Stephanie: Can you give some concrete examples of useful techniques parents and therapists could use to work with children under the age of 3 who are completely non-verbal and are struggling to make/imitate any sound or oral movement on command. I find that these kiddos are often some of the most difficult to help as an early intervention therapist.

Sharon: Obviously, you have to start where that child is and take into account what they are bringing to you in regards to attention, behaviors, maturity, etc.  There is nothing different about that than working with any really young child.  Secondly, it is unlikely that many children are diagnosed younger than say age 2 or so.  Typically we see children getting diagnosed closer to age 2 ½ or 3 years old.  However, if CAS is suspected, you can begin to bring into therapy that understanding of principles of motor learning to the greatest extent possible.  What I'd like to do is bring to your attention an article on our Apraxia-KIDS website called, Apraxia: Speech Therapy and Treatment for Toddlers and Young Children. There are many concrete ideas included from various experts that may give you and your readers new ideas about engaging younger children.

Stephanie: Since our last interview, which was a year ago this month, is there any new information, research and/or resources regarding apraxia that you have acquired and could share with readers?

Sharon: Thanks for asking!  One major thing to mention is that CASANA's 10^th anniversary is this year!  We are having our Annual Childhood Apraxia of Speech National Conference in Pittsburgh, PA (our "hometown") from July 7-10 and it is going to be extra special to celebrate our anniversary.   I encourage any interested folks who might want to present a session at the conference to fill in our Request for Presentation form and submit it by January 31, 2010.  To keep abreast of what is going to be happening at our conference, this is our main conference online headquarters.

Last fall nearly 2,500 walkers not only raised awareness about childhood apraxia of speech but also raised over $200,000 through the 2009 Walk for Children with Apraxia in support of our programs and research.  As a result of this amazing response and effort we are able to continue funding our Apraxia Treatment Research Grant program; will be implementing some new research efforts; are expanding our training, educational and multimedia tools on childhood apraxia of speech for parents and professionals and much more.  In late winter and early spring we will be revving up for the 2010 Walk for Apraxia.  We are very excited about this year and hope that you and your colleagues and readers will visit us often to see what is new.

I would like to thank Sharon publicly for her incredible devotion to helping children with apraxia and for taking the time to participate in this interview. I feel the information she provided is invaluable for therapists, parents and children dealing with CAS.

Please continue to share your thoughts, questions and feedback regarding this interview and your real-life struggles with diagnosing, treating and living with CAS.

This is the topic discussed below in the third part of my interview with Sharon Gretz, MEd, the founder and current executive director of the Childhood Apraxia of Speech Association of North America (CASANA).  In today's post, Sharon outlines what therapists should do when treating a child with apraxia but not making appropriate progress:

Stephanie: You and I had chatted over email a few months ago and you mentioned that if SLPs are treating apraxia and are not meeting with success, they should not allow therapy to continue on and on. I completely agree. In your opinion, what are the questions and issues parents and therapists should look at if the current therapy is not effective?

Sharon: First, there obviously is no "guaranteed" outcome for a child with apraxia of speech. But we have seen over the last decade that CASANA has been in existence that many, many, many children can learn to speak quite well and be entirely verbal and intelligible if given early appropriate therapy and enough of it. 

What does "good progress" mean?  Let me ask you if, after six months of speech therapy at the rate of two or three or four times weekly, your child had two additional phonemes that they were capable of producing or could approximate two words, would you consider that the therapy was working?  I don't think so.  Let me be clear as I was in the last interview that we did together - this is tough stuff.  These children take a great deal of effort from the SLP and the children themselves expend incredible effort, especially early on.  It is not easy, but two phonemes in six months?  Several new word approximations over the span of 6 months?  That rate of progress should be questioned, I think.  We should not settle for this without examining what is occurring.  Instead, we should ask some key questions, such as:

• Is the diagnosis correct? Does the child REALLY have apraxia of speech?  Are we pretty certain after working with them for 6 months?  There have been more than a few occasions in which we have helped families get connected for second opinions only to learn that in fact the child's biggest issue is pretty significant dysarthria or previously undetected structural issues, not apraxia.  Also, remember that CAS is both overdiagnosed and underdiagnosed.  Children are being given the diagnosis when in reality it is likely that the child does not truly have apraxia, and, children who probably really do have it, are not being diagnosed.
  
