Kids Say the Darndest Things

Social Group always makes Debbie and I exchange smiles.  This is a fun group of boys! Yesterday was a particularly stormy day in East Texas.  Although the storms had not yet broken, one child with ASD came in very excited and disturbed about the weather forecast.  Trying to restore a sense of calm we asked where he lived, he replied, "I live in my house." We pressed him further asking if he lived in town.  He responded, "I live next to my neighbor".

Here a few more funnies from my clients (wish I could remember more of them):

Child looking at picture of a space shuttle:  That's a "Space Shutter"

Therapist:  Tell me more about an elephant.
Child:  They have long trunks and they have "cankles". (therapist cannot stop laughing as bewildered child stares at her).

Sam:  Give the block to me.
Therapist:  Joe might give the  block to you if you ask politely.  What's the magic word?
Joe:  "marshmallows", that's the magic word. (enthusiastically & totally serious)

Therapist to 4 yr. old child:  What do you want to be when you grow up?
4 yr. old child:  Batman!
4 yr. old child to therapist:  What do you want to be when you grow up?
Therapist:  Well, I think maybe I want to be a speech teacher.
Child:  (large grin)

The Musings of a Middle-Aged SLP in Private Practice

It has been a stressful month for me.  Heck it has been a stressful two years, to be quite honest!

I bought our Speech House in order to execute all kinds of really fun plans, like a real garden for the kids to dig into.  Sadly, I have made very little use of this wonderful facility due to the stresses of life and private practice.  I am looking forward to the second year plan (although we technically have 3 more months until we hit our one year anniversary in our new home).

I love private practice.  It has many wonderful benefits:  being my own boss, holding high ethical practices, keeping treatment personal and fun, setting up a homey atmosphere....

But it has its share of stresses also:  being my own boss, dealing with bills, payroll, and INSURANCE companies.  Things have gotten really bad in the realm of reimbursement over the past two years.  Making a living is getting harder.  I have actually considered packing it all in and just working for someone else again.  I did say "ALMOST".  Warning to anyone considering this venture:  It is not for the faint of heart. 

Eleven years ago when I entered into my own business there was very little support for the private practice therapist.  Fortunately things are improving in that arena.  TSHA (Texas Speech and Hearing Association) now has a Private Practice taskforce that provides business workshops at convention; they were both helpful and frightening at the same time (sometimes you would rather not know what all you are doing wrong!).  ASHA now holds a yearly Private Practice Conference (have not had a chance to attend one yet).  So the support is improving. 

However, insurance reimbursement is dismal.  We constantly have to fight for coverage.  In the past two or three years things have gotten much worse.  Insurance companies have cut reimbursement rates severely.  They have actually gone back three years and started to recoup funds saying they mistakenly paid too much money for services rendered.  Sometimes I think I am INSANE to do business in this climate.  Yet, here I am. 

No wonder, I have no energy left to carry out fun ideas.  I am swamped in appeals, paperwork, back billing, re-billing, .... endless frustration. 

Add to all of this the fact that I am middle-aged. For those youngsters reading this, that translates to parenting young adults/teenagers and caring for aging parents at the same time, not to mention my own aging body and failing mind. YIKES!

I just spent the last month dealing with both parents ailing.  My dad being diagnosed with lung cancer, having a lung removed, and heart complications.  Luckily, he went home from the hospital today and it looks like the cancer was stage one or two.  God was kind to us through all of this ordeal. 

Mental and physical exhaustion are taking their toll.  Sometimes I contemplate whether I can keep up with this pace.  But when I seriously consider stepping out of private practice, it makes me sad.  Ultimately I do what I do because I love working with the kids.  I love making a difference in the life of a family. 

One of the reasons I purchased our Speech House was so that I could develop more group oriented programs thus reducing the cost of sessions for parents.  Hopefully I can move away from reliance on insurance reimbursements and build some much needed programming to bring affordable speech and language services to families. 

So tonight, as I muse on all of these things, I realize I need to take a deep breath, get a good nights sleep, pray long and hard for strength, look with thankfulness on all of the blessings in my life, get up in the morning, and start having fun again! 

