Early Intervention Speech Therapy : field experts

Revisiting Apraxia

Stephanie Bruno — Thu, 22 Oct 2009 21:36:00 GMT

Every few days or so, I read through recent comments posted throughout the blog and attempt to address the questions that have been raised by our readers. One of the most pressing issues that is frequently raised by parents reading the blog is apraxia....(read more)

Part 2: Parents and the Five Stages of Acceptance

Stephanie Bruno — Mon, 14 Sep 2009 18:24:00 GMT

Last week I wrote a post entitled Parents and the Five Stages of Acceptance . Today's post is a continuation and will provide more information about what Elizabeth Kübler-Ross taught us and how we can utilize it in early intervention. Based on my research...(read more)

Christy Marzzacco Interview; Part 2

Stephanie Bruno — Tue, 02 Jun 2009 14:52:00 GMT

On Friday, I posted the first half of my interview with Christy Marzzacco. She is a therapist dually certified as a teacher of the deaf (CED—Certified Teacher of the Deaf) and a speech language pathologist (CCC-SLP). She also has a special certification...(read more)

Interview: Christy Marzzacco, SLP and CED

Stephanie Bruno — Fri, 29 May 2009 14:29:00 GMT

Over the last few months I have had the wonderful experience of collaborating with Christy Marzzacco. We have been working closely together on the case of a little boy who was born completely deaf in his right ear. Due to his hearing loss, the county...(read more)

Online Speech Therapy

Stephanie Bruno — Fri, 10 Apr 2009 14:54:00 GMT

Teletherapy helps link therapists with clients from miles away. Although, speech therapy over the computer may not be the best option for all clients, it's a wonderful opportunity for many! In addition, The American Speech-Language-Hearing Association...(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.

Childhood Apraxia of Speech Interview, Part 2

Stephanie Bruno — Fri, 30 Jan 2009 17:22:00 GMT

Tuesday's post highlighted Sharon Gretz, the Founder and Executive Director of CASANA (Childhood Apraxia of Speech Association of North America). Today's post discusses the services CASANA provides, as well as possible causes and therapeutic suggestions for treating apraxia effectively in young children.

Stephanie: Please tell us more about CASANA and what services it provides and offers families.
Sharon: CASANA is a 501c3 public charity, governed by a board of directors and which provides multimedia information on CAS to families, professionals, and other members of the public. We do this through our Apraxia-KIDS website, the largest repository of apraxia information anywhere that receives 400,000 page views each month.

Several years ago, CASANA cosponsored the first childhood apraxia of speech research symposium with 25 international researchers. Additionally, the ASHA CAS Ad-hoc Committee Technical Report identified that the "limited evidence on treatment efficacy is one of the most clinically pressing needs in CAS research." In response to the ASHA Report, CASANA established its CAS treatment research fund to encourage pilot research studies in CAS treatment. We have just awarded our first treatment research grant and hope to award at least one in 2009.

Stephanie: Earlier we talked about what worked for your son, have you since seen other helpful methods emerge and be implemented over more recent years?
Sharon: The overarching principles needed for speech therapy for children with CAS are called the principles of motor learning. In a nutshell, one applies those principles to speech motor learning and these appear to be what benefit the children, regardless of the particular "name" for the method. The following variables are what is important:

Frequency and intensity of practice opportunities. Skilled motor activity is acquired through repetitive practice. The SLP needs to maximize the number of practice trials in each therapy session and those sessions need to be frequent. Incorporating parents as therapy extenders is also ideal so that the child is practicing throughout their day. Parents need mentored in order to understand how and when to elicit practice. Observation of therapy sessions by parents is key! This is how they will know when to try to elicit a speech production from their child, how to get multiple repetitions, and when to back off. They will know not this by hearing a summary of what happened in therapy.
Type of practice. Children with severe apraxia of speech would start with a small set of core functional words. When they practice one word over and over, then another word over and over that is considered mass practice and early on this may be helpful to get more success going. When the child practices their set of words, randomly, over and over this is called distributed practice and overall this is felt to lead to the best generalization of motor skill. So children severely impaired would benefit from both types of practice.
Type, amount, and schedule of feedback. Early in therapy, the SLP who follows understands the principles of motor learning is likely to give pretty immediate feedback to the child about their accuracy and about their performance, i.e.: "Yes, that was it, you got your lips to pop" "No, you need more air in your cheeks. Puff up your cheeks, lips tight and pop them." However, as the child's speech motor system improves less immediate and direct feedback on performance is provided so that the child's system does not become dependent on YOUR feedback but the child's own system begins to take over and they can "feel" and hear when they have been successful. Visual, tactile, and verbal cues and feedback are very important, but equally important is cue fading.

