Tuesday, November 16, 2010

The Value of Scrapbooking in Therapy

I've always loved scrapbooks.
As a child I always enjoyed looking through magazines, cutting out pictures I found interesting, and sticking them in scrapbooks. Even now I have one for dress styles I find in magazines. I've also applied this concept to my work with children. Every parent who comes to see me in clinic, at some point has to buy a scrapbook. It doesn't have to be anything too fancy, just a simple construction paper pad that is durable and has enough space to stick pictures. Most tend to look like this:

We work together in session to stick worksheets, pictures related to the theme, reward stickers, and anything of interest in the scrapbook, then parents get to do it at home with the children as well. It's great for vocab building, artic/phonology, exp and receptive language, AVT, a bit of everything. For example we may work on:

/s/ in therapy, sticking pictures of /s/ words into the scrapbook after saying them, then the next mission would be to go home and search through magazines and newspapers for other things which may begin with /s/ and sticking them in. Having a page for each sound.

SVO constructions- looking for and sticking in pictures of people doing actions- simple

Feelings (ASD)- Finding pictures of people for a happy, sad, angry, etc. page, talking about why the person might feel that way, then the next page would be a picture of the child with I feel happy, sad, angry when......

Vocab around themes: farm, things around the home etc. (that's another post soon to come)

Phonological Awareness: cutting out pictures and sticking them on their various 'syllable pages'
e.g monkey would be stuck on the "2 syllable page."

Prepositions; pictures depicting on, under, behind, etc.

These are fun and exciting and really works well in eliciting speech and language, both in sessions and at home. The good thing is that you can look through the scrapbook and see what has been covered and what progress has been made. '

I have a patient who travels to the US to see another speech therapist every few months and instead of sending a long report on what he has done they carry up the scrapbook, and that gives an even better idea of that is happening in therapy. I've also got many preschool teachers on board, and they incorporate the scrapbook into some of their activities.

I took some pictures of one of my favourite scrapbooks today to share with my readers. This little one has a cochlear implant and this is his 'listening scrapbook'.

Working on the "learning to listen" sounds for transportation.

Learning to listen sounds for animals. Also saying "open" to lift the flap, and 'bye bye' to close.

hop with plastic frogs (/p/ input)

Incy Wincy Spider Visuals

Finding family members. His favourite character is Ben 10 so I used this as a motivator. I ask him "where's mummy" and he lifts the flap to find then says word.

working on parts of the body

Sounds for listening (Ahhh vs brrrrrrm)

I'd encourage any speech therapist/pathologist, EI specialist, teacher, parent to try it, and let me know how it goes :)

Saturday, November 13, 2010

Speech & Language Twittology

I remember deciding a few years ago that I wanted to be a Speech & Language Therapist.That decision fuelled an obsessive search for all things related to speech & language therapy. I wanted to know everything, what it was like, what it involved, the types of patients (and of course the salary scale). When I did my search back then I got quite a few results explaining the role, patients, pay etc. However I was dissatisfied, something was missing. There was no personal aspect to it. Most pages started “A speech therapist/pathologist is someone who…..” Somewhat informative but even more impersonal. I started searching for terms like “A day in the life of a speech therapist”, “Speech therapy blogs” “Speech therapy communities.” What I really wanted was a personal perspective: Do they feel fulfilled in their jobs, what is a typical day like, what area do they prefer to work in? How did they survive grad school?....I found nothing.

Over the years the field has evolved and become more technologically driven. Blogs and communities have popped up all over the web and there has been an increased awareness of not only the role and importance of SLT(P)s but also a detailed outlook on what therapy is really like. A simple google search opens up a whole new world of resources, shared experiences and life stories. This is even more evident from the posting of hundreds of youtube videos showing therapy sessions, and more recently with the use of social networking to create a speech therapy community.

