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Early Intervention Speech Therapy

Addressing Reader Issues, Questions and Concerns

Published July 27, 2009 2:41 PM by Stephanie Bruno-Dowling
A Message to Readers:

Recently, more and more readers have been commenting on the blog and have also been sending me personal emails asking for advice and guidance regarding various populations and disabilities. I absolutely love the feedback and I think the networking that has occurred is invaluable. What I am attempting to do in order to answer as many emails/comments as possible, as well as continue to generate discussion, is to use various inquiries to create posts around the issues that are in question.

My goal is to serve the readers and our profession in the best way I can, which is to connect parents and therapists involved in the EI process. As I stated back in October 2008 when the blog first began, my "hope is that as this blog develops it will become a touchstone for both therapists and parents in search of the delicate balance between educating the mind, strengthening the body and liberating the spirit of a child with special needs".

Thank you for helping to make this hope a reality.

Below are several questions from readers that have been sent to me in recent weeks that I wanted to impart to the public.

Please share your thoughts, comments and expertise with your fellow therapists. Future blogs for August 2009 and beyond will also address many of the topics highlighted below:

  • I have been working with a 2 year old girl w/ Cytomeglovirus for about a year. She presents as a child with severe CP. She has limited limb movement, a feeding tube, and has difficulty holding her head up. She vocalizes randomly and occasionally produces a consonant. I think that I am doing everything I possibly can with her (Beckman Oral motor, bubbles, eye gaze choice from field of 2, cause & effect toys, vowel production w/ accompanied gestures, etc), but would love to hear ideas from any of your readers.
  • Can anyone help me make a decision about the use of "oral motor therapy (OMT)" when ASHA's stance is that there is no valid research that supports using it? I want to do the best possible therapy for all the children I serve but I'm confused that I'm still hearing about OMT when our national office doesn't support it. Same holds true for sensory integration. There is an OT in the area who has had amazing results working with children on my caseload who have severe autism. Although she has offered to train me at no charge (brushing, swinging, pressure, etc.), I am reluctant to go there as again, ASHA does not approve it and I don't want to end up getting sued for "doing it wrong." Thanks.
  • I'd like to see you address the role of the ST as a support/resource person, as counseling is one the primary things our therapists do (in EI).
  • I would like to see you talk about (especially for new EI therapists) the devastation and grieving process that families go through when their child is given a diagnosis.

11 comments

Thank you for your suggestions, David!  She is hearing-impaired and is checked by an audiologist at regular intervals.  She wears HA in both ears.

I do use switch toys w/ hand-over-hand assist to operate switch.  She seems to like most of these, but some startle her.

Bubble machine is great idea.  She loves bubbles!

Best,

Cheryl

Cheryl, EI - SLP August 13, 2009 12:46 PM
Richmond VA

1.  We have lost two adults with DD in our community this summer and the heartache among us all is unbelievable.  In a small community such as ours we see our clients at the grocery store, etc.  This is a big topic for be as a therapist right now.  I am able to spend time with my families who have had nothing but therapists come into their homes for 30 years and now nothing...another family waits for the fate of their toddler   with Otohara's (sic)syndrome. We therapists must also take care of ourselves so we can be strong for our families.  Don't forget about some counseling for yourselves or maybe a few days off.  As an old timer, I try to coach my younger therapists on how to approach a family who has lost or is losing a child.  Funeral services are important to attend, a phone just to say I'm so sorry, take a pie, a visit after wards when everything surrounding the death has subsided.  Adelaide

Adelaide Simpson, SLP - SLP, Rainbow Road therapies, Inc August 9, 2009 11:59 AM
Las Vegas NM

YES!  My Husaband (also an SLP) both support SLPA's.e need more and think SLPa'S are great to carry out therapy.  I am an owner of a wonderful clinic and have not found out how to get reimbursement.  A

Adelaide Simpson, SLP - MS CCC-SLP, Rainbow Road therapies, Inc August 9, 2009 11:40 AM
Las Vegas NM

Elise, I just started at an office here in Tampa as a SLPA. I just graduated in May decided to take a year to work and save some money. I also had hard time finding any sort of listing for SLPAs so I asked my professors if they new of any offices that may be hiring but didn't really get a helpful answer there. They did say that I could work in the school system, but it was unsure how much supervision I would receive (didn't really like the sound of that). I didn't really know what else to do so I googled SLP offices in my zip code and started calling around. It may be that because I am in a large city that I was able to find a position or it may have been luck. I replaced another SLPA that is going into grad school so maybe it is the right time of year.  I hope this gives you a little hope in your job hunt, I know it gets frustrating. Good Luck!

