Lately with various kids I have been working with, I have been thinking less about what I am teaching, and rather how I am teaching it.

First off, before I jump on my soap box, this is not to say that what you are teaching is not important.  I have suggested in earlier posts that I do think there are better ways of teaching a child the sounds in the English sound system that others (e.g., teach later developing sounds rather than earlier developing sounds).

On the other hand, there are somethings like colors or basic concepts where I think, Wait, what am I doing? Not as in, Why am I teaching this? But rather, Why am I sitting here drilling them on this stuff? Isn’t this how they are being taught in the classroom?  The point is, I have the luxury of sitting down with him or her one-on-one. Shouldn’t I take advantage of that? Shouldn’t I be looking at how my patient learns best and try to teach them, if at all possible, through the method that works best for them?

Too often lately, I’m finding myself strapping them into a chair and showing them flashcard after flashcard. While increased number of repetitions of a skill is obviously part of how they learn (since they haven’t learned whatever skill after the same number of repetitions a typical child is exposed to), but shouldn’t I be incorporating how they learn into my skilled intervention as well? Where’s the creativity I had in grad school? (Or maybe that’s just the graduation goggles talking.)

A lot of my kids now seem to be tactile/motor learners. Time to bring out the scavenger hunts! The manipulatives! The crafts!  This giant mess for me to clean up between patients somehow…. (Sounds like a future blog post for how I will manage the chaos.)

Well, at least in baby steps. I can’t get all that together in one night. But it is something I need to be mindful of and begin to incorporate into my therapy.

What about you guys? How do you incorporate your patients’ learning styles into your therapy? How do you figure out their learning style? What type of activities do you do to incorporate these different learning styles?

So, I was doing some continuing education in FEES this past weekend. (Finding fun in sticking a small camera up your colleagues’ noses for two days.  Not sure what that says about me as a person.) It was a mix of speech-language pathologists working across of variety of (mostly) medical settings.

Nerd that I am, I liked to hear what it was like for each of them working across different settings. (Especially those working in long-term care facilities with trachs and vents! I mean, PEOPLE EATING AND SPEAKING ON VENTS???  I had an entire class on trachs and vents and my mind still  boggles.)

Anyway, in reflecting on the interesting information I had gathered about various clinicians’ job settings, I suddenly had a questions.

Q: Did I just miss an opportunity to network?

A: Yes.

Not necessarily in the job crawling sense (although if I were looking for a job, it would have been a good place to do it), but rather in a, Let Me Make Contact With People Who Know More About Certain Stuff Than I Do. Maybe the opportunity for me to do that was not particularly obvious to me because I already work with a good group of clinicians with whom I can ask questions. But that’s not true for everyone! And it’s also not true that everyone I work with happens to be an expert/have a lot of knowledge in a particular area that I have questions in. Not to mention if there comes a time in my life where I am looking for a new job. Wouldn’t it be nice to have some contacts in my back pocket?

The question is, how do I make that leap from chatting about my/their job/s to, “So can I call you sometime.” “Can I have your email address in case I ever have questions about X?”

Of course, not all of these SLPs were doing work that related to my current interests and activities in my own job (see also: people talking on vents.) But it got me thinking about future workshops or conferences I attend. Guess networking falls under one of my Top Goals of All Time: Being Assertive.

Does anyone else have thoughts on networking? Do you use it? How do you make (and keep) contacts? What do you use it for or have you used it for? How do you work exchanging contact information into the conversation?  Or is that last question an obvious sign that I am insecure and un-assertive? Guess I have a lot of work to do.

So.

The SLPing SLP’s (very own, very personal, heavily influenced by her graduate training) Definition of Articulation:

So, looking back at my definition of phonology, that…pretty much covers everything.

Basically, when I think of articulation, I think of a strictly motor or placement problem.  For example, I think of a lisp as an articulation problem. Also, if I child is still having difficulty producing sounds after around the age of five or five in a half (when phonological growth plateaus [see Shriberg & Kwiatkowski, 1994; Shriberg et al., 2994-a, -b]), I begin to see it as pretty much a motor issue.  The child has been mis-pronouncing a sound or sounds for so long that is has become a learned motor pattern.

