Saying Goodbye to an Old Friend

After 26 years as a speech-language pathologist, I am moving on to a new position as an AAC consultant.  That means I will be supporting school districts by helping them support students with complex communication needs using high-, mid-, and no-tech communication systems.  I was already doing this in my own school district as most of my students were nonverbal but now I am going to take what I learned from the AAC consultants who helped me and use those skills to help others. 

While this is an exciting opportunity for me, it has left me with a problem that is now spread across my entire family room, the problem of what to do with all of my therapy stuff, all 26 years of it. Now, I managed to give away a fair amount to the teachers in my building but there is only just so much of my junk that they were willing to take.  So here I sit surrounded by bags and boxes of books, picture cards, toys, and other materials, most of which I created myself.

I am going through box after box trying to sort out what I should keep and what I should toss.  And this is just the stuff from my office.  It doesn't include the 2 utility shelves of stuff sitting in my basement.  I have worked hard all year cleaning out the basement so I am reluctant to put even more stuff down there. I have resigned myself to deal with my mess once and for all. 

The first box I opened was a box of therapy games that I had printed, colored, and laminated myself.  I remember when I first started working and how I spent hours making all of this stuff.  I had the box sitting in my family room for months as I had intended to bring the games to work and start using them again with students. They were simple games that I had used during articulation therapy to distract from the boredom of repeatedly saying the same sound or word over and over again. 

One of the first games I made was the game pictured above, the "Find the Squirrel" game.  In this game, you had to select a path of footprints, roll the die, and move along the path to the end.  Whatever number you rolled on the die was how many steps you could move and also how many words/sounds/etc that you had to say. The first person to the end of the path got to turn over a tree to try and find where the squirrel was hiding.  I had glued 4 envelopes on the backs of the trees and hidden a squirrel inside one of them.  If you didn't find the squirrel, you had to keep rolling the die and practicing your sound until you finally found it. If I had a group, the first one to find the squirrel was the winner.  It was kind of a stupid game if I'm being honest but the students really liked it.

When I opened the box and unearthed this game, I was a bit shocked to see it.  I know I made it at the very beginning of my career so it is 20-something years old.  I had found the game in an activity book and, judging from the telltale purple splotches on the game pieces, I made them on a Ditto machine.  For those of you who were not alive between 1923 when it was invented on through early 1990s, the ditto machine was the precursor to the copy machine.  I was working in a Detroit elementary school in 1993 and, while the school did have a copy machine, it was heavily guarded by the building secretary.  Many teachers in Detroit at the time had to purchase their own paper to use in the copy machine or pay for copies at a copy center using their own money. Ditto paper was cheap and we had reams of it in our building so the ditto machine was still in heavy use. 

Making a copy on a ditto machine was a fairly complex task with many opportunities for failure.  To make this game, I had to feed the page from the activity book through a machine called Thermofax.  The Thermofax imprinted the game piece images onto a waxy purple master copy.  About half the time, the master was blurry and unusable. The master was then attached to the large round drum of the ditto machine and the paper was loaded into the tray underneath.  Then you turned it on and the master would rotate around so that it could be dipped into a chemical solution that would transfer the waxy impression of the master onto the blank paper.  The copies were printed in purple and even the best copies were hard to read. The machine could make about 40 copies before the waxy ink-like substance on the master was used up. And there was always a risk that the master would wrinkle as it rotated around the drum leaving a giant purple zigzagging line running across the paper like a lightning bolt.  Then of course there was the smell.  The copies emerged from the machine slightly damp from the solvent with a distinctive slightly sweet chemical smell.  I remember sniffing the fresh copies back in elementary school in the 1970s. 

After my trees and squirrel came out of the ditto machine, I traced them in black marker and colored them in before driving over the the materials center which happened to be across the street from a huge and very dangerous high-rise public housing project.  At the materials center, I laminated the pieces and cut them out.  Finally, the game was finished and ready to play.  That game traveled to 3 different school districts and spent 3 years in a storage unit before making its way to the basement of my current home.  And while many other similar games were unceremoniously dumped into the trash, this game has remained. 

So why have I kept it all this time?  I guess it brings back memories of the very beginning of my career when I was young and ready to fix all of the communication problems of the world.  And even though I have changed so much in the past 26 years, this game represents how much I have stayed the same.  At my feet right at this very moment are 2 large bins of materials that I created myself because the store-bought materials that I had purchased over the years were always such a disappointment. 

So what is a girl to do with this relic unearthed from the past?  I know in my heart that even if this consulting thing doesn't work out and I find myself back in a school, I am not going to use this game ever again.  I know that the day will come when it will end up in the trash just like all of the others. For sure it will need to go when I retire and move to a smaller place.  I know I should let it go but somehow it is so hard to say goodbye.

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.