Breaking Up is Hard to Do: Dismissal from Speech and Language Services

As SLPs we are awesome at evaluation.  We are able to take multiple pieces of data such as standardized test scores, work samples, classroom observations, teacher reports, and parent reports and quickly determine if the student has a communication impairment.  We can easily identify what type of communication impairment they have and what goals we will work on to address the problem.  

When it comes to dismissals though, we are not as confident.  Because, really, how can you tell when the student is done? If you work in the medical or clinical area of our profession, the insurance eventually runs out.  Many parents stop the services when they have to pay out of pocket. Not so in the school system. Students in schools are with us from Kindergarten to 12th grade or longer if they receive post-high school services.  

With staff and funding cuts, we are often faced with making decisions about who continues to require speech and language services to access the curriculum and who does not.  Also, what about those students with articulation disorders who just can’t get that /r/ in place after 8 years of working on it? How do we make a good case for dismissal? Here are some tips:

1. Focus on the essential questions.  There are 3 questions you need to answer in order to determine if a student requires special education services: 1. Does the student have a disability? 2. Does the disability limit access to or progress in the general education curriculum? 3. Does this student need speech and language services to access the curriculum?  This is different from whether the student qualifies for services based on test scores.  You need to be able to answer yes to all 3 of these questions in order for the student to be eligible for special education services.
2. Standardized test scores are one piece of data.  A student’s score on a standardized language assessment or articulation assessment should not be the only data used to determine if a student requires speech and language services. It only answers the first of the 3 essential questions. Don’t forget to look at grades, attendance, work habits, other supports available, work samples, observations, teacher reports, student motivation to work on the goals, etc.
• For example:  Skyler is a 10th-grade student with language scores in the high sixties and low seventies.  Clearly, he has a language impairment based on these scores and if that is all we were using, he would definitely be getting speech and language services.  Let’s add a bit more data: Skyler also has a learning disability and is taking special education supported core academic courses. That means he pretty much gets special education support in all of his academic classes with the exception of History.  He is getting a lot of support for his language and learning disabilities within the classroom. Now let’s add another piece of data, grades. Skyler has all As and Bs in his classes including 2 general education electives and a C in his gen ed history class.  Let me repeat, a C in a very challenging gen ed class. In speaking with the history teacher, Skyler frequently asks for help with assignments and the teacher has been very good about supporting him. Now let’s add an observation of this student. Skyler has been observed in multiple classes to ask for help and using his study hour wisely.  He has been observed making flashcards on multiple occasions to study for upcoming tests and he has also been observed working with other students on assignments and quizzing each other before tests. Let’s add that this student has only 2 missing assignments and they were due to a recent absence due to illness. Skyler’s attendance is also excellent.  So, here is a student who is passing all of his classes and is fully accessing the curriculum given the supported academic classes. He is a hard worker, does his homework, and studies. Also, his therapy progress in recent months has been limited because he would prefer to stay in his study hour and study for tests rather than receive my services. While he is perfectly agreeable when I work with him, he has reported that he no longer wants the service.  If we go back to the question, “does this student need speech and language services to access the curriculum?” the answer is “no.” He has supports in place to meet his needs. If I had just looked at his standardized scores, I would have felt the need to keep him on the caseload until graduation but, with all the other data, I can’t make a case for continuing to provide services.
• Now let’s look at Philip.  Phil has a learning disability and a mixed mild expressive and receptive language impairment.  He was one of those that I was on the fence about doing a dismissal and left the decision up to the student who said that he still wanted the service.  He is very inconsistent in his school performance. Sometimes he does well, and sometimes he doesn’t. He has all gen ed classes with the exception of a special education supported Math class as Math is an area of weakness.  He is struggling the most in language arts, a class he is currently failing, and often misinterprets the writing prompts or does not use enough detail to write a quality essay. I made the decision to continue to support his language arts goals and assist him with clarifying language in the assignments as well as increasing his output and detail.  While he barely qualifies for speech according to test scores, he is not accessing the general education curriculum very well given his failing grade in LA. Unlike Skylar, he is not getting much support in his core academic classes. I decided to Keep Phil on in order to get him back on track.
3. Ask yourself the right question. Does the disability interfere with the student’s participation in the general education curriculum?
• Now let’s take a look at Tiffany.  Tiffany is a 9th grader with a learning disability and hearing impairment.  She also had a noticeable articulation disorder with errors on the /s/, /sh/, and /r/ sounds.  Her parents had recently taken her for an evaluation at a local hospital. Her scores on the standardized articulation assessment were in the impaired range.  The hospital therapist recommended continuing articulation therapy and suggested that some work on nasality be added to her other objectives. Thanks private therapist! So, there was one piece of data.  Let’s add my therapy data. Tiffany loved coming to speech and chatting me up but when it came to working on her errors, she just wasn’t interested. She didn’t really have a decent /r/, even using all the creative elicitation techniques.  She couldn’t really hear the difference either. In all the years of therapy, she had improved a lot and was intelligible but not perfect. Let’s add my observations of Tiffany. Tiffany was a talker. She talked all the time and was extremely social.  I eavesdropped on her out in the hallway talking with peers several times. I counted the number of times she was asked to repeat herself because someone didn’t understand her. Over several observations in the classroom and with peers, she was asked to repeat herself or had an incidence of miscommunication exactly 2 times over the 5 observations.  This indicated that, while she continued to have an articulation disorder, it was not interfering with her ability to participate at school. She was not reluctant to speak in class or to friends and they were able to understand her just fine. When I met with her mother, a school psychologist, I shared my data. She was disappointed as she, of course, wanted as much service for her daughter as she could get, but she agreed that it really didn’t interfere with her life.
• Contrast Tiffany to Angelo.  Angelo approached his counselor about getting speech therapy for his /r/ sound.  He had never had speech in his life but had a mildly distorted /r/. Like Tiffany, Angelo would come out in the impaired range as /r/ should have been in place at the age of 14.  Unlike Tiffany, Angelo avoided speaking in class due to his /r/ sound. He reported that a couple of peers had said something about his speech sounding funny. So, while Angelo was much more mildly impaired than Tiffany, it was having an impact on his education and socialization.  He was also highly motivated to work on his speech. Angelo was in, Tiffany was out.
4. You are not the only game in town.  As SLPs in the public school system, we are lucky to be part of a team.  Most students with significant disabilities have multiple professionals and multiple supports in place.  Language impairments, cognitive impairments, and learning disabilities can often be very intertwined. As students get older, sometimes support for a language impairment is best provided by a special education teacher in the classroom or resource room.  Most of the special education teachers that I know work on a lot of the same things that I do. They directly teach vocabulary, they work on comprehension, verbal expression, etc. If you can make a case that the supports and instruction are already being provided in the classroom then the student might not need your extra services to access the curriculum.  In addition, we don’t own pragmatic language disorders either. A good Social Worker can certainly handle teaching social skills as well as we can. The social worker and I would coordinate these services, she would take the students who knew social rules but needed practice applying them and I took the students who didn’t know social rules well or had a receptive language impairment along with the pragmatic impairment.
