Helping Students Who Are Orally Defensive in Speech Therapy

I was working with a group of students last week and I wanted to help them grasp proper tongue placement for /s/. I pulled out the mirrors, tongue depressors, and toothettes when all of a sudden one second grader flipped out. With his hand covering his mouth he pushed himself away from the table and expressed with terror in his voice, "I don't like things in my mouth!" Okay," I responded, "no worries we don't have to use these." He remained fearful even with reassurance that I wouldn't come anywhere near him with the toothette. His peers on the other hand, were eager to use the cherry flavored tongue depressors. That session was lost for him and yet I still needed to help him understand tongue placement. I have a Super Duper Jumbo mighty Mouth Hand Puppet, but I wanted him to have a more personalized experience.

In the car on my way home (where all my ideas/thoughts happen) I decided that in order to have him develop comfort with his own mouth, he had to make one and not just a paper mouth, but a mouth where he could move the tongue. I've seen mouth craftivities with mini marshmallow teeth, but I wanted this one to be used more than once. I also didn't want to spend too much money as lately I've been a little too spendy. I ordered 1/4 inch white pom poms to be used as teeth and found pink baby socks at Walmart. I bought the 0-6 month size. I made a mouth template from card stock that the students traced on pink paper with a small rectangle where the sock tongue would be glued. Unfortunately, the pom poms didn't arrive in time, so we used crumpled tissue paper for teeth. I wish I had thought of that before I bought the pom poms!  I struggled stapling the tongue in when it occurred to me to use hot glue. I also trimmed about two inches of the sock cuff off, so there wasn't excess sock.

My little ones placed their fingers in the sock and moved it all around their mouths. They used tongue depressors and toothettes to touch all around the teeth and tongue. My colleague from our PK had a great idea to add some texture to the alveolar ridge I had drawn on. I think I'll outline it with white glue and sprinkle sand, glitter or salt on top. I'd like them to understand that the alveolar ridge is bumpy.

Years ago, I worked with twins one of whom was very orally defensive. His parents were at their wits end, because he was having considerable dental problems, yet they couldn't get him to the dentist. We are fortunate to have a dental program in our school whereby a dental hygienist comes and cleans students' teeth.  They asked for help so I ordered some dental tools. Never fear, they were never placed in the student's mouth, they were simply to desensitize him to the tools. He used them on the Jumbo Mighty Mouth and used the mirror tool to look in my mouth. It worked like a charm.

I'm fairly certain it's going to take repeated exposure "playing" with these mouths before this particular student becomes more at ease. It may never happen, in fact, but at least he will have  a greater awareness of his tongue in his mouth and will be less anxious when I pull out tongue depressors for use with his peers.

One last picture. I was able to find some white pom poms in my big ole bucket of pom poms, so one student glued them on his mouth as teeth. I actually think I like the look of the crumpled tissue paper better, plus there was no drying time because we used glue sticks.

Any other suggestions? How do you help your students with oral defensiveness? I am open to any and all suggestions!

Carnac The Magnificent in Speech-Language Therapy

I was working with a student last week, in science class. He was getting very frustrated with me because I was asking him about the group plan and needed to ask for clarification several times. What became very clear was that I didn't have all the information and he wasn't giving it to me in his responses, despite asking him clarifying questions. Herein lies the rub with social communication difficulties, "you think I know what you're thinking." I don't I'm not a mind reader!

In the car on my way home I was drafting my weekly email to his teachers...in my mind. I wanted to help them understand that our student has difficulty understanding that he has to communicate what he thinks and knows in order for us to all be on a level communication playing field, because we aren't mind readers. That notion jogged a memory of Johnny Carson and his Carnac the Magnificent character. How could I bring Carnac to speech therapy?

I immediately ordered a giant turban from Amazon because who doesn't love a little kitsch in speech? I plan on helping my student understand that others don't know what's on his mind using a mind reader scenario and some games from my therapy closet. I found three games I believe will lend well to this concept: Inklings, Buzzword, and Whoonu.

