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How I didn’t want to spend an hour of my morning:

Drenched in my own sweat as my legs became plastered to a vinyl covered sofa on which I sat with a 3 year old girl.  Because if it’s 84 degrees outside, it’s 90 degrees inside the Philly rowhome, as the stagnant air sits heavily in the darkened room.  No air conditioning, no fan, no cracked window.  Just a neighborhood girl outside distracting the child I was working with inside, making us both long for the relatively fresh air the sunshine promised.  No air, just vinyl covering every soft surface, and just three million ceramic angels tacked to every vertical or horizontal surface. Two gigantic TV cabinets in each corner of the living room, one filled with a TV, the other, with angels.  Angels on the wood paneled walls, angels on knick-knack shelves looking over the couch, angels on the end tables, angels gracing placemats seen through the glass coffee table.  Angels going up the stairs, angels on the doorways.  And each table (dining room, end-table, coffee table) covered with its own hermetic layer of vinyl.  The entire home could be cleaned by Windex. 

Not the ideal place for a 3 year old who needs to run around and use up her energy.  Can you imagine building a pillow fort out of vinyl cushions?  Just sayin’.  So I wasn’t altogether surprised to hear the little girl, who had until now used a quiet voice to utter short, shy phrases to me, scream at her mother the top of her lungs, “You bitch!” and then, a few moments later, “You ugly!”  If my eyes had widened as they adjusted to the dark and then were assaulted by the heavenly bound cherubim, my jaw now dropped in shock upon hearing this little girl yell epithets at her mom. 

Children learn by example, by what they see, what they hear, how they observe their families interacting.  But no amount of Windex can clean up the mouth of a 3 year old whose mother has modeled screaming obscenities as appropriate language in her home.

Wednesdays at 11:40am are my regularly scheduled time with Ryan. Before I leave my car, I carefully switch my heavy Pendleton wool winter coat for a lighter, machine-washable variety, in preparation for entering the dark, dank, smoky row-home Ryan lives in with his mother, his grandparents, his sisters, and assorted aunts/cousins. I can’t keep track of who exactly lives there, but there are always people coming and going and sleeping on the couch during my sessions.

While I’ve asked that no one light up when I’m actually in the home, the smell permeates all the surfaces — the carpet, the couch, my clothing, my skin, my hair. I get regular migraines on Wednesdays from being in this house for an hour. And I take regular showers on Wednesday nights. Last week, it was too cold to switch my coats, and I’ve been waiting a week for the smell in my coat and scarf to become manageable where I can wear it again.

I very much dislike going in that home. I sit on the nasty carpet in the room designated by the builder as the “dining room”, though I’ve never seen anything in it resembling a table and chair. More usually, I see various sizes of bicycles and toy-motorcycles stacked against a wall, an open box of wrenches, and a chest freezer. I block out the sound of the ever-present television and try to do therapy with Ryan and his little sister. She’s not on my caseload, but she wants desperately to have my attention and she’s a really hard worker with her speech, which is probably delayed, though not as severely as her brother’s. At the very least, she models speech sounds for Ryan and provides opportunities for taking turns with materials.

Despite my agency’s insistence (and mine at my interview) that I can do therapy with a spoon and a box, and that I should do therapy in the “natural environment” within the family’s “routines”, I bring toys into this home, because I have not seen any there. I bring books and I bring bubbles. I bring fishing games and play-dough. I bring blocks and puzzles. And I play with those kids.

Ryan is challenging to work with in his own right. He acts out and while I’m reasoning with him to sit back down, and using strategies I’ve developed, I hear his grand-mom piping up in the other room threatening to “beat his butt”. Then his mischievous eyes turn soft and he pleads with me “not to tell mom-mom”. It’s hard to use my own approach of logical consequences such as not bringing back certain troublesome toys, and laying out my expectations at the outset of each session, when it seems he’s accustomed to responding only to threats (and I’m sure, follow-though) of physical violence. He fears his mom-mom, and nothing short of her voice inspires him to stop climbing on the bikes and sit back down on that filthy carpet with me.