5. Plant the seed early and water it often.  When you start to see that a student is nearing the end of their speech therapy career, give the parents a heads up.  I usually make a phone call or send an email saying, “Lindsay has really made a lot of progress on her goals so far this year.  It looks like she may be ready for dismissal by the end of the year. Most parents are happy to hear this news and are just fine with it.  Others are not so fine with it. Some SLPs don’t like giving the parents advanced notice because parents can get really upset and start to panic.  Some will take their child and have a private evaluation done to add support to their case or start calling your colleagues or supervisor to complain about you.  I say, bring it on. I don’t mind the input of other professionals in my field and I am happy to consider their input in making my decision. I have found that the direct approach is much better than trying to pull a fast one on the parent.  Trying to sneak in a dismissal during the IEP is just not fair to the parents and will come back to haunt you in the future. Not only will the parents not trust you, but they will also distrust the rest of the team as well. Often, by the time the IEP comes around, the panic has died down and the parent is able to hear what you are saying.  Sometimes I even start warning the year before the student is ready for dismissal by saying, “Lindsay probably won’t need speech forever. She will probably be dismissed in the next couple of years.” The more warning the better!
6. Don’t be a wuss!  Once you have collected your data and consulted the team, stand by your decision.  Repeat these words, “the data just doesn’t support a continued need for this service.”  Of course, you should listen to the parents' concerns and consider any data that they add to the discussion.  Once or twice the parents have pointed out a skill that was needed that I hadn’t identified in my assessment and I did keep the student on to address that skill.  And if the parent has a valid piece of data, you absolutely should consider it. Most parents who disagree, however, do not have a valid reason for continuing the service. They say things like, “I just wish you would keep him.  Just for one more year.” A wish is not data. This is where therapists start to cave. “OK fine. One more year,” we say. One more year and then what? Believe me, it won’t be an easier conversation next year. And don’t be an ass and pass the buck on to the therapist at the next school.  Nothing makes me madder than getting a kid who clearly doesn’t need speech and having to take time out of my week to provide services that are a waste of their and my time just because you were too spineless to stand up to the parent. Just be kind and firm and most parents will not fight you on it, even the really prickly ones.  But, if you are wishy-washy about it, they will smell your fear.  
7. A word about consult services.  Many SLPs offer up consult services when the parent is really making a fuss over a dismissal. I would caution you to continue to stand by your data and move forward with a dismissal if that’s what you believe is the right thing to do. Consult services should be used sparingly.  If you decide to offer consult services, be VERY CLEAR about what that would entail. Spell out exactly what you will be doing for the student and make sure the parent understands and agrees. While we have the best of intentions when we are sitting in the meeting, we all get busy and the consult students often go by the wayside.  We get to the end of the month and think, s**t, I didn’t consult on Steve this month. So, we run into Steve’s teacher in the bathroom and say, “how’s Steve doing?” That’s our consult, a one second interaction with the teacher in a public restroom. Trust me, as someone who has had to sit with some of the most aggressive and unpleasant advocates, make a consultation plan and stick to it.  Also, document everything you do to support that student. If you don’t, it will come back to bite you in the ass.
8. What about the old articulation kids who aren’t making progress?  This is a really tough one for SLPs.  If you do your prep work appropriately, you should be able to make a compelling case for dismissal.  This will involve looking back at the student’s old IEPs if you can. Look at the number of years the student has had services for articulation. Knowing the number of years of therapy for articulation will be important to show the student has perhaps hit a plateau. If she has had service for 8 years, perhaps we have taken them as far as they can go. Next, look at the service times and note any changes over time, Looking at the service time over the years can give a clue about whether the student was given sufficient time to work on the goals.  If the previous therapists are still around, ask them about whether services were delivered at the rate listed on the IEP. There may have been frequent absences or behavioral problems that hindered service delivery.  If that is the case, you may want to try a short period of increased service time to see if it improves progress. After that, look at the goals as well to see if they start to repeat themselves. The goals over time will give a huge clue as to the progress being made.  If the goals have been recycled multiple times, then we know the therapy is likely not working. Lastly, If you can get copies of progress reports, review those as well and see how much progress has been made over time.  Be prepared for the fact that this student may not have had adequate therapy over the years or an adequate amount of service time and practice to make gains. Also, were multiple approaches attempted to help this student or was he given the same approach all those years?  This might be a time to do a little research to see if there are new techniques or elicitation strategies that might help. A trial of more intensive intervention using new strategies would be worth a try before throwing in the towel. Also, institute some kind of home practice that the parent needs to sign off on.  This may help the progress and indicate the parents' true level of commitment to improving their child’s speech. This intervention will definitely give you data to suggest that continued therapy would be useful or just a waste of the student’s time. Let the parent know of your concerns and that you are trying some new things to see if any further progress can be made. Make sure that the parent understands that a dismissal is possible.  
• This brings me to Liam.  Liam is a student with a significant emotional impairment who also has cognitive scores in the borderline cognitive impairment range. He has a distorted /r/ and is unable, after many years of trying, to make a decent production.  His speech is difficult to understand until you get to know him. In addition to /r/, he leaves off /s/ and /z/ endings on words including when they are grammatical markers like in the word cookies. The other problem, he talks really fast.  When he speaks slow enough, people can understand most of what he says. And, like our pal Tiffany from the earlier example, he really doesn’t care about his speech. He talks all the time and participates in class. The teachers often have to ask him to repeat, which he is willing to do without becoming angry or shutting down.  When I started with Liam, he hadn’t had adequate services due to his frequent behavioral outbursts. The previous therapist did her best to provide services but he was often in crisis when she showed up to provide services. I tried upping the service time. I tried using different assessments to get to the root of the problem. I tried pacing techniques, worked on his grammar, and many other strategies to help him along.  The bottom line is, he just doesn’t care about his speech and isn’t very motivated to change it. He is good for about 5 minutes of pacing and then he goes right back to his rapid pattern. I will be dismissing him this fall. The parents have been warned that this might be it. I will be bringing my report describing everything that has been done for their son and also his lack of motivation. I will also note that he does not notice an impact at school. The teachers will certainly tell you that they don’t understand him all the time but that when he repeats slower, they can get the gist of what he is saying.  I will fully admit in the report that he continues to have an articulation disorder and that it does have a mild impact on his ability to be understood by teachers. I will note that his progress has tapered off and he is not benefiting from the service at this point. I am sure that they will be disappointed but they will not be surprised and they will understand.  

