Early Intervention Speech Therapy : feeding

Happy Halloween Therapy Treats!

Stephanie Bruno — Mon, 12 Oct 2009 18:19:00 GMT

Halloween is just a few short weeks away and those who read my blog often know how much I love the holidays and festive therapy sessions! Last October I wrote a post filled with simple ways to add a little Halloween fun to your therapy sessions. The post...(read more)

Reviewing Speech Resources

Stephanie Bruno — Fri, 25 Sep 2009 14:23:00 GMT

Over the past year this blog has addressed a variety of syndromes, disorders and conditions that affect the many children we treat in early intervention. Due to my lack of time (but not lack of interest!), I do not always have a chance to research all...(read more)

Beyond Early Intervention

Stephanie Bruno — Tue, 19 May 2009 15:44:00 GMT

Tomorrow is my final visit with a little girl I work with every other week at her daycare. She will be turning 3 later this month and I have worked with her for about a year now. During that time I have seen her at home and daycare and have worked closely...(read more)

Interview: SLP and OT Collaboration

Stephanie Bruno — Tue, 17 Feb 2009 16:51:00 GMT

Today's post will focus on the third and final part of my interview with Lona Otero-Nardone, Occupational Therapist. The first and second parts addressed Sensory Integration Dysfunction—the facts and ways to treat; however today's post features the relationship of speech therapists and occupational therapists, which when approached correctly will be mutually beneficial to both the therapists and the child.

Stephanie: Now, let's talk about the relationship between speech and occupational therapists. Tell us your feelings on the benefits of both disciplines co-treating in early intervention home care.
Lona: One of the most obvious benefits to co-treating lends itself nicely to the old cliché, "two heads are better than one". When we are dealing with a child that has multiple issues (there is rarely an isolated issue), it is almost always beneficial to have two minds, two pairs of hands and two sets of eyes and ears all working toward the same overall goal—to improve the child's development and enhance their functional skills.

I have co-treated regularly with several speech therapists, including you Stephanie, and have found it to be of most benefit to the child and family that we are seeing together. This is especially seen in two particular populations of children:

1) Those with a combination of sensory processing difficulties and delay in communication and/or feeding; and;

2) Those with moderate to severe physical impairment who also have difficulties with communication and/or feeding skills.

Starting with the second group mentioned, two of the primary benefits of an OT and SLP working together, is that it allows the OT to focus on positioning a child, as well as, determining what adaptive devices or strategies may be required. Many underestimate the power of positioning when it comes to language and feeding challenges! It helps to improve posture, facilitates or inhibits typical and atypical motor patterns and muscle tone, increases breath control, improves ability to swallow, increases the ability to attend and allows the body to move more freely. All of which are necessary components for effective speech and feeding to occur.

With the other population identified, those with difficulties in sensory integration; we know from Part 1 of this interview, that we are often dealing with multiple sensory systems and accompanying issues. All of which may impact the development of feeding and communication skills. By co-treating with a speech therapist, you can simultaneously "attack" the sensory system to help organize and prepare a child for the components that a speech therapist is working on.

In short, here is a small list of some of the benefits of addressing sensory processing skills prior to and during feeding and communication sessions/activities:

It increases attention and the ability to maintain a seated position.
It improves body awareness and motor planning (which includes the muscles of the face and mouth) for increased ability to imitate actions, sequences, and sounds.
It can help to improve the ability to tolerate a variety of touches, textures, tastes and smells.
It helps to increase or decrease arousal levels and puts a child in a more optimal state for learning.
Providing movements (vestibular and proprioceptive input) can increase sound production.
Providing vestibular, proprioceptive and tactile sensory input can enhance muscle tone and strength all over the body.
Providing appropriate oral motor stimulation helps to prepare for better feeding and communication.

As you can see, there are clear benefits to teaming an OT and SLP together. Once some of the underlying issues are addressed, it allows the speech therapist to get in there and more effectively practice and facilitate communication (verbal and non-verbal skills) and feeding within their area of expertise. I believe, that in the end, co-treating not only benefits us as professionals, it benefits the child in learning to function in their daily routines. Communication and feeding are big parts of those routines.

I enjoy co-treating with our speech therapist(s) and our families and children usually do too. I believe it's twice the benefit to the children!

Stephanie: I completely agree with you. I have learned so much from co-treating with OT's, as well as PT's, Special Educators and Nutritionists and I think it can be to the ultimate benefit of the children and families. Tell us what you feel SLP's can learn from OT's to improve their therapy and also vise versa, what OT's can learn from SLP's.
Lona: Really I think that is individual to each SLP and OT, depending on their knowledge and skill base. I feel that the most important thing that a speech therapist can learn from an occupational therapist is to have a basic understanding of positioning and sensory integration and how it impacts as well as enhances communication and feeding.

In so far as what I can learn...well that really stems from my own areas of weakness. Some things that I feel SLP's can help me to learn to incorporate in my sessions and to expand my knowledge base are:

The mechanics of chewing and the associated oral motor structures.
The mechanics of sound production, which includes knowing the developmental sequence of sounds/letters/word production.
Learning how to facilitate a more coordinated suck-swallow-breathe pattern.
Learning different types of oral motor stimulation and exercises to improve tongue, jaw and lip movements.
Learning typical and atypical swallowing and tongue movements.
Learning how to better facilitate verbal and non-verbal communication through different activities or presentation of questions and materials.

As with anything, the more informed you are the better choices you make. Seeing my lengthy list above makes me realize that I don't ask enough questions of my speech therapists; which brings me to one final point that I'd like to make in this interview. I am a big advocate of the OT/SLP teaming approach. I feel the two compliment each other well and can be quite the "dynamic duo" together. However, one must recognize for any team to be successful it is imperative to always keep an open dialogue with one another. To truly benefit [all involved] you should discuss how your co-treating sessions are going. "How did the child respond?", "How did we work together; was is smooth or did it seem like two separate entities with two different agendas?".What new strategies should we try or what should be repeated, revisited or rejected?". It is very important to keep the lines of communication open so you can truly work together as an effective team!