The object of Inklings is to write clues to help your teammates guess the seven answers on the subject card. The idea is to get your teammates to guess your seven answers using as short a clue as possible. More points are awarded for shorter clues.  For instance, if the subject is things that are yellow and the answer is lemon, a possible clue could be sour.  After we play using the subject cards provided with the game, I am going to add more social subjects such as relating an experience from school with answers including subjects, date, place, discourse, conclusion, etc.

Buzzword will be wonderful for helping students express a specific message. The object of Buzzword is to have your team guess the answers to the clues around a central theme. I think I am going to modify the rules so that the Buzzword isn't given at the outset of the turn, but needs to be guessed. So players would give the clues and the others would guess the theme or buzzword. I'll have to select specific cards and omit some more obscure clues, I think.

The last game I plan on using is Whoonu. In Whoonu players win the most points by correctly guessing other players' (the Whoozit's) favorite thing. The snag is that the players guess the Whoozit's favorite thing from the cards in their hands.

These games are introductions of sorts and will pave the way for more discussion and activities around sharing thoughts to improve communication. The bottom line is I want to help my student understand he bears a portion of the responsibility to provide information to others to prevent communication breakdowns as well as to learn to ask questions about what others may or may not know. I''l let you know how it works

Does anyone have any suggestions as to how I can make this different or better? I would love to hear your thoughts, I'm not a mind reader after all! :)

Thoughts from the Back Porch 2017

 I am an artist. I have amazing, creative visions of drawings and paintings, mixed media works, and projects. Then I try to put these ideas on paper and poof, my hands don't procure what my mind envisioned. Why? I saw it so clearly in my mind, the color, the perspective, the light. I often look at my work and utter with disgust, "This is crap!" Sometimes I am brought nearly to tears. I look with awe and a fair amount of envy at the art of others and wonder, "Why was I behind the rock when the art gene was distributed?"

My family members have it. My grandfather was an accomplished artist who made his living by his hand. My cousin, Jeanette is an an artist. Her brother Christopher is an architect. My brother Jimmy is an amazing musician, playing the viola, piano, and composing. My other siblings are craftsmen and poets and writers. Why was I gypped? Oh the cruelty to have such a yen and not be able to create! But if I have the vision, why doesn't it translate to paper? There must be a way!

One of my strengths is perseverance and a desire for lifelong learning. This summer I began exploring how I can untether my creative juices and really make art happen. I started reading, Drawing on the Right Side of the Brain and it is fascinating! Not just from an art perspective, but from the educational and speech-language pathology perspectives as well.

This summer, I am going to go on a journey to tap into the right side of my brain, which is very counter intuitive for a left-brained language oriented sort of gal. I am going to share some of the nuggets I learn on this artistic journey in my Thoughts from the Back Porch 2017 series.

In her book, Betty Edwards, purports that drawing is an essential skill, like reading, that has implications for the perception and understanding of both visual and verbal information. She continues that our education system, that is so heavily language based is missing the mark in terms of cultivating creativity, perception, imagination, and intuition. This is fascinating. In her introduction, Edwards includes this quote from Albert Einstein, "The intuitive mind is a sacred gift, and the rational mind is a faithful servant. We have created a society that honors the servant and has forgotten the gift." Nowhere is this more prevalent than in our schools! Furthermore, with the emphasis on facts, standards, and standardized testing as the measures of competence, we see less and less competence and more and more behavioral struggles and anxiety in our students, who are, in fact, unable to think their way out of a paper bag.

Edwards includes a 1969 excerpt from Rudolf Arnheim that is striking in its accuracy, "The arts are neglected because they are based on perception, and perception is disdained because it is not assumed to involve thought. In fact, educators and administrators cannot justify giving the arts an important position in the curriculum unless they understand that the arts are the most powerful means of strengthening the perceptual component without which productive thinking is impossible in every field of academic study. What is most needed is not more aesthetics or more esoteric manuals of art education but a convincing case made for visual thinking quite in general. Once we understand in theory, we might try to heal in practice the unwholesome split which cripples the training of reasoning power."

This just intrigued me, that perception fosters productive thinking; reasoning and problem solving. We know this as it relates to social pragmatics, but it truly extends to all aspects of the curriculum and life in general. We talk ad infinitum of metalinguistics and metacognition, but what of the magnitude of those. The simple fact that the brain is the only organ that ruminates on itself! I had never thought of it in those terms. The liver doesn't think on the liver, the stomach on the stomach, the skin on the skin!

