OC SLP

Welcome to the official website for OC SLP where you’ll find information about my private speech language pathology (SLP) practice in Orange County, CA, as well as my blog on any and all things related to communication.  If you would like information regarding speech therapy, language intervention, or social coaching in Anaheim, Anaheim Hills, Brea, Fullerton, Placentia, Orange, Tustin, or Yorba Linda, please click on the Available Services or About pages.  To access my blog, please click on one of the topics at the top left of the screen, or check the Archives on the left.  If you wish to contact me, please post a comment here on this site or send me an email at dbrunner@ocslp.org.

 Thanks for your visit!  Hope to see you again soon.

(Originally posted on September 28, 2010)

(Cartoon developed by author using www.pixton.com)

In my last post, I introduced Gabriel and Vera, two young kiddos who both fall into the category of having “moderate-severe autism” but who are very different in terms of how their autism spectrum disorder is manifested. I wrote about the heterogeneity of autism, and stated that this “spectrum” of neurodevelopmental disorders is anything but clear-cut in terms of categories and labels, which makes it especially difficult for parents, professionals, and individuals to explain this condition to others and treat clinically.

To add to the confusion over categories and labels, the American Psychiatric Association (APA) has proposed changes to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) which eliminate the terms “Aspergers’ Syndrome (AS)” and “Pervasive Developmental Disorder-NOS (PDD-NOS)” entirely from the diagnostic codes used by psychologists and medical practitioners.  Individuals with a former diagnosis of these conditions would now be considered to demonstrate an Autistic Disorder (Autistic Spectrum Disorder).  The specific criteria for an Autistic Disorder would include:

1.  Clinically significant, persistent deficits in social communication and interactions, as manifest by all of the following:

a.  Marked deficits in nonverbal and verbal communication used for social interaction:

b.  Lack of social reciprocity;

c.  Failure to develop and maintain peer relationships appropriate to developmental level

2.  Restricted, repetitive patterns of behavior, interests, and activities, as manifested by at least TWO of the following:

a.  Stereotyped motor or verbal behaviors, or unusual sensory behaviors

b.  Excessive adherence to routines and ritualized patterns of behavior

c.  Restricted, fixated interests

 3.  Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)

These proposed changes have stirred up a whole lot of controversy.  Folks applauding these changes argue that the current diagnostic categories, labels, and criteria do not necessarily describe the actual symptoms present in individuals with autism spectrum disorders, so that diagnosis is made in terms of overall severity or based on a single area of development, such as whether the individual demonstrated a language disorder early on.  It’s suggested that by eliminating AS and PDD-NOS, as well as collapsing the two social and communication criteria into one (i.e., “Social communication”), diagnosis would be based on the presence and severity of symptoms, which would result in greater accuracy and ease in making a diagnosis. Some parents of higher functioning kiddos have even commented that the single “autistic disorder” category might make it easier to access services and resources that were formerly denied their children due to the less severe nature of their symptoms. 

Opponents to these changes argue that collapsing these categories into one autistic disorder further masks the heterogeneity of autistic spectrum disorders.  In addition, individuals with Aspergers’ Syndrome (some referring to themselves as “Aspies”) may take pride in their differences and of the fact that many brilliant individuals (Einstein, Isaac Newton, and Thomas Jefferson to name a few) are thought to have had AS.  As a result, these folks may be reluctant to refer to themselves as “autistic” or include themselves in the same category with individuals who have significant functional impairments.

As an SLP who has worked in the schools, a single diagnostic category is not altogether foreign to me.  Public schools have been using “autistic-like” as a category to qualify kiddos for special education services for some time.  Further, the terms “autism spectrum” and “the spectrum” are commonly used to describe individuals at all levels of functioning and with a myriad of symptoms that stem from a neurodevelopmental disorder.

My concern is that the variegated nature of autistic spectrum disorders may be overlooked.  Special educators may attest that many ”autism programs” are unsuccessful because individuals with autism spectrum disorders are so different from one another. The same can be said for clinical treament models.  Autism intervention and programming seem destined to fail when they lack the flexibility to address the whole child with his or her unique pattern of strengths and weaknesses.  But flexibile and individualized programming equates to greater costs, and there’s the rub, especially in states teetering toward bankruptcy. 