Various methods exist and use the above principles for the most part. So whether it is Dynamic Tactile Temporal Cueing (a variation of what some may know as Integral Stimulation) or the Kaufman Method (a variant and expansion of Successive Approximations) or the PROMPT Method or the Multi-sensory Method, what seems to be successful is that the principles of motor learning are incorporated by the clinician and that the clinician is actually working directly on speech production.

Stephanie: As a professional, what would you like to say to both parents and therapists regarding apraxia treatment?
Sharon: Well, truly, after speaking with hundreds of parents and SLPs in the past decade or more, please, please learn about appropriate speech therapy methods. I switch between sad and angry when I continue to hear stories about children with significant apraxia who are receiving a cursory amount of speech therapy, not nearly the frequency and intensity that is most likely needed. I know we are all stretched by resource limitations, but let us dedicate ourselves to advocate for what these children need.

There is no way around the reality that these are the children that will need the individual, direct speech therapy. The ASHA Technical Report suggests three to five times weekly of individual therapy is appropriate for children with moderate to severe apraxia. The good news is that when this help is delivered using appropriate treatment methods, many, if not most of the children make great strides and over time need less individual therapy.

There is a delicate relationship "dance" that both parents and SLPs need to learn as part of the treatment process. Parents need to learn to place trust in their child's SLP while still using their discerning judgment, and the SLP must be dedicated to earning the parent's trust while being honest about the limits of their professional knowledge and experience with this population.

To the professionals, please do not expect to find the "answers" for how to provide therapy to these children in a box that you buy from a catalog. Therapy materials are just tools that can be helpful when applied by a knowledgeable clinician. Take the time to learn about motor learning principles which undergird most appropriate treatment methods for CAS.

Finally, this is going to be hard work, for the SLP, for the parent and most of all for the child. There is no quick fix. SLPs, you will need to expend more time and effort on this child. Parents, you cannot expect that the SLP alone is going to "fix" the problem. You have to be involved and help with practice and therapy carry-over. After experiencing so much failure in their speech attempts, that precious child needs to have faith in the process and in both of you. However, keep hope and faith that your hard work will pay off. The sheer joy of seeing the progress of which the children are capable is simply inspiring!

Stephanie: I have recently heard that there has been an increase in children diagnosed with apraxia. Have you seen this in your work and do you have any thoughts on why we may be seeing this?
Sharon: You know, this is hard to determine because of limited research, but at least a number of large outpatient facilities are reporting that they are seeing more kids with apraxia of speech. We cannot be sure, for example, if awareness has increased and thus more children are being appropriately identified or if there are actually more children with the disorder. I would like to think that CASANA has played a major role in increased awareness in the proper identification of these children. However, we also know from research that children are both misdiagnosed as having apraxia when they really do not (false positive) and that the diagnosis is also missed in children who really do have it (false negative).

While research and attention has progressed in the last decade it is far from complete and agreement of the core characteristics of apraxia is still being refined. Drawing from the ASHA Technical Report on CAS, possibly the key characteristics for differential diagnosis that seem to be rising to the fore and to which there is some consensus among researchers include:

inconsistent errors on consonants and vowels in repeated productions of syllables and words;
lengthened and disrupted transitions between sounds and syllables; and
inappropriate prosody, especially stress

I'd like to emphasize again that every child with limited or unclear speech does not have apraxia! However, apraxia should be considered and appropriate evaluation, including a motor speech exam, should occur in order to rule apraxia in or out as a primary explanation for the child's speech production deficits.