• Is there something else beyond apraxia going on that is interfering with progress? Does the child have, for example, significant attention issues; behavioral issues; health issues; family issues and so on that may be interfering with their ability to benefit from speech therapy?  As an example, a child with obstructive sleep apnea may be getting insufficient sleep and thus is constantly tired and unable to fully benefit from therapy.  Or, a child who is so distractible that they are totally unable to attend to the clinician's face in order to pick up on salient cues to articulatory placement or verbal cues and may not be benefitting entirely from the speech therapy process.
  
• Is the frequency of therapy sufficient for this child? Is the child getting that recommended range of therapy weekly?  For example, a child with severe apraxia of speech who is receiving 20 minutes of speech therapy weekly.  It is not hard to understand why there would be little benefit and painfully slow progress.  We have often seen the pace of progress pick up nicely when additional appropriate therapy is added.
  
• Is the intensity of therapy sufficient for this child? Has this child been getting enough practice opportunities within each session?  Is this child actually receiving group treatment instead of individual treatment? A child who is mostly silent during the therapy sessions is not going to have good progress.  The clinician would have to modify what they are doing to engage the child and enable them to take some communication risks.
  
• Is the therapy approach appropriate (think principles of motor learning)? Consider all of the principles of motor learning that were discussed earlier. Is this what therapy looks like for this child?  Time and time again we see that when children begin to receive therapy appropriate for their core issue of speech motor planning difficulty, the pace of progress picks up significantly and is noticeable sometimes even immediately.
  
• Is there appropriate follow through happening at home? If there is no follow through happening at home to continue to extend the practice opportunities perhaps this has made for less than optimal progress. Or if the family is not feeling competent or secure enough to practice with their child or if the child refuses to practice with parents, the child may not be getting additional practice that can truly make a difference in rate of progress.

If, after asking these questions and adjusting whatever needs to be adjusted, the child continues to make poor progress, I would hope that the SLP would feel an obligation to invite in a more experienced colleague or supervisor to observe therapy sessions and see if a fresh or external eye may see something that the SLP has been unable to see. 

Further, we hope that SLPs get up to date training on providing treatment to children with CAS.  We are encouraged to hear things like local school districts that are supporting interested SLPs to develop expertise in CAS or a rehabilitation outpatient facility that has an apraxia study group.  These are very positive developments and the individuals who are involved are to be commended.  The bottom line is that unproductive therapy should not be allowed to continue indefinitely.

Please join us this Friday for the final portion of our interview!

Here is the second part of our interview where Sharon outlines in detail what apraxia therapy really needs to look like to be effective and successful!

Stephanie: Back in the summer, we had a debate on the blog regarding oral motor techniques used to address apraxia. Many therapists weighed in on the topic and things became a bit heated. During the debate, you stated, "Speech therapy that incorporates principles of motor learning is what appears to be most effective for children with apraxia of speech". Can you expand on what "principles of motor planning" means? I believe both parents and therapists need a clear, well-defined plan for what apraxia therapy and "motor planning" techniques should look like.

Sharon: First of all, doesn't it make sense to you that if the child's major issue with speech production is the motor planning and programming for speech that the "remedy" should address speech motor planning and programming?  We should be "attacking" the problem at the right level of the system.  There is a lot of published literature on motor planning and programming and the role of these processes on how humans learn "skilled movement".  Speech is perhaps the most highly skilled movement of all!

Appropriate speech therapy for children with CAS is based on the SLP's understanding of Childhood Apraxia of Speech as a motor speech disorder.  Additionally, they need to provide treatment with the understanding that the child's main issue in regards to their speech production is the inability to plan and program SPEECH movements.  The clinician would understand the need to use principles of motor learning in their therapy approach.  There is a whole body of scientific data that exists and describes how humans learn skilled movement (motor learning). These principles involve conditions of practice that lead to permanent change in the motor system. Some of these principles are the careful consideration of the following:

