Emotional Impairment and Speech and Language Therapy: How am I going to do that?

Emotional Impairment and Speech and Language Therapy

How am I going to do that?

"Kylie" is 7 and has suffered unimaginable trauma at the hands of family members.  She currently lives with Grandma as parental rights have been terminated.  Dad is in jail and Mom has a long history of substance abuse.  Kylie has been placed in a self-contained classroom for students with emotional impairments due to her extreme behaviors.  She has been known to hit, kick, bite, pee on herself or others, smear feces, and spit blood at the classroom staff.  She also frequently exits the building and runs toward the road...and... she has errors on her /k/ and /g/ sound.

She shows up in your building with speech and language services on her IEP 2 times per week for 15-30 minutes.  You’ve seen her in the hallway melting down and you are a nervous wreck.  How will you provide her services, you wonder, when she can’t even stay in the classroom for 5 minutes?  

Well, as an SLP working in a center-based program for students with severe emotional impairments, I can tell you it can be done! Here are my best tips for getting the job done.

1. Calm down! Take it easy.  This child has only been in the building a few days.  It will take a while before she is fully acclimated to the routine of the classroom.  The behavior always looks way worse when they first arrive and tends to go from a boil to a simmer within a few weeks. Don’t say “I can’t” before you’ve even started.
2. Stop making excuses! “Well, he’s got bigger problems than speech right now,” you might be tempted to say to the parents.  And, yes, that is probably a very true statement but behavior is a form of communication and the better a child can communicate his needs and problems verbally, the less often he might resort to aggression.  I am not here to suggest that fixing a child’s distorted /r/ is going to completely turn around his behavior, but having clearer speech and less teasing might help a little. At the end of the day, we make excuses when we are uncomfortable with a difficult situation and we don’t want to try.  Try first, make excuses later.
3. Show your face. Come into the classroom multiple times before you start providing services to the student.  Introduce yourself and explain what you do.  It helps to know the name of the previous therapist, if possible.  You can then say, “Remember Miss Linda from your other school? I’m going to be working with you just like she did” Do some classroom observations while you are there to get a sense of what the child likes or is willing to do.  Keep reminding the child that you can’t wait to start working with them (even if you are scared sh-tless).
4. Set a therapy time and stick with it.  I have been pleasantly surprised at how well setting a therapy time and showing up on time works.  Power through your doubts fears, and nervousness and get in there. And don’t show fear. Most of my students have simply jumped up and come along with few issues.  Many of these students crave adult attention and are happy to come and play a game with me.
5. Be ready for refusal.  Some of your students will refuse.  And they won’t refuse politely either.  “Go away you f---ing b-----!” is a likely response. These students have often been rejected or mistreated by adults so they will behave badly to see if you will reject them too.  They need to get the message that you are not going anywhere and that you do care about them. I had one student who was particularly stubborn and I was going on 2 weeks without having done any real direct therapy.  Finally, I said, “this is your speech time and I am going to sit here by you until your time is up.”  I sat by him and helped him with his work and generally just tried to develop a rapport. Eventually, he stopped refusing once he figured out I wasn’t going away.
6. Start small.  Start by working in small increments of time and with easier material.  Set a timer for 5 minutes (or less if needed) and do an activity that will likely be easy for the student.  Perhaps, you don’t make any speech and language demands at all, just teach them a new game.  Once the timer goes off, shower them with praise and tell them you can’t wait to see them again. Slowly increase the time until you are meeting the IEP time requirements or have a good sense of how long they can work.  
7. Be realistic about service days and times.  I can’t tell you how many times I have received a student into our program with a present level statement that reads: Melissa often refuses to come to speech therapy.  She has refused to come for services 15 out of 20 attempts to provide services.  Then, on the service page, 30-40 minutes, 2-3 times per week is recommended.  The student is currently only participating in 25% of therapy sessions, is it realistic that she will participate in therapy 3 times per week? No!!!  With a student who is not compliant with therapy, start with a lower amount of service, maybe once a week to start. As the student is able to participate for longer periods of time and more days, you can amend the IEP to increase the time.