Stephanie: I have also heard that there seems to be a link between autism and apraxia in some children. What has your experience been in this area?
Sharon: There are certainly some children who have both autism and apraxia, though we do not currently know how many children with autism may also have apraxia. Unfortunately, we do hear of situations where the child does have apraxia and this is eventually determined but the child's speech problems had been attributed to autism with no consideration as to whether or not there could be motor speech involvement.

It can be difficult to make a determination when a child with autism is essentially nonverbal and is unable to cooperate with a motor speech exam. Every nonverbal child with autism does not have apraxia! But some may, and so it is worthwhile that SLPs be thorough in their evaluations and be sure to consider motor speech disorder in any child with significant speech production issues.

It is not just with autism that apraxia of speech can coexist. The same can be said of children with Down syndrome who also have apraxia of speech. Quite often we have heard of limited intelligible speech being attributed to cognitive deficits when motor speech was not ever evaluated or considered. It is always worth considering and investigating whether a child has a motor planning or motor execution aspect to their speech difficulty.

That said it is also important to remember that each additional diagnosis makes treatment all the more challenging. Just because a child with autism has apraxia does not mean you abandon working on communication, language, and social relatedness skills in favor of apraxia type therapy nor should the professional ignore motor speech approaches that would help with speech motor planning skills. In these situations, careful planning needs to occur to assure that all aspects of the child's speech, language and communication deficit are addressed in therapy.

Another related issue especially for early intervention professionals is that just because a child has limited verbal skills does not mean they have autism! We have also seen children diagnosed on the autism spectrum who did not have autism. They could not speak due to severe apraxia and secondarily developed some behavioral characteristics from their frustration or had some co-existing sensory issues or had more overall global apraxia that made manipulating toys and their environment very difficult. We have also seen kids diagnosed as having CAS who really have autism, not apraxia! We need to become very knowledgeable about teasing out the differences and subtleties that exist! It can be very trying on the families who are struggling so hard to help their children.

Stephanie: Sharon, I would like to thank you for all the incredible work you have done for our field, as well as for children and families dealing with apraxia. It has been a delight to speak with you. With all the work you have done in apraxia research and education, what is your hope for the future and for all those faced with the diagnosis?
Sharon: Obviously, the greatest hope is to understand the causes of apraxia and to either provide effective treatment at the earliest possible moment or to determine a cure or prevent the disorder. Awareness and understanding of the challenges these young people face is very important to their future. I dream about teachers who understand, friends who understand, physicians who understand...

I would hope that sources such as private health insurers, government funding entities, and school systems would commit to providing the financial resources that can support the outcomes that we know are possible. I just see it as an investment. We know about the potential cascade of future ramifications when a child has a speech sound disorder like CAS. We know that we could prevent some of those negative ramifications through early, effective treatment. It is my dream that each child will receive the help that he or she needs and requires.

Our slogan is: Every child deserves a voice, and whenever possible, the one that is their very own. While this speaks to their speech capacity, it really means so much more. Children with apraxia deserve to be heard, understood and appreciated as well as feel their own personal power through self expression. Communication is perhaps the most important of all human qualities. If a child has the ability to develop intelligible speech, they should be given that opportunity. This is my passion and this is what CASANA'S work is about each and every day!

Sharon and I both hope that you have found this interview informational and advantageous. Please write in and share any feedback YOU have regarding this week's interview and/or YOUR experiences with apraxia.

More information on CASANA's work is available at www.apraxia-KIDS.org.

Interview: Sharon Gretz, MEd, on Childhood Apraxia of Speech

Stephanie Bruno — Tue, 27 Jan 2009 22:02:00 GMT

Sharon Gretz is the founder and current executive director of the Childhood Apraxia of Speech Association of North America (CASANA). She also is the parent of a child diagnosed with apraxia of speech.

Sharon's personal journey with her son, as well as her professional dedication to helping children and families affected by apraxia is both inspiring and incredibly insightful. My hope is that therapists and parents will be moved and motivated by her story, her words and her passion.

Stephanie: Sharon, thank you so much for taking the time to speak with me and complete this interview. Let's start off by hearing about you and your background.