Just over a year ago “twitter” was a foreign concept to me. I was introduced by a friend and could not for the life of me figure out how it worked. I thought “why would I keep randomly posting ‘what’s happening’?” and in 140 characters too. It really wasn’t working out for me. Then a few months on, I saw a random post by a guy called @StutteringMe. I was quite intrigued and followed him promptly. This gave me the motivation to search for other persons related to the speech therapy field, and was the start of a beautiful relationship with twitter. I found persons tweeting about autism, down syndrome and many other areas I was interested in. Most importantly I started to meet speech therapists/pathologists from all over the world. They were only a few at first, but this number started to gradually, then quickly increase over the next months. We shared our experiences, talked about our lives, our practices, patients, offered ideas, asked questions, and it made the community more real, more like a family. Here were these people all over the world who had never met, only sharing the same profession (or passion I would call it), coming together to talk, while waiting for a patient to show up, waiting in traffic, cooking dinner for family, even while in labour! This was the new face of speech therapy. Then Bob Bateman (@speechbob) showed his creative genius and came up with the term #slpeeps. This was a perfect description of us. Now any SLT(P) who joined twitter could use this hashtag to find us all, and we could use it to speak directly to our community.

We have grown and progressed in leaps and bounds, with over one hundred slpeeps now present on twitter, from the newbies like myself to the veterans. The big organisations such as ASHA and CASLPA have taken notice and become involved, and so have many of the major companies such as Super Duper and Proed Inc. This has contributed significantly to our professional development. We’re able to discuss topics of interest, share info on new research and resources, and we have somewhere to turn and bounce ideas off of when we have absolutely no idea what to do with a patient. It is guaranteed that if you present a case to the #slpeeps you will get some feedback, sometimes within minutes. SLPs-to-be are also an active part of the community, something I wish I had while in grad school.

Most importantly the #slpeeps community provides a strong support network for therapists. On those days when you feel absolutely useless, they are there to say “I’ve been there, you can do it.” They are motivating, they are inspiring, they keep you going. We talk about real issues that affect us. Recently in a conversation about burnout, after hearing others experiences one member asked

“Where were you twitter #slpeeps telling me that years ago? I had such a rough patch I wanted to work as a cashier!”

Now we are here to provide support, and it looks like we’re here to stay.

We’ve recently taken it a step further than 140 characters, with the addition of a “Twitter SLP Goal Bank,” a “Shared Resource Links” page and a “Resource Share Folder,” via Google Docs. Here slpeeps can share and access goals, links and files all in one place. This is developing well and is already gaining worldwide recognition across SLT networks.

I am proud to be part of the #slpeeps community and I think that we can only keep moving forward from here. This is the start of something huge and I would encourage everyone who hears about it to become a part of it quickly, because they’re already missing out on greatness.

"Josh's Progress" - An Update

These past couple weeks I have been focusing on going into Josh's school and trying to make PECS as functional for him as possible, showing carers how to use it etc, so I didn't get to do as much imitation practice as I would have liked. However yesterday's session made up for it all. He was so amazing and really exceeded my expectations for how the session would run. I really need to stop tearing up whenever my patients accomplish great things or parents might think I'm a softie lol.

I started as usual with his 'warm up' actions (chap hands, touch head etc), again using Tic Tac Tony as a reinforcer. Interestingly he no longer gets enjoyment from flipping the chips off the tail into the slots; he is now fascinated by arranging them in patterns in front of the dog(Tony). I followed his lead with that because all I really need is a good reinforcer.

First sound was /m/. I rubbed my tummy and did a big exaggerated mmmmmmmm. He watched and just rubbed his tummy when it was his turn. I gave him a confused look and held back the reinforcer, then modelled again. This time an even louder MMMMMMMMM. He hesitated, cocked his head to the side like he was thinking about it then gave me this loud, absolutely perfect MMMMMMM. Success! He definitely got his reinforcer for that one. We did that exchange about 3 more times then I moved on. I went really close so he could see my sequencing and went mmmmmmeeeeeeeee, which he imitated like he was doing forever (teary eyes part 1). I did me a couple times then I went on and tried 'my' and 'ma'. 'Ma' he not only produced well, he also carried it on 'mamama.' I tried 'moo', but he definitely had some sequencing difficulty there. He watched me intently as I made it (his eye contact has come such a long way) and took his fingers and tried to squeeze his lips in to make the 'oo' /u:/ sound (bless him). I tried 'more', but he did the sign instead of imitating.