Edwards's premise is to waylay the language dominant left brain and allow the perceptual right brain to run the show for a while. I think this practice may change the way I do language therapy in that the verbal overload in school is so very taxing on our language impaired students. It raises the question for me, "Is more language always the way to remediate language?" "Will drawing help remediate perspective and reasoning?" The basic components of drawing are listed as:

1. The perception of edges (seeing where one thing ends and another starts)
2. The perception of spaces (seeing what lies beside and beyond)
3. The perception of relationships (seeing in perspective and in proportion)
4. The perception of lights and shadows (seeing things in degrees of values)
5. The perception of the gestalt (seeing the whole and its parts)

The correlation between these components and social pragmatics is staggering to me!

The crux of this journey will likely be a challenge for this language infused individual.  It occurred to me as I was reading, that my self-talk is a boon and an axe. I use it to do my job and express my feelings, to make my unending points and to write. I also use it to sabotage myself, to quit when I'm exercising ("I can't. This is too hard.), to beat myself up ("This is no good.), to remind myself of my failures ("Remember when you couldn't/wouldn't/didn't?"). I am excited to pull away from the language Annie and cultivate the perceptual Annie and to share that journey here.

The Rockin' Tale of Snow White Meets CCC-SLP

Well it seems I have taken the month of April off from blogging. It wasn’t intentional (it usually isn’t, is it?). Spring in New England isn’t really the stuff of spring. There are glimpses here and there, but overall it is dreary. I expect spring to be chirping birds and daffodils and unfortunately in New England late March and early April often are chilly, sometimes snowy, and generally muddy. I guess I was in a funk.

I did have something fun and new to keep my mind off the lack of spring warmth, a play! I wasn’t performing this time, I was assistant directing our middle school play. A very different activity for me, but one I felt well suited for given my background in speech-language pathology. As I embarked on this challenge I was reminded of how theater and speech-language pathology are interrelated. In fact, I recalled thirty-three years ago when I was a graduate assistant. I had nearly forgotten that my time was split between two departments, communication sciences and disorders and speech and theater. How could I forget that? In working to help our students give a spectacular performance I was so happy to have a background in articulation, anatomy and physiology, voice, and social pragmatics. Here is how this all played out:

• Articulation - I was dumbstruck by the number of girls who dentalized everything. Not only that, they didn’t voice /d/s and /z/s! They seemed to want to sound like all the Disney pop stars. On the other hand, some of the kids over-articulated their lines to the point where they sounded forced. Neither of those practises translates well to the stage and I was able to help them achieve better placement of their articulators for lines and singing.
• Voice – The other piece of sounding like a Disney pop star is nasality. WHEW! We worked on establishing oral resonance when singing, but they always went back to Disney pop. I was also able to help our actors learn how to use their larger muscles as a basis of support for voice volume and projection and with the music director’s expertise how to adequately use breath support for both volume and pitch. We helped them recognize the difference between shouting while singing and supporting. We worked on appropriate rate and helped them understand that during performances when all that adrenaline was surging they had the potential to go even faster. 
• Social-Pragmatics – This was the really fun piece: acting. My background in social was extremely helpful here. We talked about eye contact and body position on stage, remembering to never turn backs to the audience, but rather “cheating” out a tad. We worked heavily on not sending a mixed message. For instance, learning how not to laugh when telling the king that his wife has died or actually smiling when happy. By the same token, I helped the actors understand that it’s crucial to use a tone of voice that reflects the sentiment of the line that is being delivered. So if you are an evil queen you need to use a tone of voice and body language that is wholly evil. Performing in a play, like role playing in therapy, is a great opportunity for students to practice perspective taking in a non threatening and fun situation. It provides students the ability to stretch themselves as well as to consider the perspective of the other characters. I recall watching Robin Hood Prince of Thieves starring Kevin Costner. While overall I enjoyed the film, I was disappointed in Kevin Costner’s British accent. It seemed sometimes it was there and sometimes it wasn’t. Maintaining the integrity of the character played is as much a part of social as it is acting. We all assume different roles in different social scenarios. The work Annie is different from the home Annie who is different from the party Annie. They are all me, but they shift according to the scenario and other “actors.” This was a fun perspective to help our middle school actors understand. They still had to maintain their characters, but their character could shift as the context and other actors shifted in different scenes. 