8. Use visuals.  I have a visual schedule that consists of a laminated file folder with velcro cards.  I set up the schedule and have the students remove the cards as we complete the activities.  Similar to children with Autism, children with Emotional Impairments need to have a sense of how much they need to do before they are done.  Timers are also helpful.
9. Give choices. When setting up my visual schedule, I often allow the students to help me plan the session.  I might allow them a choice of 2 different games or a choice of which warm up activity they’d like to do.  These students often have a need to control their world so giving them opportunities to do so will improve compliance. Just keep your choices to a minimum and don’t get into extended negotiations or you won’t get anything done.
10. Hide the game pieces. I have had several students who would wrench the game box out of my hands, whip off the lid, and engage in their own version of the game, refusing to do the speech/language activity I had planned. Now, I have gotten smarter, I hide the game pieces in my pockets and make them earn the pieces by doing their work.  In the end, I allow them to play the game however they would like.  I get much more work out of students this way.
11. Be safe. Sometimes I start by doing therapy in the classroom for a student with safety concerns. There are also times when I might pull the student out but take a teacher assistant with me to assist if there are behavioral issues. Some days we need all hands on deck and we can’t always spare a staff person.  If I am alone with students, I make sure I have a means of calling for help if needed.  We are blessed with walkie-talkies to radio for help in our building.  I am also trained in nonviolent crisis intervention and I have had to use those techniques several times when a student became aggressive toward me, himself, or another student.
12. Attempt to provide services even during In-School Suspension or crisis. When the student has been removed from the classroom to an alternate or in school suspension area, you are not released from your requirement to provide services.  Be prepared to provide services in the alternate location. Obviously, if a student is in a full-on crisis, she may not be in any condition to work but at least check in on the student and document your attempt.  I have had several instances where my presence has distracted the child from his meltdown and he was able to calm enough to do therapy and go back to class.  Just keep in mind that failure to provide services can cause you a world of hurt if an advocate becomes involved.  Always try to provide services and always document your attempts and the outcome.
13. Use bribery if necessary. My students get to pick something out of the candy locker if they have done all of their work.  I never used to do this when I did traditional elementary school therapy but, all I can say is, it works.  I have learned to limit the options to 2.  If they start grousing about not liking the options, I offer them one option and say, “thank you or no thank you”  I learned this from a teacher and its been so helpful. They usually choose real quick when the choice is something or nothing.  If they don’t choose, the locker gets locked and they leave empty-handed. Obviously, check for allergies or special diets first.  I find that gum is usually a pretty safe choice.
14. Be careful of your materials.  I once decided to do a scissors and glue activity and one of the students started cutting his own hair and attacked me with the scissors. Another student ate the worksheet we were working on while my back was turned. “Oh yeah,” he said, “I eat paper.” I have also learned to keep materials locked up and my desk area clear of potential hazards. Also, I run all new activities by the teacher before doing them as they will often be able to spot potential problems.  
15. Something will go wrong and it’s OK. When you work with students with behavioral challenges, eventually something will go wrong.  Perhaps the student is having a bad day or has run out of medication.  Perhaps a word that you said or an activity that you chose triggered a negative response in the child.  You just never know.  Sometimes the classroom staff is really nice about it and other times they will blame you for “setting her off.” Either way, try to learn from what went wrong and forgive yourself.  If you feel like you may have inadvertently caused the behavior, apologize to the child and the classroom staff. No one is perfect and there is no avoiding negative behavior 100% of the time with this group of students.
16. Love them.  These students can be hard to love at times but, trust me, they need it. And, PS, they really are lovely once you get to know them.

Despite Kylie’s extreme behavior, she was generally well behaved during speech/language therapy.  In the 2 years that I have known her, she has only had a serious issue twice. Most of the time she is sweet and funny and a pleasure to work with.  This is true of most of the students on my caseload who have emotional impairments.  While this is a challenging population to work with, the rewards are great in the end.