THE FLOW OF INTERVENTION By: Nancy Rice, MA, CCC-SLP
SOCIAL THINKING® and THE FLOW OF INTERVENTION
By: Nancy Rice, MA, CCC-SLP
This blog is written based on my experience working with individuals with social communication disorders, which is largely based on the Social Thinking curriculum designed by Michelle Garcia Winner, MA, CCC-SLP, and colleagues. I will attempt to summarize the process I use in treating my clients with social communication disorders. This framework is designed primarily for individuals who have average to above average cognitive abilities; however, with creativity and care, it can be adapted to meet the needs of a wide range of clients.
Working with individuals with social communication disorders is challenging, to say the least. These clients are complex and their skills vary tremendously, making it difficult to know where to start and how to proceed. I have found that it’s important to start at the beginning (see diagram below), no matter the client’s chronological age or stage of social communication development. I have many adult clients with whom I adapt the materials and content delivery to respect their age and stage. Nonetheless, I always start at the beginning, with self-regulation of behavior.
Spend time teaching the “zones.” Blue Zone: sad, sick, tired, bored, moving slowly; Green Zone: happy, calm, focused, ready to learn; Yellow Zone: frustrated, worried, excited, loss of some control; Red Zone: mad/angry, mean, terrified, out of control. Work on developing an emotional vocabulary and tie each term to a real-life situation or role-play activity. Talk about how the body acts and reacts when experiencing each emotion (i.e. smiling, hitting, yelling, jumping, etc.). Develop strategies and “tools” for self-regulation of emotions and behavior. Zones can be continually inserted throughout the therapy process, so start with developing an understanding of the four zones and establishing tools that help the client, for example – breaks, physical activity, fidgets, problem-solving tools, etc.
Materials: “The Zones of Regulation” by Leah M. Kuypers, MA Ed. OTR/L; Problem and Reaction Meter (PDF)
- Develop an understanding of thoughts, feelings, actions and reactions. You want the client to understand that our thoughts and feelings can be comfortable or uncomfortable, and our actions/reactions can be expected or unexpected. Then, develop an understanding that, when we do something expected, we start (or continue) a positive chain reaction that makes us and others feel comfortable AND when we do something unexpected, we start (or continue) a negative chain reaction that makes us and others feel uncomfortable. The goal of this stage is to help the client realize that choosing to do what is expected (i.e. starting and continuing positive chain reactions) will result in making him/herself and others feel comfortable – a good choice to make.
- Develop an understanding of “thinking with your eyes,” including an understanding of WHY we should think with our eyes. This stage takes a while because the concept and process is new to them, and their eyes and brain are connected in a much different way than in a neurotypical brain. This stage involves a great deal of mirror work, imitating facial expressions, using exaggerated affect, and “look where I’m looking” games.
- Develop an understanding of how and why we want to identify and follow “group plans.” At this stage, start connecting all that was learned in skill #1 (above) with daily activities, games and learning activities. This is where the client really starts to understand the concept of expected and unexpected actions. Following the group plan is expected; and when one doesn’t follow the group plan, it starts a negative chain reaction.
- Develop an understanding of why we want to keep our “body in the group” and help the client to do so in a variety of activities. Along the way, you’ll be strengthening the ability to keep their body and brain in the group AND the “green zone.”
- Develop an understanding of using “whole body listening” – which is done with lots of help from the “Zones” tools. We want the client to realize that listening doesn’t just involve our ears. We listen with our brain, quiet hands, quiet mouth, caring heart, etc.
- Develop an understanding of how to “follow the leader” (i.e. understanding the concept of an authority hierarchy). This is done with lots of work on what it means to be a good leader/follower; and how and when to be leaders vs. followers. This stage is not in the Michelle Garcia Winner curriculum. It is my own stage that has been added because I’ve found that individuals with social communication disorders don’t know where they “fit in” and so they tend to take the lead (usually in an unexpected way – and then get confused because they think they’re doing what’s expected) or they get anxious (which also causes unexpected actions/reactions). In additions, individuals with social communication disorders tend to have difficulty identifying good leaders/followers. Taking time to add this stage helps clients deal with issues surrounding friendship, bullies, handling boring moments, parent/teacher/employer relationships, and more…
Materials: “Meet Thotso, Your Thought Maker” by Rachel Robb Avery, Ph.D.; “What is a Thought?” by Jack Pransky & Amy Kahofer; “We Thinkers, Volume 1” (formally “The Incredible Flexible You” series) by Ryan Hendrix, Kari Zweber Palmer, Nancy Tarshis & Michelle Garcia Winner; “Whole Body Listening Larry at School” and “Whole Body Listening Larry at Home” by Kristen Wilson & Elizabeth Sautter
- Develop an understanding of the “hidden curriculum:” the idea that there are always rules that we aren’t told but are still expected to follow. Spend time studying the rules of different settings and activities to the client. Practice following the rules by “thinking with our eyes.” Do this in role-play and pretend play activities and then in “real-time.”