Social Skills: Eye Contact / Social Referencing / Joint Attention / Thinking with our Eyes

When dealing with Autism Spectrum Disorders, the terms "eye contact, social referencing, and joint attention" are often part of the discussion.  These terms all indicate a very similar skill involved in typical development.

Eye contact is a term often seen in treatment goals for children with ASD. Eye contact is simply looking at another person during a communication exchange (verbal or nonverbal). Very few of us neurotypicals can stomach looking directly into someone's eyes for any lenghth of time. It can, in fact, be creepy. So, I always struggled with the idea of teaching eye contact to children with autism. I would never try to teach a child to look into my eyes, though I have seen some try to teach this. Instead the child needs to learn to look at or towards the communication partner. I feel "eye contact" is a term that relates directly to whether or not a child has developed the skills involved in social referencing and joint attention. These areas are functional deficits seen in children with ASD. See this post, Social Skills: Social Stories, for a social story for higher functioning children regarding eye contact.

Joint attention develops in children between the ages of 9-12 months.  It involves the ability to follow another person's eye gaze or pointing finger to gaze at an object together, or for the child to get the attention of another and direct them to look where the child is indicating. 
http://eigsti.psy.uconn.edu/jt_attn.html

Social referencing involves looking to a significant person in order to gauge one's own emotional response.  A child may not understand what is happening in a particular situation (for example the door suddenly swings open).  He will look to his mother or father to see whether they express a specific reaction of alarm, humor, or calm.  The child will often take his cue of whether everything is okay or if he needs to laugh or cry from the parent. Social Referencing example.

Michelle Winner's work gave me a better understanding of what was needed in addressing this area and how to go about achieving the goals.  She uses the term "thinking with our eyes". So in the child with a high functioning ASD, teaching the importance of using our eyes to gain information from others or from the environment is one of the earliest lessons.   The lesson starts simply as a game involving detecting what objects someone is looking at by following their eye gaze. It then progresses to determining what someone might be thinking about when looking at a particular object.  The child learns that people look at things when they are thinking about them, thus when they are looking at something they are likely thinking about it.  From there the child learns the importance of using his own eyes to look and think about things and others, to glean information this way, and to convey his own thoughts this way.  For some reason, some children do not develop this skill intuitively; this is especially a problem in children with ASD.  But once a child is taught the power of the eyes, natural "eye contact" develops. 

I think that perhaps many of the difficulties in children with autism are linked to this specific area of deficit. The child may have trouble with making transitions or accepting change when he or she is unable to take in cues from the environment.  Most of us are aware of the subtle indications that mark the winding down of one activity or the beginning of another one.  The child who lacks the skills of social referencing or joint attention is at one moment enjoying an activity and in the next moment that activity is suddenly stopped or taken away.  If they are unable to attend to the fact that another toy has been brought out for play or that it is time to transition to another activity, such as eating lunch, then they have no sense that a change was coming, or of why the change is occurring, or of what to expect next.  It must be confusing, bewildering, and anxiety producing for them.   Likewise, it may be part of the explanation as to why they have narrowed interests or prefer to play with the same toys or activities over and over.  If they fail to attend visually or otherwise to their environments, then they do not learn how to do other activities or how to play effectively with a variety of toys.  These referencing skills may be foundational to so many of the deficits we see in autism.

In younger children or children more severely affected by autism, activities to increase basic referencing skills are important.  Stanley Greenspan's Floortime or Steven Gutstein's RDI (Relational Development Institute) present activities to specifically work on these skills.  Activities might involve the use of minimal speaking to increase the need to observe the communication partner and playing games that require the child to look at the communication partner in a natural and functional context such as interactive games of hide and seek, turn taking, imitation, or funny faces games. 

Baby Games
Son-Rise
Autism games website
Your baby is reading your face    Article on site called Raising Children.  Check out the tabs on various ages of development and explore.  "Connecting" shares info on social emotional development.