In concluding this interview, I'd like to thank you, Stephanie for allowing me to participate and hope your readers find the information contained within the interview helpful. I thoroughly enjoy working with you and feel that together we have a positive affect on the families and children that we work with. I hope this interview encourages other occupational and speech therapists to co-treat together.

Stephanie: Lona, thank you so much for taking the time to talk with me. I have learned a great deal about sensory integration dysfunction and how to use new techniques effectively in my daily sessions. I hope that the readers have gained some new information as well as a fresh perspective on the benefits of a trans-disciplinary approach to early intervention treatment.

Interview: Lona Otero-Nardone OTR/L on Sensory Integration Dysfunction

Stephanie Bruno — Thu, 12 Feb 2009 17:30:00 GMT

If you missed Tuesday's post, it featured the beginning of my interview with Lona Otero-Nardone, occupational therapist. Lona has been working in early intervention for over 8 years now and has become an excellent resource for her colleagues and clients on the topic of Sensory Integration Dysfunction (SID) in young children.

Today's segment is a continuation of the interview and will highlight an easy to understand list with effective strategies for parents and therapists to use when working with SID in young children.

Stephanie: Thank you for explaining sensory integration dysfunction. Let's continue on now and address ways in which parents and therapists can address sensory needs effectively with young children.
Lona: Much of the sensory integration activities and techniques that OTs use focus on the child being able to appropriately alert to, organize and respond to a variety of sensory stimuli so that he/she can function . There is no real "cookie cutter" recipe as each child and their response can be different.

Another thing I often tell a parent is that there is no "black and white" when it comes to SI, there is a whole lot of "gray area" and much trial and error. The effectiveness of treatment is based on watching how the child responds...Does he appear to attend or focus better? Are responses better organized and executed? Has distractibility or sensitivity diminished? Has desired or inappropriate behavior increased or decreased? These are just a few questions that I ask myself in order to tell whether or not the chosen method is working.

Many activities or techniques used in SI address three sensory systems: proprioceptive, vestibular and the tactile sense. These three systems are quite foundational to sensory processing. Difficulty in these areas often underlies or affects the other remaining sensory systems. They are also closely related and dependent upon one another. Therefore, most of the activities that I will provide when addressing sensory issues, deal with these three systems but can help all systems function more appropriately.

Here are some suggested activities to address sensory issues according to each system, but feel free to get creative with them modify as needed. You can also easily incorporate language/communication skills into many of these activities.

Proprioceptive: These activities are often considered to be calming and organizing and help to provide deep pressure input to the body.

Allow for play that incorporates crawling, jumping or climbing. Create an obstacle course using tunnels, trampolines, pillows, etc. for child to maneuver through.
Provide bean bag chair or weighted lap pad for sit down activities.
Do push/pull activities such as vacuuming, shopping with cart, tug-a-war or a more resistive form of "Row- Row Your Boat" with partner.
Provide deep pressure massage using lotions, vibration or brush (as tolerated).
Have child perform activities such as coloring or puzzles while lying on belly.
Incorporate rhythmical songs that include clapping, stomping or slow rocking.
Have child roll up in a blanket (regular or weighted) like a hot dog.
Allow child to "sandwich" themselves between pillows or bean bag chair. You can further provide deep pressure by pushing down on the outer surface.
Provide great big bear hugs.
Provide weighted or pressure vest (20 minutes on 20 minutes off or as instructed by OT).
Have child do heavy work activities such as pushing in chair or carrying heavy object. This is especially helpful during transition times.
Provide warm (calming) or cold (alerting) bath.
Have child wheel barrow walk...if they are confident with this you can add objects for him/her to gather and put in container or play floor hockey using this position.
Provide resistive materials to play with such as play doh, silly putty, kneading dough or pop beads.
Bang rhythmically on therapy ball or drum - try altering patterns to see if they can imitate.

Vestibular: Always use caution with these activities, watch for changes in skin color, heart rate or breathing. Stop immediately if these occur. Never force a child if they are frightened.

Provide swinging, which is always best if it is child directed. Slow linear swinging is calming, fast swinging is more alerting.
Incorporate songs or games such as "Follow the Leader", "Simon Says", "Head Shoulders, Knees and Toes" or any other that requires changes in the position of the head.
Do activities that require jumping, rolling or somersaults. (Avoid somersaults with those children whose joints are very lax such as those with Down syndrome.)
Vary play by doing on scooter board, hippity-hop or ride-on toys.
Bounce on trampoline or large therapy ball (seated).
Do sit-ups or pull-ups.

Tactile: Never force a child to participate

Provide weight bearing activities, brushing or deep pressure massage to hands/body prior to exploring and manipulating new materials to help decrease sensitivity.
Play in tubs of beans, rice or macaroni, packaging noodles, etc. Hide items in materials for child to find.
Play in textured materials such as pudding, shaving cream, play doh, finger paints, corn starch and water. If child is resistive, do not force, offer encouragement or try offering a tool with a long handle and gradually decrease size of handle until comfortable enough to manipulate with hands.
Encourage child to participate in meal preparation...could be cookies, pizza, preparing dough, peanut butter and jelly sandwiches, fruit salad, you name it! Also encourage tasting the end product, especially for those who exhibit sensitivity in the mouth.
Do daily brushing protocol as provided by trained OT.
Provide alerting foods to increase attention and oral motor awareness ...crunchy, chewy, sweet or sour, pretzel sticks, Twizzlers, Gummy Bears etc. (always supervise and take caution of possible choking hazards). Can also provide chew tubes or similar items to further increase input and awareness.
Can massage around mouth area with cloth or vibration. Can also massage inside mouth with Nuk, Toothette, Z-Vibe or toothbrush (usually best if child directed and made into a game). Using firm strokes helps to decrease sensitivity and increase body/oral motor awareness.