- Introduce the concept of being “flexible.” We don’t have to do things our “own” way, we can do things “any” way. At this stage, provide lots of practice on being flexible about day-to-day things, i.e. playing a game someone else wants to play, doing an activity in a new way, dealing with disappoint or losing a game, not getting the color desired or handling it when told “No.”
- We have to teach our clients with social communication disorders to “share imagination.” This is done in pretend play with the younger clients and joint storytelling and conversation with the older clients.
Materials: “We Thinkers, Volume 2” (formally “The Incredible Flexible You” series) by Ryan Hendrix, Kari Zweber Palmer, Nancy Tarshis & Michelle Garcia Winner
- Develop an understanding of how to identify cues that help us to know what’s “expected and unexpected.” This is the stage where clients practice seeing and using social thinking skills in real-life experiences.
- Learn to use “flexible thinking” is all we do. Practice identifying when and where flexible thinking was or was not used.
- Develop “strategies” that will result in more flexible thinking – resulting in successful social interactions.
Materials: “You are a Social Detective!” by Michelle Garcia Winner & Pamela Crooke; “Superflex: A Superhero Social Thinking Curriculum” package by Stephanie Madrigal & Michelle Garcia Winner; “Superflex Takes on Glassman and the Team of Unthinkables” by Stephanie Madrigal & Michelle Garcia Winner; “Superflex Takes on Brain Eater and the Team of Unthinkables” by Stephanie Madrigal & Michelle Garcia Winner; “Superflex Takes on One Sided Sid, Un-Wonderer and the Team of Unthinkables” by Stephanie Madrigal & Michelle Garcia Winner; “Social Town Citizens Discover 82 New Unthinkables for Superflex to Outsmart” by Stephanie Madrigal, Michelle Garcia Winner & Pamela Crooke; “Superflex Superdecks”; Social Thinking YouTube (PDF); Video Modeling; Individual Social Thinking Binders (PDF)
Along the road to Social Interaction, try to keep the activities very content driven and always explain the “why” behind what you are doing. In addition, involve parents! After all, social thinking is a 24/7 thing.
I will be forever grateful for the contributions Michelle Garcia Winner and colleagues have made to the field of speech language pathology. They have provided a greater understanding of social communication development and disorders, and have opened my eyes to a world of intervention resources and techniques that really work! ~Nancy Rice
PRIVATE PRACTICE- TAKING A LEAP OF FAITH
By Kitty Griffin MSCD, CCC-SLP
Thinking about private practice? You could spend years writing a business plan or you take a leap of faith and get in there in the near future. Never once in my neatly laid out professional goals did the word private practice get written. My practice rose out of the ashes of a job loss. ( I should have called my practice the “Phoenix”!!!) Healthcare changed, and rehab jobs were eliminated or pared down to a point where it would be hard to support yourself, much less a family.
My kids were 5 years old when that job loss came and I was scared. I called my parents. I thought some sympathy might be in order. My mom (ever the fainting flower-NOT!) said “Are you any good?” I was taken off guard and didn’t answer. “Are you?” she pressed. “Then open your own office- just do that”. We went on other topics.
If nothing else, I am a woman of Faith. I called some local doctors, packed some toys in my old 65 Mustang and entered into home based treatment. Things went well and I learned about insurance, Medicaid and how to submit billing forms. I drove around MT with no phone- cell phones were not big yet! I then saw patients from a dedicated space in my home. I later rented space from our local hospital.
Nothing lasts forever, and the space in that area was needed for other functions. The hard choice was here: move to another space or buy something so I never had to move again. The day I came home and asked my low key husband Jeff :”Do you think we could use our house as collateral?” I held my breath. He said “You know what you are doing.” I never loved him more. We renovated a 2 bedroom house and State of the Heart Therapy moved into Taylor Drive. We have been in this location for 10 years now.
Everyone is different and I think every private practice is different, too. Just a few things to know:
- Try to grow slowly, many new businesses fail in the first 3-5 years due to the cost of doing business.
