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Speech and Hearing Perspectives

Building Sounds One Block at a Time
August 25, 2015 8:59 AM by Speech Merion

Susan Gottlieb, TSHH, speech therapist, invented the following speech game for helping children correct speech production. Children find it very interesting, as they need to produce the proper sound in a word before they can add a block to a tower. What’s more, there's no additional expense, as the tower can be built with toy blocks or virtually anything stackable. Thanks Susan, for sharing your game! Have a game or technique you'd like to share? Email us at Enjoy!

By Susan Gottlieb, TSHH

Blocks to build a tower

Child and therapist alternate saying sounds in words they’re working on from a word list.

For each correctly produced sound, the child gets to add a block to their tower. 

Whoever builds a 10-block tower first, wins the game. 

And just for fun, at the end of the game, the child gets to knock the tower down! 

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Sammy the Lisping Parrot
August 6, 2015 10:59 AM by Speech Merion

By Susan Gottlieb, TSHH

Tommy was an only child. He always wanted a pet to keep him company.

On his fifth birthday, his wish came true. His mom took him to the pet store to buy a parrot.

Tommy was so excited to take his new parrot home and teach him how to talk. But days and months went by, and Sammy the parrot didn't utter a word.

Every day, Tommy would come home to his parrot: "Hi, Thammy!" he would say.

"Mommy, when will Thammy learn how to talk?" Tommy asked finally.

“It takes time,” his mother explained. “Just like when you were a baby and you were listening to mommy and daddy speak in order to learn how to form words to talk. It will happen, don't worry.”

SEE ALSO: Stuttering: Acceptance & Commitment 

One day after school, Tommy heard outside the door as he approached, "Hi, Thammy! Hi, Thammy!"

Tommy got so upset. "Mommy, why does Thammy sound so funny?" he asked perplexed.

Mom smiled, and said, "Tommy, he's listening and saying it the way you say his name."

"But mommy, I say Thammy, not Thammy?!" Tommy insisted, not realizing his lisp was making the bird hear and mimic something entirely different than he thought.

That afternoon, his mother took him to an electronics shop and bought Tommy a tape recorder.  When they got home, she taped his conversation with Sammy. When she played it back, Tommy yelled, "That doesn't sound like me! It's the way Thammy says my name. What's wrong with him?!"

Soon, it was time for Tommy to go to speech therapy at school. When Tommy and his mom met Miss Susan, the speech therapist, Tommy was only worried about how he could help Sammy sound normal.

Miss Susan said, "It's time you learn to parrot me now." Tommy did not understand what she meant."Mith Thuthan ithn't a bird," he said under his breath.

After many sessions of working very hard practicing tongue exercises and positioning his tongue in the right place, for better speech, "Mith Thuthan" began sounding like "Miss Susan."

Tommy began to change his speech. "Hello, S...S.. Sammy. I'm home!" he would say very carefully.

More time passed, until one day after school, as he opened the front door at home he heard his parrot say, "Hi, Sammy. I'm home!"

Tommy grew excited, and proud.

"Mommy, Mommy, come here quick!" he exclaimed. "Did you hear Sammy say ‘Sammy?!’"

"I sure did Tommy!" said mom, as she gave him a big hug. "I sure did."

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Tribute to Muhammad Ali Parkinson Center
July 30, 2015 9:30 AM by Speech Merion

Having managed nearly 200,000 patient visits, and conducted in excess of 12,000 education and wellness classes, the Muhammad Ali Parkinson Center in Phoenix is celebrating its extraordinary accomplishments with a unique testimonial video featuring patients paying tribute to the 17-year-old comprehensive center and its famous namesake.

"To have Muhammad Ali's name on our center implies a terrific responsibility," says Abraham Lieberman, MD, neurologist and director at the center. He speaks in the video about finding the best doctor and getting the best treatment. "This video is an incredible testament to the strong community we've created to offer the quality care and support that all patients deserve to receive."

Since opening in 1997, the center has seen three expansions and grown to become the nation's farthest-reaching Parkinson's program. Additionally, with support from surgeons at Dignity Health St. Joseph's Barrow Neurological Institute, it has become a leader in deep brain stimulation (DBS), which is a revolutionary treatment for movement disorders that involves a surgically implanted medical device, the so-called ‘brain pacemaker.’

Over the years, the Muhammad Ali Parkinson Center has held education and wellness classes in both English and Spanish throughout Arizona, into Nevada, Texas, Montana, South Dakota, Washington, and Florida. Home to the nation's largest Hispanic outreach program for Parkinson's, the center currently hosts annual Spanish education webinars with audiences in several South and Central American countries as well as Switzerland.