Sharon: I am married with three children, the youngest of which was diagnosed with severe apraxia of speech at age 3. He's now 17 years old and considering colleges to investigate. I have my Masters Degree in counseling (MEd) and have completed all graduate course work toward my PhD in communication sciences and disorders. I have a long history of working in disability services and nonprofit program development and this gave me a real advantage when my son was diagnosed with CAS. I incorporated CASANA in 2000. Shortly thereafter, CASANA received its 501c3 designation as a public charity from the IRS. Our organization is governed by an active board of directors, all of which have a personal connection to apraxia. I am happy to say that just January 1 of this year I became the first full time Executive Director of CASANA, our first full time paid staff position.

Stephanie: Please tell us what it was like to first receive your son's diagnosis. How did it affect your family?

Sharon: Goodness, it affected our family in countless ways! First of all, once my son was diagnosed we were told both that apraxia is a very challenging speech disorder and that his prognosis was guarded. As we understood it, with appropriate therapy and enough of it, our son would be able to "improve his intelligible speech" but how much, no one knew. I felt pretty numb. You go in thinking your child has a "speech delay" and come out not even sure your child will have fully functioning speech - ever. Numb is the best word to describe the initial feeling. Then came the fear.

Would we "know" appropriate therapy if we saw it? What if we could not find someone who really knew how to help? What if we let our son down? In the end, we were connected with a true expert and for that we will always be grateful. My son started one on one individual private speech therapy four times a week. It made working full time hard. I was fortunate that my boss at the time let me change to part time and working from home so that I could take my son to his speech therapy, sit in the observation room and watch his treatment, and spend lots of time with him at home following through on his therapy program. It felt for some period of time that our lives revolved around speech therapy; both private and at his preschool. Add occupational therapy (which many of the kids end up needing) and the financial burden and we were very stretched!

I was very fortunate that our entire extended family rallied around us. Aunts, uncles, grandparents - everyone became committed to doing whatever it took to provide my son his best shot at speech. In that way, we were very rich.

Stephanie: Can you tell us more about the specific therapeutic techniques that were instrumental in helping your son?

First of all, let me tell you what did NOT benefit my son's speech production. For the first year of his speech therapy, prior to any understanding by myself or a professional that he had childhood apraxia of speech (CAS), he received EI speech therapy akin to what you would know as "language stimulation." He received this type of therapy for one year, first once a week, then twice a week, with no benefit at all to his speech production.

This was a child who brought many strengths to speech therapy including an extraordinarily good attention span; good cognitive and receptive skills; and a strong intent to communicate. It was after one year and his transition to preschool services from the birth to three early intervention program that I sought out a private speech-language evaluation at our local children's hospital. That was where he was diagnosed with very severe CAS when he was 3 years old. In retrospect, that lack of progress in my son, despite treatment being delivered, should never have been acceptable to the professional.

My son immediately, and I mean from the very first day, began to make progress with a new SLP, David Hammer, from his eclectic "multi-sensory" approach. Specifically, my son's attention and effort were directly brought to his articulators and what he was doing with them. Visual, tactile, and verbal cueing was used that appeared to help him associate the cue with a particular speech movement. It was as if the cues sparked a motor memory for what he was being asked to produce. The focus of this treatment was on speech movement and being able to join movements, first, for short functional words and then into longer units such as phrases and multi-syllabic words.

Very early in my son's "new" therapy, he benefited from a core vocabulary approach. I think this is a great strategy for early intervention SLPs. Basically, the SLP, after getting a complete phonemic inventory, worked with me to identify a small set of functional words with high utility for my son in particular. So, my son was having some success with bilabials and alveolar stops and amazingly had a final /s/ in his small repertoire. He had few vowels aside from schwa. With this in mind we crafted a list like "me, bus, boy, eat, mad, up, pup..." and several others. We used a small photo book and inserted both a photo of the word/action and the written word. This became a practice set for us to be able to use at home to reinforce what was happening in the therapy room. My son could show the book to his father and siblings and was proud to practice "reading" it.

Once the set of words became more automatic and accurate, new words were added with consideration to the phonemes he could produce, those that were stimulable, and so forth. Eventually, he got so good we dropped the book!