Auditory:

Provide child with quiet spot, try to eliminate extraneous, loud or unpredictable noises.
Provide child with headphones or ear muffs to increase ability to attend to task and filter out noise. Can upgrade or downgrade ear coverings according to thickness of covering.
Provide rhythmical classical - type music in background.
Experiment with different intonations and vary loudness to see what the child tolerates the most and responds to better.
Provide auditory information combined with other sensory stimuli such as verbal or visual cues.
Use less descriptive and straight forward sentences when asking questions or giving directions. Use fewer words but quite clearly.
Provide activities that have a repetitive beat or pattern to help calm and to organize auditory information being received.
Incorporate prorioceptive and vestibular activities as these are also foundational to the auditory sense.

Visual:

Provide area with limited visual distractions such as a tent, tunnel, an area with a screen divider or a corner of the room.
Increase lighting to help alert, decrease/dim lighting to help calm.
Experiment with different types of lighting and shades (amber lights, fluorescent lights, incandescent lights, black lights, etc) to see what the child tolerates the most and responds to better.
Provide sunglasses and hat if sensitive to bright lights outdoors (can be indoors too, if necessary).
Always use caution when using flashing lights. They should not be used with a child with a seizure disorder.
Use reflective materials or tape to increase visual awareness and attention.
Use higher contrasting materials or backgrounds to help increase visual attention ability to visually discriminate or determine background from foreground.

Gustatory and Olfactory:

Gradually introduce new smells and tastes to those who are hypersensitive. The smaller the better. Increase amounts as tolerated.
Combine new tastes or smells with more familiar accepted ones or use those that are very similar to one another.
Provide child with activities that incorporate strong smells or tastes...baking and cooking, or making scented and/or edible play doh are always fun activities.
Provide child with scratch and sniff stickers and books.
Provide child with his own special box of materials that he/she can chew or mouth. Direct the child to the box when you see them inappropriately licking or mouthing. Thoroughly clean items daily.

Stephanie: This is really great information! I know that I will be able to use all you have provided in my weekly sessions. So, now, let's talk more about your other roles and responsibilities as an early intervention OT. Tell us about the most challenging part of your job, as well as the part you like the most.
Lona: This is an easy question because the most challenging part of my job is actually the part I like the most, which is dealing with a variety of families and environments. It is what drew me to early intervention (that and a love of children and knowing what a significant impact early development has on life long skills).

When you deal with families, you are dealing with a lot of individual differences that you must acclimate to, adapt and accommodate for. You are constantly adapting based on each child's needs, family goals, family structure, beliefs, culture, language, home, socio-economic status, etc. It definitely keeps you on your toes but is what makes this job more interesting, fulfilling and challenging!

As previously mentioned, when using activities that are rooted in sensory integration, it is imperative to continuously monitor the child's response and to evaluate the effectiveness of the strategies that you are using. I hope these suggestions are helpful and remember to have fun with it! The more fun, the more motivated a child can get.

Stephanie: The "fun factor" is definitely an aspect that you have mastered. I know because I have seen you in action and know how the parents and children love and appreciate the work you do!!

Join us next Tuesday for the third and final part of our interview. In that segment, Lona will discuss the Speech-OT relationship and how it can work to create a mutually beneficial therapeutic experience for both professionals and the children we treat.

Interview: Lona Otero-Nardone, OTR/L

Stephanie Bruno — Tue, 10 Feb 2009 20:08:00 GMT

Today's post is my in-depth interview with coworker and friend, Lona Otero-Nardone. Lona is an occupational therapist who works in early intervention homecare and has over 8+ years of experience in the field. I have learned so much about Sensory Integration Dysfunction (SID) by watching and working weekly with Lona. As an EI speech therapist, SID affects many of the children and families I see everyday; however I sometimes feel ill-equipped to address their needs appropriately. Lona's incredible knowledge and skill-set has been a blessing for both me and the many children we see everyday, which is why I chose to interview her.

Our interview covers a wide range of information including SID, how it affects a child's body and speech development, as well as Lona's experience with co-treating with speech therapists. Due to the extensive amount of information, this interview will be featured over 3 consecutive posts.

Stephanie: Hi Lona! Thank you so much for speaking with me. Please begin by telling the readers about yourself, your background and what you do as an OT.
Lona: I graduated from Temple University in 2000 with a degree in occupational therapy. Shortly after graduation, I was employed by Elwyn as a pediatric occupational therapist in their Early Intervention program that provides therapeutic and educational services to families with children between the ages of birth to three years. They are children who have been identified as, or at risk of, having a developmental delay in one or more areas. Some of the children I see may have a diagnosis of: Cerebral Palsy, Down Syndrome, Autism/PDD, prematurity, seizure disorders and visual or hearing impairment, to name a few.

Elwyn's Early Intervention team consists of OT's, PT's, SLP's and special education instructors. We work directly with the family and their child within their home and community settings (daycares, libraries, music or play groups, etc.). Our team, which includes the family, a service coordinator and one or more therapist, work closely together following a family centered and trans-disciplinary approach.

In-so-far as what I do as an OT for Elwyn...well, that varies according to the needs of the child and the goals of the family (which is also stated in their Individualized Family Service Plan - IFSP). In general, my role as an occupational therapist is to work with the family to assist their child to learn functional skills in order to maximize their child's independence and improve function during daily activities within the family's routines. These skills include: fine motor, self-care, sensory processing, and play skills (especially since this is the main mode of how children learn and develop).

Given that Elwyn follows a trans-disciplinary approach, the skills I also work on or incorporate into my sessions, also include: gross motor, communication, cognitive and social skills. So, what I do as an OT is pretty all-encompassing, but the ultimate goal is to help the family and their child, reach their maximum potential.

Stephanie: Great! Now let's talk about your forte...please tell us about Sensory Integration Dysfunction and how it affects the body.
Lona: Hmm...seems like such a simple question for a very complex subject. I will try my best to keep it as basic and as understandable as possible.

