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Treating Vowels: A Tactile Treatment Program (Part II)

April 1, 2014 By

When Sam began therapy he had difficulty tolerating any sensory input in or near is mouth. Bringing a toothette close to his mouth would lead to an involuntary tongue protrusion to resist any stimulation. Placing a bite block between his molars would lead to gag reflex. My first goal therefore was to decrease his tactile defensiveness, while building his proprioceptive awareness (knowing where his lips, tongue and jaw are in space) of his oral structures. The first step of course, was to build his trust and comfort level with me and the tools I would use. We named the toothette with the vibrator “Mr. Tickles.” Mr. Tickles would always start the session. Sam could tell Mr. Tickles where he wanted to be tickled. We would usually start with the palm of his hand or his arm and gradually work our way to his mouth. Within a few sessions, Sam could tolerate several minutes of stimulation with a toothette without any negative reactions.

vibrator-tootethOnce Sam’s tactile defensiveness was significantly reduced, my next goal was to stabilize his jaw and increase jaw grading (i.e. opening and closing of his mouth to various jaw heights without jaw sliding or jerking). Since Sam tended to “fix” his jaw at jaw height 1 (closed mouth position) during speech, my objective was to move him gradually through Sara R. Johnson’s Bite Block hierarchy. Unless Sam was able to lower his jaw to jaw height 3 or 4, production of vowels such as /Ɔ/ would be challenging. We started with Bite Block #2 and within several weeks were able to move to Bite Block #6, which requires considerable jaw opening. Sam can now hold a lower jaw position without sliding. As a part of a comprehensive oral motor or oral placement program, we also worked on lip rounding, lip seal and tongue retraction. Sara R. Johnson’s Horn and Straw Hierarchy’s were employed for this purpose. In addition, a tongue depressor with added “weights” (pennies taped to both ends) were used to build lip strength and lip closure.

Filed Under: Apraxia of Speech, Autism, Autism Spectrum Disorder, Speech Therapy Tagged With: , , , , ,

Treating Vowels: A Tactile Treatment Program (Part I)

March 18, 2014 By

Sam came in with a diagnosis of Autism Spectrum Disorder and Apraxia of Speech. During the initial intake over the phone, his mother informed me that her main concern for Sam’s speech was his vowel production. And sure enough, all of Sam’s vowels were substituted by a neutral /Ʌ/. There was no discrimination even for round vowels like /Ʊ/ or /Ɔ/. On further observation, it was evident that Sam had oral motor deficits. There was limited if any jaw grading. He tended keep his jaw height at 1 for all his words. His lips did not appear to dissociate from his jaw with no rounding or retraction. Similarly, tongue and jaw dissociation was also limited. Basically, he used his jaw to elevate his tongue. For vowels, the tongue stayed at the floor of his mouth with little to no tongue elevation. Sam had difficulty imitating non-speech oral postures such as a lip pucker, smile, a wide open mouth, even with visual cues like a mirror. It was clear that using purely auditory and visual models to increase his vowel repertoire was a path to frustration and limited success. I therefore planned a unique treatment program that used a two pronged approach:

  • Building sensory awareness, increasing strength, coordination, grading and dissociation skills,
  • Using tactile approaches (P.R.O.M.P.T, TalkTools Therapy Tactile Tools for Apraxia of Speech and TalkTools Ice Stick) to build speech production for vowels.
tactile-tubes-apraxia

TACTILE TUBES FOR APRAXIA

ice-stick

ICE STICK

 

Filed Under: Apraxia of Speech, Autism, Autism Spectrum Disorder, Speech Therapy Tagged With: , , , , ,

Whole Body Listening Larry at School

January 15, 2014 By

Review of “Whole Body Listening Larry at School” by Kristen Wilson and Elizabeth Sautter

This book is the sequel to “Whole Body Listening at Home”. Personally, I prefer to start the instruction on holistic listening with this book rather than the “Whole Body Listening at Home” only because it seems like such an integral and critical part of school learning. In addition, comments like “You need to do better listening,” and “Pay attention” often occur more frequently in the classroom than at home.