• Amount of Practice—Practice matters. Developing skilled motor actions does not happen as a result of maturity or time; it is about practice of the actual skill, lots and lots of practice. Children with apraxia need a large number of speech practice opportunities for accurate speech movements to be learned. The amount of practice makes a very large difference in learning skilled movement.
• Practice Distribution—Carefully weighing how to practice the target utterances in either a "massed" approach or a "distributed" approach. The SLP should be seeking a way to see the child more frequently over several days, for example 2 - 30 minute sessions on different days of the week vs. one 60-minute session. For this reason, parents are also key to the process as they can help "distribute" practice if (and this is a very important IF) they are explicitly and carefully guided on how to elicit speech production at home and in the community from their child.
• Practice Schedule—Many experienced SLPs think that when a child is very severe or learning a new target that some period of "blocked" practice (the child is asked to say "mom" 10 times, then say "up" 10 times, then says "no" 10 times) is appropriate, versus what is called "random practice" where, during a therapy session, the speech targets are still elicited many, many, many times, but in random order such as: mom, mom, up, no, up, mom, no, up and so on. There is some thinking that blocked practice helps improve performance during the speech session but that overtime, random practice facilities motor learning.
• Variability of Practice—The SLP should be considering how to vary practice for the kids. They would not want to train the child to only be able to produce certain targets under certain conditions. Also, It doesn't help much if the child can only perform certain speech tasks in the speech therapy room and not in the waiting room, or in the car or at home. Kids with apraxia need opportunities for variable practice.
• Type of Feedback—In motor learning theory this is called "knowledge of performance" vs. "knowledge of results". It is the difference between providing feedback to the child based on the quality of the speech movements (i.e.: "you need to puff out your cheeks more," or "... not so wide") which is known as "knowledge of performance" vs. providing feedback based on whether or not the child achieved the target goal (i.e.: "yes, that was it"... "No, try again.") This later type of feedback is called "knowledge of results." Again, many knowledgeable SLPs feel that early in therapy or on complex speech movements, knowledge of performance helps the child through added input in order to shape their speech movements. As the child is more competent with their speech motor system, knowledge of results may be the more appropriate feedback for motor learning to occur.
• Amount of Feedback—Early in treatment, there is more feedback to the child on their performance or results, perhaps even after each trial. For example, when the child attempts a word, they get feedback. The child attempts again, they get feedback, and so on. When the child's system is more competent for the target, perhaps the feedback is given after every 3 attempts or every 5 attempts. Why? Again, this is so that at some point in time the child's own system takes over the processing load.
• Timing of feedback—Early in treatment, the SLP's feedback may be immediate. As the child is improving, the SLP may delay their feedback for a few seconds so that the child can process and judge for themselves, which may improve their self-monitoring skills.

Other important factors that we educate about are:

THERAPY IS FREQUENT—Per the American Speech Language Hearing Association (ASHA) Report on Childhood Apraxia of Speech for children with severe to moderate CAS the suggested range is 3 - 5 x a week of individual speech therapy, taking into account each child's individual circumstances and ability to tolerate it, etc. Do you see how this ties into principles of motor learning related to amount of practice?

THERAPY IS INTENSIVE—By intensive, I mean that the child has the opportunity and experience of producing speech targets and having assistance from the SLP to shape those utterances to be more accurate, dozens and dozens of times EACH speech therapy session.  So, that would mean, for example, that providing GROUP therapy would reduce intensity for the child with severe CAS because they would not have as many practice opportunities nor the complete attention of the SLP who can individually assist them with their productions.  This is why 1:1 therapy is recommended and why group therapy, while helpful for other reasons, is not likely going to lead to substantial progress in speech production skills and motor speech improvement for kids with significant apraxia of speech.  This is also why we don't want to see these kids sitting silently in therapy with just occasional utterances or worse, with the SLP doing most of the talking!  The child needs to be engaged and producing speech attempts and a lot of them, while receiving the appropriate feedback!  Once more, this directly correlates back to principles of motor learning as it relates to practice conditions.

THERAPY ENHANCES SENSORY FEEDBACK DURING SPEECH—Most effective therapy methods for apraxia appear to include multi-sensory feedback in the form of visual, verbal, or even tactile/touch cues to help guide the child's speech movements.  There is some research, and more emerging, that children with CAS may not be processing internal sensory feedback or are not able to adjust their movements based on their "online" internal sensory feedback systems.  As SLPs will remember from their speech anatomy and physiology courses, the motor and sensory system are intimately connected.  So, interestingly, perhaps that is why these multi-sensory methods appear to be more effective than other methods.

It is unfortunate, that there is no single "recipe" on speech therapy for children with CAS.  The fact is, Stephanie that clinicians need to use their understanding of the nature of the disorder, the needs of the individual child and then apply thoughtful consideration to these issues that relate to motor learning principles.  The clinician is always thinking, altering, and evaluating these conditions in a dynamic process for each child and within each therapy session.  There is still much research needed on effective speech therapy for CAS.  That is why we (CASANA) established the Apraxia Treatment Research Fund and award grants so that investigators can conduct the studies that will lead to better knowledge and thus, and most importantly, better outcomes for the kids.  Until more is known, we need to rely on practices that theoretically make sense given the understanding that childhood apraxia of speech is a speech motor planning disorder.