First, it is necessary to provide a brief explanation of what sensory integration (SI) is. Sensory integration is a process of alerting to and receiving sensory information, interpreting it correctly, combining it with other senses or previously learned experiences to form the "big picture", deciding on how to respond to the sensory information, and finally, executing an organized an appropriate response through our muscles, joints, actions and behaviors. SI is a process which occurs in the central nervous system. It is the taking in information and experiences in an organized an effective way through one or more of our seven sensory systems, which include:

Proprioceptive Sense. The sense of body position, body parts/muscles/joints/tissue. It provides body awareness, our relationship of our body and body parts to people or objects. It is related to muscle tone and posture. It helps us to make sense of touch and movement. It helps to regulate our arousal state. This system is closely related to and inner twined with the vestibular system.
Vestibular Sense. Sense of balance and posture. It provides information about gravity, movement and changes in head position. It also helps to regulate our arousal state. This system is also closely connected to the auditory sense as its receptors are located in the inner ear; as well as the visual sense as our eyes are dependent upon detecting positional changes.
Tactile Sense. Sense of touch. Provides information all over our bodies about light touch, pressure, vibration, temperature and pain. It helps us to use the process of discrimination (being able to determine the properties of an object by feeling).
Auditory Sense. Sense of hearing.
Visual Sense. Sense of sight.
Olfactory Sense. Sense of smell.
Gustatory Sense. Sense of taste.

All of our sensory systems work together; and for the most part, sensory integration is an unconscious effort. An example of what SI may look like in a typical daily scenario and how some of the senses work together is this: You hear a fly buzzing around your head (you alert to it and take it in through the auditory sense), you turn your head to look at it to see that it is indeed a fly (involves proprioceptive, vestibular and visual sense - you combine senses and a previously learned experience to determine what it is), and you swat at it to get it away from you ( involves proprioception, vestibular, auditory and visual sense - you have decided on and organized an appropriate response through your actions).

As you can see, there a number of systems interacting with one another, as well as a number of processes that occur within SI. When we speak of a child with "sensory issues" (It also known as sensory integration dysfunction - SID, however this term is used less and less because the acronym is the same as Sudden Infant Death; but for the purpose of this interview, it is what I will call it.), we are usually referring to multiple issues/challenges. There is rarely only one isolated "thing" that can be "off".

However, occupational therapists often use two general terms when describing issues that we may see in children with SID; they are hypo-responsive/hyposensitive (under responsive, requires more intense levels to register and respond to sensory information, response often takes longer) and hyper-responsive/hypersensitive (over responsive, requires much less input to register and respond, response is often quick). Hypo and hyper sensitivities can occur in any one or all of the systems. To further complicate things, sensory issues can change over time or fluctuate. The only exception to describing issues as hypo or hyper, is proprioception. When we discuss issues within this system, we are usually talking about difficulties with motor control and motor planning (also known as dyspraxia).

When determining what areas or systems are not functioning properly, an OT must have good observational and listening skills and a strong knowledge base of SI and SID. A Sensory Profile or similar tool may be performed as well to further help gather information and determine areas of weakness. But, I believe that observation of responses and behaviors of a child is key...observation over time is even better. I often tell my parents that if you listen to and really observe your child, your child is telling you what his system needs.

Stephanie: I have heard you say that to parents and I have learned how true it is. I think the difficulty for me, as a speech therapist, and for parents is to decipher what exactly the signs look like and what each means. Can you give us a description of how SID presents itself in children to help our readers know what to look for when treating children with both speech and language and SI needs?
Lona: Sure...here are some common ways in which SID can be seen in a child according to the seven sensory systems.

Proprioceptive Sense:

Trips over or bumps into objects.
Enjoys "rough-housing", likes to crash into things or seems aggressive.
Assumes slumped body postures, or W-sits.
Has difficulty properly grading movements; may over/under shoot movements.
Has difficulty using correct force, may break things easily, draw very lightly or seem heavy handed or heavy footed.
Has difficulty planning sequences of actions/movements.
Walks on toes.
Has difficulty manipulating small objects, especially fasteners.
Has difficulties with transitions and may prefer more predictable activities and routines.
May avoid trying new things or dislike being in new settings or social situations.
Seems to "zone out" or doesn't respond when called. May seem "lazy".
May stuff large quantities of food in the mouth or seem to pocket food in the mouth.
May have preference for certain foods such as hard, crunchy or chewy foods. May have difficulty handling softer, lighter foods such as pudding or yogurt.
Chews on toys, clothes or other non-food items.

Vestibular Sense:

Seems to seek out or have a high threshold for excessive movement experiences such as running, jumping, swinging, rocking, spinning or climbing.
May avoid or be fearful of movements, especially when feet leave the ground (also called gravitational insecurity).
Eyes may not seem to move in conjunction with the head.
Has difficulty staying seated or maintaining attention during more sedentary activities.
Assumes precarious positions or likes to hang upside down.
May have difficulties with communication/speech.
May seem over-active or "always on the go".
Gets upset when head is tilted back when washing hair.

Tactile Sense:

Seems to seek out a variety of things to touch. May repetitively manipulate or feel objects.
Is constantly touching people.
Demonstrates fearful reaction or avoids touching or eating certain textures (also called tactile defensiveness).
Gets upset when face and hair are washed.
Gets upset when hands are dirty and insists hands be washed.
Dislikes, upsets or avoids certain food textures.
Dislikes brushing teeth.
Has difficulty with discrimination of objects.
Avoids playing with play-doh, paints, glitter, glue, etc.
May have delayed fine motor skills.

Auditory Sense:

Upsets or avoids loud noises, may cover ears.
Gets easily distracted by environmental noises, has difficulty filtering or screening out background noises.
Has preference for or responds only to certain sounds or intonations.
Has difficulty with communication/speech.
Does not respond when name is called.
Seeks sensory input to ears or head area. May press objects against ears.
Gets overwhelmed or seems "oblivious" in an active environment.