There is no easy or even clear solution to the confusion surrounding this perplexing spectrum of disorders we call “autism,” but I do have a few thoughts and observations which might be helpful.  

1. The unique set of symptoms and special needs of  kiddos with an autism spectrum disorder require the development of a PROFILE by a TEAM OF PROFESSIONALS, which clearly articulates the child’s STRENGTHS and WEAKNESSES in all DEVELOPMENT DOMAINS.  This, of course, is what IEP teams are intended to do, but many times they fall short due to a myriad of financial or organizational issues.  In particular, public schools often lack the personnel to manage the social and emotional difficulties that present in kiddos with autism spectrum disorders, especially those who are higher functioning.  
2. GOALS AND SERVICES that are BASED ON this PROFILE are far more likely to succeed than those based solely on the diagnosis of “autism.” This is that flexibility I was talking about earlier. 
3. the PARTICIPATION of ALL PROFESSIONALS working with a child with an autism spectrum disorder is critical to the successful planning and implementation of an IEP.  For example, the input of an SLP is important throughout the entire IEP meeting because the kiddo’s communication needs are present throughout the day.  Further, much of “behavior” is actually communication-related.   On the other hand, I’ve found it extremely helpful and necessary to be present when the OT is going over sensory issues.  I’ve had many successful sessions after implementing some sensory activities prior to starting speech/language tasks.  In short, the child benefits when the whole IEP team is present throughout the entire meeting.
4. Last, ON-GOING COMMUNICATION among all members of the team (including parents, of course) is a key component to flexible and effective treatment and programming.  This seems obvious, but is so difficult to actually implement.  Large class sizes and caseloads make regular correspondence an insurmountable task. 

I wish I could say that I’m less confused about autism spectrum disorders after organizing my thoughts to write a couple of blog posts.  I really do.  I adore the kiddos I work with and feel so frustrated when I can’t do more to help them.  But I can’t blame it entirely on the caseload size, available time, limited resources, or additional training I myself may require.   Autism, the very nature of it, is like an insidious tangle of holiday lights.  Just when you think that you’ve managed to loosen a knot, another tightens elsewhere.  But here’s the thing…the light itself is beautiful no matter the knots.   And sometimes just standing back and admiring it’s delicate mid-tangle glow gives you the energy and patience you need to resume your challenging task.   

WEB References:

APA DSM-V Proposed Changes

APA “Report of the DSM-V Neurodevelopmental Disorders Work Group”

National Public Radio ”Aspergers Officially Placed Inside Autistic Spectrum”

(Originally posted on August 31, 2010)

Gabriel could be one of Raphael’s angels with his curly locks and sweet full-lipped smile.  Sitting at his TEACCH station, Gabriel whizzes through his sorting task with otherworldly speed.  His classmate Vera, on the other hand, throws her work on the floor in frustration and begins a perfect recitation of the opening narrative from “Beauty and the Beast” while twirling her long red hair around each finger on her right hand.  This reciting and twirling will not end without a tantrum until the entire repertoire has been repeated exactly four times.

I often think about Gabriel and his sorting.  There’s comfort in sorting a mess into convenient containers, whether that mess is an overturned drawer, an in-box spilling it’s contents onto a nearby file-cabinet, or a mental tornado of “to do” items whirling in one’s consciousness at 2:00 a.m.

Sorting implies categories which imply labels which are mental constructs of anything and everything “out there” and “in here.”  Categories arise when there are too many labels to manage.  It’s a whole lot easier to ask your kiddo to “fold the clothes” instead of listing each and every item in the laundry basket.

Let’s get back to Gabriel and Vera for a moment.  Gabriel has not uttered a word since he was 19 months, even though he had babbled delightful syllables containing a variety of sounds as an infant and could even say “ma” “da” and “no” on his first birthday.  Gabriel independently communicates his needs/wants using PECS.  Vera is highly intelligible and started reading at 2 1/2 but does not use language to communicate her basic needs unless she is prompted. Gabriel has “moderate-severe autism.”  So does Vera.