Since then, many questions have continued to flow into the blog regarding CAS (Childhood Apraxia of Speech). Therefore, I decided to contact Sharon and revisit the topic that she knows best. Over the next two weeks, or 4 posts, apraxia and my latest interview with Sharon will be highlighted. I felt that the questions asked and answers given deserved extensive time and attention on the blog.

Please refer back to the post from January 27, 2009 to read about Sharon's background and personal and professional experience with CAS. Below is the first part of our most recent discussion:

Stephanie: Sharon, thank you so much for allowing me to pick your brain once again! One of the questions most recently raised on the blog is regarding the correlation between apraxia and eating issues. Do you see this often? What are your thoughts on this?

Sharon: Stephanie, there are certainly anecdotal reports from families that suggest children with childhood apraxia of speech or suspected to have CAS may have early feeding issues.  We also see this mentioned frequently among clinicians.  There is only one published study by Highman, et. al which compared parent reports of early history from 20 children with suspected CAS, 20 with Specific Language Impairment (SLI) and 20 typically developing children.  In this study, 45 percent of the parents who had children with CAS reported feeding and dribbling issues.  While there was some statistical difference between the CAS group and the early history of typical children, there turned out to be no or little statistical differences between the CAS and the SLI group.  That means that both of the clinical groups were reported to have these issues at a higher rate than typical children.  There are limitations to this study, especially the small numbers and the reliance on parent's memories.

Last year a student, Jessica Hoyer (under the guidance of her faculty advisor and CAS expert Dr. Kathy Jakielski) conducted a parental report type survey of 107 families who are part of our Apraxia-KIDS network as research for her undergraduate thesis. Out of these families, 48 percent reported choking or gagging on food; 35 percent reported sucking issues; 55 percent reported sensitivity to food textures; 52 percent reported overstuffing the mouth; and 40 percent reported dribbling.  Of course there are also limitations to this unpublished study including the reliance on parental memory; the lack of comparison groups; and the uncertainty whether or not the children represented truly had apraxia of speech, as this was not verified.

So, what does this mean?  I think it means that we still don't know for sure how significant early feeding issues are for kids with CAS.  It may be that many clinical populations have these early issues and it is not unique to CAS.  Children with CAS may have co-occurring disorders to which feeding problems may relate.  But I also think it is certainly worthwhile that questions about early feeding be asked of families who have children with CAS receiving services and obviously any presence of feeding problems should be addressed.

Please join us Friday for the second part of our CAS series with Sharon Gretz!

During their dinner, my friend noticed all of these behaviors as well as several others. She is worried and knows that the early years are a critical time in a child's development. She isn't sure if what she is seeing is really serious or is she overreacting. Should she say something to her friend and even if she does, what should she say and how should she say it so as to not offend or upset her? Although her friend has some concerns about her little one, she isn't sure she really wants to or is emotionally ready to do anything about it.

That's when she called me. She rattled off her list of concerns and wanted my opinion. Many of us have been in this situation before and will be again, so here are some suggestions:

• FIRST! Ask Questions and LISTEN—Find out if the parent has concerns and if so, what are they? Are they already planning to seek advice or help on their own?
  
• This Blog—You can always direct a friend to today's post, as well as one I wrote in December 2008 called Web Resources for Parents. This blog as well as other websites may be very helpful and comforting to concerned parents. If they see that they are not alone, they may be more likely to reach out for help.
  
• Read!—Books such as What to Expect the First Year and What to Expect the Toddler Years, as well as websites such as www.babycenter.com will help to break down what "normal" development should look like month by month, acting as a guide for parents.
  
• Talk to a Pediatrician—Encourage the parent to raise their concerns with their child's pediatrician or another doctor or therapist they know and trust.
  
• Call the Office of Early Intervention—And, when necessary, encourage parents to ask for an evaluation team to come to their home and assess their child's skills. Finding out early if a child qualifies for services can make all the difference.

As I read through the comments, I once again know how blessed I am to have both a family and a career. As one therapist, Pamela wrote, "It's a great life!"

Now, I'd like to continue the practice of answering reader questions frequently on the blog. The following question was submitted recently:

I have two kids on my caseload with similar issues:  used to have 10-15 words, but have lost them.  Now use mostly babble and do not tolerate solid foods well, either gag or can not chew them and form a bolus.  They are both active, engaging little people and a puzzle for me, because the parents say they were talking and now are not.  I do not believe it is autism.  One of these children has had two surgeries this summer with anesthesia and intubated for 8 days; the other has had no significant events. Any ideas?