The role of assistant director was new for me and I thank Monique for showing me what a good director does, as I performed in her plays. It was a wonderful distraction from my spring melancholy and despite being a ton of work was a fabulous experience, one I hope to have again.
Reflecting back, my colleagues and I had, what I consider, the perfect quantities of let’s make this good and let’s make this fun. We remembered when to be firm and when to laugh, when to remember this had to be performed and when to remember these are kids. We brought our own unique talents and strengths and I think we complemented each other perfectly. I am so grateful for my professional background, because without that expertise I think I may have missed the why behind the what in theater!

Unraveling Confusion: Helping Students with Academic Success

At ASHA this November I attended a session in which the presenter reminded us, "you are not tutors." That comment made an impact on me because there are often times when students bring their classwork to speech therapy. I want to help them, yet sometimes can't. For instance, I don't understand how math is being taught. Truth be told, I struggled learning math 50 years ago! Sometimes the work they bring doesn't align with their speech-language goals and while I would love to help, I am not a tutor. That is important to remember. However, as SLPs, we do support curriculum areas like vocabulary, critical thinking and speech-language targets that are critical for academics and there are many instances where we can and should help students with their assignments. That is our job in the school.

No, we are not tutors. It seems though, our particular area of expertise is sometimes the exact thing our students need when they are struggling to understand a concept. This is most prevalent when students enter middle school. By the time these students enter sixth grade, often they have been on our caseloads for as many as seven years. While they have had seven classroom teachers, two or three special educators and a whole passel of para educators, we have been the constant. We understand their language difficulties and know how to tailor material so they can understand it. We get that they need constant cycling back to previously taught material. We understand that they need very explicit language. We understand that they need a highly linear approach. We know they may need this instruction in a one-on-one context. We are often the right ones to unravel the confusion and relieve academic frustration.

So when a student's paraprofessional recently came to me expressing the difficulty she was having explaining sonnet writing to a seventh grade student, I changed my therapy plans from inferencing to sonnets. My daughter had to write a love sonnet in eighth grade. She is a good student with no language difficulties and she struggled. It took her hours and I recall seeing the teacher who gave the assignment the next morning and saying, "Sonnet this!" We laughed, but it was a very challenging assignment, one I have never had to do myself. This year it is being done in seventh grade! For our students with language difficulties this assignment can be a doosie!

I am neither an English teacher nor a poet, so began my crash course in sonnets. This is how I broke the task down for my student:

1. I provided the order and parts of a sonnet (fourteen lines, three quatrains of four lines each and a concluding couplet).
2. We talked about sonnet vocabulary and the definitions of: quatrain, couplet, metaphor, stanza, iambic pentameter, rhythm, and syllable.
3. I explained the requirements of a sonnet: number of lines, rhyming pattern, ten syllables per line
4. I explained a sonnet must have meaning in terms of a theme, a conflict and a conclusion. 
5. We practiced the ABABCDCDEFEFGG rhyming structure and the stress pattern of the lines with random words.

I whipped up some visuals and graphic organizers so my student could practice iambic pentameter and the syllable structure of each line before deciding on a theme. You can access these here.

At the end of one of our therapy sessions, this student said, "You explain things to me so I can understand. I like that." That is what we do. Our expertise in language and breaking information down into its component parts and knowledge of our students and their needs often make us the right people to unravel confusion. The next morning I popped into this student's English class. He already had three lines to his sonnet written! I could see his anxiety decreased with his understanding and I was very happy. Next week we'll work on inferences!