Visual Sense:

Avoids or upsets in presence of bright lights. Prefers to be in the dark.
Avoids eye contact.
Stares intensely at people or objects.
Hesitates or is fearful of going up/down stairs.
Has difficulty picking out items from a background.
Has difficulty assembling puzzles.
Has difficulty visually attending to tasks.
Is easily distracted by lights or moving/spinning objects.
Eyes may not seem to work together or fixate well, especially when head position is changed.

Olfactory Sense:

Avoids or upsets with certain smells. May hold nose to avoid.
Appears to seek out certain odors. May smell many non-food objects. May press nose against objects.
Does not seem to respond to many odors.
May avoid or prefer certain foods based on smell.

Gustatory Sense:

Is a picky eater.
Avoids or upsets with certain tastes. Prefers to eat only bland foods.
Craves very strong, sharp, sweet or sour tastes. May refuse to eat bland foods.
Can't seem to tell the difference between foods.
Mouths/chews/licks many non-food items.

Join us on Friday when our interview continues! Lona will share numerous ways for therapists and parents to address sensory integration needs both at home and in early intervention treatment.

Amy's Last Day

Stephanie Bruno — Fri, 23 Jan 2009 18:20:00 GMT

A few months back I did two posts about Amy, a little girl who I have been working with for two and a half years through early intervention. I started treating Amy when she was just six months old. This Friday, Amy will turn 3 and will be entrusted to a new speech and feeding therapist. Today was my last session with Amy. We made vanilla birthday cupcakes! She loved cracking the eggs, turning on the mixer and shaking sprinkles on the icing. At the end we sang the Happy Birthday tune and Amy blew out her little pink candle.

Before leaving today, I took the time to thank Amy's mom. I remember walking into their home for the first time back in July of 06. I was new to early intervention and feeding therapy. Amy was just 6 months old, very fragile and completely tube-fed. Looking back, I did the very best I could at that time. I was honest and I told Amy's mom I did not have much experience with a child like hers. I called my supervisor and asked my colleagues for guidance and advice. I also started going to feeding trainings and reading all I could about how I should direct therapy. Although my heart was open and my intentions were good, there are many parents out there who would have requested a new therapist and rightly so. One with more experience, confidence and know-how in the area of feeding, but Amy's mom stuck with me. As she stated today, "we were all learning together."

Working with Amy has been a very humbling experience for me. The situation stretched me to become a better therapist. Seeing her progress and the dedication of her family inspired me to continue even when I was unsure of the path.

Just a few weeks ago, there was a comment posted on this blog by a "Speech Pathology Intern" who recently saw significant progress in one of her students. She wrote "...we DO make a difference." I look at Amy today on the verge of 3 years old, making cupcakes and singing as she stirs the batter and I know that this is true. Because we all worked together, this once delicate infant has blossomed into a vivacious and spirited little lady, winning the hearts of all who meet her.

Tune in next week to read my interview with Sharon Gretz, MEd, the Founder and now Executive Director of CASANA (The Childhood Apraxia of Speech Association of North America).

Shrink Stress for Happy Holidays!

Stephanie Bruno — Tue, 23 Dec 2008 15:26:00 GMT

Several families I currently work with have expressed concern regarding their child and holidays events. Many kids, especially those with social anxieties, sensory issues and/or communication delays/disorders have a difficult time transitioning to new environments and participating in novel events. Hence, holiday time, which is often filled with long rides, unfamiliar people and unique experiences, can be very stressful for small children, as well as their parents, siblings and other family members.

So, fear not! Here are some tips that I hope you find helpful for shrinking stress this holiday season!

The Name Game - Talk about the people your child will be interacting with over the holidays. For example, if you will be visiting aunts, uncles and cousins your child rarely sees, talk about them! Practice saying their names. If you have pictures of these people, that is even better. Show your child their picture each day for a few days leading up to the event and prep them for the social gathering.
The Santa Scene - If you would like to do a trip to sit on Santa's lap but fear the experience due to your child's stranger anxiety, prepare them for the event! Show your child pictures of Santa ahead of time. Read books about Santa and help your child become familiar with an image of what Santa looks like. You may want to go visit Santa and even look at him from afar first, but make plans to return a second or third time for the actual photo shoot.
It's a Family Affair - All the work you do to prepare your child for the holidays can be wonderful, but it can be even better with support! Remember there is power in numbers! Get your husband, wife, grandparents and your other children involved. Many kids love to be like their siblings, so get them on board as well. Play the name game at dinner and look at family photos together as a group. This will help to reinforce your goal and help make all your children feel safe about where they will be traveling and who they will be meeting.
The Comfort of Home - Last, but not least, remember that preparation is vital. If you are traveling and leaving home, bring some of your child's favorites along for the ride....favorite foods, favorite toys, etc. The goal is to make the holidays as enjoyable as possible for everyone involved including your little one. So, bring along their favorite teddy bear and choice sippy cup! Having something on-hand to comfort and soothe them if they become overwhelmed, fearful or completely over-tired may make all the difference!

Please write in and share your own ideas for reducing holiday stress!

Happy Holidays to all!! Wishing you peace and joy this season!

In the Spirit of Giving...Toys!

Stephanie Bruno — Fri, 19 Dec 2008 14:39:00 GMT

On Tuesday, I submitted a post discussing the dangerous presence of toxic chemicals in toys. As I had stated in that post, parents will often ask for suggestions regarding toys that would be appropriate and helpful for their child with a diagnosed speech and/or feeding delay/disorder. Especially at this time of the year with the holidays and gift-giving approaching, parents are eager to purchase items that will foster communication and support the speech/feeding needs of their child. Our last post focused on the possible hazards of toys, but today's post will focus on the benefits of using healthy toys to support the play, speech and feeding skills of children!

