Observation Hours:

COMPLETED HOURS: 20

John Hopkins HospitalMay 17, 2016: 9:00 am – 4:00 pmContact: Kate Holden (Head of SLPs at Johns Hopkins Hospital)Worked under:Eleni – Adult Acute Rehab:

1. 85 year old women Breathing through a trach Dysphagia Worked on swallowing Ice chips Neuromuscular electrical stimulation (NMES): The electrical

stimulation when applied in this manner accelerates muscle strengthening, accelerates cortical reorganization (especially after stroke), and increases the effectiveness of the exercise therapy.

Worked on breathing and speaking with a valve speaking purple trach ventilator

On thickened fluids2. 64 year old man

Cancer all over body Tumor on Vagus (CN V) Dysphagia Breath-y – sounded like a whisper Weak left VF Worked on reading out loud to get the VF moving Checked tongue strength – low for age Tongue elevation strength is the maximum pressure of the tongue

pressing against the hard palate. The IOPI measures this when the Tongue Bulb is placed in the “standard” position – agianst the hard palate just behind the alveolar ridge. The image to the right shows this position. You can simulate this placement if you suck on your thumb: the pad of your thumb will be pressing against the hard palate behind the alveolar ridge and your tongue will be pressing on your thumb nail instead of a Tongue Bulb.

Not aspirating – 3 liter water test On thickened fluids

Dana – Adult Acute Care, Surgery Service:1. 65 year old women

General acute care Progressive Aphasia “Yeah” for mostly everything, occasional “no”, but not able to

coherently communicate or understand direction Can follow a model: say, “stick out your tongue” – doesn’t

understand; if you stick out your tongue, they will copy Can recite days of the week and numbers (1-10) – in order

Trach Dysphagia Only on thin purée and water Receives medicine with applesauce

2. 83 year old man Had a liver and kidney transplant Doctor asked to have a cognitive test: patient was having memory

problems, trouble focusing, saying strange things Result: Can’t encode or store new information – visual input was

better received and relied than auditory3. 55 year old man

Just checked in Dysphagia Saw his barium swallow test: A barium swallow is a radiographic

(X-ray) examination of the upper gastrointestinal (GI) tract, specifically the pharynx (back of mouth and throat) and the esophagus (a hollow tube of muscle extending from below the tongue to the stomach). The pharynx and esophagus are made visible on X-ray film by a liquid suspension called barium sulfate (barium). Barium highlights certain areas in the body to create a clearer picture.

Trach: purple valve On thick purée – honey

Chain Bridge Speech & Language, LLCMay 19, 2016: 3:00 pm – 5:00 pmContact: Kristin Keller Daus (Founder of Chain Bridge Speech & Language)Worked under:Kristin Keller Daus

1. 17 year old boy Down syndrome and autism Non-vocal AAC: iPad - Augmentative and alternative communication (AAC)

includes all forms of communication (other than oral speech) that are used to express thoughts, needs, wants, and ideas. We all use AAC when we make facial expressions or gestures, use symbols or pictures, or write. People with severe speech or language problems rely on AAC to supplement existing speech or replace speech that is not functional. Special augmentative aids, such as picture and symbol communication boards and electronic devices, are available to help people express themselves. This may increase social interaction, school performance, and feelings of self-worth.

Worked on syntax Verbs, adverbs, pronouns, commands – on iPad

2. 12 year old girl Worked on reading aloud Summary Relying information Asking questions

Chain Bridge Speech & Language, LLCJune 27, 2016: 9:30 - 12:30Contact: Kristin Keller Daus (Founder of Chain Bridge Speech & Language)Worked under:Kristin Keller Daus