These are two kiddos who share the same category of “autistic spectrum disorder” and the same sub-category of “moderate-severe.”  Gabriel is also considered “non-verbal,” while Vera is considered “verbal.”  Both kiddos have “sensory integration dysfunction” (another category), but Gabriel is “sensory seeking” and Vera is “sensory avoiding.”  Vera is considered to have “mental retardation” (I really hope this label soon lands in the great big dumpster of offensive words). Gabriel, on the other hand, WAS thought to have MR, but his IEP team isn’t so sure about that anymore.  Both have “behaviors” that interfere with their adaptive functioning.

Are you confused?  Overwhelmed even? Yeah, me too.

To bend your mind a bit further, consider that these two kiddos are not the most severe, nor are they “mildly autistic” or “high functioning.”  What happens when we include labels such as “Aspergers Syndrome,” “Pervasive Developmental Disorder, NOS,” and “Non-Verbal Language Disorder” (which by the way is NOT an autistic spectrum disorder and does NOT mean that an individual is non-verbal)?  Confusion, confusion, and more confusion.

And now the American Psychiatric Association (APA) is proposing to scrap several of these labels altogether in exchange for “Autistic Disorder/Autism Spectrum Disorder” in the DSM-5 (more on that in my next post).

It’s no wonder that individuals, parents, families, and professionals find understanding, explaining, and treating autism so difficult.  This “spectrum” of neurodevelopmental disorders (more on this too in my next post) is anything BUT clear-cut and defies convenient labels and categories.

As the saying goes, “You’ve met one person with autism, you’ve met one person with autism.”   After working with at least 100 kiddos with an autism spectrum disorder and knowing at least 100 more, I have to wholeheartedly agree with this.

Debra L. Brunner, M.A., CCC-SLP

(Originally posted July 28, 2010)

Standing on a wooden railing while attempting to pry a bird’s nest out of a tight space created by a rain gutter, I notice that I have become an object of fascination and suspicion for the early morning donut shop coffee crowd a few hundred feet across the parking lot.  Oh man!!!  MUGGLE DETECTION!  I know better than to get caught.  In my defense though, there was only one guy inside when I pulled in.

Before you report me for unlawful activity (or psychiatric instability), you should know that I was geocaching.  “GeoWHATing?” you might ask.

“GEOCACHING,” a hobby I share with an estimated 4 to 5 million other people, is all about this fascinating parallel reality where “caches” are hidden in very public places all around the world.  You walk/drive/ride by them every day and don’t even know it.  Sound a bit like the Harry Potter’s world of magic?  It did to me too, which is what got me hooked.  In fact, non-geocachers are referred to as “muggles” (hence my above mention).

“Ok…but what does this have to do with speech and language?” you might be asking.  First and foremost, geocaching is a fun, family-friendly, and free activity that’s practically oozing with social opportunities.

Kiddos, put down the DS, toss the Wii controller on the couch, turn off Phineas and Ferb, cuz here’s a real life treasure hunt!  Many caches contain “swag”…a fancy word for really cool stuff…that you can trade. Just make sure you’ve brought something to put in it’s place.  My kiddo has found Star Wars figures, trading cards, and an excellent skull ring with “ruby” eyes.  And don’t even get me started on “travel bugs” and “geocoins,” which actually travel from cache to cache around the world.  We just hid one called “Finding Hogwarts” whose goal is to visit as many castles in Scotland as possible.

Moms and dads, geocaching is the quintessential “quality time” with your kiddos and, in case you didn’t catch this the first time, it’s FREE. Also, when playroom, playground, and Mickey D playdates become stale, here’s a great option to freshen things up.

SLPeeps, particularly those in private practice, this is a wonderful activity for kiddos with social thinking difficulties to practice generalizing social concepts and skills in the context of a real-world  activity that contains a particular structure and set of pragmatics.

So, here’s what you need to get started:  1. an iPhone, Blackberry, or handheld GPS device (mine is a Garmin Legend I picked up at Best Buy); 2. a free membership on www.geocaching.com; and 3. an hour or more to be outside in the fresh air.