In some cases, my son was directly taught to produce single sounds because his apraxia was so severe. In fact, I think that in his case nearly all consonant sounds were directly taught. That being said, the focus of therapy was not to perfect those sounds prior to moving on to working on short words. There was constant shifting between working on the movements needed for words and backing up to fix accuracy of individual phonemes.

My son was asked to produce many, many repetitions of the syllables or words that were targeted. The SLP was quite creative in setting up fun play scenarios and setting rules for games that made it nearly mandatory that my son make multiple attempts (think "drill play"). It was not uncommon to hear dozens and dozens of productions of the speech targets in a single therapy session.

Simple sign language was used to not only bridge communication gaps when my son's verbal attempts were not understood but to also serve as visual and tactile cues. It helped enormously when the sign and verbal attempt were paired as they always were. The great thing about signs is that you can fade out the cues over time as the child's system becomes more competent. I found that it also served as motivation early on when speech attempts were unintelligible. When paired with a sign, if I could not understand my son's verbal attempt I had a good chance of catching the sign and thus could respond appropriately, and reinforce his communication attempts. Many children can learn simple signs, although for some children it may be too frustrating due to fine motor deficits. In that case, the SLP can still use signs as visual cues for the child.

Stephanie: As a parent, what advice would you give to other parents who may be hearing the diagnosis of apraxia for the first time?

Sharon: Well, first of all, parents should not blame themselves, as if they did something to "cause" apraxia in their child. Secondly, they should go ahead and allow themselves to feel sad, mad, and/or sorry for their child and for themselves for a short period of time. This is understandable and necessary. However, inevitably they must pick themselves up, brush themselves off and get out there and learn as much as they can about this speech problem and how children are best helped. Becoming an effective advocate is something all parents should strive for and which is critically important to their child.

While it is important to have hope and to know that children can actually do quite well with appropriate help, each child with apraxia is a unique constellation of strengths and needs. No two of our children are totally alike. So be somewhat cautious comparing children with CAS to one another.

Learn how to critically evaluate and weigh all information and sources of that information and to then apply knowledge vis-à-vis what they know about their own child's needs. Treatments recommended should be able to withstand a parent's critical scrutiny. I highly suggest trying to form a team with your child's SLP, physician and others.

Get connected! Our online groups are a great way to get valuable information but also personal support available in your home, when you need it. Our summer conference is immeasurably valuable and inspirational too!

The good news is that with appropriate help and enough of it, many of our children become quite effective speakers, so much so that others could not possibly guess that they once had a severe speech disorder. CASANA will continue to push for research so that we can learn more about all the factors involved. Hang on and have hope!

Stephanie: Unfortunately, there are many parents out there who are struggling the way you were years ago when your son was first diagnosed. What prompted you to go beyond your experience and begin CASANA?

Sharon: First, when my son was diagnosed, I had not heard of apraxia of speech in children. There was no information specifically designed for parents. What I was able to locate was the very sparse professional literature and quite frankly, from my read of it, the future for these kids sounded pretty bleak. We were fortunate to get connected with a SLP who had years of successful experience treating children with CAS, and so the clinical experience of our SLP did not necessarily match the dire prediction of the professional literature.

My son struggled through about 5 years of individual speech therapy, and I do mean "struggled". The amount of time, concentration, and intense effort that was put forth by both my young son and his wonderful SLP was truly something to witness and something I could not forget. CASANA is a tribute to both of them and to the reality of what this disorder means to children and their families, as well as the professionals who provide help.

The partnership between our family and our son's SLP was critically important and benefited my son in countless ways. In my "spare" time, I dedicated myself to learning everything that I could about apraxia, reading and deciphering every text book and journal article that I could locate. My son's SLP took me under his wing almost like he would a graduate student and provided additional knowledge. I also observed over 200 individual speech therapy sessions. At the end of the day, I had learned a TON about CAS. The decision for me once that I knew my own son was going to be ok, was... do I walk away and go my merry way? Or do I have a responsibility to share what I learned and to help other families?

