Stepping up to the challenge of Challenging behaviors and surviving to live another day

I would say at least 50% or more of my caseload has exhibited challenging behaviors for the last 16 years that I've been practicing.  Hitting, throwing, spitting, biting, work refusals, crying, refusing to leave etc.  Today I'm going to talk mostly about individual sessions.  At school settings when I have one student who is more difficult, I use different strategies.  When I can, I try to set up individual sessions with them to start and then work them back up to a group.  

When I have a child that is not complying in therapy, I ALWAYS start by looking at their activities.  Is the activity the just right challenge for the child?  Have I used motivating materials to engage them?  Have I explained what the expectations in a way that they understand?  Have I established rapport with them?  I find that taking the time to gain their trust makes a huge difference in how I can manage their behaviors.  I've talked before about therapists who say "THEY need to change-or not everything is fun or THEY need to learn how to do this work because they are in 4th grade."  I don't disagree that they need to learn how to follow the rules to be successful in society.  But I don't know that I've ever seen a case where the therapist has just put their foot down-and the kid has started complying and learning.  Here are a few tips:

We statements:  I encourage my clients to think of us as a "group."  We can work on this today.  We are friends.  Friends like to say nice things to each other.

Use humor:  For some children, I can diffuse a situation much more quickly by using humor than insisting that they make restitution (example, stopping therapy until a child to pick up the materials after they have thrown them.)  Once they are calm, we go back to clean up.  But if they are agitated, it's not a good time to try to get them to comply with anything.  (and it's wasting valuable therapy time.)

Use "You can" vs. "Will you" statements.  I learned this technique in Toomey's SOS feeding course.  It's really hard to remember.  But it's helpful not to ask something that's not a choice.

Offer choices whenever possible.

Utilize schedules and duration maps to give information about what they need to do and how long they need to do it.  (Check back later this week for some more information on schedules and maps!)

Offer empathy.  Instead of setting behavioral expectations when a child is getting aggressive, try giving them the words to express how they feel.  "You feel mad.  Your face is red and your fists are clenched.  You really wanted to win that game.  It is no fun to lose games."  Once the student is calm-probably on a different day, revisit the situation using social role plays or social autopsies.

Be Proactive.  Focus your energy on stopping the behaviors before they start vs. giving consequences to the behaviors.  Have you ever had an eye opening moment in therapy?  I posted this story last year but wanted to share it again because I found it to be so helpful to me.

About a week before my wedding, he bolted out the front door of the clinic in to a busy parking lot.  I ran after him SO worried that he would be injured or hit by a car.  He ended up falling on the sidewalk.  My adrenaline was so high that I couldn't stop.  I JUMPED over him, lost my balance and face planted on the asphalt.  I scraped my face up and one side of my body.  I made that horrible noise when all of the air leaves your body at once.  It was so loud that the front desk staff came running out.  It probably sounded like I had gotten hit by a car.  A woman in a walker was leaving from a physical therapy appointment and said, "Oh my goodness, are you okay?"  My little runner was getting up at this time.  "GET HIM!" I croaked out, lying on the ground.  When you start asking people in walkers to corral your clients, you know you need to start thinking about some new techniques.  The story ended "happily." I was able to get my client, most of the scrapes and bruises had disappeared before my wedding.  And my coworkers were not that upset by my hysterical crying that day.  

I understood the functions of behaviors-or I thought I did.  I made up plans, had consistent consequences, avoided (with the exception of my running leap) excessive attention to the behavior.  I spoke with the family, consulted with occupational therapy and suggested a behavior therapist. There was a 6-12 month wait to see a behavior therapist.  I watched Super nanny episodes.  I made sure that consequences were clear at the beginning of the session so there were no surprises.  I had sticker charts and schedules at the ready.  The behavior didn't change.

Every time we would walk back to a therapy room, he would run to the kitchen to get a snack.  I'd say, "No." and we'd end up in a time out.  I'd have to carry him back to the room kicking, screaming, and pinching.  We didn't get much speech therapy done.