The following is a list of toy ideas that can help to stimulate speech and healthy eating habits in young children:

Bubbles
Microphone/Recorder (something that will record the child's voice)
CD player (something to play music and stories for the child)
Musical instruments (i.e. tambourine, maracas, etc.)
Alphabet toys - ABC books, puzzles, etc (i.e. toys to promote phonemic sounds)
Whistles and whistle activated toys (i.e. Whistle/Voice activated Thomas the Train; also good for Cause and Effect)
Oral Motor Bucket - Straws, cotton balls, feathers, etc. (i.e. Items to promote oral motor strength and awareness) Great for stocking stuffers!!
Art Supplies/Easel - Markers, crayons, glitter glue, construction paper, etc - items to allow children to experiment and be creative!
Pretend Kitchen and Food - great for children with feeding issues
Mr. Potato Head - great way to practice naming and pointing to body parts
Baby Dolls - great for pretend play and practicing daily routines - "wash the baby", "dress the baby", "feed the baby", etc.
Animals - farm house and farm animals, zoo animals (also great for pretend play)
DVDs - musical and speech supportive videos
Flash cards
Books! Books! Books!

Remember to always consider not only the child's age, but also their developmental level and natural interests when making toy choices! If your child loves music, buy some toys that will support and foster their musical curiosity!

Of course there are tons of wonderful toys out there, so please write in and share other suggestions you may have for children receiving speech and feeding services!

Recipes for Toddlers

Stephanie Bruno — Wed, 26 Nov 2008 15:25:00 GMT

As a follow-up from Tuesday's post, today's topic will highlight kid-friendly recipe ideas therapists (and parents!) can make with children. With all of these recipes, it is important to have the child participate in the process - let them crack the egg, stir the batter, pour the milk etc. It's ok if they get their hands dirty or spill some the floor! All of the recipes below are simple favorites that can be easily incorporated into your therapy sessions.

Peanut Butter and Jelly Sandwich. This is sooo simple and should not be overlooked! Having the child spread both on the bread (or crackers) and lick their fingers when they are done is perfect for kiddos who may have some tactile sensitivity. You can also expand on this and make all different types of sandwiches!
Fruity Smoothie/Milk Shake. This is a perfect treat that you can make both healthy and tasty. Plus, kids will love watching all the ingredients get zoomed up in a blender! Use milk, yogurt, peanut butter and all different types of fruit etc. The possibilities are endless!
Pizza. You can use real dough and roll it out or you can use foods like English muffins or pita bread as the dough. Add on whatever ingredients you want...cheese, sauce, pepperoni, etc....great for kids with fine motor weakness!
Fruit Salad. Let the child help by using a plastic knife to cut up the fruit and a big spoon to mix it all together! You can always top it with something fun like whipped cream or cool whip!
Box Muffin Mixes. Effortless baking with only 2-3 ingredients. Muffins are great because they usually only take about 15 minutes or so to bake and if you put on the oven light, the child can watch them puff up and harden until they are ready to eat. You can always add mashed fruit to make them more healthful!
Pudding. All different types of flavors and you can always add fun things to it to change the texture, such as graham cracker crumbs, whipped cream, marshmallows, crushed cookies (put cookie/graham cracker/etc in a bag and have the child crush and squeeze them). Once again, the possibilities are endless!
Dips. Kids love to dip foods into other foods! On the website below are suggestions for homemade dips with 3-4 ingredients that keep both the making and tasting simple and straightforward!

Here is another website I found that highlights a wide variety of recipes for toddlers: http://www.wholesometoddlerfood.com/toddlerrecipedownloads.htm. It breaks down the recipes into several simple categories: "fast" foods (foods that are quick and trouble-free), snack foods, and then breakfast, lunch and dinner foods. It also offers a Sample 5-Day Meal Plan in a chart form that you can print out and share with families who may be unsure of what foods to try with their child. Use it to help families who need guidance with nutrition but may not have the luxury of a nutritionist on their child's EI team!

Hope you found today's post helpful! Over the next month we will talk about Christmas/Holiday crafts as well as toys to buy and recommend this holiday season for young children, especially those with disabilities.

Please write in and share other topic requests you may have as well!

Cooking with Amy, Part 2

Stephanie Bruno — Tue, 25 Nov 2008 15:31:00 GMT

As promised, today's post will highlight some feeding therapy ideas you can use with young children - easy techniques with simple food ingredients that are common around the house!

Before beginning I wanted to share with everyone this wonderful website I found called Speaking of Speech where Mayer-Johnson Company pictures are pre-made for specific recipes: http://www.speakingofspeech.com/Cooking_Materials.html *There are copyrights on the pictures and restrictions on the way in which they can be used so take note of the message at the top of the page when visiting the site.

In last Friday's post I shared a story about Amy, a little 2 year old girl who I currently work with in EI. After 28 months of feeding therapy and numerous other therapeutic supports, Amy is eating thick, chunky pureed consistencies (similar to a stage 3 baby food) and we are working to improve her bite and chew. In addition, Amy and I are now cooking and creating meals together! She loves the hands-on actions of stirring, pouring, mixing, etc and seems to be more willing to taste new foods and foreign textures because she is part of the process. Amy's mom recently reported that her two-year-old daughter is now pulling out her pots and pans and pretending to cook on her own!

Over the last two weeks we made Whole Wheat Pancakes and Cinnamon Banana Muffins during our therapy sessions. Both were a big success! We started with the pancakes because she has eaten them before and I wanted to start with something with which she was familiar. It went so well that I decided to step outside the box the following week and try a new food that she has not eaten - muffins! Amy has eaten mashed bananas and loves cinnamon, so I chose muffins that included these items; therefore we used ingredients she was familiar with to build on her repertoire. Whenever I have done feeding therapy in the past, starting with what is recognizable and favored and then expanding on that has been a very successful technique and seems to help the child feel safe enough to taste the new food.

When we made both the pancakes and the muffins, Amy loved adding in each ingredient and stirring everything together. She enjoyed watching the pancakes bubble and harden into solid disks. She was also amazed by how the muffins grew in the oven and changed shape. Amy, her mom, her nurse and I all enjoyed devouring our creations afterward!

