps me decide which type of /r/ I want to target.  If they don't ever make an accurate /r/ then I try both types with them to see which they have a better approximation with and that is what I target. 

Bunching R (more common)
"Pull your tongue back tight, like a fist."
"Smile while you say /r/."
"Growl like a tiger. GRRR!"
"Bunch your tongue up."

Retroflex or Tip up R (less common)
"Smile when you way /r/."
"Make your tongue tight."
"Tip up."
"Curl your tongue."

When teaching either type of /r/ be sure to show them what you mean in your mouth and/or with an oral puppet. 

Free CEUs

Don't forget to check the tabs regularly!  I just posted the link to some free CEU webinars that are coming up this month and next month in the Free and Inexpensive CEU tab. 

Accent Reduction

Accent reduction is a fun area to treat.  Generally the patients do not present with any other diagnoses which impact treatment so therapy is very effective.  Accents are characterized by substitutions or alternations of vowel and/or consonant sounds.  Most accents occur because the speakers native language does not include the Standard American English (SAE) sound.  They may have the letter in their alphabet but they produce it differently. 

1.  The first step to accomplishing accent reduction is to do an articulation assessment.  It is absolutely necessary to do an assessment that includes vowel sounds.  Be sure to use diacritics so that you can identify and remediate all differences between SAE and the speakers productions. 
2.  I generally like to record some of the differences that the patient presents with.  This allows them to hear the differences.
3.  Next, check for stimuability.  See which new sounds they can most easily make.
4.  Begin treatment.  Train for position of articulators, voicing, nasality, etc.  As they master (80% acc) a sound add a new sound to target. 
5.  As they are reaching mastery of their target sounds record them again and help them ID differences between their first recording and later recordings.  Help them ID areas of further concern. 

I like to practice target phonemes in the most natural contexts possible.  I have them read, we play games with their speech sounds, we have conversations, we talk on the telephone, etc. 

*Accent reduction is not a necessary treatment.  Most insurance will not pay for it.  It is optional; however, many professionals like to have it done so that they sound more educated. 

Notebook for the Elderly

Whenever I am working with an elderly person I recommend that they get or I provide them with a small notebook.  This is beneficial for multiple reasons.  Share these reasons with them and their caregiver as well as write these uses in the front of the notebook.
*write down questions/concerns for the SLP, doctor, nurse and/or other professionals that they interact with
*write down strategies for whatever their weakness is as explained by professionals
*keep track of how well they are using strategies (memory, swallowing, orientation, etc)
*write down important information that they need to remember like appointments, instructions for home exercises, names of people that work with them, etc.
*write down memories for themselves and posterity
*you can also record basic information about the pt is their notebook to help them stay oriented (name, age, where they are, month, etc)
Depending on the pt there may be other important things that they should be recording.  Help them know what they should record and check back each visit to see that they are using their notebook appropriately.

Hypernasality

I worked with an adult who presented with hypernasality (sounds coming through the nose that should not).  The only sounds that should be produced with nasality are n, m, and ng.  Two strategies that we used were pinching the nose shut while saying these sounds.  Then, trying to replicate the sound when the nose is not pinched shut.  And, using a mirror horizontally below the nose (above the mouth).  After saying a word with no nasals they could see if the mirror was clouded.  If it was then they were too nasal.  Audio recordings are also very helpful so that they can hear what they really sound like with and without nasality.

There expensive gizmos on the market that measure nasality, these can be good for more complicated cases but I've found that the above works for the more mild cases where they can understand what the goal is. 

This is a short list of sentences that do not have any nasal sounds in them that can be used for practice when trying to eliminate nasality from non-nasal sounds.

I go to the store every day.

The dog is at the park today.

Carrots are good for your body.

Happy birthday to you.

Broccoli is a good choice.

I love babies and toddlers.

Have hope for the future.

Speech will get better with practice.

Bikes are good to ride.

How did you get to the party?

 

*A word of caution:  Be sure to do a thorough oral motor examination before initiating therapy for hypernasality.  If the pt has velopharyngeal insufficiency or cleft palate they will not be able to eliminate nasality whatever they try.  These must be corrected surgically.  Refer to an ENT, following surgery they can benefit from therapy to retrain muscles for better closure. 

Coming to Therapy

Here is another personalized story that I have used with some preschool and school age children who struggle with staying on task in therapy. 

Cover: Coming to Therapy!
Pg 1: At therapy I play and work. (picture of them playing or working at therapy)
Pg 2:  I try to listen to my teacher.  (picture of them listening to me)
Pg 3:  This makes her happy.  (picture of me smiling)
Pg 4:  I sit on my bottom so that I can listen.  (picture of them sitting on their chair)
Pg 5:  I have fun when I work and listen. (picture of them smiling)

Big Bang Theory

*Update:  I love this clip.  You can talk about all kinds of social issues in this clip.  A few ideas . . . -Should the girls be trying to get this information from Sheldon?  Why or why not?  If they want to know the information, how should the try to gain the information?
-Should Sheldon talk about his relationship with his girlfriend in front of her friends?
-What is the problem with Sheldon's explanation of the "community property law"?   Why is Penny confused?
-Is Bernadette still invading her husband's privacy?  How?
-Why is it inappropriate for Sheldon to acknowledge his vast knowledge so strongly?
-Why is it rude for Sheldon to tell Penny, "Sometimes I don't give you enough credit, Penny."?

The Big Bang Theory is a funny television show whose main character has Asperger's Syndrome.  This show can be used in therapy.  Selectively pick scenes from the show (as parts are inappropriate) with Sheldon (the main character) doing things that are socially inappropriate.  Watch these clips with a teen or your adult with Asperger's and have them identify what was inappropriate, why it was inappropriate, the feelings of each person in the scene, and then have them tell what Sheldon should have/could have done that would have been appropriate.  This can also be an appropriate activity for some individuals who have experiences a traumatic brain injury (TBI) who exhibit poor social skills.  If your client cannot figure out the problem, the emotions, or how to fix it provide scaffolding until they are able to figure it out.    

Very Basic AAC

I used AAC boards similar to this one with pts who had recently had a stroke or TBI.  It is useful until they can either speak or learn to use another (faster) AAC.  I always include the numbers so that they can identify their pain on a scale of 1-10.  Using this they can tell you anything.  When they are spelling words remind them to point to a blank space between words.  Often the "listener" will benefit from writing it down, esp. if the message is long.  The listener should say the letter they think is being pointed to so that they get the right message.  I have created very large ones (table top) for persons who have significant difficulty with fine motor skills.
 

A	B	C	D	E
F	G	H	I	J
K	L	M	N	O
P	Q	R	S	T
U	V	W	X	Y
Z		1	2	3
4	5	6	7	8
9	10		YES	NO

st Blends

There are articulation cards on the market that target initial st blends.  However, I have yet to find any that address the st blend in other positions of the word.  This may be due in part to the fact that there are few words with the st blend in the medial position of words.  Here is a short list that I was able to come up with to target st in medial and final positions of words. 

 

Medial

Easter

monster
yesterday
sister
twister
roller coaster
east coast
west coast
master
costume
pistol (may or may not be appropriate based on the setting you are in)

Final
most
just

best

list

fist

fast

almost

beast

host

most

ghost

worst

feast

coast

first

boost

last

(any adj. that can have an -est ending added to it)

*There are several more final st words but these are the ones that most children would know and you could create a picture for fairly easily.