"At the Muhammad Ali Parkinson Center, you learn that there's so much more that you can do to keep a good quality of life," says Ida Stanford, a patient featured in the video which pays tribute to Muhammad Ali and illustrates some of the center's topnotch services. "You have to learn to live the best you can. I couldn't imagine having Parkinson's and not having a place like the center here."

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The center's outreach programs have been designed by experts to help people living with Parkinson's and their family members build positive support systems and better understand the disease. With emphasis on maintaining a positive quality of life, the center's current offerings include support groups, education classes, art and voice classes, music therapy, singing groups and unique Parkinson's specific exercise opportunities including dance, yoga, golf, tai chi and pole walking.

Attracting patients from all over the world, the Muhammad Ali Parkinson Center is a designated National Parkinson Foundation Center of Excellence supported by the world-renowned neurosurgeons at St. Joseph's Barrow and includes movement disorder neurologists, outpatient rehabilitation and neuropsychology services, nurses, researchers, medical fellows and supportive staff.

"Muhammad Ali became the face of our fight," says George Prescott, another patient featured in the video. "If you really want to put PD in its place, you couldn't do it without St. Joseph's and the Muhammad Ali Parkinson Center."

Watch the video here and share your thoughts below on the legendary boxer and the advances in treatment for Parkinson’s he has helped researchers achieve.

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Your Child and AAC: One Mother’s Tips for Success
June 30, 2015 10:22 AM by Speech Merion

Elizabeth Kenkel is a 21-year-old young woman with Moebius Syndrome and cerebral palsy who no longer has to rely on anyone to share her ideas, thoughts and feelings thanks to her speech-generating augmentative and alternative communication (AAC) device. Her mother, Sandra Kenkel, shares the following tips for other parents of children using AAC:

Don’t underestimate your child. Set the bar high and then celebrate any progress toward it. Kids in general tend to rise to expectations. Kids with special needs are no different. Doctors don’t have a crystal ball. We ignored the ones who told us “she will never” and felt justified when “she did!”

Kids are always listening. Remember that kids are listening even when they are not talking. They do know your secrets and sometimes stress over them. Don’t talk in front of your silent five-year-old about things you wouldn’t discuss in front of a chatty five-year-old. Years later, we learned that Elizabeth worried unnecessarily about things that she was too young to understand and didn’t have enough language to ask about.

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Keep talking. When Elizabeth was a baby, her neurologist told me to “Describe the world to her; she is listening.” I’d sit her in the dirt and talk about the dirt, help her pull cupboard doors open to play with the Tupperware. In the car, I’d talk about what we saw. We have to remember we are modeling a speech pattern that we hope they will imitate.

Jump on your child’s bandwagon! Elizabeth had so many things to work on – OT, PT, speech, feeding, drooling, walking, crawling, math, money, reading. It’s overwhelming, but at different points in her life, different things were more important to her. When she was determined to walk, we directed our attention to supporting PT and practicing with her. That meant that other goals fell by the wayside, but only temporarily. She made so much more progress in the area because it was her goal; we knew we could always come back to working on strengthening her arms later.

Do with them, not for or to them. Elizabeth always wanted to be like everyone else.  She fought technology when she was the only one using it. She didn’t open up to it until we “stole” Dad’s laptop. I increased his font size on the screen. She liked that, because she was using a “normal” computer, not a “special” computer. But the mouse was frustrating her. I asked her permission to try the joystick mouse. That was great! She could do the keys, but it was awkward. I asked if the Intellikeys would make it easier -- we added that piece in. By the end of the experiment, the laptop was only serving as a monitor, but she was accepting it because in her mind it was still Dad’s laptop, a computer like everyone else’s. She had time to try out “normal” and request the accommodation. Then we transitioned to the systems designed for people with her abilities and she saw them in a whole new light.

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Working Your Way Through Retirement
June 4, 2015 7:56 AM by Speech Merion

Many people who waited eagerly for the day they could stop working and enjoy a leisurely retirement find that the reality doesn’t match their dreams.

“Some people are not prepared financially or mentally to retire,” says Michael Bivona, a retired CPA and author of the book “Retiring? Beware!! Don’t Run Out of Money and Don’t Become Bored” (

He suggests a part-time job provides a possible solution for both deficiencies–giving a boost to your bank account and a mission to your daily living that another round of golf just isn’t supplying.

“I don’t think many people realize that they may live 30 to 40 years after leaving the workforce,” Bivona says. “The amount of money required to sustain a comfortable lifestyle is staggering.”

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Meanwhile, boredom becomes an insidious enemy, even for retirees with a beloved pastime they hoped to make the centerpiece of their existence. Playing tennis or lying on the beach is relaxing and pleasurable when done once a week or a couple of times a month. But the novelty wears off quickly when it becomes a person’s primary occupation, Bivona says.