Everything else you need to know is on  GroundSpeak’s Geocaching website, which presently lists over a million caches.  Just enough to keep you busy!

Happy Summer!

(Originally posted on July 26, 2010)

OK, this one goes out to all my SLP friends, or “SLPeeps” as the Twitter hashtag goes.

SCENARIO: Little Bryan Gerald Greenhauer is working on his “r”s [Sidenote: Why is it that kids with artic issues always seem to have problems with sounds in their names??]. Brian (or “Bwyan” as he refers to himself) comes into my office with eagerness and hope in his little eyes and says “It’s Fwiday. Ow we gonna do something new?” “I DO have a new activity for us,” I answer with mock enthusiasm while reaching into my cart o’ supplies. Hopefulness is quickly transformed to disgust as Bryan notices I am holding the same r-blend flashcards we’ve been using for months. I don’t blame him. I’m tired of them too. There are only so many games of Go Fish and Concentration you can play. And no matter how I try to sell it (“Sure, we’ll play this new Transformer game. See that number on the spinner? Well that’s how many times you have to say ‘bread.’”), Bryan and I both know that for the next 30 minutes, we’re gonna be bored bored BORED! At this point I fantasize about taking a metal trashcan outside, throwing the cards into it, lighting a match, and roasting smores over the r-blends…after all, “marshmallow” and “graham cracker” would be good targets for Bryan, right??

SOLUTION:  So you may be wondering where I’m going with all this. Well, here it is, the solution to the flashcard frustration we’ve all been feeling…SMARTY EARS…I’m hearing stadium level applause right now in my head.

I’m all about bringing technology into therapy to motivate my kiddos, as well as myself  (after all, I readily admit to a Facebook fixation supported by my IPod Touch and LG Versa).

Smarty Ears is a company that sells apps for IPhones, IPods, & IPads which puts treatment stimuli directly in the palm of your hand. What’s even better, these apps were developed by an SLP, so they not only include SLP-friendly menus to select targets, but also allow you to collect data live for each individual client and store it so you can track progress.  The price is right too (around $30 per app).  They have apps for Articulation (MAP, Spanish Articulation Probes, R-Intensive), Language (Wh Questions, Taking Turns, Verbs), Fluency (Disfluency Index Counter, Fluency Tracker), and Utility (Yes/No Communication, Chronological Age Calculator).

The first app I tried was the Mobile Articulation Probes (MAP).

You can select stimuli by phoneme, mode of articulation, or phonological process, as well as position in words.  Just click on the targets you want. You can even mix things up by including multiple targets per set.  Then up pops the first visually pleasing photo along with icons at the bottom to indicate if the client’s production was correct or incorrect (my kiddos like to press these buttons themselves which helps with self-monitoring skills).    MAP includes 930 total items.  Think about it. That would be like lugging around 930 flashcards and attempting to keep them organized. I have also purchased the Wh-question, R-Intensive, and Verbs apps, which are all equally wonderful.

Have you tried these or any other technocool products?  I’d love to hear your comments, questions, etc…

Debra

(this blog entry was originally posted August 2, 2010)

The Inspiration 

We were just finishing our speech session when my office phone rang.  Recognizing the extension as belonging to the school secretary (AKA “Guardian of All that is Critical and Necessary”), I understood it was imperative to take this call.

“Okay kiddos, good work today.  You can play a quick round of UNO for the last 5 minutes.”  My kiddos LOVE UNO, so I of course withhold the cards unless I see terrific effort and excellent adherence to my “Speech Rules.”  A great bunch of kiddos, this articulation group was fun fun FUN and had very good  pragmatic skills to boot.

While attending to details over the phone about the ETA for my printer cartridge replacement (with an impending IEP at 2:30, I was starting to sweat), I simultaneously listened to the shuffling of cards and general chatter.

“No way!  Finn belongs with Rachel. Quinn’s mean!”

Like a bear to honey, a cat to unscathed furniture, a 7-year-old to Pokemon cards, my attention was completely and instantaneously drawn to the kiddos’ conversation…GLEE!  They were talking about GLEE. [ This is probably the point in my blog where I come out as a full-fledged GLEEK.]