Here are some nice videos:
 
RDI Emotion Sharing with Mommy
Social Referencing 1
Autism Follow My Eybses Game
Another RDI example

Please check back to this post as I will add ideas and samples as I come across them.  Instead of a regular blog that adds endless new entries, I like to simply go back and edit my old topics with new info.   This is my strategy for creating resource files for myself and others. I also welcome any suggestions or ideas you would like to share.  Simply post them in the "Comments" box.

Social Skills: Thinking & Language: Non-literal, Sarcasm, Reading Between the Lines, Inference

One of the chapters of the Social Thinking curriculum by Michelle Garcia Winner addresses ambiguous language skills which includes non-literal langauge, indirect messages, figurative language, idioms,  and sarcasm. Speech Language Pathologists have all at one time or another worked on these skills.  Children with ASD, ADHD, pragmatic disorders, etc. usually have some degree of difficulty with this type of language. 

There are many resource materials available for addressing this issue.  Super Duper Publications sells cards, books, and software devoted to non-literal language.  Linguisystems and most other retailers for speech therapy or education also publish such materials. Here are a few of the materials on my shelves:

Super Duper Publications:
Idioms Fun Deck: There are several good Fun Decks (card decks) dealing with inferences, multiple meaning words, etc.
From Rags to Riches idioms game
Read Between the Lines
Uderstanding Inferences Fun Deck
Webber Interactive WH- Questions:  This cd-rom has a level on inference.  It shows a scene and then asks a question, it gives 2-4 choices and the child must have attended to the visual information in the scene. 
Social Inference Fun Deck
Go for the Dough game has a multiple meanings word activity

Linguisystems
No Glamour Idioms
WALC 9 Verbal & Visual Reasoning

Non-Literal Language:
The Literals (figurative language - Amanda show)
Mr. Gullible (Amanda show)

Sarcasm:
Sarcasm 101 Matthew Perry
More Sarcasm
Wild Thornberry's
Big Bang Theory (Caution: cursing in the clip)
Big Bang Theory 2 (no cursing)
Friends:  Ross on "the Baby locked in the apartment"

Idioms:
Idioms
Idiom:  Don't count your chickens before they hatch.
Geico commercials: Is the Pen Mightier than the Sword?  Don't live under a rock? Does a woodchuck chuck wood?  Does the Buck stop here?  Play the commercial and discuss the difference between the idea being presented in a literal way versus the inferred meanings and how the terms are used as figurative language.

Not  figurative language, but correct use of homophones "there, their, they're"  since homophones can confuse us also.

Figurative Language:
Metaphors & Similes
Metaphors & Similes in Pop Music
Lesson Plans @ speechlanguage-resources.com

Inferencing:
Mime: Learning the Art - Many children with Social Skills deficits have difficulty with representational thinking.  Body language and Charades activities can be difficult for them to understand.  Learning to imitate and infer actions can help improve observational skills, perspective, and delivering an effective message.
How to Catch a Ball
How to Catch a Butterfly
How to Chew Gum
How to Dig
How to drink from a cup
How to Create a Story in Mime
How to pull a rope

PB SocialThinking on Inferencing

Think with Your Eyes:
Chevy commercial:  Man adjusts his words based on his observations when he sees the salesman who looks a lot like Santa Claus.

Uses for Board Games and Card Games in Speech Therapy

I am not going to actually write a blog on this subject.  I am however posting this as a link to my Facebook site where I list several games and a few of the ways I use them in speech therapy sessions. There are endless ways to adapt a game and address goals; limited only by our imaginations.  I do not list a number of grammar goals or articulation goals because on almost any game you can set the parameters.  For example, any race game (Sorry, Candyland, Trouble...) or game requiring any type of assembly (Kerplunk, Buckaroo, etc.) or game that requires the turning over of a card or roll of dice can have a prerequisite to a turn being taken or a piece being placed on the game. 

Sample prerequisites might be:

Articulation - Say your sound, or word, or sentence prior to each turn
Grammer - Repeat or create a sentence with your target: pronouns, verb tenses, conjunctions, synonyms...
Processing - Answer a question or respond to a prompt of some kind. (Can ask various "wh-" questions, pull items from various listening/processing books, etc.)