On top of that, his speech is a mess. He has articulation delays, and he also is showing signs of stuttering. The articulation I’ve been targeting since I started working with Ryan, but his progress is slow. We’ve worked on /l/ and /sh/, sounds he can kind of make. However, he has been unable, despite my multiple attempts and support, regardless of my strategies and tricks, to make a /k/ or a /g/ sound. These are a class of sounds that can be very hard to teach, because a kid can’t “see” when you demonstrate. It involves the back of the tongue making contact with the back of the palate, and most kids who need to work on /k/ and /g/ product them as /t/ and /d/, using the front of the tongue instead. In Ryan’s case, it’s the error impacting his intelligibility the most. If he could make /k/ and /g/, it would get him the most “bang for his buck”. And it might get me out of that house sooner rather than later.

Today, I resolved to do something I’d been trying not to do. I bought a bag of Dum-dums from the drug store, and used them in therapy. Not as a bribe, mind you, but actually for working on /k/. This is a strategy my supervisor in my preschool clinical placement in grad school showed me. Try it if you have clean hands or a spoon or a lollipop handy. If you push down the tip/front of the tongue and even try to make a /t/, you’re forced into making a /k/, since the back of your tongue humps up instead. It was kind of magical the first time I heard that melodious /k/ sound. So Ryan made his first “crashing sounds” today, as I call /k/ sounds.

The reason I didn’t want to bring in the candy is many fold. I really dislike using food in therapy as a bribe, and though I knew that wasn’t the purpose, I was worried Ryan and his family would view it as such. Food has long been used as a “motivator” (reward) in therapy, to work with children who are motivated by very little, but who would cross the desert for a cheese doodle. Though I’ve doled out endless Goldfish crackers and bites of food during therapy, I don’t like the message it sends to children who ought to be able to work for stickers and high-fives. And Ryan is one such child.

But if it works? Should I worry about giving out sugar at 11:40am? Should I worry that it makes me into the Candy Lady? Should I worry about the precedent it’s setting? It’s only supposed to be used to stimulate /k/ sound until a kid can do it with less support, but will he end up relying on it to get the sugar rush? Am I thinking too much?

I will go back to the office and raid the cupboards for flavored tongue depressors, the more P.C. tool for the same purpose of pushing down the front of the tongue. I will hope Ryan is as motivated by artificial grape flavored wood as he was by the sugar on a stick, and I will keep trying. I’m never just working on speech, no matter what the IEP says.

My clinical supervisor once told me that, when it seems I’m working on too much “big picture” development, or focusing too much on non-“speech”-seeming targets, to remember that my job as a preschool speech therapist is also to take a malleable, impressionable, wild child, and send him off to kindergarten as a little human being. When we’re talking about making therapy functional, molding human beings seems a lofty yet important goal. One that, if I need lollipops to achieve, then so be it.

I’m going to take a break from brooding about Christmas for a while.  I’ve finally seen some tasteful lawn decor — giant blue ornamental balls dangling from a barren deciduous tree, and not a blow-up character in sight — but I’m burning out on all the family time, holiday shopping, charity appeals, endless baking, and scheduled commitments.  I’m ready to bring you another installment in my “series” of favorite therapy toys/techniques. 

Actually, this one is more about the therapist/adult as the toy.  Surprisingly, I don’t mean this literally.  I’m well aware of the wonderful times that can be had swinging children upside-down from their toenails, flying them in circles, and flinging them onto resilient sofas.  I’ve wanted to fling many a hyperactive child, for the right and wrong reasons.  Hanen is a beautifully designed series of programs for parents helping their children to communicate.  In their program developed for children with autism-spectrum disorders or difficulty with the social aspects of communication, they advocate the human-as-toy approach, though I come at my ideas a little differently.