I moved on again a bit later in the session and tried 'bee', this time touching my chin with my fingers and moving them away as I said it (like signing thank you), and guess what! He did it, and said it the same time. I tried 'boo' as well but that also seems to give sequencing difficulty. He was so excited about this sound, even as he was leaving he was saying 'bebebebe'.

I am over the moon with the progress he is making. I recorded some of the session and can't help watching it over an over and smiling.

Our journey continues and I love where it is going :)

Friday, October 22, 2010

Case presentation: The Beauty of Imitation

This is my first of what I hope will be many updates on a patient’s progress in therapy. It’s good for parents and professionals to see the beauty of progress, to keep them encouraged. I think it is very important therefore to share some stories. Due to confidentiality and other ethical principles we will call this patient Josh.

Josh is 5 years old and is Autistic. He is nonverbal, but he is so communicative by any other nonverbal means. I have introduced PECS with him and he is flying with it. He is one I wish I could video as an example to other parents, as he is doing so well. We jumped to symbol discrimination in about 3 weeks with only 1, 45 min session per week. Anyway this is not a PECS post, this is about his imitative skills. Children on the Autistic Spectrum are known to have weak imitative skills. I know this as a speech therapist and someone who has had interaction with children on the spectrum, but somewhere in my goal setting I think this got lost. However, thankfully not lost forever.

One day while working with Josh it hit me in the face. He is stuck between Stage 1 and Stage 2 of imitation. How was I expecting him to imitate sounds then. Yes, he could imitate me building blocks and knocking them down, he could imitate me pushing a car around, if I splashed a toy into the water he could do that, or if I jumped he would copy, but after that the breakdown occurred. I had to go back to the books. I remembered in my early development class learning about imitation being one of the key precursors to speech development. I went through my files and found a handout called “Imitation before Speech!!” Eureka! Where I was stuck was at level 3: Imitation of actions/gestures. As I’m also trying to use evidenced based practice a lot in my clinical work I went to some journal articles as well. I found some research which looked at the effectiveness of mand training techniques and motor imitation tactics to elicit first sounds in children. The result of this study was that 5 elementary school children with autism could be taught to vocalise when the instruction first started with a generalised motor imitation sequence. I was really fascinated by this research.

The next week I started a ‘copy me’ game. I needed to find a way to get Josh to try to copy me and then reinforce him for his behaviour. I started with clapping, but he didn’t imitate. He either watched me or when I said your turn he took my hands and tried to make me clap. I got his parent to sit behind him and prompt him to clap and then fully reinforced him with putting a “tic tac tony” chip into the space. After 3 tries he no longer needed the prompt from behind, and we have launched into a 6 week journey (so far) of “copy me”. Every week we have added one or two actions working outwards- in. We went from clap hands, tap table, wiggle fingers, touch ears, touch head, touch nose, blow a kiss (which was adorable), to peek a boo (which has been a bit difficult due to what might either be proprioceptive difficulties or some possible apraxic tendencies). He has been doing really well with these and catching on very quickly. He is my little superstar.

Last week started a big move, transitioning to stage 4: Imitation of face and mouth movements. I had to be very cautious with this since when a task becomes too challenging we tend to lose him. I started with a kind of lip trill where I rubbed my index finger down my lip and made a vibration while vocalising. He was so fascinated by this and watched closely a few turns before he finally gave it a try. However, there was no vocalisation with it. I was thinking ‘uh oh’ this is our brick wall…no sound. I rewarded him for the slightest ummph of a vocalisation and put lots of emphasis on my vocalisation in my model. This week I pushed for it, making lots of loud silly vocalisations. Then….he tried it and made a long, loud, brrrrrrrrrrrrrrr, and loved it. I almost cried! We played with that for a few turns then I introduced a new one ; what I call an “Indian call”, where you vocalise and keep patting an open palm over your mouth. He did this like it was nothing and I was the proudest speech therapist in the world.