Then one day, as we were walking down the hallway, I stopped right before he usually ran away.  I looked at him and said, "Tell me I want snack."  He did.  We went to the kitchen, got a snack and then went to the therapy room and had a fantastic session.

For him, I needed to provide an alternative COMMUNICATION behavior prior to his maladaptive behavior.  The consequences weren't working for me because it wasn't helping him to get his needs
met.

Here are a couple of things I learned that day:
1.  Preventing a behavior rather than providing consequences works really well when you only have 30-60 minutes to work with a child.
2.  Constantly repeating strategies that aren't working is a useless exercises.  The strategies need to change.
3.  As the adult, I'm the one that has to change my behavior in order for the child to adjust theirs.

 

4.  I'd still refer to a behavior therapist any time I can.  They are the experts in this

Love It AND list It {Linky party}

Thank you to Jenna from The Speech Room News for hosting another awesome Love It and List It.  This month's topic is behavior management.  What a great topic-especially when students get so squirrely at the end of the year.  I always start by making sure that my activities are fun and motivating.   Because I work with many individuals with multiple impariments, I use a lot of visuals to give information during out sessions.


Here are some of my favorite resources for visuals to work on behavior management:

1.  5 Point Scale: by Kari Dunn Buron and Mitzi Curtis:  I have made up blank templates of these in each of my therapy rooms-so versatile-you can use this for almost anything.  I use this a lot to work with kids on voice volume.

2. The New Social Story Book by Carol Gray.  Do you ever get tired of people asking you to write social stories?  This book has a great introduction which explains how to write social stories.  When I am in the clinic-we talk about the steps and I train the parents on how to write their own Social Stories.  They can personalize and hopefully feel comfortable enough that they can make them up on the fly as needed.

3.  Sandbox Learning:  Customized social stories online.  This is great for busy therapists or busy families.  There is a lot of flexibility with these stories.  You can customize the characters to look like the student with whom you are working.  You can add personal information to tailor the story to them.  Each story costs around 9.00 but you have unlimited access to the story for one year.  So if you have 10 kids who need to work on waiting, it ends up being fairly cost effective.  They offer a free sample story on their website.

4.  Time Timer  I love time timers for giving a visual representation of time to my students.  I try to get the ones that hang on the wall and beep because they are easily destroyed.  They also have an app now which is great too.

5.  Lesson Pix  I joined Lesson Pix this year.  It's an online resource which allows you to create your own visuals.  There are a variety of options for visual schedules, first/then boards and token boards.  Plus the website is inexpensive which makes it easier for therapists on a budget to afford.  I do have Boardmaker at work.  Lesson Pix is very similar but with more options for templates and clearer pictures.  It's convenient for me to use at home if I need to make up a visual for a client while I am watching Game of Thrones.

I'm excited to read everyone's ideas!  To join the linky party OR to just see all of the other awesome resources, head over to thespeechroomnews.com OR click on the button below.

Autism: Zeroing in on WHAT to teach.

I've been working with children on the Autism spectrum for the last 16 or so years.   I've noticed more consistently in my state (Minnesota) that these students are not always being serviced by the Speech Language Pathologist.  I've heard some colleagues mention that these students need services from an Autism specialist or that they need ABA services and that speech therapy can do nothing to help them.  Some of this is an issue of caseload sizes-I get it.  It just makes me sad when the answer to caseload sizes is to stop servicing students instead of hiring more speech language pathologists.  That's a complex issue related to funding which would I could probably write about at length-some other day perhaps.  It's probably just because I love working with this population so much that I get concerned.  

Communication is the tool by which we relate as human beings.  I'm a story teller by nature, but if you observe others in conversation-most of it is sharing stories or experiences.  We bond over past experiences (Remember that time when you got locked in a dumpster?  Wasn't that hilarious?)