In Hanen, you, the adult, involve yourself as part of the play to make the play include a human aspect.  Instead of filling up a bucket with toys, you might use the bucket as a hat on your head, and let the child delight in seeing it fall off your head again and again.  You might build a train track that uses your legs as a tunnel, or hide toys in your hands.  Either way, you’re looking for opportunities for interaction and communication in play, and, truly, in a multitude of everyday activities. 

The reason I think of my ideas as using myself as part of the therapy is that I am often wearing the toy.  I am the toy.  I try to bring something irresistable (for a 3-5 year old) that impels them to communicate.  Though I may be every bit the bill-paying adult,  I often dress in a manner that is a combination of easy-maneuvering for work + machine-washable + kid-friendly that sometimes leaves me feeling a bit like I’m 12 years old.  The pigtails don’t help, I’m sure.  It’s nice not to be limited to dress pants, button-down shirts, blazers, and high-heels for work apparel.  I could very easily pull on scrubs, as many teachers and therapists who work with preschoolers are inexplicably doing these days.  I much prefer, however, to wear Snoopy skirts, striped tights, My Little Pony sweatshirts, and WALL-E barrettes.  Yes I do.  I made the Snoopy skirt out of an old bedsheet.  I made the WALL-E barrettes out of Shrinky-Dinks. 

In my personal life, I would much prefer to eschew commercialized products for children.  In my previous life teaching at a Quaker school, it was the school philosophy, and I grew to appreciate it very much.  Were I working solely with typically developing children, you’d be more likely to hear the following exchanges:

Timmy: “Look at my new light-up Disney Cars holographic supersonic animated licensed character sneakers!”

Me: “Are your shoes fast?”

Jojo: “Do you like my new Disney princess Cinderella Jasmine Ariel Belle lunchbox?  It has a matching Thermos”

Me:  “I like you!”

Now, however, I’ve found that kids who do not/will not talk about anything else, will come to life when they seem familiar characters.  Their faces will light up when they see my WALL-E barrettes.  “Why you got WALL-E in you hair?”  “Hey! Dat Robot in you hair!”  “Yook!  Wall-E!”  I remember the first time I observed this phenomenon.  A new school year has just begun, and a little girl who had a speech delay and wasn’t saying much more than 2 words at a time, even though she was almost 4, was shyly flitting around the classroom.  I tried to engage her in a conversation of some sort, and finally asked after her shoes, which looked new as they were still white.  She looked at them, she looked at me, and she burst out, “PONIES!”  We bonded over My Little Pony.

Though they don’t really recognize Snoopy anymore, and I haven’t gone all-out in Disney paraphernalia, I still marvel at the power of a familiar TV character to elicit a response in reluctant talkers.  

It is expressly for this purpose that I have kept somewhat up-to-date on my knowledge of current children’s TV programming and toys.  Well, maybe not exclusively.  I love PBS kids television shows.  I’ve been watching Arthur since high school.  I’m hooked on “Fetch” and “Cyberchase”, though those are a bit over my students’ age levels.  I know about Backyardigans and Caillou.  I can recognize Wubbzy.  I seek out Spongebob on On Demand.  Barney has always made me vomit, and I can’t sit through an episode of Blue’s Clues the way I can with Sesame Street, but I keep up.  And I think it pays off. 

The other gimmick I use in making myself the toy is nail polish.  I noticed that a particular child who otherwise would not say much voluntarily and would just sit there unnoticed in a corner of the classroom like a bump on a log took one look at my nails and launched into a dissertation on the colors and benefits of nail polish.  She counted the number of yellow-colored ones, compared it to the number of red-colored ones, and recited the alternating pattern that Mr. Apron had unwittingly created when he painted my nails in alternating hues.  She told me who paints her nails at home, and how she hopes to get them painted soon.  Even children who are non-verbal, or “communicate with their eyes” have been known to stop what they’re doing and focus on my nails.  They may rub them gently, examine their own, count them, or – gasp! – look up at me and make eye contact. 