Eating WITH Amy is another technique that we have also incorporated daily and has proven to be been very successful. The family, the nurses and myself all model good eating behaviors and demonstrate how to bite, chew and swallow food. I believe this also helps Amy feel socially connected and engaged, which is also a key ingredient for successful feeding therapy!

My next post will highlight some step by step recipes you can incorporate into your therapy sessions! HAPPY THANKSGIVING!

ENJOY and Happy Cooking!!

Cooking with Amy

Stephanie Bruno — Tue, 18 Nov 2008 17:09:00 GMT

Today, I'd like to tell you a true story about a little girl named Amy (her name has been changed to protect her identity). I have been working with her now for over two years. When I first started working with Amy she was only six months old and was completely g-tube fed. She had almost no suck or swallowing reflexes and was absolutely petrified anytime a stranger came near her. To be honest, at that time, I think I was as afraid of her as she was of me! She cried our entire first three sessions and I went home each week with a headache and a big dilemma!

At that time, we were both very new to the feeding therapy scene, so I made a phone call to my supervisor and asked for HELP! I needed very specific instructions on how to treat this delicate little baby. I thank heaven for my wonderful boss who helped me create a feeding plan that was not only thorough, but also flexible enough to grow as this little wonder grew as well. Over the last 28 months, I've watched nurses and therapists come in and out of Amy's life. Her incredibly strong and wise mother drove her to A.I. duPont's feeding clinic weekly for over a year for private feeding sessions. I went to several of these visits in addition to her last swallow study to collaborate with and learn from the specialists, knowing that if we were all working together, Amy's progress would be expedited.

Amy will be turning 3 in January and I already tear-up when I think about it. Amy is truly a miracle and her presence is such a blessing for all those who come in contact with her. Despite all the medical fragility that has hindered her physically in various ways, Amy's speech and language skills (and her sense of humor!) are essentially perfect. She is bright, insightful and always delightfully cheerful. She makes me laugh every time I see her. When I return each week I am continually surprised by her limitless strides and the new skills she has been able to conquer.

Today, Amy is completely orally fed and like a typical two year old, prefers to feed herself. She still struggles with her bite and chew, but both continue to progress through practice with oral motor tools and carefully selected foods. The little girl who once would only accept a dry spoon to her lips will now eat mashed pancakes, yogurt and bananas and pretty much anything in a chucky pureed texture. She loves cinnamon and parmesan cheese and will frequently ask to add both to her meals. Now when I visit Amy each week, we cook together and she taste tests the results! As she told me last week with an excited smile, "I am loving this!"

Tune in next week to read about the recipes Amy and I have made together and what we are planning to make during her remaining two months of therapy. I will also share other resources I have used in the past to help me develop my speech and feeding based cooking lessons!

Interview: Mary Pat Winterhalter, MS, RN

Stephanie Bruno — Tue, 11 Nov 2008 15:19:00 GMT

Today, I am very excited to present our first blog interview!

Part of my current position in EI includes a weekly visit to Lauren's House in Boothwyn PA, which is a Prescribed Pediatric Extended Care Center (PPECC). Every Thursday I co-treat with three colleagues, an OT, a PT and a Special Instructor and together we run a dynamic multi-disciplinary group for the children we treat at Lauren's House. The children at this daycare facility are medically fragile and are cared for daily by a dedicated team of nurses.

Today's interview with Mary Pat Winterhalter, the Nurse Administrator at Lauren's House, will highlight the benefits of the program, the challenges it faces and how speech and other therapies play a crucial role in care of the children.

Stephanie: Mary Pat, tell us about yourself and what you do at Lauren's House:

Mary Pat: Well, I'm the Nurse Administrator here at Lauren's House in Boothwyn, Pennsylvania. I'm a Registered Nurse with a Master's Degree in Health Administration. I came to this position one year ago from Children's Hospital of Philadelphia. In my position I wear many hats. I oversee everything involved in the Lauren's House program. I manage the professional nursing staff and the unlicensed support staffs, oversee the maintenance of the building, and coordinate the care of every child in the program. I communicate with the primary physician, specialists, & therapists on a monthly basis for each child. I should also mention, we have two sites and my colleague, Beth Hoy, is the Nurse Administrator in our North Philly Lauren's House.

Stephanie: Tell us now about Lauren's House and the type of children you care for at your facility:

Mary Pat: Lauren's House is a Prescribed Pediatric Extended Care Center (PPECC). We take care of medically fragile children in a fun, active, stimulating environment. The staff is all nurses and the children come to Lauren's House in lieu of one to one shift nursing in the home. Funding is from insurance not the family and transportation is provided free. The center allows for socialization with peers and stimulation they may not get in the home. We take the burden of child care off the parents so they can go about their life with work or school. Children with a delayed ability to PO feed are a large constituent at Lauren's House. We care for children with GT's or NGT's while therapists work on increasing the child's ability to eat or drink.

Stephanie: Which leads me to my next question - tell us about the therapies the children receive at Lauren's House:

Mary Pat: Every child at Lauren's House gets some kind of therapy. Therapists come from all different agencies, backgrounds and funding sources. I get great feedback from therapists indicating Lauren's House is a safe, clean, wonderful environment to treat a child. Because of the convenience, many children are co-treated by different disciplines. Children receive speech and feeding therapy, as well as occupational, physical, vision and educational services. Therapy is an integral part of our program and, along with the nursing, is what sets our program apart from others.

Stephanie: Now, I know I enjoy my weekly time at LH, but can you tell our readers what LH can offer therapists as well.

Mary Pat: The center has various rooms which can provide privacy for the therapist and client if needed. Sinks are easily accessible for preparing food along with a full kitchen. The kitchen allows for baking or experimenting with food. Several bathrooms are available for the staff and a specially equipped bathroom is available for the children. In addition, the advantage of this type of setting and team-based approach is that nurses are able to carry over each child's exercises or feeding regimen when the therapists leave.

Stephanie: Wonderful. Now tell us some of your own future goals for Lauren's House.