He suggests a few part-time job possibilities that could work out nicely for retirees, whether their needs are financial or they just want a place to go every day to mingle with co-workers, such as cruise ships, libraries, bookkeeping or even being a virtual assistant.

“If you look around, there are a multitude of opportunities out there,” Bivona says. “I recommend first trying to find something you have a passion for. But if you aren’t successful with that, widen the search because there are plenty of other possibilities that will put extra money in your pocketbook.”

How about you? Do you know any retirees who have taken on a part-time job or otherwise found ways to stay active and earn money in their golden years?

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SLP Overcomes Stroke to Help Others with Dysphagia
May 13, 2015 3:47 PM by Speech Merion

Personal experience has helped make Heather Storie, SLP, a speech-language pathologist at Texas Health Harris Methodist Hospital Fort Worth, passionate about helping patients with something most people take for granted – the ability to eat.

Storie began her career at Texas Health Fort Worth as a speech-language pathologist in 2008. She has spent her entire career passionately helping people speak and swallow normally again.  

However, at the age of 26, Storie had a terrifying experience.  She developed the right-side facial droop, slurred speech, and tongue deviation, textbook stroke symptoms which she knew like the back of her hand. Storie was diagnosed with a rare condition called moyamoya, a disorder caused by blocked arteries at the base of the brain which occurs in less than 1% of the population.

Now, a few years after her first mini-stroke, Storie has recovered with her speech intact and an even greater commitment to her mission to help stroke patients. Storie enjoys sharing her knowledge with other speech therapy professionals and is an advocate for the dysphagia community.  She speaks to members of support groups and provides education to nurses and the community.

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Recently, she became one of 16 therapists statewide, and one of two in Dallas/Fort Worth, to complete certification with the Specialty Board on Swallowing and Swallowing Disorders (BCS-S).  Also known as dysphagia, swallowing disorders include problems with chewing, starting the swallowing reflex, and closing off the airway to prevent food or liquid from entering the airway (aspiration) or to prevent choking. They can happen with nervous system damage due to stroke, brain injuries, Parkinson’s disease, Alzheimer’s and multiple sclerosis.

To achieve board certification, Storie participated in a three-year process that included documenting at least 350 clinical hours that has a focus on dysphagia and 75 hours of advanced level dysphagia training.  In addition, Storie participated in three years post certification clinical work that has a focus on dysphagia, volunteered on a national committee that worked to advance the field of swallowing disorders, acquired three confidential letters of recommendation confirming her clinical skills and advanced knowledge in swallowing and swallowing disorders, and passed a 2-hour board exam on all aspects of swallowing and swallowing disorders.

The certification demonstrates advanced clinical competency and provides consumers, colleagues, and referral sources her commitment to providing the highest quality clinical approaches that most effectively and efficiently evaluate and treat individuals with swallowing disorders.

“By achieving board certification, Heather will be prepared to provide the most recent evidence-based treatment possible in order to give her patients the best opportunity to enjoy a task that is largely taken for granted – eating,” said Scott Shelton, PT, MPT, Therapy Services Manager at Texas Health Fort Worth.

Storie says she “fell in love” with the discipline during her master’s program. “During my student internship, I had a supervisor who loved the field of dysphagia and instilled that love in me to help my patients, and I pass this devotion on to the students that I teach.  There is no better feeling than to help a patient get back to the point where they can eat again.”  

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Tic Tac Tongue
March 24, 2015 12:53 PM by Speech Merion

Susan Gottlieb, TSHH, speech therapist, invented the following speech game for tongue thrusters. Children find it very challenging, as they need to produce good placement and sound before they can post an O or X on the board. And the best part -- there's no expense, it just requires a paper and pencil. Thanks Susan, for sharing your game! Have a game or technique you'd like to share? Email us at Enjoy!

Tic Tac Tongue

  1. Find a piece of paper and pencil.
  2. Draw the board (3x3 squares). Children love to make the board!
  3. Therapist and child alternate turns.
  4. Place an X or O in a square.
  5. First player who draws 3 Xs or Os in a row ... horizontal, vertical or diagonal, wins the game.

Child must produce correct sound with good articulation before he takes his turn to draw his letter on board.

The children are motivated by the challenge of winning. The game is lots of fun while improving their oral motor skills.

One Size Does Not Fit All
March 11, 2015 11:15 AM by Speech Merion

**UPDATE: May 14, 2015: The Australian Government has turned down SPA's proposal. Thank you to all of the SLPs and parent who have spoken up to educate SPA on the ramifications of their request for program-specific funding. We hope that SPA can work with stuttering specialists to develop a more well-rounded proposal to benefit children who stutter. 