Music and Speech-Language Therapy

When I was a much younger SLP, it seems there was more of an emphasis on developing auditory skills with our students. There was a wealth of materials on auditory discrimination skills and discriminating environmental sounds. We spent time teaching students HOW to listen and follow verbal directions explicitly, encouraging eye contact and subvocalization. My articulation therapy training in the early eighties included spending considerable time teaching students to listen for target sounds in my speech, in isolation, syllables, words, then in their own speech (Mysak's Developmental Feedback). We then would work on auditory comparing student productions with therapist productions. Who remembers the games Dig for Gold and Old Itch? Discovery Toys had a great game What's That Sound whereby students listened to sounds on a cassette tape and covered a lotto board in order to identify the sound. I still have all those games and have actually started using them again. It seems our little ones are really having a difficult time sitting still and attending and listening! Hmmmm, I wonder why? I could hypothesize on the myriad reasons (excessive television and electronic media time, little family discourse, etc.), but the bottom line is we are seeing students who struggle with verbal directions, auditory skills, social listening and more.

At the outset of our school year, our school district offered a series of in-services presented by fellow colleagues. I decided to attend a session on Music and Literacy offered by a dynamic and creative music teacher in our SAU, A.J. Coppola. A.J. uses a method of instruction referred to as the Kodály Method. Kodály was a Hungarian composer who was dismayed with the state of music education in Hungary. He felt there needed to be better teacher training, better music curricula, and an increase in the amount of time devoted to music instruction in schools, thus, the Kodály method was born. The framework of his method is solidly based in child development. Students are introduced to skills according to their developmental levels, first being introduced to more simple tasks and progressing to those that are more difficult as they master skills. It is a very linear and sequential method whereby skills are continually reviewed and reinforced through movement, games, and songs. It really sounds a lot like what we as speech-language pathologists do in therapy!

We know melody and rhythm is valuable in increasing fluency in patients with aphasia (Melodic Intonation Therapy) and can be very effective when working with students with ASD.  From a speech-language perceptive, music has many applications including helping students with Central Auditory Processing difficulties detect pitch and stress differences to developing social skills through song. A.J. introduced us to several books I thought would be wonderful to utilize in therapy (the Feierabend Series publishes a book each year using folk songs and the Musicmap Series uses multicultural songs in an illustrated format.)

Songs are a wonderful way to calm anxious students and establish connections. They provide the basis for rhythm, pattern, and pitch which are basics in speech-language therapy. Listening skills are foundational to communication and classroom functioning. Auditory skills, from sound discrimination to figure-ground discrimination to perception, reception, and synthesis, are skills necessary for learning. I, for one, am going to pull out my shaker eggs and maracas, Old Itch and Listening Games books and return to some SLP roots. So grab an echo mic, learn a folk song or two and SING.

Thinking Outside the Box in Speech-Language Therapy

One of the things I have really come to appreciate about our profession, is the ability of an SLP to be a nonconformist.  I consider myself a fairly traditional gal, but when it comes to my work I will do what ever it takes to help my students understand a concept or reach a goal.  I would venture, most of us feel the same way.

Today was no exception.  I have an absolutely darling little kindergarten student who has a phonological processes difficulty.  We have made incredible gains using the cycles approach along with some other articulation techniques.  She is very highly motivated and just relishes being better understood by her peers, teachers, and family, and as soon as she learns a target production, she scans ahead and self-corrects like nobody's business.  Stopping is reduced, gliding is reduced, but fronting of /sh/ (sorry, don't know how to insert phonetics into my blog!) was eluding her.

This is where thinking outside the box became critical.  We had previously talked about the parts of the tongue, we did auditory bombardment, we used pictures, apps, flashlights.  Zilch!  I was grasping when it came to me...a pipe cleaner and a bead.  We knew she could now produce /s/ consistently, but moving to /sh/ was vexing.  The pipe cleaner represented the roof of her mouth and the pink bead was her tongue.  As she moved the bead along the pipe cleaner, she was able to grasp how her tongue had to change for the /sh/ sound.  A couple of trials and she had it.  That little girl fell into my arms and then sprawled across my lap with relief.  She did it!  We laughed and said /sh/ over and over and over. Then she showed her teacher what she had learned and her teacher jumped for joy.

Thinking outside the box in action!

It was a bead and a pipe cleaner, and it resulted in improved communication.  It is days like today that I am happy to announce I am a nonconformist.  It is days like today that make me so happy I am an SLP.