Early Intervention Speech Therapy

Interview with Helen Vadala, MS, OTL: Part 2

This week is the second part of my interview with Helen Vadala, MS, OTL, an occupational therapist working and supervising in both the homecare and preschool settings in Delaware County in Pennsylvania.

Our discussion continues as we look at the recent changes in homecare and how budget cuts are affecting early intervention, as well as the ever-growing need for speech-language pathologists. Please see the first part of our interview, which was posted last week.

Steph: If you could summarize, what do you feel are the main changes taking place in early intervention homecare?

Helen: There are three main changes: no equipment is to be brought into the homes; working within the natural routines of the family; and consultation versus direct therapy. 

Less hands-on therapy is being provided and much more information sharing is occurring. This has good points and not so good points. Early interventionists are not permitted to bring in their own equipment. This stretches your skill set, as you can no longer control the environment in which you are expected to make the change. The therapist must use what is in that environment if they are going to model for the parent. For well-stocked homes, this is not so much of an issue. For our more socio-economically challenged families, it is a little trickier.

And think about the use of specialized equipment we need, like vibration for oral stimulation or therapy balls for trunk control - simulating this with what is in a home may be more challenging. Also, you lose what I call "The Barney Bag Affect" - the novelty of your activity or new equipment motivates the child to engage in a challenging task. If you use what they have, motivation may be a little harder. However, while it takes innovation and a shift in mindset, when you do use what is already there, the benefit is huge. Caregivers can easily follow through with the suggestions made. They feel competent and are more open to trying what you have suggested.

Secondly, working in naturally occurring routines can present scheduling difficulties. For example, if bath time is the challenge for a family, perhaps due to the sensory differences of their child, it is not always feasible to go at 8:00 at night when it is naturally occurring. So you must discuss the issue, which requires good interview skills or perhaps simulate it at another time. The benefit once again of assisting in a natural routine is that it is real and changes can be made in the real-life setting. Modeling within the context of the natural routine makes much more sense to a family than to fabricate a situation and ask them to make the jump to the actual challenge they are experiencing. 

The third change, the mindset of consultation versus hands on therapy, is perhaps the most challenging for me. As a therapist, I am hard-wired to do the actual work. I have been trained to feel muscle tone, to handle a child to grade their movement, to facilitate the grading of an activity to promote optimal performance, to use my hands in providing sensory input to calm or alert a child's nervous system, and so on. So to do so through a caregiver is very challenging for me. Once again, it stretches my skill set to the max. I must be able to articulate what these things look and feel like to a caregiver. I must shift my focus from "teaching" the child to "teaching" the caregiver. This is hard. But as I have stated in the other two challenges, when it goes well, solid change is promoted. The caregiver is able to take the lead in their child's growth and, after all, they are the ones there 24/7.  

Consultations with other professionals are also becoming more the norm, rather than adding and layering services in a home. For example, if, as the OT, I am the only service provider and speech issues arise, a consultation with the speech therapist is provided rather than direct services. This too can stretch my skills, as I am now responsible for implementing and monitoring these suggestions. The caregiver and I must implement strategies that are outside of our areas of expertise together, which is challenging to say the least.

The benefits to this model of professional consultation versus layering of services is that the primary treating therapist already has established a rapport with the family, the family has less to manage logistically as it minimizes the number of persons in their home, and it adds to the treating therapist's "bag of tricks."

Steph: We all know there have been major budget cuts in many areas of education. Do you see these cuts affecting homecare as well? How so?

Helen: Steph, in today's economy, fiscal challenges are everywhere, including homecare. While early intervention special education (preschool and infant/ toddler) was spared in the last round of Pennsylvania state budget cuts, the push for fiscal responsibility is strong, as it should be in today's challenging fiscal environment. As dollars become tighter at both a state and federal level, fiscal responsibility becomes more important. We in EI are competing for a shrinking pot of money and must be willing to stand up and say, "Yes, we are a needed and valuable service; we make a difference." The ripples of this are twofold: prove your efficacy and effect change with fewer resources.