By Brooke Leiman MA, CCC-SLP  

Speech Pathology Australia (SPA), Australia's professional organization for speech-language pathologists (SLPs), recently submitted a proposal that suggests that SLPs working in clinics run by the Australian government must be trained in the Lidcombe Program in order to treat pre-school aged children who stutter.  SPA is also supporting legislation that would extend this mandate to private practitioners and require them to provide the Lidcombe Program in order to be reimbursed by Medicare.  Although the SPA's intentions may be to increase access to treatment for young children who stutter, we must not overlook the ramifications of having the government and private insurance companies intervene with clinical decision-making.  

The first thing to consider is that there are multiple factors that are known to contribute to the onset of stuttering.  Each child has a unique set of abilities and vulnerabilities that determine if and how stuttering is going to persist. Those different circumstances demand different approaches to treatment.  A speech pathologist cannot be expected to develop a treatment plan that is specifically tailored to the client when the SPA is using Medicare reimbursement to limit them to one approach. Speech pathologists could be faced with the unfortunate dilemma of deciding whether to use an approach that best fits the child and families' needs or to use the approach that will get reimbursed. 

We must also consider that although this mandate is exclusively impacting children who stutter in Australia, it has the potential to set a precedent for how all communication disorders are reimbursed by the government and private insurance companies across the world.  Clinicians who focus on disorders, such as Childhood Apraxia of Speech or feeding/swallowing disorders, must think about the ramifications of being limited to one single approach to treating their clients as well.  Jane Fraser, the President of the Stuttering Foundation of America, released a statement concerning SPA's proposal to the to the Australian Government.  "We can't imagine a policy that limits a cardiologist, an oncologist, or a surgeon by controlling reimbursements to one single approach for all patients -- why limit Speech-Language Pathologists (SLPs)?" 

Finally, the decision of the SPA to restrict SLPs to one treatment approach has the potential to negatively impact the future of stuttering research. We must not hinder research or the recognition of new and effective clinical approaches by mandating the use of one existing approach.  Organizations such as the SPA and the American Speech Language Hearing Association (ASHA) were developed to ensure that our field matures and moves forward, however a mandate such as this will only hold us back.

If this policy is accepted, its impact has the potential to extend well past the country it is originating in and beyond the disorder it is addressing.  Although this is occurring thousands of miles away, it is imperative that we voice our concerns about this issue now to make certain that our field continues to advance our knowledge of communication disorders and to ensure that the families we treat receive individualized and comprehensive care.   

Brooke Leiman is director of the Stuttering Clinic at National Speech/Language Therapy Center ( also hosts the blog at 

No Stuttering, Please
January 27, 2015 1:02 PM by Speech Merion
Recent reports out of Cleveland have the stuttering community reeling, and not in a good way. The local CBS-affiliate TV station in Cleveland reported that a Cleveland Police cadet was stopped from graduating because of his stuttering, despite having successfully completed the police academy. The National Stuttering Foundation wasted no time in condemning such action.

"Our initial reaction to this news was that this decision by the City of Cleveland to prevent him from graduating would have a chilling effect on the stuttering community -- and we immediately issued a statement saying so," Jane Fraser, president of the Stuttering Foundation, shared with ADVANCE. "Far too many people who stutter can identify with the difficulties of applying or interviewing for a job. For anyone, the experience can be nerve-wracking. For those who stutter, the anxiety can have a crippling effect on fluency." 

"The fact that he successfully completed the full training was proof that his stuttering should and could not have been used as a reason for not allowing him to graduate," she continued.

Fraser stressed that it's the speech-language community's job to use this event as a way to educate the public, and especially employers, on stuttering and the resources readily available on the Stuttering Foundation web site. It's also an opportunity to let people know that those who stutter can be excellent employees ... and deserve the same career opportunities as everyone else.  

"Much as we used the movie The King's Speech to educate the general public about stuttering, we use all coverage, positive or negative, as an opportunity to teach," she said. "We encourage discussion about stuttering in both social and traditional media. In this case, we are very hopeful that we'll hear from the City of Cleveland that the officer has graduated and moved on to active duty.

SLPs across the country were shocked to hear this news, and might have even been performing damage control with some of their less-confident clients who stutter. But Fraser knows SLPs are equipped to handle this and any other controversy that affects their practice.

"SLPs know better than anyone that those who stutter are capable of monumental achievements, so we hope they will share that sentiment often in therapy, on social media, in the articles they write and the presentations they give," Fraser concluded.

So, what are you doing to educate your clients, their families and the public about stuttering? How are you turning this negative into a positive?