I think, what this book does, like most other Social Thinking Curriculum materials, is to break down an abstract concept like “better listening,” “paying attention” into concrete segments using simple child-friendly language and pictures. When I first reviewed the book, I have to admit I was a little disappointed I hadn’t thought of this myself. It seems obvious and intuitive. The book uses school-age characters to describe Whole Body Listening. Whole Body Listening, according to the book includes using your eyes, ears, hands, feet, brain, and heart to listen. The situations used to teach how each of these body parts is actively involved in listening are easily relatable for most children. Breaking down the process of active listening by explaining the role of each individual body part makes so much more sense than simply asking the child to show “good listening” since the book actually explains what that means.

For the lesson, I took my time reading the book with my client. We discussed each picture in detail talked about what she saw and what Lea and Luka (the characters in the book) should do differently. We also did some role-play to make it fun and engaging. A critical piece that the authors discuss is making a link between the behavior to the feelings and emotions of others. Talking about how the listener feels when you are not listening with your whole body was challenging for my client. But making that connection repeatedly throughout the book discussion did eventually pay off. The Social Thinking website has a free download that could be incorporated in the lesson. It is a coloring page with pictures of all the body parts involved in Whole Body Listening.

I used several weeks to really hone in the concept of Whole Body Listening. I was surprised with how many activities and ideas were available online to incorporate into the lesson. I thought it might be helpful to list the resources I used to make it easier for readers to plan their “Whole Body Listening” lessons.

  • In addition to the poster/ coloring page available on www.socialthinking.com, I used Mr. Potato Head to reinforce the concept. While the eyes, ears, hands, and feet were available, I wanted to also include the heart and the brain. So I cut out a heart shape from cardstock and used Velcro to attach it on Mr. Potato Head. I also used an image of a brain. When my client added each piece to Mr. Potato Head, she had to explain what body part needs to do for Whole Body Listening.
  • I also used the “Biscotti Kid” video that is available on YouTube. It is a hilarious 5 minute video by Sesame Street ©. The video demonstrates how hard Whole Body Listening is for Cookie Monster, but finally he gets it and wins a black and white cookie belt. It is an excellent kick off for a discussion on Whole Body Listening and why it can be challenging sometimes. I used it to list some of the common distractions in my client’s classroom.
  • I also used the Whole Body Listening portion of Kathleen Pedersen’s “Monster Fun! Teaching Manners and Expectations. It is a free digital download on TeachersPayTeachers. It is a fun book with colorful images that review all the body parts involved in Whole Body Listening. This is Kathleen’s blog: http://growingkinders.blogspot.com.
  • “Howard B Wigglebottom Learns to Listen” by Howard Binkow is a book Howard, who gets into a lot of trouble for not listening. It is an excellent accompaniment to the Whole Body Listening lessons. The “We Do Listen Foundation Media Center” has an online animated version of the book with excellent sound effects. The website to access the online video is https://wedolisten.org/?.

Overall, I think it is an excellent book. I would highly recommend it. The book is simple, but fun and engaging. It makes an abstract concept concrete and easy to understand, even for younger preschool aged children. The handy poster is a great reminder to have in your clinic or classroom.

Filed Under: Social Communication DIsorders, Social Thinking, Speech Therapy Tagged With:

Oral Myofunctional Therapy to Eliminate Tongue Thrust

December 2, 2013 By

Oral Myofunctional Therapy to Eliminate Tongue Thrust using the SMILE Program by Robyn Merkel-Walsh and Sara R. Johnson (TalkTools)

According to ASHA, Oral Myofunctional Disorders (OMD) is when the tongue moves forward in an exaggerated way during speech and/or swallowing. The tongue may lie too far forward during rest or may protrude between the upper and lower teeth during speech and swallowing, and at rest. Although a “tongue thrust” swallow is normal in infancy, it usually decreases and disappears as a child grows. By age 3 years, a child will typically develop a mature swallow and the tongue thrust is usually resolved. However a tongue thrust may persist due factors such as thumb sucking, cranio-facial abnormalities, allergies, repeated ear infections and Down’s Syndrome. In terms of speech, the most obvious impact of a tongue thrust is during the production of /s/, /z/, /sh/, /ch/, and /j/. The sounds appear distorted and will often attract listener attention due to the atypical quality. In addition, the /t/, /d/, /n/ and /l/ may also appear impacted.