The impact of proving efficacy is the need for better data and tracking of progress.  To the everyday clinician in the field this means no more general "warm and fuzzy" record keeping. It means real hard data: tracking progress through measuring against established goals. This has been a shift in this system and created much angst for clinicians, as we are working with families and relying on them to provide this data to us. We are only there one time every week or one time every other week, which is challenging to say the least for both families and clinicians. Let's face it, if someone said to you, "Write down every new food you try for two weeks and show me when I return," well, that is a bit out of the ordinary in everyday life. That is to say, the meshing of family-driven goals that are executed within a naturally occurring routine and hardcore data keeping can be tricky. Once again, ultimately it assists us as clinicians, who have such a small window of observation with our clients in the homes to gather more information on which to base our service plans. Better data also allows us to provide information to our funders (state and federal) on the changes we make in the lives of the young children we service, thus justifying the cost. However, capturing this data is not easy in a family driven, home-based system. But we are working on it.

The other impact of tight dollars I mentioned is effecting change with fewer resources. As monies are tighter, greater oversight of resources occurs. In EI, this translates to spreading out resources so more children can receive services. Therefore, whereas five years ago a child may have received occupational, physical and speech therapy as well as sensory integration, now they may get one or two of those services. This creates an environment where early interventionists must expand their skill sets to work across areas of practice. So as the treating OT, I must also address areas that may not be in my usual domain, like communication. Or as the SP, maybe motor development. The professional consultations I mentioned earlier assist this. It enlarges your skill set and makes you a more efficient and effective therapist. However, for newer grads, it could be overwhelming. Children in this age range (0-3) are just developing skills and they are not as differentiated yet, so a transdisciplinary model works. As children develop more skills, more differentiation in services must also occur. I think while it is sometimes hard to explain to families why we are crossing professional boundaries in EI, it ultimately makes it easier for the family as they are not having so many professionals in their homes. So logistically it is a little easier to manage for them.

Steph: I know that there is a tremendous need for speech-language pathologists. Is not having an SLP hindering your places of employment? How?

Helen: Over the 20+ years I have been working in EI, "in demand" disciplines have shifted. SLPs have always been in the higher demand category. And most definitely, Steph, we need SLPs in all three of the programs I am associated with right now. At Elwyn, we have been without an SLP on our infant/toddler team for almost two years! This is not a good thing for team programming for our kiddos - it is a crucial piece of the puzzle missing. I highly value a team approach to services, and find the absence of an SLP to be disturbing. The skills SLPs bring to the table are invaluable in the work we do with young children. Communication, language and feeding skills are just beginning to develop in the infant/toddler population, and when there is a deficit in one or more of these it can be devastating to the child and the family. In fact, social communication is crucial at this stage of development and the absence of this impacts all areas of learning for a child as they grow. If a child is to learn, they must attend to and communicate with the adults around them.

Many of our children enter EI because they are delayed in their language development. Infant-maternal bonding also relies heavily on this social communication piece, so when a deficit is present, it can negatively impact the way a caregiver responds to their child. And feeding your baby is instinctual and fulfilling to a caregiver. When there is a feeding issue, it creates feelings of inadequacy in caregivers. This sets up negative interactions and very stressful situations. Not to mention that feeding issues can create life threatening situations for the children themselves.

So, yes, SLPs and what they bring to early intervention infant/toddler services are invaluable, and missing that piece on our teams is crushing. 

Steph: Helen, I think this is the perfect time to provide your contact information for our SLPs and readers who are interested in working in the homecare setting. How would you prefer readers contact you?

Helen: They can call me on my cell phone at 610-308-7198. I can also be reached via my personal email at vad6@comcast.net. I love working in early intervention and find that there is no better time to effect a change with a patient than when they are developing the skills. We have been looking for SLPs consistently for several years now, so I welcome the opportunity to speak to therapists who may be interested in working in homecare in Delaware County.

Join us next week for the final part of my interview with Helen, as the discussion moves to the preschool setting and the challenges and successes of early intervention at the 3-5 year old level.