Wednesday, April 27, 2011

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)

Monday, April 25, 2011

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! 

Saturday, April 9, 2011

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.

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
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.