I want these clients to be able to request but also to be able to stay in a back and forth interaction.  I want them to be able to tell their parents what they did at school and how they felt about it.  I want them to learn how to share a memory with another person.  I want them to be able to tell a joke and giggle with their friends.  I want them to have at least one friend.  I don't always get there but that's my end goal for them.

Here's a secret of mine: I don't really care if these clients learn how to use an embedded clause or communicate using the appropriate verb tense forms.    I want to focus more on pragmatics than on form with them.  Okay, I said it-please don't take away my ASHA card.

Instead I try to work with parents to focus on building up foundational skills such as Joint Attention and turn taking.  This brings me to a produce I purchased from Maria at  Communication Station: Speech Therapy  "Beyond Eye Contact: Connecting with the Young Pre-Verbal Child with ASD."

She has created an extensive, 47 page power point presentation that discusses how you can establish and increase joint attention for children on the autism spectrum through play.   

This is a must read for clinicians who are new to the field who are working with children on the Spectrum.  It is a great refresher for more experienced therapists.  

These types of power points are focused on teaching the person reading the slides (vs. being presentation ready).  Each slide was filled with useful information.  

The presentation is teaches you how to connect with children on the Autism Spectrum using the following steps:  

• Observation of the Child:  Provides specific information for what to look for as well as what objects and toys to use during your observation.  
• Accommodating for Sensory Needs:   This section provides basic information related to what sensory needs you should assess during your observation.  Additional power points are available to provide more detailed information related to sensory processing.  
• Following the Child:  Learn how paying attention and valuing the child's interests can help you connect.
• Using High Emotions: Discusses the importance of exaggerated emotions as well as some activity ideas. 
• Bringing the Child Into Your World.  

She also includes information on eye contact, verbal imitation and strategies to use when the above techniques don't work.  I really appreciated getting the charts on play development and ASD observation checklist that were included at the end of the presentation.  

Here's the best part:  She has offered Speech2U readers a discount coupon through this weekend.  Simply head over to her website: Communication Speech and you can purchase Beyond Eye Contact: Connecting with the Young Pre-Verbal child with ASD for 50% off her usual price of 19.99.  Just enter the code: Speech2u50 at checkout.   This offer is valid through 4/27/14.   

Finding your TPT niche {linky party}

I'm excited to be linking up to Teach Speech 365's "Finding your TPT niche" linky party.   I am a big fan of the origin movies for comic books (sorry-I'm a nerd who married a nerd) and this linky party is an opportunity for us to share our "origin" stories.

I was a TPT and Teacher's Notebook shopper for about 6 months before I opened my own store.  Jenna from Speech Room News had a blog posting about how she made her own therapy materials.  I'm not sure if this is the exact entry I read-but it gives some great information regardless.   Speech Room News custom therapy materials.  Can I just take a minute to talk about how awesome she was to post this tutorial?  First she started by providing awesome free resources for year and then starting selling some of her products.  She didn't have to share how she created them but she did-and I think a lot of the SLP's on TPT saw the same post.   Here's what I thought when I read first her post-"Wow.  That seems pretty cool but I'm not creative enough to come up with my own materials.  But I sure appreciate people who can create their own products."

A lot of my life has been a series of "surprise accidents."  For instance, I only became a Speech Language Pathologist when I misread the code during our aptitude testing.  I HAD wanted to go into speech communications and work in marketing.  But when the college brochures started coming describing Speech Language Pathology programs, I thought that it would be worth checking out.  My brother qualified for speech and language services for most of his schooling and I'd always loved children.  It must have been fate.  Some of the "surprise accidents" I encouraged.  I spent a whole year making dating decisions based on a Magic 8 ball.  (Should I go out on another date?  Signs point to no.) 

Joining TPT was another "surprise accident"-although not really a happy one.  I worked on my first product: Alien's Multiple Meanings when I was in Arizona for my dad's second funeral.