Ashley, SLPA August 3, 2009 10:53 PM
Tampa FL

Dear Elise,

I am unaware of any practicing SLPA's in Pennsylvania at this time.  Early Intervention would not allow for it - as a matter of fact, in PA, a brand new SLP on their CF is considered a Special Instructor (and billed at that rate) until they are licensed.

Your best bet at this time would probably be school districts in the South.  Larger schools that require more that one SLP would provide an opportunity for you to manage a caseload with an SLP on site for supervision.  

Tracy Cowles, SLP - Owner, Next Step Therapy August 3, 2009 10:10 AM
Seneca PA

I have a general question:  Are there any SLP's that support the use of SLPA's in their practice?  I have had a rough time finding many job opportunities listed anywhere in the country, where I would happily choose to live and work.

Elise Porter, SLPA August 2, 2009 4:06 AM

Great suggestions.  I have a couple other thoughts about the child with CMV.  First, I assume that her hearing has been tested thoroughly and recently.  I have had other children like this who lost their hearing gradually over the first two years.  It wasn't until they had fairly severe losses that we really became aware of the issue.  Don't assume that because (if) she passed a newborn hearing screening she's good until school age.

Another thought.  You mention that you are working with cause and effect toys.  Some switch-operated toys would also be a very good thing for a child like this -- they take much less in the way of motor skills.  (I didn't know if you were using them or just non-electric toys).  I've had really good results with bubble machines (bubbles seem to be magic for kids, as they are for me!)

I agree with Penny's comments about SI and oral motor.  The ongoing debate about the effects of oral motor therapy on speech articulation seems to me to avoid the issue of children with specific motor impairments like cerebral palsy.  I have used the Beckman approach and seen good results with several kids, when the parents carried through.

Likewise with SI treatments.  I went to a workshop with Pat Wilbarger to learn about SI -- it was fantastic.  I'd encourage any SLP working with young children to learn more about it.  I don't do a lot of specific SI treatments in my therapy, partly because I'm not sure I can bill for it.  I do use the approach a lot, however.  Having a good grounding and basic training in SI techniques is just another tool in our professional repertoire.

Thanks for the opportunity to comment, Stephanie.  I'm sure that this blog takes up a lot of your time, but it is sure useful!

David Harper, B-3 - SLP August 1, 2009 6:42 PM
Superior WI

I am very happy to  learn that sensory integration will be listed as a disorder in the next DSM. As numerous people have already stated  it is  important to be flexible, and incorporate bits and pieces of different  strategies.

Would like to hear more comments about oral motor therapy.  I have decreased it the past year since it has become so "controvertial".  

Still have found it very helpful for children with low muscle tone and tongue protrusion (Down Syndrome, certain neuromuscular disorders).  I have noted increased intelligibility, by reducing tongue protrusion, strengthening jaw, improving ability to make dissociated movements of tongue lips and jaw. Also helpful  with numerous cases  where child displays oral posture: retracted lips and a fixed jaw position.  

I always do intensive training of sound production. I love my articulation flip book for C.V. production and practice of varying CV  production. Also Kaufman speech praxis workbook.  Geri, SLP

Geri , , SLP homecare 0-5 August 1, 2009 11:05 AM
Westchester NY

I am very happy to  learn that sensory integration will be listed as a disorder in the next DSM. As numerous people have already stated  it is  important to be flexible, and incorporate bits and pieces of different  strategies.

Would like to hear more comments about oral motor therapy.  I have decreased it the past year since it has become so "controvertial".  

Still have found it very helpful for children with low muscle tone and tongue protrusion (Down Syndrome, certain neuromuscular disorders).  I have noted increased intelligibility, by reducing tongue protrusion, strengthening jaw, improving ability to make dissociated movements of tongue lips and jaw. Also helpful  with numerous cases  where child displays oral posture: retracted lips and a fixed jaw position.  