Mary Pat: Looking towards the future, I see Lauren's House as a vibrant community center that provides a bridge between parents, physicians and therapists. It can be a stepping stone for all special needs children who also need medical care. Parents can take advantage of our services before school age and then as a wrap around nursing service during the school years. Unfortunately there are lots of pediatric professionals who are unaware of PPECC's in Pennsylvania. I hope to reach out and educate all pediatric providers of the wonderful resource Lauren's House has become.

Stephanie: I often have people ask if I know of families or facilities that are in need of supplies and are willing to take donations. What is the policy at Lauren's House?

Mary Pat: Lauren's House accepts all donations. Donations of children's toys, especially sensory integration toys, would be wonderful. Also, we can use any toy that lights up or plays music as well as any baby swings, high chairs, crib sheets, etc. New or used would be terrific. The best gift of all would be a pediatric size exam/treatment table!

Stephanie: Thank you so much for your time today. Before concluding, is there anything else you want our readers to know?

Mary Pat: Thank you as well. I would like to let everyone know to please feel free to stop in, meet me and see our center. I'm proud to be associated with an organization that provides such first-rate care. I would welcome the opportunity to meet you and tell you all about Lauren's House. If you are working with a child who you believe could benefit from our services, give me a call. I would be glad to answer your questions.

I hope that you found today's interview informative. If you are interested in contacting Mary Pat she can be reached at 1-888-340-9420. Lauren's House is located at 17 Creek Parkway in Boothwyn, PA and is located about 30 minutes or so from Philadelphia.

Interviewing Parents: Part 3

Stephanie Bruno — Fri, 07 Nov 2008 13:46:00 GMT

Thank you for your comments and input over the last week. Please continue to communicate issues, questions and topic requests that you may be dealing with in your part of the world!

For those of you who may have missed the last post, we had a speech therapist write in from South Africa working with children with HIV/AIDS. It is exciting to know that our blog is reaching across continents. There is so much we can learn from each other!

Now, to our third and final post regarding interviewing parents. Below is a continuation of the questions therapists can use when interviewing parents/ daycares:

Sensory/Oral Motor Feeding

Does the child have sensory needs?
How is their oral motor control? Do they have oral sensitivities? Like/dislike brushing teeth?
Does the child appear to have low tone? (this question can be answered more through your own observation)
Do you see excessive drooling?
How is feeding going? Is the child a picky eater? Are there any texture issues and/or food aversions? What are their favorite foods? What does their diet consist of?
Does the child have reflux or other gastrointestinal issues?
Does the child have food allergies?
Does the child have failure to thrive?

Play and Social Skills / Overall Development

How is the child's eye contact? How is their attention span?
How are their play skills and social skills? Is the child easy to engage? Can they take-turns with others and share toys?
What are the child's opportunities to socialize? Are they exposed to other children consistently?
When did the child meet other developmental milestones? Were they delayed in other areas? How is the child's overall physical development?
How is the child doing cognitively? Is there a gap between receptive and expressive language OR do they coincide?
Is the child able to imitate movements and verbal sounds? Does the child strain to make sounds? How are their motor-planning skills overall?

I hope that you have found these questions helpful! I'm sure there are other inquiries that you may think of and already use when assessing, so please feel free to share your ideas!

Next week, tune in for our first blog interview with Mary Pat Winterhalter, an Early Intervention Administrator here in Pennsylvania. She will talk about the challenges and the benefits of the program she oversees, as well as the role therapists play with the children at her facility.

The Feeding Solutions Part 2: Treatment Overview

Stephanie Bruno — Tue, 28 Oct 2008 16:09:00 GMT

As promised, the current post will focus on a broad overview of treatment ideas and techniques for feeding disorders. Since the last feeding post, several therapists have requested treatment suggestions and ideas. My hope is that this post will at least begin to outline some therapeutic solutions for this often complex issue.

Below, I have separated feeding therapy into four main areas complete with a few suggested treatment techniques. The following overview is a broad look at feeding therapy and can serve as a guideline, but is not a comprehensive treatment plan.

1. FAMILY DYNAMICS: This component focuses on training the family to have healthy and positive mealtime interactions and routines.

Eat as a Family - demonstrate HOW to eat. Other family members serve as a natural model for children with feeding issues.
Create a Routine for Mealtime : Set rules that all family members follow
Pick One Meal a Day to Address Feeding - feeding therapy can be very overwhelming. Sometimes it is helpful to only address concerns during one meal a day so that other mealtimes are less structured.

2. ORAL MOTOR: This component addresses the numerous hands-on techniques and tools that help increase awareness, strength and mobility for the child's oral musculature.

Oral Motor Tools: nuk, dry spoon, chew tube, chewy cord, etc. - Present tools both dry and wet, with food/liquid on them.
Massage cheeks, lips and chin - use lotion and vibration
Tongue and Lip Exercises
Biting and Chewing Exercises
Blow Bubbles and Whistles to address motor-planning and breath support

3. SENSORY: This component focuses on texture sensitivities and food aversions.

Use Food During Play - although this is not always appropriate this can be both fun and functional when sensory issues exist. (I.e. finger paint with pudding, etc.)
Put Food on External Oral Area - cheeks, chin and lips to help stimulate appetite and interest, as well as desensitize children.

4. BEHAVIOR: This component focuses on issues surrounding avoidance techniques that many children engage in to circumvent mealtime.

Use Simple Rewards - 30 second video, short book, a song, etc.
Use Preferred Foods - use to encourage tasting un-preferred foods
Count Bites - often very motivating and gives the child a goal.
Give the Child SOME Control - both you and the child get a spoon to help the child feel engaged.

I am aware that numerous ideas, techniques and strategies exist when addressing feeding. As this blog develops, we will further explore each of the four areas and discuss problems and solutions more in depth. I hope that readers find this introductory guideline useful.

Please share your feeding questions, concerns and solutions! I welcome your feedback and look forward to reading your comments and ideas.