I found this question to be particularly interesting and puzzling, which is why I wanted to share it with readers. I usually do not see children have 10-15 words and then lose them completely. The few times I have seen this, either the child had experienced some sort of medical trauma (i.e. a severe seizure, a TBI, etc) or the child was showing signs of autism. My guess is that the child who had two surgeries and was intubated for 8 days may have suffered some trauma that negatively impacted his/her speech and language. I am curious what type of surgery was performed.

Regarding the other situation, the therapist reports that the child is "engaging" which makes me think that autism may not be the culprit. I am wondering if something else is as play. Are other areas of development being affected?  Has the child regressed in the areas of fine and/or gross motor? Are there other important characteristics and/or behaviors being displayed? Has anything else significant happened in the child's life that would affect their growth and development - the birth of a sibling? Moving to a new home? Parents separated or divorced? 

Have other readers seen situations such as this? Please weigh in with your thoughts and questions.

Let us take a moment to pray for all the people suffering in Haiti. May they find peace, safety and healing soon in the days and months to come.

A Special Note:

In February, the blog is expanding! I will begin highlighting both home-based and center-based early intervention speech therapy practices, as I will now be working with children ages birth to 5 in both therapeutic settings.


Returning to work after maternity leave is no easy task. Although I've decided to take it slow, only working a few days over the next couple weeks, there is plenty to do as any good home-care therapist knows. I've spent several hours over the last few days consulting with the therapist who replaced me in my absence, learning about all the new kiddos on the caseload, as well as the progress some of the other children have made in the last three months. I've been busy calling families, scheduling appointments and of course, MapQuesting all the different destinations trying to strategize my future car routes. Oh, and I can't forget that I should pack a lunch, charge my phone and fill the tank before venturing out!

I must admit, I am looking forward to some temporary freedom and getting out of the house for a few hours! I am also very excited to observe the gains the children have made while I was gone. I'm eager to see my colleagues so that we can co-treat and collaborate and get the old brain working again in a way it hasn't in a few months!

In the meantime I also need to get my house organized! I want to make sure there are enough diapers, wipes and clean white onesies for grandmom to put on my little bundle of love while I'm gone. I need to wash and leave out fresh bottles, as well as double check that there is enough milk to satisfy her until I return. I spruce up her nursery and organize her books and toys so that everything is neat and easily accessible before I leave.

I run the vacuum, do the dishes, take out the trash, fold the laundry, wipe down the bathroom, restock the toilet paper and paper towels, leave out some freshly baked cookies and do my best to leave our home welcoming for both my baby and everyone who will be watching her this week.

And so a new adventure begins, as my career expands, the journey of motherhood continues and I welcome the challenges of another year.

I, like millions of other women in America, am facing the reality of returning to work a mere 11 and a half weeks after having a baby. I have had many people offer various nuggets of advice, such as, "Don't work! You'll never get this time back with your baby", "You should definitely return to work so you can keep current with your skills", "It's important for you to work so you can be a good role model for your daughter" and the comments go on and on.

Whatever your personal philosophy may be, one thing is for certain, many of you reading this blog are also in the same boat, the working mom (or dad!) boat. You are both a speech-language pathologist and a parent, not to mention a spouse as well! The responsibilities and demands that you face each day and night, seven days a week are endless. Needless to say, I'm feeling a bit overwhelmed right now as I hover on the brink of returning next week to the business of my job.

One of the most beautiful aspects of this field is the fact that it tends to be family-friendly. Speech therapists (especially in early intervention) do not need to work nights, weekends or holidays. With the demand of the field on the rise, we are basically able to dictate the amount of time we want and/or need to work—one day, five days, full or part-time hours. There is a ton of flexibility which allows us valuable time with our family. It is one of the main reasons why I chose the profession.

In November 2009, right after my daughter was born, I wrote a post on being thankful. I mentioned then how truly blessed I felt because I had a healthy baby girl and a job to return to after my maternity leave. I meant every word of it; however now that I am being faced with leaving her for several hours each week, I am concerned about the consequences. Will I miss her first word or first step? Will she cry for me when I walk out the door and wonder why is mommy leaving? Her little face and big blue eyes looking up at me with a puzzled look of concern haunts me.

I have devoted my life to loving and caring for children and now I have one of my own. As I write this, I realize that it is this same love making the transition so painful deep at the core of who I am.