- You will work harder than anyone else you know, your life depends on it.
- Surround yourself with people to advise you, who are from different backgrounds in business. It could prevent costly mistakes. Jeff once said; “You are NOT doing that!!!” PS- he was right and I was crabby that he WAS right.
- Go for diversity in your caseload payors. A mix of contracts, clinic patients with insurance and with entitlement programs like Medicaid offer stability if the bottom falls out of one payor. Trust me, it is likely.
- ASHA has wonderful resources: asha.org and type in private practice!
- You will not be raking in the big bucks; the owner is paid last.
- This is the time to shine clinically. You will get referrals if you give more than is expected. It will cost you time and effort. And it will keep you in business.
- Take a leap of faith sometime soon. Maybe not in private practice, but somewhere: have Faith not fear.
You can reach Kitty on her mobile email firstname.lastname@example.org
Catherine “Kitty” Lebahn Griffin, M.C.S.D. CCC-SLP is a master’s level speech and language pathologist. Kitty has spent her career working with families in home based and clinic based treatment. She has worked across the nation including The Helen Beebe Center in PA and the Listen Center in CO. One of Kitty’s clinical specialties is working with families whose children have hearing loss. Kitty has worked for MSDB as a Family Advisor and is currently a DHH Outreach Consultant in SW MT. She is a certified Baby Signs® instructor.
Kitty is a former MT Speech Language and Hearing Association president and currently chairs the PR committee of that organization. (She likes to get the word out about services!) She also owns and operates her private practice, State of the Heart Therapy, Inc. in Dillon MT. Kitty’s most prestigious and rewarding assignment thus far is as mother to twins David and Elizabeth, who are studying at UM and making their Mom proud!
Conversational Skills: Teaching them can be Free!
Conversation Skills: Teaching Them Can Be Free!
Jennifer K. Schoffer Closson MS CCC-SLP
Teaching conversation skills is not something to be accomplished in two or three sessions. In fact, according to Spitzberg and Adams, the developers of The Conversational Skills Rating Scale, there are 25 skills that are required to be a conversationalist. In reality it could take two to three years to meet one’s conversational potential with intervention.
For a communicator that is daunted by conversation, The Conversational Skills Rating Scale will help identify areas of challenge. It is very subjective, however, SLPs are highly trained to make judgements about communication. It is also a little loose, but lends itself to follow-up observations and questions. For example, one of the items is “personal opinion expression (neither too passive nor aggressive).” If this item raised concern, the clinician may look deeper into flexibility, ability to respectfully disagree, personal space, tone, emotional regulation, etc.
Conversation skills are tough to teach. Every child with autism or related disorder is going to have a unique constellation of challenges with conversation. For this reason, I encourage SLPs to individualize their approach and implement evidence based practices (EBP).
The National Professional Development Center on Autism Spectrum Disorders (NPDCASD) http://autismpdc.fpg.unc.edu/evidence-based-practicesis my favorite resource for EBP. They have joined forces with The Ohio Center for Autism and Low Incidence (OCALI)http://www.autisminternetmodules.org/ and this is my favorite training resource for when it is needed now. These two resources are user friendly and reveal what really works.
Some of my go-to EBPs are great for teaching conversation skills:
Social Narratives: Social narratives describe the expected behavior clearly. They tell the learner what the setting looks like and how to respond. The nice thing about Social Narratives is that they can be shared with teachers, parents, and other support personnel for generalization of skill. This allows the stakeholders to have common language, common expectations, and a tool to pre-teach a skill to support social success. The NPDCASD and OCALI (the two sites above) will support you in learning how to develop social narratives. My favorite person to consult is Carol Gray.http://carolgraysocialstories.com/social-stories/
Video Models: Video models provide expected behaviors for the learner to emulate. These videos can be purchased or be made quickly on a smart phone by using the learner, an actor, or the point of view of the learner. One of my favorite tools for purchase is Fitting In and Having Fun. Here is a video they produced about Taking Turns Speaking. https://www.youtube.com/watch?v=3RjRZ9jMfs0The reason why I like these videos is that they share the perspective of the participants. They show the old way and the new way and provide social narrative at the end. But, for those of us that have a budget of $0, go ahead and make your own. Here is one about Making Plans. If you are curious about the point of view video “Petting the Dog” is an example.https://www.youtube.com/watch?v=ieM8GHE6RLk
Scripting: Scripting is quite useful for skills related to employment or independent living. A script can be faded as the communicator becomes more competent. Here is a script that would be affixed to a pouch for ordering food (fill in the blanks with dry erase marker):
Hi, I would like ____________________________ please.