It was about 6 months after he had died-but I couldn't sleep so I decided to try signing up for TPT and making a product.  My first 6 months of products were probably brought on by my insomnia.  This is weird-but it was soothing for me to just sit and create products-focusing on making sure the pictures and words lined up correctly.

I think it took a little longer to find my niche.  One of the things that I love about TPT is that it has made me more creative-and it's opened up doors for me to be a more inventive therapist.  If a client or student isn't making progress, I can come up with a new product to motivate or help teach them in a different way.  Here are a few of my "niche" products.

Interactive Flashcards are products that I made to try to teach skills to children on the Autism Spectrum or other students with developmental disabilities.  I wanted to make things more visual-while giving them an opportunity to physically manipulate the pictures.

WH Question and conversation starters are a fun way to address articulation carryover or to check on generalization of wh-questions using holidays and seasons.

Flip Flap books are a fun way to create a project within a therapy session or to add a little bit of movement to activities.

Finally, I'm really excited about my newest set of products: Nothing Minimal about These Pairs.  I'd been trying to find some good resources for minimal pairs for about a year when I finally realized that I could just try to make something.  I really like the included activities as well as all of the visuals that are included.

I'd love to hear your story too!  You can click on the image below to link up with Teach Speech 365.

Recycled Guest Posts: Teaching communication Alternatives to Challenging Behaviors in Young Children.

Shari was a 5 year old girl who just started therapy.  She wasn't producing any words, had minimal eye contact and cried during most of each session.  She really enjoyed ball slide types of toys but became upset when she wasn't allowed to control the entire interaction.  When the clinician touched the ball she cried, tried to throw the toys across the room or threw herself on the ground. 

Sometimes children like this will be described as "behavioral" or "having behaviors."  Behavior is Communication.  Everything that we do is a behavior.

If we label a child or student as "behavioral," it seems to indicate that the blame lies with them.  There is little for us to do or try, we can only provide consequences to the behaviors.  However, it is very rare that the child is capable or able to change without the adult changing their behavior first.  We adjust our expectations or how we are interacting with the child in order to affect change in them.

The first step is to look at our activity choices and consider our own interactive style.  Sometimes our expectations are too high or we may have chosen toys that are less than motivating.  In the case above, I ended up backing off from toys and really focusing on interactive "people" games such as Ring around the Rosy."  When we went back to object play, she was still having a really hard time with any back and forth turn taking.  It seemed like she had learned to use crying/yelling as her "turn" within our interactions.

In general, behavior can be broken up into four different functions:

• Tangible 
• Attention 
• Escape 
• Sensory

When you are considering trying to replace a behavior with a more socially appropriate communication choice, there are a few things to consider.  We need to make it as easy as possible for them to communicate.  Sign language may not be the best choice as you need to provide hand over hand assistance or the child may have motor delays.  I try to have pictures of the common ones we would teach and then have the child tap it in the earlier stages.  This is a simple motor movement that is easy for the child to complete.  When implementing these programs, it's really important to try to respond as soon as the child touches the picture.  Don't worry, you can work on compliance in a little bit, they only need to get these immediately when they are first learning them.    The Checklist of Communication Functions and Means Assessment is a great way to start looking at different communicative behaviors and how the child is attempting to communicate them.

Tangible:
This refers to behaviors which the child is using in order to try to get an object or do an activity that they want.  We want to teach the child to request the object.  In the example above, the child had learned to request by crying and throwing herself on the floor.  (at a greater frequency than a typical 2 year old.)  We started by breaking the behavior chain.  We started the ball slide activity by just giving her the balls when we played.  Once she understood that she could get the toys, we were able to increase the challenge.  Now, she needed to just touch the toy to get the ball.  Eventually we shaped this into pointing and then holding her hand out to receive the object.  

Attention:  
The function of this behavior is to gain the attention of someone.  Here's what can be tricky-children don't always differentiate between positive vs. negative attention.  When you think the child is trying to gain attention, you can work on teaching them to say things like "Look," "Hey," and calling people (ex. Mom/Dad)   Calling games and hide and seek can be really fun ways to work on gaining attention.  You can hide under a blanket and have the child call out for you.