For my first post of 2010, I'd like to begin with a Speech Spirit entry to start the year with a positive message. My inspiration for today's post comes from when I attended church over the holidays. During one of my visits, the priest discussed his recent assignment at a local university where he taught theology to a group of freshmen students. One of the topics that he introduced to them was the concept of "vocation". The priest mentioned that when he initially presented it, many of the students had no idea what he was talking about; however as the semester unfolded, so did their understanding of what it is and what their true vocation may be.

To help the students understand the concept better, the priest described "vocation" as "what a person is called to do and will allow you to change the world in a way that no one else can".  He went on to explain that some people know and understand their vocation at a very young age, while others discover it much later in life. Either way, the soul of each person will yearn until its true vocation is fulfilled.

My wish for all of you reading the blog today, whether you are a therapist and/or a parent, is that you come to embrace and celebrate your vocation. For I believe, it is a divine calling to love and serve children, especially those with disabilities.

This most appropriate comment was recently posted by a new reader and aspiring therapist:

"Hi Stephanie and Community....I wanted to let you know that you and your contributors are real inspirations to me.  After twenty-five years as a legal secretary, I am working toward my SLP degree, and reading your blog confirms to me that I am making the right decision. I am at the point in my life where I no longer want to be an "asset to the firm," but be an "asset to life."  

And lastly, a quote from Marianne Williamson, an internationally known spiritual teacher who inspires others through her words and work everyday:

"Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that most frightens us. We ask ourselves, who am I to be brilliant, gorgeous, talented and fabulous? Actually, who are you not to be? You are a child of God. Your playing small does not serve the world. There's nothing enlightened about shrinking so that other people won't feel insecure around you. We were born to make manifest the glory of God that is within us. It's not just in some of us; it's in everyone. And as we let our own lights shine, we unconsciously give other people permission to do the same. As we are liberated from our own fear, our presence automatically liberates others".

Before beginning this week, I'd like to extend my heartfelt holiday wishes to all! I hope you had a beautiful Christmas with your family and friends and I would like to wish everyone a very happy New Year as well. May all our readers have a healthy 2010 filled with peace, love and joy!

For today's post I have chosen to extend our feeding discussion. Questions continue to flow in and I think it is necessary that they be addressed.

Here are two questions that arose from last Monday's post entitled Feeding Therapy: Questions Answered:

I believe that the simplest answer to this question is that whenever you are treating a child who has a feeding goal on their IFSP and you are specifically addressing the goal, then you are engaging in "feeding therapy". As far as I know, there is no level of severity scale that specifically outlines feeding therapy. The need(s) of each child can obviously vary; therefore the goals and strategies used to address them may also vary. Therefore, what would actually qualify as "feeding therapy" can vary as well. Please comment if you agree/disagree with this response.

2. What is your typical treatment plan when an infant/child is first allowed to eat by mouth. For example, a 14-month-old who has been tube fed and is now clear for puree and honeythick trials. How much do you feed (ounces/bites) per session? How do you transition to increase volume and progress with textures?

As I mentioned in my most recent posts, I am certainly no expert in feeding. However, I have and will continue to share techniques that I have learned from seasoned colleagues, trainings and my own hands-on real-life therapy situations. That being said, I would like to direct readers to 3 posts I wrote in October 2008 regarding feeding. So, to answer the question above, I think the information provided below will help you find a place to begin.

Oct. 14, 2008: The Feeding Challenge—acknowledges and discusses the challenges that surround early intervention feeding therapy
Oct. 17, 2008: Feeding Solutions—Discusses the importance of evaluating and observing your "feeding kids" BEFORE beginning therapy.

Some ways to do this effectively are:

• Ask a feeding specialist and/or a nutritionist to consult with you.
• Videotape the child eating.
• Go to hospital visits and swallow studies with the family.
• Co-treat with other therapists!

First, for those therapists out there who have been told NOT to engage in feeding therapy in early intervention for whatever reason, here is ASHA's official position statement which can be found on the ASHA website:

It is the position of the American Speech-Language-Hearing Association (ASHA) that speech-language pathologists have a central role in providing services and supports for families and their infants or toddlers with disabilities as members of the early intervention team. Furthermore, the appropriately certified and licensed (as applicable) speech-language pathologist is qualified to address delays and disabilities in communication, language, speech, emergent literacy, and feeding/swallowing.

So, according to ASHA, any SLP, if trained, licensed and certified properly, is able to treat a child with a feeding and/or swallowing delay or disability. According to ASHA, it is within our scope of practice.

That being said, I would like to add a few additional details that my employer insists be in place BEFORE beginning any type of feeding related therapy. First, there must be a script written by the child's doctor giving medical permission for feeding and/or swallowing therapy. A medical professional must verify in writing that the child is able to receive feeding therapy IF there has been any history or threat of aspiration.