My nail polish is my bling.  I don’t wear make-up. I don’t put much time into my hair.  I can’t wear much jewelry to work.  The one piece of jewelry I wear is my wristwatch.  No one seems to wear these anymore either, which of course immediately makes children focus on my wrist.  My watch is pretty special, too, since it’s a self-winding skeleton watch with a chunky orange band.  What does this mean?  It means that it has endless moving parts, and you can see through it to the winding mechanism in the back.  When you shake the watch, you can see the weight swing around and wind the watch.  You can see not only the hands ticking, but also all the gears moving.  It’s really cool.  And kids think so, too.  I’ve engaged a small class of children “timing” them as they run around the gym, exhausting themselves.  I’ve used it as a reward to keep kids focused for a few more minutes.  And I occasionally let them hold it (ah, only a few trustworthy kiddos) and shake it themselves. 

These little things – the familiar characters I can share, the nail polish Mr. Apron chooses, the wristwatch I use to make sure I’m giving them the right amount of therapy – make me more kid-friendly.  It doesn’t have to be Mickey Mouse scrubs, or a shirt with the entire alphabet on it.  They don’t care about how tall I am, how I wear my hair, what religion I observe, or how old I am.  They don’t care I can find acceptable gifts for my mother this year, or if I remembered to shut the dog gate this morning.  They only see what I can present to them.  Inadvertently, or by choice, I have found little gimmicks that can help me do my job by making communication with me a little more exciting, a little more rewarding, and, hopefully, for the hard-to-reach kiddos, irresistible.  

Mr. Apron and I were discussing last night, or this week, how change comes so very slowly.  We were particularly discussing starting new projects, new careers, new businesses, and how “five year plans” may look very different indeed at the five-year mark from how they were initially projected. 

We then moved onto talk about one of my kiddos at work — I’ll call him Antoin — and how slow his progress is in speech therapy.  I’m pretty sure (110%) he has childhood apraxia of speech, which means he has difficulty sequencing the movements needed for speech.  His speech is enormously difficult to understand and I’ve taken to fretting more than I should about how arduous and painstaking slow his progress has been.  How slow any progress or positive change is. 

Today, I had some blessed down time.  Many children were absent, and the children who were here, I had already seen this week.  I had a lovely lunch with Monet, where she requested for and consumed three bowls of mandarin orange segments, and then I came  back to the office.  I spent the next hour writing up an IEP for this afternoon, and making materials.

In grad school, making materials was a necessity.  There were premade flashcards and commercially available toys and such in the cabinets, but they were often being used by the other 59 student therapists at the clinic, or they were inappropriate for our clients’ needs.  I had one little guy who said so few consonants correctly I couldn’t find any word targets that focused on only one sound he was learning.  So I made my own.  I found and printed images from google image, cut and pasted them onto record jackets (excellent weight cardboard), and laminated them in the back room, inhaling the heady fumes of melting plastic.  At my school-age practicum, I continued to make materials when I grew tired of the materials in the cupboard, or when I was looking to tailor an activity specifically to a child’s targets.  One little boy was having difficulty answering questions and using pronouns correctly.  I don’t even think he knew what I wanted him to do.  I drew a boy and a girl, several props (jump-rope, skateboard, bicycle, book, snacks), and three backdrops (home, school, and playground).  I started by just placing a character on a background, and asking where the boy/girl was.  Since there were few distractions (compared some some I-Spy-style of other illustrations), they had more success.  I upped the ante and gave the boy/girl a prop.  “What is he doing?” I asked.  And they were able to do this.  I worked on “he” and “she”, and even “they”.  The interactive nature of the toy meant I had raptly attentive six-year-old boys, and because the materials were done thoughtfully, I was able to achieve my (and their) objectives.

Today I found myself again making materials.  This time it’s not because there are no commercially available tools, or the center doesn’t have money for educational materials.  The kids in room 6 are starting to get assigned daily “jobs”, such as feeding the fish, holding open the door, and, the perennial favorite, being the line leader.  On Monday I saw them struggling to tell the teacher which job they wanted, without any sort of visual hint.  They ended up asking for jobs that were already taken, or just telling the teacher where they wanted to play.