Escape:  
The function of this behavior is to stop an activity.  I might start by looking at the activities, is it too difficult?  In terms of teaching communication alternatives, we could work on saying "help" or requesting a break.

A big concern of parents and professionals is that if we teach the child to request "all done" or "break" that they will use that all the time and never get any of their work done.  They will try this.  BUT remember, they were already requesting a break.  They were just doing it by throwing or hitting or screaming.  Once the child has had success and understands that they CAN request a break, then we can start to build in tolerance for activities.  For example, "Okay, you can have a break but first we need to finish one more turn.  Eventually you can increase to multiple turns before they can have their break.

Sensory: 
Generally if the behavior doesn't fall into the other categories, it can be considered to be meeting some sensory need for the child.  Consultation with an Occupational therapist may be helpful in determining more socially appropriate activities to try to meet the sensory need.

When we know the function of the behavior, we can start to provide more socially acceptable communication alternatives.  Please note, maladaptive behaviors can be complex.  If you attempt a few of these interventions and do not find success, it may be helpful to contact a behavioral analyist to complete formalized assessment in this area.

Recycled Guest Posts: Wise Wallet Wednesdays: Don't Throw Away those Packing Materials.

Hi! I'm Kelly from Speech2u.blogspot. I'm really excited to be participating in the dabblingspeechie's Wise Wallet Wednesdays. I know I'm always looking for a way to stretch those budget dollars (when I have a budget, that is.)  If you are lucky enough to get a budget and get materials, I'm going to show you a few ways you can use your packing materials in therapy.

1.  Packing Peanuts:  I simultaneously love and hate packing peanuts.  They are SO much fun to play in and they are SO HARD to clean up.  You could probably design a fantastic common core aligned activity related to static electricity.

If you get a big box, you can throw your little ones in it and work on concepts  like: in, out, up, down and under.  I will take my box of vocabulary or articulation objects and hide them in the box.  We can work on naming while they take the objects out of the box.  Sometimes we work on blowing the styrofoam off of our hands or lay on our backs and see if we can blow the peanuts up in the air.  

If you are a crafty type, there are a ton of craft of Craft Ideas for using packing peanuts on Pinterest.  You can glue them onto a snowman or I love this sheep craft idea from Mommy Doodles:  

2.  Air Pillows:  Air pillows seem to be replacing the packing peanuts.  I think the warning labels say that these are not toys for children-but in the care of a responsible Speech Language Pathologist they can be a lot of fun.  

You can separate them and put them on the floor and have a blowing race from one end of the room to the other.  Adding a "card deck" or "worksheet" station at each end of the room prevents this from becoming a completely pointless activity.  Also, you don't want to do this with kids who spit when they blow.  It's more of them than you would think.  

I like to cut out pictures for articulation practice and then tape them on the bags.  We practice our sounds a certain number of times (like 10) and then they can try to jump or step on the bags to pop them.  You need to hold onto the kids hands when they do this because some of them are tricky to pop-and they are slippery.  No need for anyone to break a leg in speech therapy.  

And yes, I have a high heeled tape dispenser.

3.  Traditional Bubble Wrap.  This stuff can be addicting.  It's fun to just lay a big roll of it on the floor and have Pre-K kids walk across it to hear the "popping noises."  I also use this one with worksheets:  

This is a Super Easy one-Just place the Bubble wrap on top of the worksheet.  Students say a row of words and then pop the bubbles on that row.  

Sometimes I just place larger picture cards under the bubble wrap.  For this activity, we were practicing CV combinations-the client had to say the CV word the same number of times as the bubbles on the card.  This would work great with Super Duper cards as well.  

It's also a fun way to work on multiple choice questions by pinching the correct answer!  For this activity I used Teach Speech's  Who, What, where, and When Questions with Visuals product.