Volunteer Hearing Aid Services
January 5, 2015 9:42 AM by Speech Merion

By Christine Cubelo, CAOHC

If you've ever volunteered at a nursing home, you probably helped feed residents, walk them to various areas of the facility, or change the bed sheets. Residents have probably also enjoyed your fellowship during a game or craft activity, manicure or pedicure, being read to, or simply sharing their life story with open ears. But researchers using the Nursing Home Hearing Handicap Index (NHHI) found that, out of 60 nursing home residents surveyed, 20% reported moderate hearing loss.1 In another study, only 30% of hearing impaired adults over 70 actually use hearing aids.2 So, there is a significant proportion of residents facing social isolation due to difficulty following conversation, and may be missing out on your fellowship. Perhaps the disparity between aided and unaided hearing impairment is related to frustration with malfunction and perceived complex repair needs of hearing aids.

Because many people give up and put their hearing aids in the bottom of a drawer to be long forgotten, the threat to personal safety and physical, cognitive, emotional, social and behavioral function will fester. Imagine the burnout that nursing home staff experience, as various handicaps require more and more costly intervention and monitoring. Yet, many facilities, for example in Maine,3 New Jersey,4 and Texas,5 are unable to keep up due to funding cutbacks.

Hearing aids successfully reduce the multifaceted handicaps resulting from hearing impairment in aged people,6 and the common malfunctions are not as complex as one may think. Consistent with patients at our own clinic, a study from Michigan found that the most common problems were weak batteries, tubing abnormalities, and receiver obstructions7; because 78% of the hearing aids were 5 years old or less, most issues can be easily remedied by easily obtainable replacement parts. Many professional offices provide battery and battery door replacement, tubing changes, and wax removal services at a charge, while a few facilities provide these services for free. Basic maintenance can also be done by anyone with some basic education and training.

In sum, here are some ways to alleviate nursing home staff and residents' challenges with hearing aids, and in turn enhance their quality of life:

  1. Provide training to volunteers, family members, even residents if able -- there are many educational websites available for free, such as Family members and residents gain greater sense of independence and reduced out-of-pocket expense for hearing aid purchases from gross damage.
  2. Seek charitable work from local dispensers, audiology service centers, or universities -- make arrangements for a trained professional or college student to travel to your facility to provide basic maintenance, or even provide in-service training. Professional providers benefit from greater marketing opportunities and gain positive reputations as a community business. Students benefit by earning work experience while your nursing home staff benefit from lighter workload.
  3. Seek donations from hearing aid manufacturers, local dispensers, or non-profit organizations -- ask organizations to donate batteries, tubing, or cleaning tools to alleviate the costs of hearing aid maintenance.
  4. Sign up for special Social Services or Public Health programs -- residents or nursing homes may be eligible for a government program, such as a special grant or Veterans program that can help alleviate the costs associated with hearing aids, hearing assistive devices, or audiologic rehabilitation.

The next time you visit your local nursing home, ask if they would consider implementing any of these ideas, or use the ideas to launch a brainstorming session for other creative solutions!


1. Nilfouroush MH, et. al. Comparison of nursing home hearing handicap index with audiological findings: A presbycusis study. Journal of Aging Research: 2012. Article ID 423801.

2. American Academy of Audiology Hearing impairment in aged people. Audiology Today. 1991;3(6).

3. Mitchell J. Maine nursing homes struggle to stay afloat. Maine Public Broadcasting Network. 2014.

4. Mcardle K. County-run nursing homes struggling in NJ. New Jersey 101.5. 2014.

5. Kling K. Texas nursing homes struggling to keep up with demand. Time Warner Cable Enterprises LLC. 2013.

6. National Institute on Deafness and other Communication Disorders. Use of hearing aids by adults with hearing loss. 2014.

7. Ferguson NM and Nerbonne MA. Status of hearing aids in nursing homes and retirement centers in 2002.,%20%20JARA,%20%202003.pdf.

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Gestational Diabetes and Newborn Hearing Risks
December 1, 2014 9:22 AM by Speech Merion
By Christine Cubelo, COHC

When my father went to his doctor for a check-up and his A1C test results came back abnormal, it elicited a sense of urgency for him to warn me of being potentially pre-diabetic. Given this newly learned term, I decided to do a bit of research, and as an audiometrist, I was amazed to find there is a significant connection between hearing health and diabetes. The American Diabetes Association says that hearing loss is twice as common in people with diabetes as it is in those who don't have the disease. Also, of the 86 million adults in the U.S. who have pre-diabetes, the rate of hearing loss is 30% higher. From this, my curiosity leapt to gestational diabetes. I wondered if there was a potential connection between the hearing health of unborn babies and their diabetic mothers.

Information thus far has been both enlightening and disconcerting. For starters, the American Speech-Language-Hearing Association (ASHA) published an article exploring the hypothesized likelihood of auditory neuropathy caused by diabetes, similar to the pathophysiology of damage to the heart, eyes, brain or kidneys. It seems that epidemiological evidence to definitively support the hypothesis is yet to fully develop. Some analyses were said to show greater prevalence of hearing impairment in younger diabetics. So, one could surmise that infants of diabetic mothers may be at risk of hearing impairment if their mother's blood sugar was poorly controlled.