This does affect my approach to treatment, because then I do treat initial, medial, and final position, and I do teach to sentence and/or conversation level. That’s because I am less changing a cognitive system, and more a (long-suffering) motor pattern.  Much harder to do!

(Where does that leave childhood apraxia of speech? Well, I guess that’s something to write about in the future.)

I think the importance in distinguishing articulation from phonology is how it affects treatment. Since I treat (most) my kids as having a phonology problem (how I define phonology), I only spend time teaching them the initial sound in words. (And yes, there is evidence to show that change occurs across the phonological system, by teaching certain sounds and only in initial word position, e.g., Gierut, 2001; Geirut, 1999.) It’s only when they are older and I see it as an articulation (learned motor pattern) problem, do I spend the time teaching it across positions and practicing it in sentences. Otherwise, I would feel like I’m wasting my own and my patient’s time (and insurance) by teaching all sounds, all positions, and all “levels” of production.

The SLPing SLP’s (very own, very personal, heavily influenced by her graduate training) Definition of Phonology:

As wacky as this week is going, I basically want to say: “Whatever is on those dreadful SuperDuper articulation and phonology cards is exactly what I think phonology is NOT.”

And then go read my book club book.  But then I like to think I take this blog a little more seriously than that.  So.

I agree with the ASHA that a phonological disorder is one where a child exhibits “patterns of sound error.”  However, I do not think of these patterns as the phonological processes that have been discussed and described in some areas of literature (final consonant deletion, fronting, backing, etc.; see Khan, 1982 in Language, Speech, and Hearing Services in Schools for an overview of phonological processes).

A pattern to me is when a child is omitting or substituting a sound or set of sounds consistently. While placement (e.g., backing) might be a noticeable pattern, so might whether or not the child is using manner or voice. I then examine these missing sounds and their features and use this to determine which sound or sounds to target.

Because I view phonology (and most the kids on my caseload with a sound/speech disorder) as a problem with a cognitive representation of the English sound system, rather than a strictly motor one, my approach to treatment is different from it is with articulation. If I have a child between the ages of three and four (maybe up to four and a half) with a moderate to severe phonological disorder, I will teach later developing sounds* in an attempt to change the entire sound system (because it is a system, isn’t it?  We have charts that show how place, voice a manner overlap, remember?), and I will teach only initial word position. No painstaking, long-suffering movement through syllables, medial and final positions, and phrases and sentences. Because I’m not trying to replace a learned motor pattern, I’m trying to replace a learned cognitive pattern, or, perhaps more accurately, teach the child something about the phonological pattern of English that s/he had not previously learned from her/his environment.

My definition of articulation is to come, and is much, much shorter than this one. (Yay! I can dig into my book club book!) What do you think of my definition? (That’s right! Now’s your chance to disagree with someone on the Internet!) How do you treat kids on your caseload for articulation/phonological disorders (depending on the definition you personally use)? Does your definition affect your treatment approach?

 

*The underlying theory behind choosing later developing sounds is that a more complex sound will result in generalization to less complex sounds. A good introduction to this approach to phonological treatment is by Gierut (2001) and can be found in Language, Speech, and Hearing Services in Schools.

Am I the only one who thinks there is confusion on this? While I think I have a pretty solid definition in my mind about what I mean when I say “phonology” or when I say “articulation” I get the feeling that in the field there is some general confusion or blurring of lines between the two when I talk to other clinicians. (And I’m not even adding in the confusion I see regarding childhood apraxia of speech into this.)

According to ASHA (on this page): “An articulation disorder involves problems making sounds. Sounds can be substituted, left off, added or changed.”

Also, according to ASHA (also on this page): “A phonological process disorder involves patterns of sound errors. For example, substituting all sounds made in the back of the mouth like “k” and “g” for those in the front of the mouth like “t” and “d” (e.g., saying “tup” for “cup” or “das” for “gas”).”

Well, that doesn’t really clear it up.  Let’s recap:

  • Articulation: sounds can be substituted
  • Phonology: for example, substituting all sounds made in the back of the mouth like “k” for “t”
  • Articulation: sounds can be left off
  • Phonology: final or initial consonant deletion anyone?