Robyn Merkel-Walsh’s SMILE (SysteMatic Intervention for Lingual Elevation) program is a fun therapy program for tongue thrust or Oral Myofunctional Disorder. I particularly like this program because it is based on Sara R. Johnson’s Oral Placement Therapy. The program utilizes the oral-motor prerequisites (horn hierarchy, straw hierarchy, bite block hierarchy) that forms an essential part of my treatment program for my children with speech production disorders. It combines oral-motor, swallowing and articulation therapy techniques to treat myofunctional disorders.

The program is designed for children 7 years and older. She uses child-friendly terms such as the “Smile Spot” (alveolar ridge), the “Smile Swallow,” (mature swallow), and sad swallow (reverse swallow). The program taps into the meta-cognitive abilities by building the child’s awareness of the “SMILE parts” (cheeks, tongue tip, palate, teeth, lips, etc.).

The lessons are hierarchical, systematic and the progress is measurable. The first lesson includes cheek exercises, while the second targets the lips. The second lesson includes exercises to work on lip seal, lip rounding, lip strength, tone and dissociation. At this point the program also includes articulation drills for lip sounds (/p/, /b/, /m/ and /w/). The third lesson works on building appropriate oral posture at rest. The program uses “cute” illustrations of Mr. SMILE to demonstrate the difference between good oral posture and poor oral posture at rest. The exercises in this lesson use a variety of tools such as a nose flute to establish volitional nasal airflow. This is followed by exercises to maintain lip and jaw closure. The final aspect to this lesson is appropriate tongue placement (at the SMILE Spot) at rest. Lesson four A.K.A. the “Lazy Tongue Buster” incorporates a group of exercises that targets tongue protrusion (as a precursor to tongue retraction), tongue retraction, tongue lateralization and tongue elevation. This lesson also includes the articulation drills for tongue sounds /t/, /d/, /l/, /n/, /k/, /g/. Lesson five targets the oral habits often associated with myofunctional disorders such as thumb sucking, biting fingernails, biting bottom lip, chewing on pencils, leaving the mouth open, and licking lips. The assumption here is that these habits will interfere with developing a new tongue position and a mature swallow. Lesson six is essentially a review of the previous lessons. Lesson seven through ten teaches the “New Swallow” – with liquids and solids. Lesson eleven focuses on making the new swallow a daily habit. This lesson also targets the appropriate placement of tongue for articulation of /s/, /l/, /sh/, and /ch/. Lesson twelve is also a review lesson of all previous lessons. Lesson thirteen and fourteen consist of maintenance exercises for the new swallow and tongue placement to ensure that it is generalized and essentially a part of the child’s daily behavior.

The systematic, simple and well laid out program make it easy and fun for the children and the families to follow. The homework practice charts make it easy to log the children’s performance at home and ensure progress. Overall, I think the SMILE program is complete, holistic approach to remediate oral myofunctional disorders or tongue thrusts.

Filed Under: Oral Myofunctional Disorders, Tongue Thrust Tagged With: , , ,

You are a Social Detective!

October 15, 2013 By

Review of “You are a Social Detective! Explaining Social Thinking to Kids” written by Michelle Garcia Winner and Pamela Crooke, illustrated by Kelly Knopp

You Are A Social DetectiveGetting started with the Social Thinking Curriculum by Michelle Garcia Winner is always a challenge. Most of us, Speech-Language Pathologists, fall under two distinct categories: 1) “Read first Therapists” that like to read and study a program until it we can recite it in our sleep before we will begin to implement it on our students, 2) “Try it out first Therapists” that will try to figure out the program while we implement it on our students.

I belong to the former category. I spent months after my first Social Thinking conference buying various books and studying them. After all that extensive reading, I concluded that, “You are a Social Detective!” was arguably one of the best programs to initiate the Social Thinking curriculum. This is possibly also because a majority of my caseload includes pre-school and early elementary students. It uses a comic book form and introduces many of the social thinking vocabulary in a clear and systematic way.

The first section points out how we all have school smarts, sports smarts, Lego smarts, etc. but we also have social smarts. It explains that social smarts means understanding that others have thoughts about us and we have thoughts about others. We use social smarts everywhere.

You Are A Social Detective

Some of the social thinking vocabulary that is explained using simple but age appropriate illustrations include “being a part of a group,” “thinking with our eyes,” “expected and unexpected behaviors.” The program uses the same social situation to contrast expected and unexpected behaviors, making it easier for children to grasp the concept.