In their 2002 study, Wang et al. found that genetic syndromes associated with Oculoauriculo-Vertebral Spectrum (OAVS) occurred more often in infants of diabetic mothers -- 46% of cases had hearing loss. In another study, Kountakis et al. analyzed 110 cases of newborns with hearing loss and found 11 risk factors in addition to those already recognized by the Joint Committee on Infant Hearing (JCIH). Can you guess one of the 11 risk factors they found? That's right -- maternal diabetes.

Here is what I found to be a bit concerning: only one out of 43 state and national public health websites I visited mention gestational diabetes on their risk factors as a potential cause of congenital hearing loss. Although many organizations refer to JCIH as a main source for identifying risks, the examples of genetic syndromes associated with hearing loss is not all-inclusive. Goldenhar is a genetic syndrome associated with OAVS, yet is not listed by the JCIH.

In response to the research, I recently presented a proposal to our nursery to include "Poorly controlled gestational diabetes" in the list of potential risk factors on our newborn hearing screening form, and they concurred! By researching a curiosity, we were able to set in motion a contingency to get ahead of a population of newborns whose hearing impairment may go undetected unless their physician suspects a milestone delay many months or years later. Likewise, I encourage all practitioners to be curious, and take action!

Christine Cubelo is a certified occupational hearing conservationist and earned her Bachelor's in Laboratory Management in 2013 from the University of Maryland University College. She has 10 years of experience as a technician in the outpatient care setting, and has been an audiometrist for nearly 4 years. Christine is currently working at US Naval Hospital Guam as the clinic manager of Audiology.


American Diabetes Association. Diabetes and hearing loss. June 2014.

Kountakis S, et al. (May-June, 2002). Risk factors for hearing loss in neonates: A prospective study. American Journal of Otolaryngology. 2002;23(3):133-7.

Wang R, et al. Infants of diabetic mothers are at increased risk for the oculo-auriculo-vertebral sequence: A case-based and case-control approach. The Journal of Pediatrics. 2002;141(5):611-7.


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Autism & Halloween: Tips for Parents
October 29, 2014 7:58 AM by Speech Merion
By Lucas Steuber, MS, SLP/CF, MA-T

Halloween is coming up, and for most people it's all about being spooky and scary! Of course, some of us don't like to be spooked and scared. I know there are definitely some movies, for example, that I will never ever watch.  For kids on the Autism spectrum, that can be especially true. Halloween inherently has a lot of change, a lot of transition, and a lot of sensory stimuli that can be unexpected and jarring for individuals sensitive to those things. As you prepare your children for this holiday, keep a few simple tips in mind to make it easy - and fun - for everyone.

  • Have a plan and share it! Making a visual story to read with your child about the holiday and your family's activities that evening can help prepare them for the transitions. Share the story with them multiple times so that they know this is a special event, and not something to be afraid of. A visual schedule could be useful as well. Then, on the night of, make sure you don't change that plan unless absolutely necessary.
  • Talk about costumes and what they mean. It's important that kids know that while someone might be wearing a monster costume, they're not actually a monster. For many of our kids, being able to see and/or touch a familiar adult is very reassuring. In that case, it's probably a good idea for parents not to be in costume - or at least not in a costume that conceals your face.
  • Be sensitive to sensory needs. If your child doesn't want to walk around at dark, do it during the day - and vice versa. Many cities also have Autism-friendly Halloween events, which can be a great way to connect with other families!
  • Involve familiar people and prepare unfamiliar ones. If you have neighbors that you routinely visit, make sure you include them in your Halloween planning. On the other hand, if you're visiting strangers, it's okay to go knock on the door yourself while your child waits with another caregiver on the street. This way you can ask them that any tricks, traps, loud noises, and lights that they might be using to scare other guests be turned off for the moment.
  • Think about the costume. It's a great idea to have kids try them on long before Halloween night to help them get used to anything they're unaccustomed to in terms of fabric, etc., and if they object to a costume, don't hesitate to try something else. Don't try to make sure they'll wear something - and it's okay if they're not in costume at all! Everyone can enjoy the holiday in different ways.
  • It's all about them! If your child isn't willing to participate in Halloween, that's their choice - although of course we should still work to educate them about the holiday and try to overcome objections. It's also important to prepare other children they may be with - like siblings - for the possibility that the trip will have to be short. Having a second caregiver who can continue would be a good way to make sure everyone gets to experience what they want from the holiday.