To view my ideas on some of my favorite therapy games as well as why I like them and various ways I use them, click on this link:  Facebook-Photos-Games

You can click on each photo and view the comments boxes for various ideas.  Check back from time to time because I add new items as I find them.  I just bought a new game and will be posting it in a few days after I have had a chance to play it with some of my clients and finalize my opinion and ideas on it.

Spring is in the Air

Today started out cloudy and windy.  The forecast included a tornado watch.  Late afternoon grew dark just before the cloudburst.  Then the skies became a clear blue with the sunshine streaming through.  Ah, Spring is well on its way!  My thoughts were, "Let it rain!"  I could almost envision the rain rejuvenating the grass and plants outside.  The advent of Spring is revealing all kinds of treasures around our new home at the Speech House.  A few weeks ago, masses of Papewhites appeared, now the daffodils are beginning to bloom, and I am pretty sure I have spied at least two dozen Amaryllis (at least, I think that is what those strong flat leaves poking up out of the soil will become).  I stopped by Lowe's and picked up a few tulips to add to the bed under the tulip tree.  No wonder my thoughts of lesson plans are turning to Springtime themes. I perused my Spring Books to try to decide what to use this year with my clients. There are so many fun themes to choose from.

Gardening Themes:  Spring is a time of renewal for all things green, is a great time to discuss plants and growth cycles.  One of the things that can be done is to plant a garden (My First Garden):  Now that we are in our Speech House, I am seriously considering making a full fledged "mini" garden.  I have already been asked, "And why would you want to do that?" (translation: "Wouldn't that be a lot of extra work you already don't have time for?" To which the answer would be, "yes!")  It seems like a fun idea and a good excuse to take some therapy sessions outdoors. Although I am unsure if I will tackle this project this year, here are some of my thoughts on goals and objectives:

1.  Sensory:  sunshine, dirt, water, smells, and after things grow, taste and texture (feeding issues).   The kids could get dirty scratching around the soil, planting seeds, watering them, and eating the product of their labor. 
2. Vocabulary:  Plenty of opportunities to learn new words from pre-k to teens:  parts of plants, fruits, vegetables, gardening tools, science from germination to photosynthesis, weather, ...
3.  Language & Verbal Expression: My philosopy is that experiential learning is the best kind:  Requesting, discussing, describing, instructing, sequencing.... Use children's literature for whole language learning experiences.

Of course, there are other fun plant activities that do not require making your own garden (easier too):

• Planting seeds in a cup and watching them grow.
• Using an egg carton and planting grass seed into an eggshell (combines Spring and Easter).  Crack the top 1/4 to 1/3 off of an egg, remove egg, fill with soil, plant seed, draw on a face, the seed grow to be "hair" and the kids can then give it a haircut.
• Place a wet napkin or paper towel in a plastic baggie.  Drop in a bean.  Tape to a sunny window.  As the bean sprouts, the clear bag allows the forming of roots and shoots to be observed.  Dampen the paper towel as needed.  Can transplant to a cup or pot later.

Other plant themed activies:

• Make a picture with various seeds/beans.
• Make flowers with construction paper or tissue paper:  create a construction paper flower or vegetable garden on one wall of the room.
• Make prints with cut up potatoes, apples, etc.

 Many thanks to SpeechTechie.com for finding these virtual links:

• Virtual Garden 
• Sensory Garden

Literature Links:  Check out these book links to find plenty of resources for fun lessons and activities.