You Are A Social Detective Versus You Are A Social Detective

The book introduces the concept of “having uncomfortable thoughts,” which, in my opinion is more appropriate and specific than using “feeling mad or angry,” especially for children on the spectrum. Feeling angry is so broad and vague and encompasses so many different scenarios and situations, that it makes it challenging for children on the Autism Spectrum. “Having uncomfortable thoughts” directly links the person’s thoughts to the student’s behavior.

You Are A Social DetectiveThe book also explains “being upset” in explicit physical terms (mean sounding voice, angry face, body gets tight) so children can identify their own states when they get upset.

The book then goes on to explain the process of being a social detective, i.e. using eyes and ears along with what they know in their brains. The authors talk about how we use our eyes, ears and brain to make “Smart Guesses” about how to behave. The contrast (Whacky Guess) is also illustrated.

You Are A Social DetectiveAnother challenge a lot of my little ones have is identifying and differentiating between peers who are nice and friendly and others who say or do mean things. The book has tables (page 44 and 45) to help the child identify and list characteristics of a “nice person” and a person who is “not nice to talk to.” In addition, the book also has a glossary with definitions of the Social Thinking vocabulary for quick reference. The book also includes three lesson plans at the end of the book for “Expected Vs Unexpected Behaviors,” “Social Spy,” and “Social Detective.”

Pros:

  • Illustrates in a simple and clear manner what it means to be a social detective.
  • Appropriate for early to late elementary aged students.
  • Contains three lesson plans that require little to no preparation.

Cons:

  • The illustrations may not be appropriate for older students.
  • Wish it included more lesson plans.
  • Some of the concepts may be challenging for low functioning students.

For me, “Being a Social Detective” forms the crux of the Social Thinking curriculum. Unless our students understand that their “unexpected behaviors” cause others to have “uncomfortable thoughts” about them, they are unlikely to change their behaviors. Concrete reinforcers such as prizes will only go so far.

Filed Under: Autism, Social Communication DIsorders, Social Stories, Social Thinking Tagged With: , , , , , ,

We Can Make it Better

October 7, 2013 By

Review of “We Can Make it Better: A Strategy to Motivate and Engage Young Learners in Social Problem Solving Through Flexible Stories” By Elizabeth M. Delsandro.

we can make it betterA majority of my caseload includes preschool and early elementary aged students. Many of them are diagnosed with Autism or demonstrate social skill deficits. If you’re like me and work with the younger students, you know how hard it is to find social skill programs that are structured, but still age appropriate. For the last year or so, the Social Thinking Curriculum has been the go-to program for many therapists to build social skills. However, finding materials that are appropriate for this age group has always been a challenge. In many settings including the public schools the Social Thinking curriculum isn’t incorporated until upper elementary or middle school years. Does that mean that the Social Thinking Curriculum isn’t appropriate for the preschool age group? In my opinion the preschool and early elementary age group is ideal to begin teaching the Social Thinking Curriculum. Introducing the Social Thinking vocabulary and concepts early on makes them a part of their everyday lives and routine. It does present unique challenges though: 1) teaching the vocabulary in ways that makes sense to younger students and 2) preparing lessons that are age appropriate, engaging and flexible.

“We Can Make it Better: A Strategy to Motivate and Engage Young Learners in Social Problem Solving Through Flexible Stories,” by Elizabeth Delsandro is an excellent starting point in terms of meeting both these challenges. This program essentially uses short stories to identify a problem situation and then encourages the students to express ideas that would “make the problem better.” It follows the core concepts of Michele Garcia Winner’s social thinking curriculum. The lessons are based on how ones behavior can alter the thoughts other people have about them (good or uncomfortable thoughts). Thus, it makes an important initial connection between people’s thoughts and their feelings. The stories follow a predictable pattern:

  • Introduction of a familiar social event,
  • A social problem, and
  • The undesirable conclusion.

Each story contains a lesson plan or pathway for the children to discover “how to make it better.” This involves active verbal problem solving to yield a preferred ending to the story. So the structure of the lesson basically involves reading the story with the social problems, then brainstorming together for ideas regarding what the characters should have done instead. Each story comes with two endings. The first one is the undesired ending and the second is the preferred ending. So, after the brainstorming, you would read the story once again, but incorporate the children’s suggestions and then use the alternate ending. Together, you have “made it better.”