Most of all: Have fun! In any planning, stories, and scheduling shared with your child, it should be emphasized that this is a special event that will be exciting and entertaining - not something to be nervous or unhappy about. Also, putting on a costume can be a fun experience in perspective-taking; on that night, they get to be a ghost, and ghosts don't worry about anything!

Happy Halloween ...

Lucas Steuber, MS, SLP/CF, MA-T, is a school-based speech-language pathologist and the founder of Portland LanguageCraft, a pediatric therapy clinic, materials development company, and advocacy group.

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Dual Language Learning for Children with Hearing Loss
October 9, 2014 10:36 AM by Speech Merion
By Michael Douglas, MA, CCC-SLP, LSLS Cert. AVT

Many SLPs, TODs and AuDs are finding themselves seeing increasing numbers of children with hearing loss who come from families that speak more than one language with a range of proficiency in the differing languages. Working in Texas at the time, we had a weekly caseload of 135 children with 50% of them coming from families who spoke another language at home. Of the 50%, half of the families who had children with hearing loss spoke Spanish only and did not understand or speak English. Myself not being a native Spanish speaker, I found it very difficult to connect with these families and serve them in a way that was as effective as I could with English only speaking children.

There was a dearth of professional resources designed to address this specific need, so we started by utilizing multilingual resources for children who did not have hearing loss. Over the next several years, we made adjustments that fit the unique needs of children with hearing loss, documented our progress and shared information for dual-language learning with our colleagues.

We found that rather than standardized testing, a more accurate indicator of a child's linguistic function was to use a variety of informal assessment measurements. Among these are language sampling that documents grammatical use, mean length of utterance (MLU) and number of different words (NDW) in each language; dynamic assessment which includes efforts to change the rate of input/cueing needed in order to note differences in performance; non-word repetition and sentence repetition tasks which help predict linguistic competence and are sensitive to language impairment; and articulation samples that document phonological mean length of utterance (pMLU) and proportion of whole-word proximity (PWP) which measures how closely the child's production matches the adult target.

When working with families that did not speak the majority language, a continuum of intervention services was implemented. This started with the bilingual support model in which a monolingual teacher and monolingual SLP use an interpreter to provide services in the minority language. Services then progress to the coordinated service model in which the monolingual teacher works with the child in the majority language while a monolingual SLP with an interpreter works with the child on parallel lesson plans in the minority language. Services then progress to the integrated bilingual model in which the monolingual SLP with an interpreter provides parallel services in all languages. Finally, as the language needs of the child become more complex, a combination of bilingual support and coordinated services models are utilized.

I piqued the interest of a colleague who encouraged me and inspired me to develop a resource for professionals. I hope the book I created may serve as a genesis that inspires others to embrace this growing population and generate more resources on this topic. Learning more than one language can open up so many doors for individuals. For children with hearing loss, it can enable them to stay connected with their families while learning the language of the country's education system and business.

Michael is a speech-language pathologist and a certified auditory verbal therapist. He mentors aspiring therapists, lectures worldwide on developing and improving the spoken language skills of children with hearing loss and is the Principal of the Mama Lere Hearing School in the Bill Wilkerson Center at Vanderbilt University, Nashville, Tenn. He is author of Dual Language Learning for Children with Hearing Loss, which is offered as a part of MED-EL's comprehensive BRIDGE to Better Communication rehabilitation program.

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Early Evaluations: A Plea to Pediatricians
September 18, 2014 9:29 AM by Speech Merion
By Jasna Cowan, MS, CCC-SLP, a bilingual speech-language pathologist on a multidisciplinary team at Golden Gate Regional Center, San Mateo, Calif. 

Dear Pediatrician,
Why? Why are the child and parent sitting in my office in front of me seeking my opinion? They are concerned with their child's speech and language skills. The parents are now officially worried because Kindergarten is around the corner and frankly they are confused. The grandparents have noticed a delay, the neighbor has noticed something's not right, and the daycare provider has even voiced concern. The parent is seeking your opinion because your opinion is held to the highest regard. Maybe the child is not too interested in others and he won't even look into people's eyes. When the child says something he is echoing the statements of his favorite TV shows. His play is repetitive and he isn't using any pretend play yet. The teachers report he plays alone at preschool and has a difficult time making friends. He is overly fascinated with letters, shapes and numbers or some other subject.