Here is my money. Inside you will find ____________ dollars.
Please put my change and receipt in the pouch. Thank-you.
Teaching conversation skills is hard. Sometimes we don’t know where to start or how to teach a skill. Using The Conversation Skills Rating Scale can provide a guide or a starting point. Implementing evidence based practices ensures that you are using researched methods of intervention. Generalization can be supported by sharing social narratives, video models, scripts, and other materials with stakeholders. Working as a team, individualizing instruction, and using EBP will likely help your client develop his or her conversation skills.
MSHA Monday-Summertime Teletherapy Update
Diane Simpson and Rachel Stansberry offered another webinar on “Getting Started in Montana Telepractice” on June 27, 2017. Diane and Rachel have been offering these two-hour webinars several times each year to help MSHA members add telepractice to their service delivery models. Telepractice offers us a chance to reach areas in our state that are not receiving speech therapy and audiology service and Diane and Rachel are committed to getting services to these areas.
Each webinar contains four parts. First, they discuss the Montana telepractice Law and the Rules and Regulations governing telepractice in Montana. Next, they cover the expectations of privacy for HIPAA and FERPA compliance. The third part deals with the equipment, platforms and physical needs to provide telepractice and they conclude with web-based resources, both for therapy sessions and for getting additional training. Diane and Rachel will continue to offer these webinars as long as there is interest. They will are also planning to present a poster on telepractice during MSHA’s fall convention in Missoula
MSHA will host another webinar on Telepractice on September 19. This one will be taught by Tracy Sippl. Tracy is a telepractioner who offers a variety of services to telepractioners. She has a course through ASHA and she does individual consultations. Rachel recently consulted with Tracy to get more ideas for online therapy materials to share. “Tracy was a great help and shared techniques to help me better utilize my teleconferencing platform and she gave me a list of online activities I could use in therapy,” Rachel reported, “and all for a reasonable price”. You can check out her site and blog here. Watch the MSHA Facebook page for more information on the September 19, 2017, webinar.
Her latest Blog was on e-helpers.
ASHA also sent this information on Sig 18 that I thought was worth sharing.
“Advocacy State-by-State pages have had a new edition – Telepractice/Telesupervision! This has been a big initiative to track the laws and regulations specific to telepractice to assist members in their endeavors to provide appropriate services within the confines of the law. Go to the Advocacy Tab, Click on State-by-State then select the state you would like to research. Telepractice is listed as one of the subsections. http://www.asha.org/advocacy/state/ Contact Cheris Frailey with questions at email@example.com. ”
Are you looking for ways to incorporate more authentic materials into your current telepractice? ASHA has a recorded webinar and has a lot of good ideas for making your own materials as well great tips for managing technology and using web based resources.
If you’d like to be listed as a telepractioner on this website, be informed of the next webinar, or receive periodic emails about telepractice resources, contact Rachel at firstname.lastname@example.org or Diane at email@example.com
MSHA Monday: Speech Therapy and Sensory
Hello MSHA Members!
I am slightly shocked over the cooler weather we’ve been experiencing as summer approaches. This is my last week of ESY, and I wanted to reflect on some career changing ideas in regards to speech and the importance of understanding and incorporating sensory needs. If you have worked with a student or adult that needs information presented in a more kinesthetic or tactile fashion, you may be able to relate to some of the ideas and activities I’ve used this year!
This year my fellow OTs showed a video about the “Sensory Funnel” (https://www.aspergerexperts.com). CAREER CHANGING. I was hooked immediately from listening to these guys explain how targeting executive function and social skills are the last skills to target (SLPs will say ‘WHAT?’). They introduce a hierarchy to work on social and executive function skills with bringing our focus to the foundation deficits before targeting the more metacognitive skills. I full-heartedly see the benefit of targeting learner’s sensory, emotional, and awareness skills before getting to social and executive function skills. Take a moment and listen to their explanation and please comment on your own ideas!
With taking this information into consideration, I made my New Year’s Resolution for my work to be “More Fun”. How many of you sometimes get into that rut and do the same games/activities? Taking the Sensory Funnel, previous pool-based speech therapy training, and participating in the SLP Summit’s training, I started by searching in my basement for plastic containers, rice, beans, pasta, and straws. I made my first sensory box! I am going to reflect on the best ideas when using sensory boxes and check out http://www.thedabblingspeechie.com/sensory-bins-speech-therapy/ and https://slpnataliesnyders.blogspot.com/2017/01/how-to-make-sensory-bins-for-speech.html. I am sure there are many other posts about sensory boxes in speech, so make sure to do a Google search!