Elliott:almost 4 Post vocalic /t/ /d/ /g/ /p/Trying to master the sounds that are typical for his age so he doesn't get behindVery socialGet syntaxJust needs help focusing on closing soundsLittle bit of a lispOlder Man (40s):Working on accentsFrom South AfricaSelf consciousEspecially on the phoneWorking on /r/ pre, post and intervocalicWants to be understood better/o/ and isWorksheetsChad:15 year oldDown's syndrome VERY socialDoes all sorts of athleticsVery popularSocially motivatedArticulationWorked on reading out loudFocusing on closing soundsTalking slowerSpacing the wordsSeparating the words on paperEx: she | ate | the | appleDifferent because you don't usually spend time working on artic with DS kids because the muscles don't really improve because of the syndrome, but he has come a long wayHe wants to be understood and wants to communicateShort storiesWorksheets

Bethesda Speech for Kids

July 20, 20169:30 am - 10:30; 10:30 - 11:30Contact: Mandy Hart (Founder of Bethesda Speech for Kids; Pediatric SLP and Drama Therapist)Worked under:Mandy Hart

Bran - 4 years old 9:30 - 10:30/Th/ placement - movie /fi/er Very talkative todayLotion on hands then cheeksUse towel on cheeks, lips and throatUsed a bee that vibrates on his cheeks and mouthUse towel to wrap iceSpray ice with flavored spray: strawberry, blueberry and appleGoal - no hot dog bun tongueWant flat, fat tongue30 licksThen he got his own treat of the ice cube sprayed with his favorite flavor

Blow into a balloon30 blows into the balloon - struggled, only did 20

Nook add spray flavor so - Apple Tongue movement Top, sides, all around, inside cheeks"Ca, Ca, Ca""Cry" "green" - tongue sit-up /r/First time he has said green perfectly25X tongue sit ups10 sec restNook is used for stimulation/u/ /is/ - 30X

Chewing stick - 30X on both sides - molarsPuppy dog - shake stick to see strengthBit, open and try to get the tongue in the holeBite all around with stick, Make sure tongue is in mouth

Lip stretchRegular biteStretch mouth out all aroundPush push push - presses on hard and soft palate chin and teeth

Note:Mandy says:

**to get /r/ - backside with nook and tongue sit ups ~ always!**

Pixie StickStick out tongue place the sugar on itWork on swallowing10XThen put the sugar inside cheeks and between top teeth gums and lips, "dump truck" scooping sugar under tongue and scooping it up to swallow, "front porch" in front of bottom teeth Work on tongue movement and placement to swallow

Working on /th/ /r/ with pixie stick - back of mouth!

Go to the tableUse cardsLip and teeth discrimination "Sit and do"Words: categories Teeth vs. lips - v vs. f and thThirteenThermometer ThinkingThermosThumbThreadThighThongs

Listening activity:Paper with mouth, th vs. v or f - place the cards in the correct picture of tongue placementThreadVegetablesVetThirteen FudgeVestThreeThinkingForkVolleyballValcherThongs Thermometer - finally perfect!VaseThermos - perfect!

FeatherFeetThumbThermosThirteenThongsFoodThread (Fred)FurThreeThighThermometer FanThief

/th/ can be hard because in out movement of tongue develops before up downNeed a certain tongue tone

**discrimination is great!****Next week: Working on consonant position - pre, inter, and post vocalic**

Nick - 12 years old 10:30 - 11:30/s/ /z/Skipped lotion, but still used towel for sensory prepTongue licks: 30Working on tongue tone

Balloon blows: 30Working on lip rounding and strengthNot distractedSitting up and straight

Nook add spray flavor so - strawberryTongue movement Top, sides, all around, inside cheeksSoft cheeks"Ca, Ca, Ca""Cry" "crazy" "grace" "crease" - tongue sit-up post vocalic /s/

Chewing stick - 30X on both sides - molarsSlow downImportant to go slowDoing double the workTouch with tonguePuppy dog - shake stick to see strengthBite all around with stick, Make sure tongue is in mouth

Ta ta taDa da daLa la laSlow downIt takes more control to do it slowerOpen mouthNa na naKata kataTaco taco tacoLatka latka latkaKatala katala katalaKit kat kit katChin is nice and still

**speeds up - fatigue**

Lip stretchRegular biteStretch mouth aroundPush push push - presses on hard and soft palate chin and teeth

/u/ /is/ - 30XDoesn't want to do anything says:"Why do I have to do this?"Side is easier than up down