I like that it uses a narrative approach similar to Carol Gray’s Comic Strip conversations. What I like to do is use Post It notes with speech bubbles and write in the suggestions made by the students and place them on the printed copy of the story. In addition, it allows children to view familiar social situations without being in it and therefore actively engaging in problem solving in a safe and non-threatening environment. All of the lessons:

  • Are structured and predictable,
  • Use illustrations instead of just auditory information, and
  • Use illustrations that are simple and free of distractions.

The program therefore caters to the strengths of children on the autism spectrum (and I have to admit, mine too. After all, which Speech-Language Pathologist doesn’t like structured, organized and predictable).

A typical lesson takes about 30-40 minutes, although it could easily be extended to encompass an hour-long session.

We Can Make It BetterAppendix A describes the story structure. The first edition contains the social dilemmas, while the second provides solutions so the ending is a preferred ending.

We Can Make It BetterAppendix C provides a visual script for the lesson.

We Can Make It BetterAppendix G provides a visual link between people’s thoughts and their feelings. This could be a very powerful and versatile tool. It could be used for far more activities than just the lessons in this program.

Pros:

  • The scripts for the lessons are provided making it easy to plan and run the session.
  • The illustrations are suitable for a wide age group.
  • It includes a CD with lots of printable worksheets and materials.
  • It incorporates strong visual supports for students that are predominantly visual learners. The visual supports could be used for so much more than just this program.
  • It also works on a variety of skills ranging from greeting and turn taking to making predictions.
  • The “thinking and feeling” board helps make the connection between our actions and what people think and how they feel because of their thoughts about us.
  • It includes goal ideas, which would be helpful for IEPs.

Cons:

  • It would be hard to make up your own stories and illustrate them (at least for someone like me who can’t draw). This means you are restricted to the story bank that is included in the program. While the stories are varied and fairly extensive (21 stories), there are several situations and scenarios I would have liked to be included.

Disclaimer: I (Sonali Shah) was provided with a copy of this program to review. However, all the opinions and thoughts are mine.

Filed Under: Autism, Social Communication DIsorders, Social Stories, Social Thinking Tagged With: , , , ,

Kimochi’s and Children with Social-Communication Disorders

August 19, 2013 By

kimochis-curriculum After 11 years in the field, I finally came across a curriculum that made teaching emotions a fun and positive learning experience. I was fortunate enough to be able to attend a presentation by Diann Grimm, M.A., CCC-SLP, Ed. S. on the Kimochi Curriculum. Kimochis in Japanese mean feelings. The program incorporates Kimochi characters with a pocket to place their Kimochis (emotions). Each Kimochi is a soft pillow with the feelings printed on one side and the corresponding facial expression on the other side. Using the Kimochis in conjunction with the feelings lessons as a part of the curriculum allows the children to learn to identify and express their emotions in a safe and focused manner. It fosters Social-Emotional Learning (SEL) which is a critical adjunct to the Social Thinking ® curriculum proposed by Michelle Garcia Winner. The adorable toys and the fun and child-friendly curriculum is a great way to support positive behavior, self awareness, social awareness, self management, relationship skills and decision making. It appears that some of the early research using this curriculum has shown positive results for children with Social-Emotional Learning difficulties (e.g. children on the Autism Spectrum). In addition, this curriculum has also been used for typical children in general education classrooms. I am so pleased and excited to offer the Kimochi Curriculum as a part of the Social Thinking groups. I think it will be an important piece to the puzzle that addresses the “Feelings-Communication-Behavior link” that Diann Grimm talks about.