You have seen this child in your office at least a half dozen times now for check-ups and illnesses. I have to wonder, did you see the same things I am seeing? I have to give you the benefit of the doubt; maybe you couldn't see what I see because the child was scared and screamed frantically when they visited. Or maybe the child was playing on an electronic device that they never set down during the visit. But did you take the time to listen to the parent when the parent mentioned to you that their child lost words, or that they are not saying many words at all? Did you read between the lines when the parent said their child was "just fine" but you thought maybe otherwise? Or did you ignore the signs or pacify the parents by saying "wait, just wait..." Wait?? Why wait? Why wait when there are fantastic social workers, occupational therapists, early interventionists, behavior therapists, and speech-language pathologists that specialize in early intervention. We get the ball moving so that the child can progress and be more ready for future challenges such as sitting at circle time, sharing their favorite toy from home in front of the class, making new friends, and telling their teacher about the bully who is hitting them. Wait, you say? Wait for what, so a therapist or resource specialist can knock on the door or their first grade class and call the child's name in front of his 23 other classmates for pull-out therapy? Wait so that when the child returns from therapy he is confused, has missed out on an important class lesson, or recess? Wait so that kids make fun of the child because he "talks funny" or is "weird"?

Frankly doc, waiting is already affecting this child's future, his self-esteem, his socialization skills. Is it really worth waiting? I know you are an expert of a child's health and wellness, but we are specialists of certain areas of these children's developmental skills. Can you please seek our opinion if you are even a little unsure or when a parent casually mentions a concern? You will have made a lasting change in the child's life and maybe even changed and fostered the new pathways to that child's developing brain. Please, I plead, please give us a chance to give our opinion so that the child can get into services that he might need. We might never be able to detect all of the benefits that the child has gotten from starting early, but we definitely know all the consequences that occur if a child is not offered the services that he needs at an early age. Please doc, give us a chance to determine whether the child needs help in our areas of specialty. That's what we are here for... to provide your patient with an EARLY START.

P.S.: Thank you to the doctors who believe in the Early Start process and recommend their patients be evaluated "just in case!"

Thanks for listening.

Jasna Cowan, MS, CCC-SLP
Early Intervention Speech-Language Pathologist and team member.

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Tips for Using Spaced Retrieval Therapy
August 14, 2014 9:19 AM by Speech Merion
Spaced retrieval therapy (SRT) is one of my favorite ways to improve memory of functional information, but it is unexpectedly difficult. This post is inspired by the questions and comments I have received in hopes of making using SRT easier for you.

Tasks to use between intervals

I have used a variety of tasks between SRT intervals and have found some things work better than others. I try to find tasks that can be easily stopped and started (e.g. not a television show or BINGO). I have successfully used the following tasks:

  • Browsing newspapers (visual scanning) with a patient who has a lifelong hobby of reading the newspaper
  • Talking about family photos to target long term memory and reminiscence therapy goals
  • Sorting items or tidying up room or bedside table which may target visual scanning, problem solving, and attention
  • And sometimes we just chat. It may not be the most skilled task for between intervals, but it helps build rapport. When working with short intervals, we are working with greater memory deficits. Finding a one-minute activity can be challenging.

I usually keep the same task for between intervals throughout the SRT session, so I am guiding the patient between two tasks (memory target and interval task).

Keeping things entertaining

If you are doing spaced retrieval therapy correctly, you might be getting a little (or a lot) bored. I read a comment from an SLP on a forum stating she was using SRT, but she felt she should be mixing things up a bit, so she wasn't doing the same thing. Do not let your feeling of boredom result in attempts to vary the task, switch to a different stimulus, or otherwise mix it up. The success of SRT relies on the repetitive nature at increasing intervals.

As therapists, we strive to build good relationships with our patients. And as SLPs we know a thing or two about pragmatics and social norms. It is not polite to ask the same question or tell the same story over and over. So if you are anything like me, when you do SRT there are days you get on your own nerves. It is okay and completely normal.

Stick to SRT protocol to increase patient progress. If you are not seeing any progress in length of intervals, your patient may not be appropriate for SRT.

Session length

To ensure I can present stimuli with the same gusto and enthusiasm that my client deserves, I may break up treatment time over the course of the day. So if I plan to see a patient for 30 minutes during the day, I may see them for three 10-minute sessions or two 15-minute sessions.

I often pop into an SRT patient's room to see if we can do a quick session. Depending on what I am trying to target, I have done a quick SRT session in the dining room, waiting for the hair salon, in the therapy gym, and in patients' rooms. If I am training a location-dependent task (e.g. using call light/button), I make sure we complete the session in the location where the task would be completed.

Hopefully these tips will inspire you to try spaced retrieval therapy with a client. It can be very successful in for training functional targets.

To learn more about how spaced retrieval therapy works, please check out my blog, Gray Matter Therapy.

Rachel Wynn, MS, CCC-SLP, is a speech-language pathologist specializing in elder care. As the owner of Gray Matter Therapy, she provides education to therapists, healthcare professionals, and families regarding dementia and elder care. She is an advocate for ethical elder care and improving workplace environments, including clinical autonomy for therapists. She has an upcoming webinar "Dementia Communication Strategies to Improve Therapy Outcomes."

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