- VISUALS. Have a visual for pre-teaching the fundamental use of the sensory box! I have each of my learners use hand sanitizer and review the rules of the sensory box before using it. Every student, even the ones who will buck directions, will follow and use hand sanitizer!
- MATERIALS. Use what you have! You can use those articulation cards or make fun ones from different TPT store creators! I found a great box of objects on Amazon that were organized by speech sounds in the initial, medial, and final position. Etsy had miniature objects for I Spy and these have been a great hit this summer for ESY. How many of you are vying for tangible objects after using the iPad so often?!
- PLAY. My favorite use for the sensory box! I find creating play based activities in the box provides significantly more opportunity for language! I used my rice and glass gems to create land and water and then sorted water versus land based animals. Then we increased the complexity by making decisions of wild versus zoo animals and made a zoo in the rice. I had the opportunity to use spelling goals, math goals, and speech goals within this one activity! PLUS my student, who usually gives the aide a difficult time to work on adult directed activities, followed EVERY direction. It was the most positive session with teaching opportunities and conversation!
Go for it, try it, and tell us what you think about using sensory boxes! I use these with pre-schoolers up to high schooler depending on their needs. Go for a hike this summer and collect! This does not need to be a pricey addition to your daily practice, but is a possible one!
MSHA Monday: We’ll be posting a blog each Monday…stay tuned.
This summer, MSHA plans to post a blog every Monday. Our goal is to share and compile information that will be useful to your practice. If you’d like to guest blog on any therapy topic, let us know. Our schedule for June is June 5-Books for Therapy, June 12 Board Update, June 19-Sensory Boxes and June 26 Implementing AAC.
“If you know me, you know I love stories. I read stories, I listen to podcasts that tell stories and I use stories in therapy to work on every aspect of language. Each year I add to my list of stories that are good for developing specific skills. While I have favorites for working on pronouns and past tense verbs, I thought I’d offer a list of books that I use most frequently for narrative and expository development. I’m a big fan of the Story Grammar Marker. I use it to help me to focus on specific stages of narrative development. The icons really help build memory for the key story components and kids love to hold the actual story braid. If you aren’t familiar with this tool, check out this site. https://mindwingconcepts.com/ I’m a random abstract person, so these are in no particular order
- Waiting is Not Easy by Mo Willems. Well, really anything by Mo Willems is great because the story elements of character and setting are so obvious that it is then easy to teach the temporal sequence and/or perspective taking. Elephant and Piggie have so many great adventures and their emotions are easy to read. I try to use at least one a month. If you haven’t discovered these books, do it. Right now.
- High Wire Henry by Mary Calhoun. Henry is another go to character for me and I use at least one of his stories each school year. He typically has one problem in each book and this offers a great opportunity to teach the critical thinking triangle for the kick off, emotional response and plan that then leads him through the temporal sequence to a solution. There is also opportunity for a two person perspective between Henry and The Man of the family. Enjoy.
- Titch by Pat Hutchins. The original Titch is great for character and setting. Once again, the pictures support the elements of the story. The subsequent stories, Titch and Daisy, You’ll Soon Grow into them Titch and Tidy Titch, offer a complete episode that is simple enough for my kindergartens to retell.
- For those students who are into non fiction, these books by Gail Gibbons are perfect. They can be read and discussed in a twenty minute session and they offer great practice for expository structures. This one is good for a List as well as Problem/Solution. There are also books about Hurricanes, Sea Turtles, The Moon, Frogs, From Seed to Plant and the Reason for Seasons.
- Finally, for the past three years, I’ve been using more classic comic books. Calvin and Hobbes are great for teaching emotional vocabulary, critical thinking triangle and problem/solution. After seeing the movie, Life Animated, I am even more committed to using a child’s interests to teach what he/she needs to learn. I have one student with ASD who has taught me how to make this happen with this book in particular.
Our first Summer Blog is from Rachel Stansberry. Rachel works as an SLP in rural schools in Central Montana. She is a past MSHA board member and a current member of the licensure board. If you have books you love, write them up. We’ll post your list along with this one. Email it to MSHA’s web manager, Emily at firstname.lastname@example.org