Filed Under: Autism Spectrum Disorder, Social Communication DIsorders Tagged With: , , ,

Using Children’s Literature to Build Social Thinking

July 30, 2013 By

When I read Michelle Garcia Winner’s book “Thinking About YOU, Thinking About ME,” it had what I call, “a domino effect.” It seemed like to the doors of Social Thinking had just opened for me and there was a whole new world to discover. During my discovery process I came across Audra Jensen’s book “I Get It!” The book delivers exactly what it promises. It helps both the clinicians and the students understand important Social Thinking concepts that in theory seem abstract and difficult to define, but when used in context of familiar children’s literature, suddenly make sense. I’ve always been a big proponent of using children’s literature in therapy. I use it to build receptive language, vocabulary, grammar or syntax, speech articulation skills and also as a reinforcement. So the idea of using it to teach Social Thinking concepts seemed inevitable to me. Audra Jensen’s book helped put it all together. She addresses the concepts such as “Body in the Group,” “Expected/ Unexpected Behavior,” “Flexible Brain,” “Keeping Brain in the Group,” as well as books that compliment the introduction and instruction of the Superflex curriculum. Superflex is a social skills super-hero (created by Stephanie Madrigal as a part of Michelle Garcia Winner’s Social Thinking curriculum). He battles social villains, called the Unthinkables that disrupt good social behavior. Supplementing the Superflex curriculum with children’s literature allows the child to comprehend the concepts as they relate to familiar characters.

For example, one of the books Audra Jenson recommends to teach “Expected/ Unexpected” behaviors is the very popular book, “No David!” by David Shannon. The book has excellent illustrations that make differentiating “expected” and “unexpected” behaviors easy and obvious. Audra also talks about how the book offers opportunities for children to analyze the behaviors and state why they are “unexpected” and what his mother is feeling when David engages in those behaviors.

Childrens Literature in Social Thinking Putting a lesson together to teach the concept of “expected/ unexpected behaviors” using “No David!” would be fairly easy for most experienced clinicians. However, for me, having the resource list of children’s books that teach specific Social Thinking concepts makes Audra Jensen’s book an incredibly handy tool. An additional benefit of using children’s literature as a tool is that lessons can be planned for individual (one-on-one sessions) as well as groups.

Filed Under: Social Communication DIsorders, Social Groups Tagged With: , , , , , , ,

The Social Thinking Curriculum for Preschool and Early Elementary Age Children

July 3, 2013 By

Social Thinking CurriculumThe area of language disorders that seemed to confound most therapists, including myself, for a long time was social skills or pragmatics. That was until I discovered Michelle Garcia Winner’s work. When I read her book “Thinking About YOU, Thinking About ME,” I finally felt relief. I started thinking about social skills in a completely different way that made sense. I realized that the reason my therapy tools didn’t seem powerful or effective was because I was focusing on teaching specific skills (e.g. How to start a conversation) in a specific situation (e.g. When you meet your neighbor), rather than teaching social thinking or social cognition. As a clinician, when you teach a specific skill in an artificial environment, the student may do well to learn the skill. But the questions “What happens when the situation changes? Can my student generalize this skill to another environment?” always haunted me. The knowledge that you can build a child’s perspective taking ability, or his ability to “listen with his whole body” to help him across situations and contexts, was my Eureka moment.

Collectively as service providers for pre-school or early elementary -aged children with social skill deficits, we seem to focus on grammar or vocabulary building. What I quickly realized was that the area of social skills seemed to persist in so many of the little ones I saw. Even when their speech is completely intelligible and the structure of their sentences and vocabulary seems appropriate, some how they continue to have difficulties interacting with peers and adults. It was clear to me that the missing piece of the puzzle was a program that worked on their social thinking skills. I am therefore very pleased and excited to offer Michelle Garcia Winner’s new program “The Incredible Flexible You,” a social thinking curriculum for preschool and early elementary years. This program uses Michelle Garcia Winner’s social thinking model adapted for ages 4- 7 years using activities and materials that engage and excite the little ones. The program uses books, music and play based activities to target core concepts of social thinking such as Thinking Thoughts, Feeling Feelings, Whole Body Listening, Thinking with Your Eyes, the Group Plan and Body in a Group.

The beauty of the program is that it is a simple, kid-friendly and systematic curriculum to teach concepts and vocabulary that are usually challenging for preschool and elementary-aged children. It teaches children to “think social” rather than specific “social skills.” It also includes letters for parents and families to keep them involved in the process to ensure carry-over.

Filed Under: Social Communication DIsorders, Social Groups Tagged With: , , , ,

Thank You, Sonali!

June 3, 2012 By

Filed Under: Apraxia of Speech, Articulation Disorder, Cycles Approach, Oral Motor, Phonological Disorder, Speech Therapy, Testimonial Tagged With: , , , , , ,
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