Then I heard “Still there?” and realized that the Guardian had detected my inattention.  “Yeah, thanks so much for calling. I’ll stop by at lunch,” I mumbled and hung up.

Transfixed I did not wish to disturb this wonderful social interaction.

“He’s a football player so he goes with the cheerleader.” Green Two

“Nuh-uh.  My cousin’s boyfriend’s a football player, and she’s in band.” Red Two

“Well Rachel’s nose is big.” Red Draw Two

“You’re mean. That’s why you like Quinn. I change it to Blue”  Wild Card

“Okay kiddos, time for you to go back to class.  See you next Thursday.”  I figured it was time to stop this before the hair pulling started.

The Idea  

Throughout the day, my thoughts kept returning to this exchange.  The back and forth of the conversation mirrored the turn-taking in laying down the cards.  I had used UNO with kiddos on the autistic spectrum as a non-verbal approach to teaching basic turn-taking and matching skills, but had not considered its use in teaching higher level social skills and concepts. Hmm…

SIDE NOTE: I just love the “Ah-Ha” moment, that giddy lightheaded rush of clarity is incomparable.  And the details seem to write themselves effortlessly.  During the great Ah-Ha, I am one with Creator and creation itself… Okay, maybe that’s an exaggeration, but I WAS really really excited when the notion of Conversation OO-NO© hit me.

The Activity

Conversation OO-NO^© is a structured conversation activity which can be used with kiddos or adults who have a mental age of 7+ years to address topic maintenance, formulating comments and questions, introducing a new topic, and expanding a topic.  It can be played with 2 or more players (one of which may include the clinician or parent) and may be adapted in terms of complexity and level of topic specificity, depending on the cognitive level and pragmatic skills of the client.  All you need is a deck (any deck) of cards, such as UNO (Mattel, Inc.) or crazy eights.

Here’s my 3rd well-worn deck:  

The Method

Deal cards and play the game according to the rules included with the deck.  The twist is this…

1. Prior to the first turn, select a topic.  This can be selected by the clinician, client, or by group consensus.  Using my previous example, the topic can be general  (e.g.,  “TV shows”), somewhat specific (e.g., “GLEE”), or very specific (e.g., “Who Finn should date”).  Make sure everyone is clear about the topic before starting.  We’ll be using the topic of “GLEE” for this demonstration.

2.  Whenever a player puts down a card of a matching color he/she makes a comment about the topic (e.g., “GLEE is the best show on TV”).

NOTE: The clinician can offer real-time feedback to the client regarding the appropriateness of the comment or model possible comments the client could make to expand the topic.

3.  When a player puts down a matching number/symbol (in the case of reverse and skip cards), he/she asks a question of the next player regarding the topic (e.g., “What do you like about GLEE?”).

NOTE: When the next player places a matching color card down, the comment should be in reference to the question that was just asked. However, if the next player uses a matching number, then encourage that player to answer the question before formulating one of their own.

4. When a Draw 2 or Draw 4 card is played, the player must make 2 or 4 comments about the topic (e.g., for the card pictured above “I really like the musical numbers.  And Sue Sylvester is hilarious.”)

5. A Wild Card (or the “8” in crazy eights) enables the player to change the topic.  This is a great opportunity to work on how to bridge from the existing topic to another (e.g., “You may like GLEE, but I really like Star Wars Clone Wars, so that’s the new topic. I change the color to red.”).

6.  The Wild Draw 4 card is special, in that the player must make 4 comments about the existing topic before introducing a new topic (e.g., “1. I’ve never seen GLEE.  2. I don’t understand why you could possible like it.  3. I really don’t like when people break out in song at random moments. 4. Musical shows like GLEE don’t belong on TV. So I’m changing the topic to an awesome show called Star Wars Clone Wars and changing the color to blue.”).

The Variations

Since developing Conversation OO-NO©, I’ve realized that it can be used for many other therapy targets at the level of structured conversation, such as fluency, semantics (select vocabulary targets as the topics), grammar (change the rules so that comments or questions reflect a particular targeted form), and articulation.  As such, it’s a great activity to use with groups of clients who have different goals.

I’d love to hear how Conversation OO-NO© works for you!