The slight difference between the two definition appears to be in how they start.  An articulation disorder is “problems making sounds” (but not to be confused with childhood apraxia of speech?) while a phonological disorder is “patterns of sound error.”  The articulation disorder definition sounds like a motor problem (the way your lips, tongue, mouth, whatever move to make a sound). The phonological disorder almost sounds like a cognitive representation, i.e., a child is missing a sound or set of sound representations in her/his head and thus makes consistent errors such as replacing /t/ for /k/ or /b/ for /ʃ/or /θ/.

Agree? Disagree? Do you have your own definition of articulation and phonology?  Do you not distinguish between the two at all?  How does it affect how you evaluation and/or how you treat? Why is there this confusion between the two?  Should they be differentiated in the first place?

I do separate them and it does affect how I approach treatment. But that’s a looooong discussion that I plan to break down into several posts. If anyone else wants to chime in, I’d love to hear it.  My perspective is heavily influenced (of course) by what was taught in my graduate school curriculum. I would be interested to hear what others have learned through their own graduate school curriculum and/or reading from the literature.

This week has been a frustrating week. To put it mildly. (Which is why there wasn’t a post last week. Sorry.)  So, I will take time to talk about something that has been frustrating me recently in my out-patient therapy.

It’s where my history in child care and my odd obsession with environmental modifications collide.

(Short disclaimer: I am pretty satisfied with the set-up at my out-patient clinic. This is a general frustration that I don’t have any suggestions to fix it. So I don’t really expect it to change, nor do I necessarily require it to change. It’s just something I’ve been thinking about.)

All day long, while I’m at out-patient, I dream of turning each individual session into Montessori-style language pre-school that lasts for under an hour. Yep, I’m clearly living in a fantasy world. Well, and to be honest, not all my therapy needs to be language pre-school style.  I still shudder to recall trying to do articulation therapy in the language pre-school at grad school.

But for very young children who are expressively and/or receptively delayed, or children who are on the autism spectrum, I can’t imagine a better way to address these goals. A small kitchen for us to play with and a table to sit and eat at. A real fridge we could walk to, open, and choose food or drink. An outdoor space with a playground where we could move around and practice verbs, or functional requests the child may use at school or at home. Hell, I wish we could go to the grocery store and practice learning the names of common fruits and vegetables that way.

I do try to come up with specific activities to give my parents to practice language skills at home, but I can never be sure how it’s going. Plus, speaking from personal experience, I always learned more when my graduate supervisor would demonstrate the technique than necessarily trying to tell me how to do it. (Guess it’s time to somehow institute a Hanen program.)

So then, is the very way an out-patient clinic structured make it too inflexible to accommodate all types of patients? Of course, we all tailor our goals and our approaches to our patients, but is there a certain rigidity that can’t be overcome in an out-patient setting? (And let’s not even get into how insurance probably would not support any slightly unorthodox approach to treatment.) All I know is that I have a few patients where I find the confines of the out-patient setting deeply frustrating. Time to get creative.

A commenter (<3) wondered if I had any tips/advice/warnings for anyone beginning their CFY. Crickets. What was I doing this past year? Do I know what I’m doing now?

Okay, well maybe.  A little.  So I thought about it for a while. Quite awhile. But this is what I came up with.