Secondly, back when my son was diagnosed in 1994, the internet was still quite "young". Imagine, there was nothing called a blog! I had found some online bulletin boards and through that, several parents of children with apraxia. In 1997, I decided to take the leap and started an email discussion group (listserv) about apraxia. Well, the Apraxia-KIDS listserv was (and still is) wildly successful. It just grew and grew and then grew more.

Later, other parents assisted in helping to set up a companion website so more information could be shared. I was contacted more and more for information and was even offered funding now and then; though at the time I was still a "mom" sitting at my home computer just trying to share what I had learned. Finally, the whole enterprise of trying to keep up with the needs as well as the time and expense became something that could not be effectively handled by an informal effort.

Third, though out the whole process I began to understand the need for factual information. In my mind, I felt that not only was relevant and accessible information needed, but also reliable information grounded in facts. It was clear very early that anyone could basically say anything they wanted to say on the internet. Who do you trust, really? There is a great responsibility when you are providing help to vulnerable people. I just really hoped that we could create an organization that's information would be trustworthy to families, professionals, and researchers.

Please join me on Friday for the second half of my interview when Sharon will talk about the services CASANA provides as well as some of the most recent information on apraxia research and treatment techniques.

Interview: Aquatic Therapist Susan B. Nachimson, MA, CCC-SLP, CMT - Part 1

Stephanie Bruno — Thu, 15 Jan 2009 22:37:00 GMT

I have had the absolute pleasure of speaking with and interviewing Susan B. Nachimson (pronounced /nakumson/). Susan has been practicing speech therapy for over 30 years in many different arenas and venues. Susan is trained in both NDT (Neuro-Developmental Treatment) and WATSU (Water Shiatsu). She is also a certified massage therapist and implements aquatic therapy with speech clients frequently in practice.

Susan's experiences both in the field of speech-language pathology and beyond, I'm sure, will delight and amaze you! Enjoy reading below as we embark upon Susan's professional journey from a young professional to a multi-dimensional therapist.

Stephanie: Susan, tell us about your background and when you first started practicing as an SLP.

Susan: I began practicing in this profession in August 1976 in public schools after having received an MA Degree in Speech Pathology at Humboldt State University, Arcata, California. I received a BA from Valley State College, now California State University, Northridge (CSUN), 1965. I spent those between years raising children and taking a graduate course here and there until I finally found myself in a great position to complete the teaching credential I began in the '60s and acquired an MA in the same year. My children were in elementary school by now and every time I volunteered as a parent I was enticed into screening students with speech and language issues who were not being served in the years before public law demanded identification, assessment and treatment for our students.

Stephanie: How did you become interested in furthering your certifications and getting NDT trained, as well as becoming a certified massage therapist?

Susan: After years of working within the ASHA model and following recommendations and strategies picked up from specialized continuing education courses, state and national speech pathology conventions and multitudes of purchased textbooks and manuals, I was asked to work with a two-year-old child with cerebral palsy. Her mother asked, ‘Are you an NDT Therapist?' ‘No', I said. ‘Do you know what that is?' she asked. ‘No,' I said again. ‘Are you interested in learning?' the mom then asked. ‘Sure,' I said.

That was the beginning of a shift in this profession for me that was very interesting, profound, and exciting.

After this, I was led to a colleague who taught NDT (Neurodevelopmental Treatment, aka Bobaths) strategies for speech pathologists and my hands-on education began. I had already enrolled in a massage therapy licensing course. I had a patient, post CVA, with oral apraxia of speech and severe limitations in breath support who appeared to benefit from a hands-on approach.

By this time I had taken some courses in Transpersonal Psychology that emphasized issues in the body that were affected by breath-holding incidents secondary to trauma. Stroke, CP, seizures were all conditions that resulted from trauma. It was simple to put the concepts together from a psychological approach to a functional speech pathology approach. I was aware that touch needed to be brought into my practice. As a certified massage therapist (CMT) I was licensed to practice hands-on chest compression to facilitate deeper and fuller breath control for my patients. So, now, I was enrolled in massage therapy and learning NDT simultaneously hoping I was heading in a positive direction!

Stephanie: Well, we know now that you definitely were! You have so many skills! So, now, tell us what led you to doing aquatic speech therapy?