These 6 weeks have been amazing with Josh’s progress and I think we will only keep moving forward and seeing greater gains. The next stage is more imitation of silly sounds and noises then after that is real words, which I’m very positive about. I’m going to continue to document our journey and I hope that it might help some professional out there who is wondering what’s the next step with a similar patient.

If you’re interested in the “Imitation-Steps to Speaking” handout feel free to email me at sharekab@gmail.com and I will share it with you.

The research article can be found at http://www.ncbi.nlm.nih.gov/pubmed/12553968

Tuesday, September 14, 2010

What's in your Therapy Bag? : Early Intervention

Anyone who has seen me going into work knows I have a huge therapy bag. It's one of those fancy bags on wheels that you pull along by a long handle. You don't only see me coming, you hear me as well. I tend to get strange looks, and often the question "What in the world is in that bag?"

I also remember while being a grad student frantically searching the web for cool gadgets, toys and other resources that were commonly used by speech therapists.

Out of this I've decided to introduce my readers to 'My Therapy Bag!'
I've decided to do 2 posts on this and separate my early intervention goodies from the other therapy resources.

Cue the music as I slowly unzip the EI bag, building suspense as I go, and take a look inside:

the feely bag
very essential to every EI bag. It does not have to be fancy. Currently I'm using an old pillowcase, which I may eventually decorate and stick on some sparkly bits. However, once you use it right it will have the same effect. Great for exploring, manipulating, building anticipation etc. Children always get excited about this new exciting object that they are going to pull from this magic bag. Paired with a therapists enthusiastic expression and a "what's inside?" It gives lots of fun times. Also good for developing the preposition 'in'.

the hider
My feely bag also doubles as my hider. A hider is simply something that hides things. It's a piece of cloth that is key to developing object permanence in young ones. You can use it to hide the car while the child is playing with it, to see if he searches for it, or you can use it to hide a person during a peek-a-boo game.

If you don't have bubbles you're not a speech therapist. Great for building vocab, artic activities (particularly /b/ and /p/ (pop pop)) and oro motor activities.

a car
Good for developing joint attention and turn taking skills, building those performatives (vrroom, beep beep), the classic "ready, steady........go", you can drive it over body parts etc. I also like to use a bus for this, as /b/ is an earlier developing sound and I find children tend to say bus before car.

a ball
Also good for similar goals to the car. I also do lots of 'ball up', 'ball down'

classic vocab builders. Great to make the animal sounds as well. I also have a Noah's Ark that I put the animals 'in' and 'on' and say 'hello' and 'bye bye' as they go.

picture books
My favourite right now is 'brown bear, brown bear' because of it's repetition and need for lots of intonation. Great for joint attention and vocab building.

velcro food halves and knife
Children love cutting open the fruits and vegetables (so do I). There's something about that velcro noise that gives good sensory stimulation. I always associate it with me saying "cut, cut, cut, open!" With some younger ones I let them roll across the floor to get the food and pull it open with both hands. Also good for offering a choice.

I have the fisher price peek-a-blocks which children always love. We build towers 'up up up' then knock them down.

Nothing gets a child more excited than running after a deflating balloon. I also like to let the air out slowly on body parts "I'm gonna get your tummy" ...

a baby (doll)
[Lots of /b/ words in my EI bag, have you noticed?] Good for dressing, feeding, washing, sleeping, and all the verbs.

Be careful when using these, as all children do not like puppets. It can make or break your session. I have experienced both. Finger puppets also work well.