 

The Tiny Seed by Eric Carle

Muncha! Muncha! Muncha! by Candace Fleming

Mortimer's First Garden by Karma Wilson

Planting a Rainbow by Lois Ehlert

Dandelion Adventures by Patricia Kite

                              

Weather:  Little Cloud by Eric Carle:  This is a great unit for this time of year when weather is changing dramatically from cold to warmer, from windy and rain to bluer skies and fair weather, making cloud watching an interesting experience.  Summertime is also a good time to use this book when there are warm lazy days, although where I live it gets really hot very quickly and the bright summer sun can make cloud watching more difficult (sun shades required).  There are some wonderful links to this unit on my Facebook page.  I have bookmarked a number of online sites with great photos of clouds so the children can work on stretching their imaginations to see cloud shapes.  This is particulary good for the child on the Autism spectrum or who tends to be a more concrete thinker.  There is also one resource that actually fills in line drawing around a cloud shape when scrolled over to assist those who simply cannot perform this task.  I borrowed from that idea by printing out several awesome cloud shapes, inserted them in clear plastic page protector, and outlined the shape with a sharpie marker.  I show the picture to the child and give him the opportunity to figure it out on his own.  If he cannot, I place the sleeve over the photo to assist him.  Lots of fun. The most interesting effect is that once the cloud is shown in outline, you can remove the line drawing and the brain recognizes the image on its own. 

Once I cut large cloud shapes out of poster board and glued batting over them and hung them around the office.  This way the kids could play the cloud shapes game while waiting for their session.  Another related ativity is on one of the Caillou computer games which has a cloud shapes game on the disk. 

Craft activties abound:
Tear out shapes from white paper and glue to a blue backround.
Paint white clouds on blue.  Can even inkblot them by folding the paper.
Cotton ball or batting clouds.
Sponge painted clouds
Clouds with raindrops dangling down
Eric Carle inspired:  Paint some paper with a mixture of color and texture and cut our cloud shapes.

Critters:

The Very Hungry Caterpillar by Eric Carle
Waiting for Wings by Lois Ehlert
Watch Me Grow Butterfly a DK book

Are You My Mother?  by P.D. Eastman

Quick as a Cricket by Audrey Wood
Old Bear by Kevin Henkes

The quintessential bug of Spring is the caterpillar!  So many great books and lessons about caterpillars and butterflies.  There are TONS of online crafts and activities; you only have to Google a few moments to glean more than enough.  Click my book link for a few I found.  Likewise, the butterfly books abound.  Choose your favorites.  One great activity is to get one of those butterfly net/hatcheries and order some painted lady butterflies.  So great to watch them grow and become butterflies.

Baby birds, baby animals.... Spring is the time of newborns! Any baby animal books are sure to be a hit.

Crickets and other bugs:  These can go with Spring or with Summer.  On second thought, I might save crickets for the lazy summer nights.

If you like this blog, check back as I will be adding more Spring ideas as I come upon them.  Instead of writing a lot of blogs, I like to compile resources as much as possible.  It helps me find things when I need them!

I Like FREE Apps :)

See my Free apps file on Facebook.  Check back periodically as I will add things as I find them.   Feel free to recommend your own faves. 

Be sure to note my Disclaimer:  I am not a techie.  I am a newbie to iphone.  These are just a few items I found that add a bit of fun to therapy or just seemed too "cool" to pass up. 

I often download free apps just because they are free.  If I like them, I keep them, if not I delete them.  These a few of my "keepers".

I prefer "hands on" multisensory activities, however, I have found that for the therapist who travels to clients (I have one school contract), having resources compactly stored on my iphone really lightens my load.  There are also a few of our kiddo who are truly enamored by all things techie.  These apps are highly motivating tools for them.

One app that I actually bought was pocket SLP and it is nice to have a quick deck of flashcards with multiple sounds.  I would love for some computer savvy person out there to come up with an articulation/phonology app that allows us to pick and choose our word lists for individual clients.  Many of the words are too long for a new pre-k client.  Also, I like to present word lists taking co-articulation targets into account.  Just putting that out there for some budding "app maker".

Click her for link to my list of  Apps (free, or minimal cost, or if they are pricey it is because they are recommended for a specific purpose).

Update (3-8-11):  Follow this link to a blog called Pathologically Speaking about a useful way to load pictures onto your iphone or ipod with Drop Box.  Looks very interesting; can't wait to try it.

Update (4-25-11): Here is a great site for app recommendations by people with tech knowledge.
http://www.therapyapp411.com/