Dismissals are hard especially when you see the progress toward goals begin to slow down or stop completely.  It’s hard when you see the student shrink down in her chair when she sees your face at the door. It’s hard when you are facing down an assertive parent who wants as many services as possible for their child for as long as possible. It’s hard when there is no definitive sign that the student is done with speech. So, take a breath and if you can collect all of the above data, you will start to see it lean either toward a dismissal or continuation.  Then look the parent in the eye with confidence in your voice and break up with them. It will be OK.

Unearthing a Relic

 

While cleaning out my basement, I uncovered this treasure.  It's my Peabody Articulation Decks.  If you remember these, you are probably in your fifties or older.  

I own this kit for one reason and one reason only, I was required to buy it.  During one of my clinical classes, we were required to buy this kit which was pretty expensive for its time.  I think it was over $100. Alternatively, we could make our own.  

Making your own kit in the late eighties and early nineties was no easy feat. There were computers and printers but no internet that was accessible to the average person.  Digital images were in their infancy. Making 10 decks of articulation cards would involve looking through magazines and newspapers or whatever other printed materials you could find and searching frantically for pictures of objects that had the appropriate sounds in them.  That meant finding 10 pictures of items with /g/ at the beginning of the word, 10 with /g/ in the middle of the word, and 10 with /g/ at the end. Then you had to cut out the pictures and glue them onto index cards. Then simply repeat for each of the sounds in the English language.  Oh, and keep up with your reading, studying, clinic patients, and projects.  Like most people in the class, I bit the bullet and bought the kit.  And, when I say I, I really mean that I begged my mother for the money.  

Those of us who took the "easy" way out and bought the kit were harshly chastised by our graduate assistant who had made her own kit when she was an undergrad.  "I cut my butt off for months," she said not really selling us on why it was better to make your own kit.  

Once I started working, I did actually use the kit and I can assure you that it was a relic even back then.  One thing we did have in the 90s was CDs but the /r/ card deck had "record player" as one of the target words.  "Roller skate" was also a target word and depicted a skate from the 70s in the age of rollerblades.  All of the people pictured in the deck looked and dressed as if they were straight out of the 1950s.  To its credit, at least the people pictured on the cards weren't all white.  They did have some people of color represented.

In addition to the dated appearance, even back then, many of the target words were terrible.  Let's revisit "record player".  If you are working on /r/ you've got an initial /r/, a medial vowel controlled /r/, and a final /r/ all in the same word.  There's an /l/ blend thrown in for good measure. Definitely not a target that you would work on very often due to the many challenges it presents.  

Despite its negatives, I used this Peabody kit quite a bit. It was handy when the copy machine went down and I couldn't run off my targets for my next session.  It was there when therapy times got switched around and I had to see a student unexpectedly.  But, over time, it got used less and less as I learned more about how to coax speech sounds from children with the most challenging articulation problems.  

And so, today I bid farewell to the Peabody Articulation Decks.  I will never again see that neon green box beckoning me from the shelf in my office.  I will never again have to try and carefully seat the decks into the box so that the lid will close, not a task for the impatient. In fact, I will never again close the box because the latch tore off about 2 years ago.  Goodbye old friend.

Share the Load but Don't Lose Control

 Several years ago my friend "Jen", a relatively new teacher, told me a story about an experience in her previous school district. during her first year of teaching.  She was teaching in a classroom for students with Autism Spectrum Disorder.  There were 2 ASD classrooms right next door to each other so she and the teacher in the other classroom decided to share their teaching responsibilities.  Jen taught math and worked on the math goals with students from both classrooms and the other teacher did the same for reading.  It seemed like a great idea at the time.  

It seemed like a great idea until the other teacher left her position just before the holidays.  It was then that Jen realized that the teacher had left no records or data about the students progress on their reading goals. Right around that time, one of Jen's student's parents decided to bring in an advocate during their child's IEP.  As you can imagine, the advocate and the parents were unimpressed by Jen's lack of data regarding their child's reading skills and did not accept the excuse that the other teacher had been the one who was supposed to collect that data.  Jen was the teacher of record. Ultimately, it was her responsibility to ensure that she had access to that data.  She filed that experience away as a lesson learned and was much more cautious when it came to teaming with other teachers.