Stacking rings
I like to put these over my mouth when making a sound, then put them to the child's mouth when it's his turn to make a sound. I also put them to my eyes to say "I see youuu" Great for a wide range of activities.

I think that's all I can think of right now in my handy EI bag. I feel like I'm missing a few more. Maybe I'll make them 'resource of the week' if I remember later.

I'd like to hear from you therapists. Let's make this interactive. What sorts of things do you have in your Early Intervention therapy bag? You can send me a message on twitter or email me at sharekab@gmail.com. I'll compile your ideas and make it into a feedback post.

I'm waiting for your ideas :)

Thursday, September 2, 2010

Speech, language and communication for individuals with Down syndrome

We know the developmental milestones for speech and language in typically developing children. However, many parents, teachers and professionals are not aware of the ages and stages of speech and language development in children with Down Syndrome. More than knowing that these developmental milestones are delayed in these children I've found a great site which outlines developmentl areas in

  • early communication skills
  • vocbulary
  • speech
  • grammar and sentence structure
  • working memory
  • general interaction

Table 5, which outlines "Typical production milestones for children with Down syndrome" is a great one for anyone who interacts with children with Down syndrome to have. It has definitely come in handy in my clinic.

Here's the link to the site: http://www.down-syndrome.org/information/language/overview/?page=3

Also follow the links to the left for the speech and language overview for children with DS from birth to 16 years. They also give great activities and advice to assist the development of speech and language skills.

Friday, August 20, 2010

Link of the Week

I currently have 12 children on my caseload who are on the autistic spectrum, so I'm always looking for new fun resources to keep them engaged. While searching through a ton of pages trying to find some fun stuff to do with my 4 today I came across zacbrowser.com, and I must say was very impressed.

Zac Browser is highlighted as the "zone for autistic children" and is a web browser designed particularly for children and teens with autistic spectrum disorders. It makes the standard browsing experience a lot less complicated and is very aesthetically pleasing. It also works on all operating systems.

I downloaded the executable file to my usb and tried it out, which means I spent hours playing games, listening to songs, enjoying the interactive cause and effect activities, and listening to stories (research of course). Along with this there's a drawing pad which can also be quite entertaining. The browser links you directly to suggested sites for each category (music,games, stories etc) and gives a nice widescreen view (no explorer bars). It caters to a variety of ages and levels of functioning.

I used it with four of mine on the spectrum today and they loved it. The highlight was the "If you're happy and you know it" song with the actions. I encourage parents and professionals to try it out. I plan to use it with all of the children I see, not just those on the spectrum, as the activities would engage and provide a great learning experience for them all.

Here's a link to the youtube video giving some information on it:

and here is the official site: http://www.zacbrowser.com/

Let me know your thoughts on it :)

Monday, August 16, 2010

Resource of the week: Mr. Potato Head

He may seem like just an ordinary guy but Mr. Potato Head has a secret. He is the life of the party in so many clinics, homes and schools around the world. He has proven to be extremely useful so far as a valuable resource for speech and language intervention. Therefore he gains the title of "Resource of the Week!" I thought I'd share with you readers 4 different ways in which I used good old Mr. PH today in my therapy sessions.

Case 1: child with autism, teaching imitation skills as well as building vocab for body parts and clothing.

It's good to have more than one Mr. Potato Head with matching items so you can do this type of activity. I put each part on while naming it, and he was required to choose the item from his pile and copy me. (saying the part on imitation was a bonus, which he achieved a few times). This also required lots of active looking to achieve. He required prompting by dad for the first 2 or so but he quickly caught on and the activity went well :)

Case 2: child with cochlear implant, in aural rehab session

I've used Mr. PH with him in earlier sessions for his conditioned response to Ling sounds, however this week was to listen for body parts. I got him to search for the body part when said, then when he found it match it to his own body part. I also provided lots of auditory input for "sh", saying pushhhhhhh whenever he was fitting an item.