  • If you’ve had a break between the end of grad school and the beginning of your CFY, brush up on your knowledge of whatever area of SLPing you’ll be doing. I brushed up on my childhood language knowledge, but ended up neglecting my dysphagia knowledge because I felt more confident about it.  I really should have done both.
  • You just graduated.  You learned a lot in the last two years.  But you just graduated. I find this field highly experience-based. Try to accept your failures and lack of experience with as much grace and self-love as you can. You may notice this is on my Goals list. I put a lot of pressure on myself (I’m sure I’m not the only SLP who does this!), but in reality, you’ve still got a lot to learn.  And that’s okay.
  • Try not to panic.  Okay, really, that’s useless advice because we’re all going to panic. But try to manage your panic as best you can. I think the majority of times I made myself look like an ass in my CFY was because I was in a blind panic.
  • Other people don’t expect you to know everything either. (If they do, they have incredibly unfair expectations and you should ignore them as much as possible.)
  • Ask a lot of questions.  If you are working with other SLPs, ask! If you don’t have a nearby SLP to ask, either email past supervisors or get on one of the ASHA boards for the special interest groups. These are excellent places for people to share and ask ideas. There are probably other online boards for you to visit as well.
  • Research the questions you have. It’s always handy to have someone to ask, or who can point you to a particular resource or resources to look at. But don’t forget the importance of finding research-based answers to your questions.
  • Continue adding to and expanding your own materials and resources. Unfortunately, you will still encounter situations/patients where you will think “If I had X….” These will usually occur at inopportune times where you will scramble and sweat to get the resource/information/activity done for a particular situation/patient. If you do have the time, consider spending a morning/afternoon/day/whatever trying to anticipate what types of information/materials you might need for your particular job setting and spending the time making them.  If it is handouts with information about something for patients or parents that you complied and ordered by yourself, make sure you put your name with your ASHA CF and maybe the year at the bottom corner. You worked hard to put that information together, and the credit shouldn’t end up with someone else. Alternately, if you borrow something specific or very closely from a particular source, make sure you credit that source, or note that it is adapted from a particular source.
  • Advocate for your patients. It can be intimidating to confront people who you think (or are) in a position of power, but when it comes to patient care, it’s very important. The department in which I work has already established itself, so there is not much work for me to do in this area, but I realize not every one is that lucky.
  • Advocate for yourself. I suck at this.  Really suck. (This is because it goes under the broader category of “assertive,” which I also suck at.) If you need something to aid/improve your work performance, ask for it.   Keep cards that patients give you telling you how awesome you are. Keep copies or evidence of presentations you have given. Keep copies or evidence of anything that you think shows all the work you do and/or how well you do it. When you do something awesome, write it down so you don’t forget and can bring it up later at your yearly performance review.

Anyone else have advice?  Comment!

I think about this a lot.  A LOT. In fact, I probably spend waaay too much time thinking about this. But I think people’s jobs/lives/general awesomeness could be improved if the immediate environment was designed to actually help us out.

I started thinking about this back in undergrad when I worked for a daycare.  One of my fellow “student teachers” (our Official Job Title) was studying early childhood education and had a real interest in how the daycare was laid out to benefit both the teachers and the children.  She pointed out a few things to me.  And then it was like a revolution: EVERYTHING EVER could be made simpler if the environment was altered to a purpose.

So that’s obviously an exaggeration. But that’s what it felt like.

I think about my out-patient surroundings a lot.  Probably because I have the most control. (Sadly, a brand-new hospital is not going to be built just because I think there are some improvements to be made. Ha!) I also think about it a lot because it plays a large role in how I manage my kids in therapy.

1. To make a room seem smaller, put an object, like a table, in the middle of the room. (Yes, even a small table. I have one of those [wretched] tiny, square activity tables for children. I placed it in the center of my [hunormous] room to prevent one of my [rambunctious] children and it [magically] mentally cut off half the room in that child’s mind, making my job much easier.  And much less exhausting.)

2. Lock them in that damn chair. (No, not a Rifton chair.  Yet.) Seriously.  Push that table and chair up against a wall if that’s what it takes.  Don’t get me wrong, most of my caseload is three years old and younger and getting them to focus for a full session while sitting in a chair is unlikely (but not impossible), there can still be a time for sitting.  And if that child must be corralled and cornered into a chair to accomplish that, then so be it.

3. Remove all visual distractions from behind you.  Or, whatever the child is facing while strapped into sitting in a chair. Unfortunately, this is not something I can really control in my current therapy room. Even when I have a kid strapped into sitting in her/his chair working on an activity, on the far opposite of my hunormous room, carefully guarded by my desk, a trashcan and two chairs (don’t ask) lies an open shelf with a few toys on it. This inevitably leads to pointing, requests, whining, and at times my herding them back into their chair.  I mostly keep it clear or keep dysphagia materials on the top-most, easily seen shelf…but sometimes I slip up.