I was reminded of this story more recently when I came upon an even more troubling situation.  An SLP and teacher contacted me with concerns regarding the methods being used to assist a student with accessing his AAC system as well as completing writing tasks.  The student was new to her and had transitioned to the building with his one-to-one aide a few months prior.  Their concern was that all communication and writing assignments were being accomplished with "wrist support", meaning that the student placed his hand on top of the aides hand while using his communication app or writing using the keyboard on his AAC system. In other words, she was using Facilitated Communication, a communication technique that is not supported by research and has found to carry many risks of misuse.  The aide staunchly defended her use of this technique saying that he had used it with great success all through elementary school and no one had ever complained about it.  In fact, she argued that, without the use of this technique, he refused to write anything at all. The attempts of other staff members to use this technique of wrist support resulted in the student writing a string of letters, a far cry from the grammatically correct and perfectly spelled sentences he wrote with the aide.  Her excuse was that he didn't know the rest of the staff well enough and wasn't comfortable.

Similar to the situation Jen found herself in, this aide requested a transfer and moved to another building.  So now a student who previously "wrote" long beautiful sentences and stories is now writing strings of letters.  He is frustrated with the staff who aren't able to make his former communication technique work because, and I am speculating here, they refuse to write the words for him.  So here we are with an 11-year-old, with limited and completely unintelligible speech, with no form of communication.  We have his parents who were under the impression that he was doing well academically who will now realize that his skills were not at the level they thought they were.  We are tasked with completely starting over from scratch.

Much like Jen put her trust in her teaching partner, The staff in this student's elementary school put their trust in a teacher's aide and then never checked in or questioned what she was doing.  The teacher never spent any time working one to one with this student to verify his skills, she simply trusted the report from the aide and the work that was turned in.  The SLP was never able to get the student to do any kind of work for her so she simply dropped him from direct service and put him on consult.  Then, she never checked in or realized that the aide was using a communication method that went against the code of ethics that she agreed to when she renewed her ASHA membership at the beginning of the year. 

Most of all I blame myself.  As a new consultant, I visited this student twice per the request of the classroom.  I was there specifically to assist in getting a mount for the student's wheelchair so that he could use his communication system from the chair.  I took pictures of the device and chair and place the order.  I even went back with our tech specialist to observe while he attached the mount. During that time I never checked in on the communication of the student.  I accepted the aide's report that everything was fine without asking her to elaborate on what "fine" actually meant.  Like all of the other professionals involved in the scenario, I not only accepted that things were fine but I was relieved that, given my busy schedule, I didn't need to do anything further for this student.  

The moral of this story is that, when you are responsible for a student's learning, you need to ensure that the student is in fact learning.  It's fine to team teach with others.  It's fine to have a teacher's aide assist the student in the classroom.  but, a the end of the day, the responsibility for the student's learning is yours and yours alone.  Make sure that you know your student's present level of functioning in all areas, even those you don't teach.  Make sure that you are in control of what techniques and accommodations are being used with your student and make sure that they are research-based.  It is tempting, given the many demands of a special educator, to offload responsibility when you can but resist the urge to completely check out.  Resist the urge to accept that things are "fine" without actually checking to see if they are.

So as I face a terrified teacher, a frustrated SLP, and heartbroken parents, I swear to myself that never again will I accept "doing fine" as an answer.  I will ensure that the students under my care, however indirect, are receiving quality communication services based on solid research and I hope you do the same.  Your students and their families are depending on you.

The Dreaded Dead Man's Goal

There I was,  sitting in a very long IEP for Lily a student with multiple impairments including but not limited to quadriplegia, vision impairment, seizure disorder, as well as numerous other medical conditions. When we came to the goals and objectives section,  the teacher read off her carefully crafted goal, " By the designated date, Lily will respond questions using alternate means (pictures, symbols, etc) given maximum verbal, visual, and physical prompts 30% of the time as measured by documented observation."  As I listened to the reading of this goal, something that I had been wrestling with for a while finally clicked into place.  I realized that this goal, which had seemed so reasonable and typical in the past now seemed like complete bullsh-t. 

So, what's wrong with this goal?  Lily has a complex body.  She has difficulty with movement and she doesn't speak so isn't this goal perfectly reasonable?  The answer is no, it's not.  When I listened to the teacher reading this goal, I was transported back to a training on IEP goal writing that I had attended sometime before.  I remember being warned to avoid writing "dead man's goals"  meaning goals that a dead man could still achieve.  At the time I thought it was ridiculous, who would actually write a goal like this?  Who would be that stupid?  And now, sitting here, I realized that not only was the teacher sitting next to me that stupid, but I had been as well.

What I realized as I heard this goal read aloud was that, when you add physical prompting as an acceptable prompt to use in achievement of a goal, you have just written a dead man's goal.  You see, Lily doesn't actually have to be conscious or even breathing and she could still achieve this goal.  The teacher could ask Lily a question, place the symbol system in front of her and then take her hand (or other body part) and physically prompt her to select a symbol to answer the question.  Lily doesn't have to do a thing and even if she, God forbid, expired during the lesson, we can all rest easy that she could continue to meet her IEP goals posthumously.  

There is a LOT wrong with this entire scenario.  Think about it. This is a goal to, presumably, further Lily's communication and use of symbols but it is padded with so much prompting that she doesn't actually have to DO anything.  This goal can be achieved if someone moves her hand for her and, they only have to do it 30% of the time.  I mean, if it's OK to move her body for her, why is the measurement so low?  Is the teacher so busy that there is only time to physically prompt 30% of the time?  Are we measuring Lily's performance or the teacher's?  