So today I made a job board.  I found images online, printed, laminated, and glued them to a recycled file folder.  Now the teachers can use clothespins with the kids’ names on them to select daily jobs. 

I presented my gift to the teacher this afternoon.  Why did I bother?  This is not in my job description, per se.  It will end up helping the children I support in that room, but it was not done with them specifically in mind.  I’m not particularly smitten with job boards, but I do love to see kids helping out in the classroom.  After seeing so many daycares where the teachers don’t know what to do with the kids while they, the adults, set the tables, it’s refreshing to see teachers who want a systematic way to involve the kids, and lighten their load. 

But I didn’t set out to that end, either.  There are so many changes I want to make here, so many ways I see I can enrich the experiences of all the children, but I am not their teacher.  Those are not my classrooms.  I do not run them, I do not make my own decisions about materials to go in them, the routines the kids do, or the objectives they learn.  I am part of a team.  If I want to stand a chance at introducing my knowledge and experience in music-based transitions, at brainstorming new ways to organize and stock the house corner, at rearranging the furniture to decrease running and facilitate ample room for circle time, at innovating new art materials, I have to build my rapport with the team.  I have to build relationships and trust with the teachers.

No one likes anyone new to come from “outside” and descend upon her and tell her how to do her job.  I’ve seen and heard the vitriol aimed at the program directors who mix and match lead teachers and associates, who dictate new bizarre mandates, and who change things from above without consulting the teams.  I have no need for those attitudes. 

Even though the changes I want to make are not huge, they are significant, and I need to make baby steps into the collaboration between teachers and therapists.  If change occurs in a thousand tiny moments, I need to seek out and seize those moments as they come by.

And that’s  why I was inhaling the fumes of melting plastic this afternoon — to start making the thousand tiny changes.

On most Mondays, I’m supposed to see about 16 children.  The kids are at the center from 8:30a till 2:30p, so I need to see 16 kids in 6 hours, including my gracious 30 minute lunch, so that’s actually 5 hours 30 minutes, an average of 20.6 minutes per child.  Most children are supposed to receive 30 minutes of therapy, and some get 45 minutes.  How is this possible?  Well, it’s not new math, my friends; it’s grouping and getting creative.  Grouping, in a traditional sense, looks like 3-4 kids sitting around a table in a little closet doing flash cards or a board game working on telling stories or the /f/ sound.  In inclusion therapy, I’m “pushed in” to the classroom, doing therapy during circle time, center time, and outdoor play.  While it’s nice I don’t have to pull a child out of something as cool as making pancakes, or as important (to me, anyway) as storytime, it can be challenging to feel like I’m doing therapy sometimes.  Which is where creativity comes into play. 

Hey, Josie and Anna are both at the sand table.  Josie is working on social interaction with peers, and Anna needs to work on having two-way conversations with human beeings.  Instant group.  Another time, I sit down with Juan to play a board game, casually yet effectively emphasizing words he misarticulates, when A.J. wanders over, wanting to play.  Then Martina spies what looks like a rousing game of Chutes & Ladders.  Never mind that Martina is not on my caseload.  I justify having her as a mature speech “model” for the boys, and I work with Juan on his /s/ blends (spider, snowman, sleepy) while I gently drill A.J. on his /k/ sound.  Instant group.  Yet these are the easy ones.  There’s circle, outdoor play, and breakfast to contend with, not to mention “small group” (a curricular institution I have yet to fully grasp the concept or purpose of).  Sometimes, when I’m supposed to see 5 children in 2 hours (24 min/child), and one of them is supposed to receive 45 minutes of therapy, and they all have the nerve to show up that day, I sandwich myself between two of them at breakfast.  I dole out Cheerios for Anita as she smacks her bowl to ask for more, while talking with Charlie about what he did last weekend or where he wants to play today.  At circle time, I am able to “support” Parker by seating him on my lap so he’ll attend to the story, while modelling gestures, signs, and choral responses (so Gina can follow along, and to increase her participation, while encouraging Dominic say some of the words the teacher leaves out) to “We’re Going on a Bear Hunt” while the teacher reads.  And somewhere along the way, if I didn’t sit at circle with Parker for 30 minutes, I’ll add onto it later by cuing him to ask for help putting his coat on; for Dominic, I’ll sit down with him during free play and do a puzzle; and for Gina, I’ll sit in the kitchen while she doctors up a baby doll.  Each kid can’t get 30 minutes of my undivided attention, nor can I work directly on therapy goals each day.  Many times, it just looks like crowd control, or herding kittens, just trying to get everyone to go along with the classroom routine.  And that’s usually okay. 