In addition, there also needs to be thorough documentation of the most recent swallow study with "permission to feed" clearly noted, as well as what texture(s) are recommended and approved. This is essential. Not knowing this information and not following it exactly, in my opinion, is negligent and dangerous even if you are a trained, licensed and certified SLP.

I think the big picture here is to always have medical permission to feed any child who is considered at risk for aspiration.

One disclaimer I would like to add regarding this topic is this:

Like most things in life, if you don't enjoy doing it and feel uncomfortable and uncertain about your own capabilities for whatever reason, then maybe it is best if you choose a position that does not require these tasks and skills.

I would also like to personally mention however that there is always room for growth and success. I did very little hands-on feeding and swallowing therapy before working in my current position. I was petrified when I first began and was very upfront with my employer about this. She hired me anyway and provided books and trainings, as well as first hand assistance with the kiddos who were considered "at-risk" and "medical fragile". She supervised my work to ensure safety for all involved. Within a year, I grew to really love feeding therapy and now I feel so much more confident treating these children than I ever thought possible.

The important point to highlight here is that I sought help and guidance in this area. Even though I met ASHA's criteria and was technically qualified to treat feeding and swallowing delays and disorders with infants and toddlers, I personally did not feel prepared to do so. Seeking out trainings and a real-life mentor equipped me with the tools I needed to complete the tasks I had been assigned and had chosen to accept.

Please share your thoughts and experiences!!

Recently, a therapist from New Jersey posted the following comment regarding the relationship between feeding therapy and the home care speech therapist:

Though there was a time that Speech Therapists in Early Intervention were very involved with the feeding skills and problems of their clients, the fact is that at present and for the recent past, have been told very explicitly that we are not  to work specifically on feeding with our clients. We are absolutely not to have feeding goals reflected in the Outcomes we write on their IFSPs. We are told that we can address these issues only in so far as they relate to the speech and language, i.e. communication skills of the child. I think the fact that feeding issues of our EI clients is now and has been in the past a subject on Stephanie's blog and that it continues to be a major concern for many of the families with whom we work, that the issue of feeding and it's importance should be revisited on the state level of Early Intervention.

My response is this: First, I think this is a very important issue that I was not aware of and obviously needs to be addressed. Second, I am not familiar with the laws and regulations in the state of NJ regarding the role SLPs play in EI feeding therapy. I have never practiced in NJ so I cannot speak about what therapists there may or may not be required to do.

In Delaware County, PA, where I live and work, I am most definitely expected to address feeding issues in my EI home care work. If the county is out of compliance somehow, that would be news to me. For the 3 and a half years I have worked in this county in EI, I have received IFSPs from our evaluation team with feeding goals on them and have been expected to address them. There are times when the OT will receive a child with feeding goals and there are times I do—in our county both disciplines share the responsibility of addressing feeding concerns. In addition, our county also employs nutritionists who work hand-in-hand with us to ensure that the nutritional needs of the children are being addressed as well. 

It is also important to mention that my current employer along with several other providers in Delaware County have started an EI Feeding Group that meets year round once a month to help therapists remain current with the latest methods and strategies to address feeding skills. This group consists of numerous SLPs and OTs who work throughout the area, myself included. In addition, various medical professionals from local hospitals have been recruited over the last 2 years to speak to and educate the group regarding feeding related issues.

As you can see, there are obviously different requirements for feeding therapy depending on where you practice throughout the country.  I am curious how other counties throughout the U.S. handle feeding disorders within EI and if SLPs are not required to address them, who does?  

Please write in and tell us if you are expected to address feeding issues

through your early intervention work.

• Holiday Bag—Ask the child's caregiver to fill a bag with holiday items from their home, i.e. a Santa hat, a favorite reindeer ornament, a dancing Frosty, etc. Have the child pick out each one and name the item. This can help with vocabulary development and word finding skills.

• Sing Family Favorite Songs—Ask the family if they have any holiday songs that they enjoy singing and listening to during this time of year. Incorporate music time with these songs into your session. Maybe have pictures to represent each song, i.e. a picture of Rudolph to represent the song, and have the child choose and name the songs that they want to sing next.

• Holiday Cooking—Most families love to cook and bake at the holidays and it is definitely the cornerstone of many family traditions. Ask if you can center one of your sessions around a cooking activity. This is especially important if the child has feeding issues and can serve as a wonderful opportunity to address the concerns in a fun and festive atmosphere. Holiday cookies, pudding with red and green sprinkles and apple sauce with cinnamon on top are all simple recipes that can be made with young children.