Susan: In 1986, after my last child graduated from high school, I prepared to take an 8-week pediatric NDT course in order to enable me to work with young children with a variety of multiple disorders with feeding, speech and language needs. I was fortunate to have an opportunity to work at Easter Seals in San Francisco as a temporary replacement for a colleague on maternity leave. It was there that I saw many under 3-year-olds in both the clinic and home-care settings.

The child who led me into water was two-and-a-half years old. He crawled with a stiff body, had severe laryngeal blocking and was frequently very angry. It occurred to me that maybe we were not a good match after frequently being hit by him.

Finally, one day, I asked his mother, ‘How is this little guy in his bath? Does he enjoy the water?' It is so amazing when the perfectly correct moment occurs. His mom responded, "He LOVES his bath—he laughs and splashes all the time!"

I heard ‘laugh' and was inspired! I started to discuss working in water. The rest is history! This sweet boy locked into his body, traumatized by limited breath support and poor muscle development, became independent in water. His warm-up time on the ramp was seconds as he crawled into the water. Mom trusted me to do the right thing.

My personal experience was teaching all of my own children and nieces and nephews and friends' children to swim for fun. In addition, I learned in transpersonal psychology workshops about a prenatal journey in water that is a tool used to help people unlock deeply rooted traumas.

This little guy just went under and used all-fours to swim towards his mom, pulling his head straight out of the water and laughing a clear, open belly laugh with no traces of laryngeal blocking or limited inhalation! It was absolutely AWESOME to say the least.

I wasn't sure how to interpret the session per goals and objectives, but I knew we addressed increasing respiration for phonation! The most remarkable awareness was how independent and functional this child was in water in contrast to totally disabled on land. I knew there needed to be a transition from water to land. Unfortunately, there were no follow through sessions with this child, but many new sessions with other children were tried with new strategies being developed with each one and hence began my love for aquatic therapy!

Today, my favorite place to practice in my field is when providing diagnostic therapy in a warm water setting, preferably in a shallow swimming pool or spa that is at least 93F!

Thank you so much for reading the first half of my interview with the dynamic aquatic speech therapist, Susan B. Nachimson. Please join us Tuesday for the second half of our interview, when Susan will explain her recommendations for successful aquatic therapy as well as where you can find Susan now!

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.

A Letter to WELCOME my future readers!

Stephanie Bruno — Wed, 01 Oct 2008 20:40:00 GMT

This is officially my first blog post and I am absolutely delighted to have this opportunity to write about a topic that I love to discuss, namely: Early Intervention Speech Therapy. I wanted to use this first post to point readers in the direction of both this blog site's description and my personal biography. When writing both, I did my best to clearly define and describe the goals of this blog and my personal vision for the site.

With the incredible growth of the Internet, this is a very exciting time in early intervention (EI)! Despite the fact that many families in EI often report feeling isolated and unsure about which path to take with their child, blogs such as this are now available to help families evaluate and address many of the concerns they may have regarding their child. Moms that may not have had the opportunities (or time!!) to network with other families in the past, can now locate invaluable information about the resources available globally and locally without ever leaving their living room! With that in mind, one of my goals for this blog is to provide a communication forum for parents and therapists to come together and share insights, offer expertise and ask questions regarding their own experiences.

My hope is that parents and therapists alike will tune in weekly to research updated information and the latest trends in both traditional and alternative therapy treatments. In addition, I welcome requests for specific subject matter - I encourage all who have been searching for answers on particular topics, to please write in and I will do my best to discuss and research, if necessary, the information people are craving.

In addition to therapeutic tips, personal reflections and the latest in early intervention news, I am also going to interview experts in the field. Some of the "Who's Who" on my early intervention interview checklist include: pediatricians, developmental pediatricians, feeding specialists, parents of children in EI (focus will be on a variety of topics), administrators of EI facilities, other therapists (including occupational, physical and other speech therapists), pediatric ENTs, etc....the possibilities are endless!! I would like to now thank my future readers in advance for taking the time to read and respond to my posts.

I look forward to sharing this journey with you as we explore Early Intervention and all that it has to offer our children.