And don't get me started on figuring out what 30% of the time means because I have no clue.  When it comes to communication, percentages are problematic.  By 30% of the time, we really mean 30% of the times WE wanted her to respond.  It measures her compliance with our request that she select from the choices that WE put in front of her.  And, last time I checked, communication was NOT a compliance task that could be measured in percentages.  Communication is an exchange of information between partners and when you are a person with a complex body, sometimes the only power you have is to NOT respond.

So, why do these goals get written in the first place? Why do administrators and compliance consultants allow these goals to continue to be written? These types of goals hint at a dirty little secret...we don't believe in ourselves as teachers.  Students like Lily are challenging.  With her limited movement, it's hard to find things that she actually CAN do.  And then she's absent for months with her medical issues so its difficult to write a goal that she can actually achieve.  And truthfully, students like her scare us.  As teachers, we develop a set carefully honed tools that work for most students.  The Lily's of the world remind us that we don't know everything.  They challenge us to reevaluate our methods and dig deep to look for strategies for those students who are the outliers in a group of outliers.  Some of us choose to rise to that challenge while others are consumed by the fear that we might fail.  So instead of rolling up our sleeves and trying something, anything to teach the student, we simply blame the student for our own failings.  We say things like, "well, she's too low to..."  or "she's to medically fragile to be expected to.." 

When we take this approach, we rarely get any pushback from our administrators.  They are afraid too.  They are just glad it's not them on the hook for teaching this student.  We, more times than not, don't even get pushback from the parents.  They have bigger fish to fry as it can be a full time job just keeping the Lily's of the world breathing let alone ensuring that they are properly educated.  And they've had years of professionals telling them what their children can't do.  Many of them have had to lock away the pain of those statements just so that they can continue with the business of loving and caring for their child.  

So what do we do instead?  Well, every child is different but I can tell you what I did.  First, I looked at Lily with a fresh set of eyes.  Instead of looking and all of the things she couldn't do, I focused on the things that she could do.  While she had limited independent movement of her limbs, she could control the movement of her head.  I also learned from her family that she had definite likes and dislikes.  She loved hearing the voices of her family members and familiar caregivers.  She loved swing and rock.  She disliked cold sensations.  Using these few motivating activities, we were able to start building her ability to use a single switch placed near her head.  She was quickly able to learn to activate the switch to hear her sister recite poems and stories that we recorded on a simple communication device.  She was able to use her switch to request a push on the school's wheelchair swing when it stopped swinging.  From there, she was able to begin to use her simple communication device to call for attention during down time in the classroom.  The reward of getting someone to come over and pay attention to her or simply call out to her increased this behavior. She was eventually able to start to use partner assisted scanning to access more vocabulary.  

Instead of writing goals that Lily was already able to achieve or writing goals with low expectations, We were able to collect data and write meaningful goals that would move her forward.  Before her next IEP we measured how many times she used her device to make a comment during a classroom activity.  It was about 2 times on average.  We wrote a goal that given the use of a symbol based communication book and partner assisted scanning, she would independently make a comment 6 times during a classroom activity.  In order to achieve this goal, we modeled commenting using her system so that she would understand what to do.  We tried to incorporate sensory experiences and activities that were motivating for her into our lessons.  Did she meet her goal? No, she didn't.  She only averaged 5 comments per session by the end of the year but, despite not achieving her goal, she improved.  She was starting to use symbolic communication. She went from working on a goal where she didn't have to do anything to one where she did.  And, did anything bad happen as a result of us having slightly missed the mark on goal achievement? No!  Nothing bad happened.  We just reviewed our data, adjusted our goals for the following year and moved forward.

Not only did we feel good about Lily's progress, we stopped having that weird sinking feeling in the pit of our stomachs knowing that we had just written a bullsh-t goal.  There was another difference as well, Lily's mom started to listen to our progress report with interest rather than checking out like she normally did.  We were now writing goals that made sense, that she knew that Lily was likely to achieve.  She could see a slow and steady path ahead.  There was hope.

Things I don't need from consultants and specialists

Despite budget cuts and funding reductions that have reduced services to our special education students, there still seems to be an army of consultants out there to "help" us.  I put help in quotes because the "help" isn't always helpful.  If you are a consultant, there are many things I need from you but just as many things that I don't.  Here are a few:

1. Judgment: Having someone come in and observe what you do is nerve-wracking as hell.  We suddenly begin to second guess what we are doing, we get nervous, we get flustered.  Then, after the observation is over, we are read the riot act.  How come you don't have a _____?  Why are you doing ______ that way?  How do you expect the student to _____ if you don't _____?  So, instead of a constructive assessment of our situation, we are getting the Spanish Inquisition.  Instead of feeling supported, we feel attacked.  And when we feel attacked, we get defensive. When we get defensive, we stop listening to you.  Now, the student isn't getting helped because why should we listen to that asshole consultant?

2. Links to websites:  I worked with one consultant who barraged me via email with links to "cool resources."  And, while I am sure that they were cool resources, I never clicked on one of them.  I have a weeks worth of therapy sessions to plan, IEPs and evaluations to complete, meetings to attend, and if that wasn't enough, I have to continuously document my activities to prove that I am highly effective at my job.  I really don't have time to spend exploring websites.  If you have a helpful resource that you found online, better to present it to me and my colleagues in person.  You could also send specific links to specific people based on their needs and tell them how you think the site would be useful to them.  Say, "this site has some great comprehension activity ideas that you might use with that student we were discussing the other day."   Information is coming at us from all sides, please filter the information before disseminating it.

3. Lists of suggestions from Google:  This one really pisses me off.  I can't stand it when I ask a consultant for help and they hand me a list of generic and vague recommendations from the internet which I could have looked up myself.  I got one of these lists from an Occupational Therapist from a community agency that had been brought in to consult on a student in my building.  Her report consisted of a list of 50 recommendations that were clearly inappropriate for the age and behavioral profile of the student.  One of these recommendations was to sit behind the student on the floor, put my arms around him and rock him back and forth.  The student was 24, a grown man, with a tendency toward aggression.  This suggestion was not only wildly inappropriate given his age but also potentially dangerous.  I was initially confused about the recommendations but, when I went on the internet and searched sensory strategies for Autism, there was the list verbatim.  As she was cutting and pasting, this so-called consultant neglected to notice that these were strategies for a child, not a grown ass man.  If you want to give me a list, at least pare it down to just those strategies that you feel are appropriate to the specific student or students in question.  And, please, make sure it comes from a reputable site.