• Other Family Traditions—Lastly, I would suggest asking caregivers if they have other family traditions that they would like their child to participate in at this time of the year and would be willing to make it part of your therapy session. Maybe they would welcome your help with decorating the Christmas tree or hanging the stockings!!

For today's post I have chosen to discuss infant reflux, a topic that has been raised several times on the blog over the past year by both therapists and parents. I have seen the realities of infant reflux from both the personal and the professional perspective. My nephew, niece and now my own baby have each struggled with reflux; however the degree of severity and the individual symptoms have manifested differently in all three children. Due to the variety of their conditions, the way to effectively treat each child has varied as well.

For parents, infant reflux is a trying and often scary condition that can really take its toll on both your baby's digestive system and your nerves. As therapists, we often deal with the aftereffects of the situation and how reflux will hinder a child's overall ability to eat properly as well as their attitude towards mealtime as they grow into toddlers.

Below is the way one therapist described the complexities of working with reflux:

What has recently become very challenging for me are young babies—6 months and under—who are refusing to eat more than 1 ounce at a time.  They eat better when sleeping. These are babies who are being treated for reflux.  They are equally as miserable when taking more solid food.  Nutrition has become more the issue than quality of feeding interactions. Any advice?

YES! Fortunately there is a great deal of information out there about reflux - the signs and symptoms and the numerous ways to treat it. Back in October 2008, one therapist shared the following Web site link as a noteworthy resource for infant reflux.

I revisited the site for the purpose of this post and found that it continues to provide very useful information for both parents and therapists.

The site discusses the various positions that can be helpful for babies suffering with reflux, such as keeping a baby upright for at least 30 minutes after eating. In addition, the site also notes that breastfed babies do better if they have reflux; however the mother's diet also plays an important role. Too much caffeine, dairy, spicy and/or fatty foods in the mother's food choices can all contribute to reflux with the child.

Overall, this is a big problem for many of the infants and children we see in early intervention and it is important the parents seek medical attention whenever necessary. Some children have reflux severe enough that it requires medication, while others may even need surgery in more extreme cases.  

Please share the resources you use that could be helpful for both parents and therapists dealing with infant and child reflux.

Over the last year, therapists are not the only ones who have been asking questions regarding early intervention. Parents have often written in and asked pressing questions regarding their child's speech and feeding skills and development. 

Today's post, "Feeding Frenzy" addresses feeding, of course, but also the often frenetic feelings that feeding a child who is struggling can evoke in the people who love them most: mom and dad.  

Here is today's reader question:

I have a 16 month old who is just starting feeding therapy. She hardly chews her food, won't try/eat certain foods, has multiple food allergies, and gags/chokes.  She won't sit in the chair.  I've been doing lots of research about feeding and I tried to implement some things at home.  We picked lunch to be the time to do it.   She had severe reflux as an infant and she's still on Prevacid so we think this has been all caused by reflux because she had bottle aversion too (now she drinks willingly out of a bottle).  We are keeping her on the bottle because she drinks hypoallergenic formula and it's the only way she will drink it.  She does use a straw sippy cup for water.  Do you have any other tips, ideas on how to get her to chew? We are having some issues with our ST, we don't agree with some of the things she is telling us to do.

• My first question is what is your ST recommending and what are your concerns about what she has advised you to do? Try to keep an open mind regarding the strategies that could help your daughter! Although there is also nothing wrong with questioning techniques to ensure that they are appropriate for your child.
  
  
• Next, I think it sounds as though your daughter could possibly benefit from a combination of both sensory-based and behavior-based feeding therapy. Sensory work will address the food aversions and doing some behavior modifications will help with getting her to sit down and enjoy eating. A nice and somewhat subtle way to address these concerns is to involve your daughter in simple food creation (i.e. make easy foods such as pudding or applesauce). Also, eat with your daughter so that she sees you tasting and enjoying a variety of foods and flavors.
  
  
• In addition, has the ST started to do some oral motor work with your daughter? Oral motor work will help to directly address the chewing. There are various oral motor toys and tools that we use in speech therapy that can all assist in helping to strengthen a child's jaw and their ability to chew (ie. A nuk, chew cord, etc.).
  
  
• Finally, we have published numerous posts over the past year that address feeding related issues, so please refer back to earlier entries for additional tips. In November 2008, we published a post entitled Recipes for Toddlers which you may find helpful as well.