4. Get rid of that mirror hanging from your door.  Who invented that? Someone who hated speech-language pathologists? Someone who has never encountered a small child? Some people may disagree, but I loathe them. I know mirrors have their place for articulation treatment, but why why why would you want one hanging on your wall when you can just as easily have a small one that you could pull out when you need it.  I can’t tell you how many children will distract themselves by making faces and putting their mouth on it.  Yuck!

5. Invest in some stop signs.  Well, not real stop signs. (Disclaimer: I am not inciting anyone to go out and steal government property, i.e., your local stop signs.) Just make some.  You can even be lazy and make them circle or square-shaped instead of the classic hexagon. I always try to put one on my door so that my kids have to request (at their language-appropriate level) to open the door before we leave. Put it at their eye level. (Fun fact: I cannot draw straight lines when using white-out to make the edges of my stop signs!)

6. Keep things out of sight. Or not. This ties in with number three.  Most of my toys are actually in our shared toy/game room, but I also have some in a closed metal cabinet. They are out of sight and my kids can’t be, well, kids and try to distract themselves and me.  Somethings I have laid out where they can see, either because I’m showing them what we are going to be doing, or so that they can see and not touch and practice requesting items.

7. Keep things out of reach. Or not. This also ties in with number six. Sometimes I want my kids to see things but have to make a request in order to get what they want. Other times I want them to pick one of the games I selected, and feel they have a measure of control in the session, so we can jump right into a good ol’ drill-play routine.

8. Be careful of your room size.  Again, this depends on the age and temperament of your patient. With really small children where you might be doing more play based therapy, you obviously want room enough to play. On the other hand, you don’t want to spend half your time chasing them around and not actually doing any therapy. Obviously, we can’t all control our room size.  I sure can’t.  But I moved things around a lot in my room to try to make it do as much work for me as possible.

9. Clean hands! There should be hand-sanitizer containers either right outside or right inside the room.  Keep everyone germ-free!!! Or close to germ-free!  My problem?  I’ve got to be more consistent having both myself and my kids use it first thing. Guess I need a STOP: HAMMERTIME WASH YOUR HANDS sign for myself.

Those are ones I have worked through in the past year. There are probably more. I always wonder: are there studies for things like this?  For therapy rooms/clinics and/or hospitals that show the proof of environmental modifications in aiding better outcomes for patients?

TodayIwill

TheListofKickingAssandTakingNames

A List:

  1. Clinical ladder!
  2. Increasing my knowledge of dysphagia
  3. Keeping up with cognitive and aphasia therapy evaluation and treatment techniques
  4. Organizing both my work places and myself so that I am not running around like a chicken with its head cut off
  5. Continue to push for therapy reimbursement guideline changes
  6. Research therapy for children with autism
  7. Do something related to education that relations to my profession (this goal needs to be more specific)
  8. Accept my failures with more grace
  9. Do not panic in stressful situations.  Stop.  Think.  Taking a moment is better than panicking.

I thought there was more than this. But this isn’t a permanent list. I give myself permission to change it as circumstances change, opportunities change, and I change.

I’ve been meaning to come back to this.  At first I was just to busy. (I got a job at a hospital!) And then I didn’t know what to write about. (People who blog about their jobs get fired from their jobs!)  I’m not sure I know exactly what I will write about, but there are a few ideas bouncing around in my head.

But for now, some thoughts on (greater than) one year past graduation and just past CFY.

1. It was (un)surprisingly a lot like grad school:  I felt very, very focused, but I also felt like a very, very hot mess.

2.  I asked a LOT of questions.  All the time.

3. I am never going to stop learning!  (Happy face!)

4.  I am never going to stop learning.  (Sad face.)

5. I love what I’m doing.

6. What in the world am I doing???

7. Fall down six times, get up seven.

8.  Ow.

Now, a year out, I am feeling unfocused.  I’ve lost the momentum of panic.  Now I have some measure of control; some understanding of the pattern of work; a very little bit of experience to look back on.  That’s a strange feeling.  The past three years have been a headlong plunge into the unknown with a tiny penlight that kept shorting out. And now I have the surprising luxury of taking some control of the direction of my life.

That is an incredibly empowering feeling.  And an incredibly terrifying one. What do I want to do this year?  What can I realistically accomplish over the next year?  I’m not sure, but I aim to find out.

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