4. Talk with no action: Similar to the long printed list of resources, I equally hate an onslaught of suggestions given verbally.  I am calling you in because I am struggling. Instead of TELLING me what to do, why don't you SHOW me?  The best consultants that I have ever worked with were willing to roll up their sleeves and pitch in.  My favorite Assistive Technology consultant would sit with me and the student and actually demonstrate the strategy that she had suggested. I learned more from a 5-minute demonstration from her than I did from all the verbal suggestions I have ever gotten. And, if you want to shut down all those naysayers who tell you that your suggestions won't work or that they have already tried everything, SHOW them that the strategy works.  Alternatively, by actually demonstrating the strategy, you might find that it doesn't work for that student and have a better idea of what the professionals that you are trying to help are going through.

5. Expecting multiple changes to be implemented immediately.  So, I've had you observe me and we've talked about what needs to change and you've shown me some strategies, but there is no way that I am going to be able to do all of those things at once.  Please help me decide what to start with and give me time to consistently implement that one thing before adding the others.  Change takes time.

6. Being a know-it-all.  There is an old saying, "nobody likes a know-it-all" and it's absolutely true.  Nobody does.  You are there to help by sharing your expertise and experience to assist those with whom you are consulting to make positive changes to BENEFIT THE STUDENT.  You are NOT there to boost your own ego.  Now, I will be the first one to admit that it can be quite satisfying to be the smartest person in the room and feel superior but, it doesn't help anyone.  If you want to actually help, be human and understand that those that you are working with are human too.

Sadly, I can say that in my many years of working as a speech-pathologist I can only name 2 consultants that were of any use to me.  In 22 years, only 2!!! That's sad.  When I think of all the precious dollars being spent on salaries for these people, it would be nice if competence were the rule rather than the exception.  And, I am well aware that consultants are providing services to multiple districts and hundreds of students.  but if all you are doing is running around passing judgment and handing out lists of useless suggestions then you might as well not be servicing any students at all.  And you will never gain the respect of those whom you serve.

Communication Based Activities for Young Adults

Recently speech-language pathologist Staci Brown asked me about best resources for communication activities for young adults with disabilities. I wish I could have answered back with a huge resource list but honestly, it's not that simple.  While there are tons of activity books and websites devoted to preschool and elementary aged students with communication challenges, there isn't much out there for our older students.  And, if we are talking about adults with multiple or severe impairments, there is next to nothing. It has only been in recent years that we have decided to raise our expectations of this population so the resources have yet to catch up. It was for this reason that I ended up making a lot of my own activities.  So where do I go for inspiration?  Here are a few places (I don't receive $$ or kickbacks from any of these resources):

1. Project Core: Project Core is a website devoted to improving communication and literacy outcomes for students with complex communication needs. It is a treasure trove of resources and information.  I specifically like the professional development modules for shared reading, predictable chart writing, and independent reading and writing.  These modules provide a framework for activities that can be used weekly to teach literacy and communication to students with complex communication needs.  You can vary the topics while providing literacy instruction in a predictable structure.  But shouldn't I be just teaching life and functional skills???  Well, yes, our students do need life skills but last time I checked, literacy and communication were both life skills.  Also, research by Jonna Bobzien (2014) has shown that students with severe disabilities showed increased signs of happiness and happiness behaviors when engaged in academic learning. Functional skills are pretty boring.

2. Tarheel Reader and Tarheel Shared Reader: Tarheel Reader is a site full of free, easy to read, accessible books with real pictures so they are more age appropriate for older students.  The books are user created so the quality varies but you can write your own books on the site or modify books already on the site to meet your needs.  You can find books on a variety of topics that might be of interest to your students.  The site can also read the books aloud (in a very weird computer voice), you can project them onto an interactive whiteboard (if you are lucky enough to have one of those), they are switch adaptable, and you can download and print them out.  At some point, we need to stop using picture books meant for 5 year olds and this is a great place to find more mature looking books. You do not need to create an account to use the site but, in order write your own books on the site, you must request a code by sending an email to tarheelreader@cs.unc.edu . Once you have the code, you can create a user name and password and start creating books.

Tarheel Shared Reader is a newer resource to go along with the shared reading procedure on the Project Core website.  Tarheel Shared Reader is a resource for books with core vocabulary based comments already done for you that you can use during shared reading lessons.  How easy is that?

In order to use Tarheel Shared Reader, first log in to Tarheelreader.org then enter https://shared.tarheelreader.org/ into your browser.  You will get a page that says select a student or group.  You can add individual students or a classroom group using the plus sign.  Once you select a student or group, you can start searching for books.  Make sure you go through the training modules first so that you get the most out of this resource.

3. Draw Inspiration from your core vocabulary.  If you aren't already using and modeling a core vocabulary in your classroom, you need to print one out and get going.  The Project Core website has core in several formats that can be downloaded for free.  In addition, most of the websites for the communication apps such as AssistiveWare and Tobii Dynavox (to name a few) have free core vocabularies that you can download.  Don't waste your money buying a core as there are so many free options. And while modeling core vocabulary throughout the day is a great place to start, you will also have to directly teach each of these words in context.