I always do intensive training of sound production. I love my articulation flip book for C.V. production and practice of varying CV  production. Also Kaufman speech praxis workbook.  Geri, SLP

Geri , , SLP homecare 0-5 August 1, 2009 10:59 AM
Westchester NY

Thanks for the suggestions Penny!  I should've added that she is 26 months old and is cognitively low (imitation abilities are very limited)

Cheryl, Early Intervention - SLP July 31, 2009 1:58 PM
Richmond VA

#1 On the child with Cytomeglovirus, because she has limited physical mobility, you may need to help her experience things her body won't seek to experience, like putting things in her mouth to check them out, feeling the softness of the stuffed bunny, etc. For vocalizing, positioning is key. If she is still having difficulty with head control, then I would expect OT/PT to be working on positioning/seating in some sort of transport device. We tend to have the best breath support while standing or even while sitting upright with everything lined up or slightly forward. If you can get that sort of postioning-even head stabilized midline would help greatly. Sounds as though you are doing a great job! I've got a similar case right now. If the goal is also for oral feeding, you'll have lots of oral stim necesary to desensitize and prepare this little one for what's coming!

Question 2-oral motor. There is no research that supports the use of oral motor exercises for speech. There is evidence in favor of it for swallow or other oral functions. For example, if you have a child with tongue thrust, they must practice to make the tongue placement changes. It's more of an oral motor retraining than exercise.

 Sensory integration techniques are like any other strategy for kids with Autism. One size does not fit all. I have seen lots of kids who do extremely well with brushing, joint compression, massage, etc. and others who cannot tolerate it or it has no effect or it is no longer effective. There is currently no solid research that supports those things because the kids with Autism vary so. However, in 2010, SI is supposed to show up in the DSM as a diagnostic category. Let's say you try allowing the child to sit in a wrap swing and it settles the child down so the child can attend for the next 20 minutes. Should you use that strategy? YES! Keep in mind, though, that with our kids with Autism, what works today may not be effective tomorrow or even 30 minutes later, so you have to be flexible and ready to try another strategy. I have one youngster who responded extremely well to pool therapy. He was focused for much longer periods of time and I felt we were making great headway. The mom stopped taking him and it was like a tornado hit all over again! You know what I mean?!

#3 Yes, we do tons of counseling and many times cannot provide the service we have come for because we are helping the parent deal with such basics as food, shelter and clothing. It behooves us to take some counseling classes, know the local resources and have phone numbers pre-programmed. That said, also know your limitations. It si critical to know when and how to get someone hooked up with a professional in that area.  For example, I went on a visit and the mom was crying and beside herself. The Dad was abusive and was kicking her out of the house with the 3 kids and HIS mother THAT day! We got her hooked up with housing and mediation...we took care of immeidate needs. If mom is crying, the child is not going to be focused for a session and neither is mom.

4. I wish grad (or undergrad) programs would offer a course in death and dying. SLP's do not expect to face this when they are new to the field, but it happens to older folks and youger and those in between. I was fortunate to have taken some courses undergrad in those areas. When a parent gets a tough diagnosis, they will go through the Elizabeth Kubler Ross steps of grieving. There have been others who wrote similar steps, but hers are the gold standard: http://www.recover-from-grief.com/kubler-ross-stages-of-grief.html

I have a family who recently (this month) received news of a terrible diagnosis. First and above all else, LISTEN. I am helping this mom right now deal with some of the issues that go with the diagnosis. For example, they received news that the medially handicapped chidlrens program will not pay for therapy after their nsurance runs out. They are receiving school therapies (educationally based) and hospital therapies (medically based). The school stuff is free, of course. Their insurance will pay for only 60 visits at the hospital. Then they are "out of luck." I am helping her to compose a reconsideration letter to the MHCP program, getting letters of support from the therapists/doctors and researching other funding options. It's sure not in my job description. It really doesn't matter if she doesn't get approval (we'll try at least twice) because there is another funding source who has agreed once her insurance is gone. She doesn't trust it yet, so we must wait until she has reached the point in her grieving to decide to trust it. Put yourself in the parents' place and think about what you might want/need in terms of support and then do it, if you possibly can.

Penny, SLP July 31, 2009 10:25 AM
NE

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About this Blog


    Stephanie Bruno Dowling, M.S. CCC-SLP
    Occupation: Speech-Language Pathologist
    Setting: Early Intervention in Delaware County, PA
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