Case 3: Child with language delay, working on following directions

I saw my supervisor do this once and fell in love with the activity. This was somewhat a test of all of the concepts we had learnt over the past few weeks in therapy. Activity involved:
  • Following 2 step directions: first put his eyes on, then one ear
  • Directions with before and after: after you put on an ear, put on his hat
  • Either....or constructions: put on either his teeth or his nose
  • Negation: which hand is not on?

I must say he worked so well on this task. I've had trouble before, finding ways to target these specific areas, so good job Potato dude!

Case 4: child with weak Phonological Awareness skills: Rhyming task

Now this was a fun way to end the day, trying to find all of Mr. PH's body parts, clothing items that rhymed. It went a bit like this :

  • Say hose, now find his........(nose)
  • Say pat, now find his.....(hat) etc.

Then I turned it around and let him tell me the rhyming word so I could find the body parts etc. This was a bit more difficult for him but with lots of prompting he got through it.

Great sessions all around.

And that my friends is how Mr. Potato Head saved the day!

Sunday, August 15, 2010

Coping with Behavioural Challenges in children with Down Syndrome

I currently have four children on my caseload with Down Syndrome. The oldest is 8 years old and the youngest 18 months. Anyone who works with these children is well aware of the specific challenges which these children present, from delays in speech and language development, oromotor and feeding difficulties, to one which we all know too well- the behavioural challenges. The latter particularly tends to impact on progress in the former areas.

My 4 year old patient loves to throw tantrums in the middle of sessions. She hits, pushes things away and runs all over the clinic. Putting some behavioural strategies into place such as visual timetables and reinforcers into place these behaviours have improved significantly much to mum's and my relief. Our biggest goal now is the carry over outside of the clinic setting.

My 18 month old patient is my newest and from session one he decided that he runs the show. He bawled for the whole session and pushed away everything we gave him (at least he knows how to protest). I remember thinking at the end of the session "what am I going to do if he does this every week???" This week's session (number 2) was a lot better. I realised that he liked physical manipulation, being lifted, spun, swayed etc, so I followed his lead and incorporated this into the session. I started by doing this only, building language around the lifts and turns, building anticipation etc, then moved to giving it as a reinforcer. There was still some crying but definitely reduced from last time, and we had a pretty good session. I also got a pretty good workout, phew!

I was doing some research this weekend and came across this article on the "down syndrome online " website. The title "Strategies to address challenging behaviour in young children with Down syndrome" was enough for me to save the page to my favourites instantly, so I've decided to share it with my readers. Hope it's helpful. Here is the link:


Also I encourage you all to comment and share some ideas on how you manage challenging behaviour in the clinic setting, at home, in the school setting etc. Lets make this interactive and informative :)

Saturday, August 14, 2010

Don't just think about it, Do it!

After lots and lots of contemplation I have made a decision to jump in and start a blog about my passion, which also forms my career. I'm a Speech and Language therapist (also known as a Speech Pathologist in some countries), working in private practice. I'm quite a newbie in the field, as this is my first year practising, but I've learnt a lot thus far. There aren't many speech therapists in my country, one working in government, and the remaining 4 or so in private practice catering to a population of approximately 275,000. Needless to say I have a pretty hectic caseload with a range of communicative needs. I work with both paediatric and adult populations with speech, language, social communication voice, fluency, and feeding disorders and my settings range from clinic, hospitals, and house/school visits. I'm also the in-house therapist at one primary school, so yes it gets quite busy.

Although I cover all areas of the field I've developed some favourite areas. These are :

  • Autistic Spectrum Disorder
  • Down Syndrome
  • Aural Rehabilitation for children with cochlear implants
  • Cleft Palate
  • Acquired Neurogenic Comminication Disorders (aphasia, dysarthria etc)

These will probably be the primary topics for my blog, along with other aspects of communication development. I hope to share information and resources which I have found, tips from other professionals, as well as my own experiences and ideas on this site.

Read, enjoy, and learn. I hope that readers can also share their experiences with me. So here we go.