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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.

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July 2020