Today, however, instead of my usual 16, I had 6 kids out!  Some of the medically fragile kids are out with regularity, and some kids, due to their diagnoses, take longer to recover from ear infections, but my Monday group is strong.  Not only that, when I checked the absentee list on my way to the classroom at 8:32am, only one name was on it — a child who is not on my caseload.  Yet when I arrived downstairs, I was informed that two were absent from one room, and two more from another class.  And in the afternoon, as I dashed in from my manic lunch/note-writing marathon, I found only 4 kids on my caseload, down from 7.  So I got ahead for later in the week by seeing 2 Thursday kids, but, more important, I felt good about the therapy I was doing today. 

I spent a focused lunch period working on imitation with a 3-year-old boy with autism.  He whose IEP said he was not imitating anything and had no words back in October was imitating myriad syllables for me today: ba, bee, bye, bo, boo, pa, pee, pie, po, poo, ma, me, my, mo, moo.  And on and on.  Each time I got to a ba, pa, ma, ha, da, or ka word, I’d linger on the ahhhhhhh long enough for his mouth to be open, and I’d slip some pureed bananas inside.  Working on eating at school (a goal) and imitation of speech sound (another goal) during focused practice.  Damn, it felt good.  Then, seeing how attentive the kid was to me, his “girlfriend”, one of the teachers threw 2 syllables together so the kid said my name.  And as lunch finished, I signed and said “all done”.  And so did he. 

The two little girls, Josie and Anna, really were at the sandbox together today .  According to the teacher, they’ve suddenly discovered each other, which is a real boon to me.  I was able to sit near them and observe as they made “pancakes” together.  I cued Josie to ask Anna for some sand, and she did.  I was able to convince Anna, the stubborn one who only wants things her way, to trail after her friend Josie to do puzzles together, even though she at first flatly refused.  They finished, then took my suggestion to trade puzzles, and finally to go find new puzzles.  As one left the table briefly, the other wondered aloud, “Where’s Anna?”  It was all I could have asked for. 

Finally, with a boy who takes most of lunchtime to process that we’re having lunch (seriously — lately he’s been starting to eat during the last 5 minutes of lunch), I got some fabulous imitating and requesting for stickers.  He sat next to me, and 25 times said “Shickuh” or “sickuh” when I asked him what he wanted.  This from a kid who usually mechanically pats his chest — a sign which is supposed to mean “me” or “mine” — to mean anything from “I want more” to “My turn” to “You took my toy” to “I want to play in the block area” to “It’s time to get coats on to go home.”  Somehow he was just cued in today, had taken up residence on the planet.  He liked my goods (stickers, of course), he had a plan (to cover the perimeter of his paper with circle dot stickers), and all he needed to do was ask.  Sometimes it’s so simple. 

Days like this, when I only have to see 11 children, when I feel like I’m using my education, when I’m seeing children make change and progress, are days when I feel like I’m doing good therapy.  Not all days can be like this.  Many more are insane because teachers are out and kids are in, because lunch is late or the fire drill lasts too long, or because I’m grouchy and so are the kids.  Yet days like today, where I feel like a real speech therapist, will hopefully get me through the other days where I feel like a coat zipper, a shoe tie-er, a nose wiper, and a seat belt.  You know, days like tomorrow.