Those are a few of the ways that I have used packing materials in my therapy room.  Do you have other ideas for how to use packing materials?  I'd love to hear from you here: 

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Or you can link up your own ideas on how you use packing materials on Instagram:

 #wisewalletwednesdays

Recycled Guest Posts: Speech Snacks Feeding

This is a post that I did to celebrate Speech Snack's 2 year blogging anniversary!

About 10% of my caseload is feeding clients.  I don't blog a lot about feeding therapy techniques because I think that these kids really need services from a feeding team and trained professionals.

Suzanne Evans Morris is a FANTASTIC resource for feeding information papers and ideas.  I was lucky enough to go to one of her courses on transitioning children from G-tubes when I was in grad school.  One of my favorite papers of hers is on different food progressions for biting and chewing.

One of the techniques that I do use is grading my food choices based on how "easy" it is for my kiddoes to manage from an oral motor standpoint.  With my feeding clients, I tend to use single textured foods until we are closer to discharge.  For instance, I can alter the food's taste, consistency or size/shape in order to make the food more manageable for my clients.

One of my favorite consistencies to use in therapy is called a "meltable hard solid" This is a term used by Dr. Kay Toomey from the SOS Approach to Feeding.  A meltable hard solid is a dry food that becomes moist and is able to be swallowed with minimal effort.  Puffed corn is an example of a food that is easily managed and almost melts in your mouth.

Once they are able to manage that, I try to find foods that you can put in your mouth and chew 1-2 times but also maintain their shape-so that they don't get scattered all around the mouth (requiring more tongue movements.  Instead they stay on the molars and kind of mush together when you are chewing them.  Mush is probably not the most technical word I could have used.  

One challenge in working with these patients is finding foods that are easy to manage and healthy for children to eat.  Cheri Fraker, OTR uses a Food Chaining Approach which links foods currently in a child's repertoire to more advanced foods.

I will generally try to get my clients to accept more liquids and smoothies as this is a great way to get in some vegetables and protein while discussing small changes in food/taste.  Does the shake taste different if we add in one spinach leaf?  What if I could get them drinking Kale shakes?  The bright green color throws them off though.  I've got to think of some cool names for them: Hulk Juice, Green Lantern Shake, Tree Shakes....

Another food that I try to build up with my clients is popsicles.  The cold can be good for triggering swallowing-and it's another way to add some vegetables in.  In general I work towards having kids accept that the vegetable is in the smoothie/popsicle vs. trying to hide it from them.  It's a trust issue.  

The Zoku Pop Makers are awesome for using in feeding or traditional language therapy.  They freeze a popsicle in about 5 minutes.  I tried Blueberry Kale (I'm on a Kale kick, obviously....) this week at home.  For feeding kids, I work on accepting different fruits as well as temperatures and how to lick foods.  For my language kids, I work on adjectives like cold, verbs like lick, bite, freeze, pour, stir, get and put.  I can take pictures of the activity and work on sequencing.

Here are a few other products I've found really helpful for using in feeding therapy:  

FREEZE DRIED FRUITS/VEGETABLES:  

Freeze Dried Fruits are a great way to introduce fruits and vegetables to kids as they are dry and more similar to a chip.  I usually check the consistency before offering to my clients.  For instance, the peach freeze dried fruits require one big chew and then kind of melt and stay in one place.  The pineapple ones require a lot of chewing.  The dried carrots were very difficult to eat and small enough to be a choking hazard.

Once opened, these snacks tend to go stale fairly quickly.  I will use these as snacks in speech or language sessions.  We might take them and talk about foods that are crunchy, more crunchy or the crunchiest.

BEAN CHIPS:

If I have clients that LOVE to eat chips-I might try these chips because they have about 4 grams of protein per serving.  The brown bean chips require more chewing but the white bean chips hold their shape in your mouth and only require a few chews before they are ready for swallowing.