Research is now saying to teach one core word per day, but if you are just starting out, at least shoot for one word per week.  Select a word and plan activities around that word as well as looking for opportunities to use the word throughout the day.  If you need ideas, try the AssistiveWare Core Word of the Week planners.  These planning guides have activity ideas and book suggestions appropriate for various ages.  Many are either appropriate or can be adapted for young adults.  There are usually links to several Tarheel Reader books that you can use as a jumping off point for your lesson.  You can easily target a word such as "put" while doing a cooking activity where you need to "put" things into the bowl to make your recipe.  In addition, AAC Language Lab is a membership site with core vocabulary based activities for a variety of ages. The membership is $19.95 a year which isn't too bad but there a several free activities on the site like this recipe for infused water to spark your creativity

4. News 2 You: News 2 You is an accessible online weekly newspaper allowing students at a variety of levels to learn about current events.  The news articles are adapted with symbols and are available in 4 levels to meet various cognitive and literacy needs.  They also come with extension activities.  Current events are definitely age appropriate for young adults.  The only drawback, it's not cheap. A one year membership is around $200.00. 

5. What are people their age doing?: It doesn't hurt to ask neuro-typical young adults what they are into if you truly want to be age-appropriate.  My teen boys like to watch other people play video games on YouTube and search for memes.  Most of my 20-something coworkers use some form of social media like Snapchat or Instagram.  Others binge-watch TV shows.  Many adults are into cosplay. Almost all of them are into music.  Some random ideas are:

a. Explore current trending popular music on Youtube: make comments (like, not, more, who). Move your students along from the babyish music that they may prefer.
b. Watch a show such as Born This Way, Dancing With the Stars, The Voice, game shows, etc.: model comments and have students make comments, predictions, etc. (thanks to Lapeer County ISD Center and Wing Lake Developmental Center for this idea)
c. Take pictures of students with different Snapchat lenses and make comments on those.
d. Develop a class Instagram or other social media account to share class happenings.  Have students use AAC to comment on activities or events.  Faces can be obscured with stickers if needed.
e. Choose a meme of the day/week and use AAC to comment.

6. Grown-up crafts:  Obviously fine motor limitations might restrict the types of crafts your students can handle but try to get away from crafts that you would do with younger students.  How about having your students make the posters for school events, design and decorate bulletin boards around the building, or make holiday or birthday cards for students and staff.  The students can use AAC to select what will go on the craft, where items will be placed, how many items, etc.  Creating modern art in the style of Jackson Pollock and other artists might also be fun.

What NOT to do:

1. Kids books, for the most part: I know our students love them but we probably need to move away from using children's books as much as possible.  Seriously, how many years are we going to do The Hungry Caterpillar?  You can probably still get away with doing some traditional folktales or campfire stories but start to phase out the old preschool favorites.  If you are really struggling to break the habit, start a children's theater group.  Have your older students each choose a character from a fave children's book and use AAC to recite their lines.  Then perform for a younger group of children.

2. Watching preschool TV shows: It's time to ban Barney.  I know some of our students continue to have a love affair with that big purple dinosaur but seriously, watch something else.  Many suggestions are listed above.

3. Preschool music:  Noticing a theme?  There is plenty of great music out there.  Try the music from popular musicals and movies instead.   My friend and teacher Jessica Lovelace plays the music from The Greatest Showman all the time.  It's upbeat and fun like preschool music but it is appropriate for all ages.

4. Relating every activity to a holiday: Our students in the state of Michigan may be going to school until they are 26 years old.  If they attend a day program starting in preschool, that's 23 shamrock projects by the time they exit school.  It makes me bored just thinking about it. It is certainly appropriate to acknowledge an upcoming holiday but I would limit activities to shortly before the holiday.  Don't spend the entire month doing lessons around one particular holdiay.  There is so much more in the world to learn about.

5. Safety signs: I am going to refrain from going on an all-out rant on this one but I soooo want to.  Every post-high school program for students with disabilities has a safety signs curriculum stashed in a cabinet somewhere.  And students spend an inordinate amount of time doing worksheets or bingo to ensure that they can match signs such as "exit" or "caution".  Before you waste precious time torturing your students with this boring and useless activity, ask yourself if they really need to know how to identify a railroad crossing sign.  Better to spend your time working on literacy skills.

Do you have ideas for young adults that you love?  Let me hear from you!   I'd love to feature you in an upcoming blog post.

Core Word of the Day - All

Having an augmentative alternative communication system with a core vocabulary is considered best practice today.  A core vocabulary is a group of words that are most commonly used in English.  The words can be combined to form novel phrases and express a variety of communication functions.  But, students will not learn these words without some direct instruction. For a while, we thought teaching one word a week was good enough but now several experts have recommended teaching one of these words each day.  That way, you can teach and reteach your entire core vocabulary multiple times per year rather than just once per year.  Makes sense right? After all, our students need LOTS of repetition.

So here's an activity to teach the core word all.  All is one of those core words that I avoided because it seemed really hard to teach in a concrete way.  Finally, I challenged myself to come up with an activity to teach this word.  And because I am a glutton for punishment, I selected a craft.  Crafts are a pain because they require a LOT of prep.  I tried to keep the cutting to a minimum to save time but it was still a fair amount of work to get ready.  You can use this activity to teach the word some also. It makes sense to teach these words together.

All or Some Gumballs

Materials:

Colored construction paper, dark for background
Colored construction paper, light for gumball machine
White yarn or white crayon
small multicolored pom poms
glue
black marker

Prep:

1. Cut light colored construction paper in to rectangles.  Draw on the gumball chute and and coin slot on the rectangle with  a black marker.
2. If students have significant fine or gross motor disabilities, you might want to glue the gumball machine onto the paper and draw the circular globe where the gumballs will go.  For visually impaired students, use yarn to define the globe.

Activity (model the words in red on your core vocabulary board or student AAC system):

1. Introduce all and some using items in the classroom.  Ex: some of the markers, all of the markers, some of the blocks, all of the blocks, some of the home folders, all of the home folders.  Model some and all on your core board or student communication systems as you do this.

2. Show a picture of a gumball machine or an actual toy gumball machine (available at most dollar stores).  Say, "look at all those gumballs."  Provide additional description for those with visual impairments such as "they are round, colorful, etc. Encourage students to use their communication systems to make comments.

3. Introduce the craft: You are going to make a gumball machine.

4. Students make a choice: Put 6 pom poms in a small container with the symbol for all attached and 2 pom poms in another container with the symbol for some attached. Ask: Do you want some gumballs or all the gumballs?  The student should use their communication system to indicate a choice on their system or using the visuals attached to the containers.

5. Assemble the craft: Model the directions for assembly using core words "put on the gumball", "help", "more", "put here", "not here", "all finished" or any other appropriate words from your core vocabulary.  Encourage the student to make comments or give directions using their communication system and attribute meaning to whatever messages they choose.

6. Have students show their work:  Once completed, have students show their work to their classmates or other favorite people in the building.  Core words can be modeled such as look, some, all, and make.  Phrases such as "I make", "look I make", etc. can also be modeled. Encourage students to use their communication system to comment on the art work and attribute meaning to whatever message they choose.

You could do a similar activity (maybe fish in a fish bowl) when the word some comes up as core word of the day.

Maybe I Really Do Have Something to Say: My first presentation at a conference

About a week ago,I found myself standing on a stage in an auditorium at a conference on AAC, augmentative/alternative communication. There I was, microphone in hand, in front of over 100 people and all I could think was, what am I doing here?  What on earth can I share with these bright professionals that they haven’t already heard before?  What do I know anyway? Is it too late to fake an illness and run from the building?

So, what lead up to my moment on that stage?  In November of last year I attended #TalkingAAC for the first time.  The conference was mentioned by an AAC consultant from the state who had come to help us with some training.  Two of my colleagues had signed up to go and I thought, why not? And so I went and it was great.  The conference reaffirmed knowledge that I already had and challenged me to implement strategies that I hadn’t gotten to yet.  It was a really positive experience and I was eager to attend again next year if I could convince my administrator to agree to send me a second time.  The key word there was ATTEND, presenting at the conference never crossed my mind.

Well, it never crossed my mind until one of my colleagues said she was thinking about submitting a proposal for the conference the following year.  Really??? I said surprised.  While she was an experienced teacher and presenter, she was very new to AAC.  What could she possibly have to share?  Or was it just that I, an experienced AAC implementer, couldn’t think of a damn thing that I knew enough about to share at a large conference like #TalkingAAC.  Upon further conversation with my colleague, I discovered that she thought about doing a presentation on the early stages of implementation of a communication system, the barriers, the successes, etc.  It wasn’t necessary to be a seasoned veteran, a session like that could inspire and encourage others to get started.  It’s nice to hear from people who have just taken their first steps when you are thinking about taking yours. It’s comforting to hear that things didn’t always go as planned.  It’s helpful to hear how problems were solved and the plan moved forward.  It’s nice to hear from a presenter who doesn’t have all the answers.

And so the idea sat there in the back of my mind for a while, nagging at me.  And then in March something major happened, an AAC consultant position opened up at my county ISD.  Over the next 3 months I went through rounds of interviews culminating in a 30 minute presentation in front of some highly respected AAC professionals who were experienced and polished presenters to boot.  

It was during this process that I became aware of how many SLPs and teachers from my county were already well known AAC presenters at numerous conferences.  I was not.  I started to realize that despite my experience on the job, I lacked the exposure and name recognition in the AAC world that many of my peers enjoyed.  I lacked street cred.  I began to face the real possibility that I was going to lose out on this job to someone who was not only great on the job but great in the conference room. But instead of just throwing in the towel and accepting defeat, I decided to start positioning myself for the next time the job came open. So armed with a computer and a glass of merlot, I quickly typed up a proposal for #TalkingAAC and hit send before I could chicken out.  

And so was born my presentation entitled “If I Have to Play Bingo One More Time I’m Gonna Lose My Mind.”  The idea was inspired by the presentation I had hoped to find at the conference the previous year, but didn’t.  I had hoped that someone would present new ideas for lessons and activities that I could take back to my classrooms.  And, even though I was hoping for new ideas for myself, I thought that maybe presenting my ideas would trick my audience into sharing theirs. 

I didn’t think my proposal had a prayer of getting accepted.  Why?  First, I was an unknown, an SLP who had never presented anything outside of my own district. I was a very small fish in a very big pond.  Second, the title wasn’t serious.  After watching all of the slick, polished, serious presentations of the previous year, I wasn’t sure that the board would go for something with such a silly title. Third, #TalkingAAC seemed to be about big ideas and my presentation was about the small ideas of the day to day work of those on the front lines of AAC implementation. I was wrong on all counts.

A few months later, I found out I got the AAC Consultant job.  An extremely well timed retirement had made space for 2 consultants instead of one.  Shortly thereafter I found out my proposal for #TalkingAAC was accepted.  So I was left to wrap up my old job of 16 years, start up my new dream job, and whip my presentation into shape. Oh and add helping my son apply to college into the mix. No pressure there. 

By some miracle, I was able to pull the whole thing together.  I read reams of research, edited, rewrote, and edited again.  I rehearsed over and over in my bedroom while fending off requests from my family as to the location of wallets, keys, and phones. I assembled props, videos and tech.  I tested and retested everything to make sure it all worked. I even managed to upload my handouts at the 11th hour.  

Finally, after pacing around and going over my slides for what seemed like the 1,000th time, I stepped out on that stage.  Did everything go perfectly? Nope! Did I set the world on fire with my brilliant ideas? No, not really.  What I did do was share my ideas. Some people learned new ideas that they hadn’t heard before, some were reminded of things they hadn’t done in a while, some just got validation that they were on the right track, and some just had a good laugh at the end of a long day.  Others probably just thought the whole thing was stupid. It doesn’t really matter either way.  What I learned was that I actually did have something to say and I hope others will realize that they do too.  

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.