Long /s/ 37 seconds - tongue blocked sound a little bit, breathing and sound/voice support wasn't great

Pixie StickStick out tongue place the sugar on itTongue not to touch lipWork on swallowing10XThen put the sugar inside cheeks and between top teeth gums and lips, "dump truck" scooping sugar under tongue and scooping it up to swallow, "front porch" in front of bottom teeth Work on tongue movement and placement to swallow

Long /z/ - 47 seconds

**/z/ is usually longer**

Use floss to get the small enough space needed to get a quality /s/

Did not want to do tongue sit ups;

claimed he already done them in the session

/ks/Books bakesTusks LocksDocksDucksKicksSocksPoxesBoxFoxFixTricksTracksLooks

Homework words:SlippersSlideSportSpringsStartSledTuskNestIsCrustCreaseWasSaidSpider4X over

Say the word and then make a sentence /u/ /es/Focus on stretching the lips - big smile

Silly sentences:/s/ with cards

Bethesda Speech for KidsJuly 13, 20169:30 am - 10:30; 10:30 - 11:30Contact: Mandy Hart (Founder of Bethesda Speech for Kids; Pediatric SLP and Drama Therapist)Worked under:Mandy Hart

Bran - 4 years old 9:30 - 10:30/Th/ placement - movie /fi/er Lotion on hands then cheeksUse towel on cheeks, lips and throatUse towel to wrap iceSpray ice with flavored spray: strawberry, blueberry and apple30 licks - could only do 25Very distracted todayThen he got his own treat of the ice cube sprayed with his favorite flavorBlow into a balloon30 blows into the balloon - struggledChewing stick - 30X on both sides - molarsPuppy dog - shake stick to see strengthBit, open and try to get the tongue in the holeBite all around with stick, Make sure tongue is in mouth

Nook add spray flavor so - strawberryTongue movement Top, sides, all around, inside cheeks"Ca, Ca, Ca""Cry" "green" - tongue sit-up /r/25X tongue sit ups10 sec restNook is used for stimulation/u/ /is/ - 30X

Lip stretchRegular biteStretch mouth aroundPush push push - presses on hard and soft palate chin and teeth

Pixie StickStick out tongue place the sugar on itWork on swallowing10XThen put the sugar inside cheeks and between top teeth gums and lips, "dump truck" scooping sugar under tongue and scooping it up to swallow, "front porch" in front of bottom teeth Work on tongue movement and placement to swallowPut sugar on teeth for /th/ spot

**next session do depressurization before session**

Go to the tableUse cardsListening activityLip and teeth discrimination "Sat and do"Words: categories Teeth vs. lips - v vs. f and thThirteenThermometer ThinkingThermosThumbThreadThighThongs

Listening activity:Paper with mouth, th vs. v or f - place the cards in the correct picture of tongue placementFishFood Thermometer VacuumThirteenThinkingFeetThermos - only one wrongFanForkThreadVanillaFurThongsThigh

Pup pup pirate game: Said a word right, put a fake knife in the barrel and a private jumps out when he gets 5 - 10 right2X

Pretty good at self correctionSays /fai/ instead of /(theta)ai//fermes/ not thermos

Nick - 12 years old 10:44 - 11:45

/s/ /z/~ Sensory prep ~Tongue licks: 30Working on tongue toneBalloon blows: 30Working on lip rounding and strengthNot distractedSitting up and straightTa ta taDa da daLa la laSlow downOpen mouthNa na naKata kataKit kat kit katChin is nice and still

Nook add spray flavor so - strawberryTongue movement Top, sides, all around, inside cheeksSoft cheeks"Ca, Ca, Ca""Cry" "green" "grace" - tongue sit-up post vocalic /s/

Bite line ups10 sec rest

Chewing stick - 30X on both sides - molarsPuppy dog - shake stick to see strengthBite all around with stick, Make sure tongue is in mouth

/u/ /is/ - 30X

Long /s/ 43 seconds - tongue wasn't blocking sound at all

Tongue sit ups - 30

**speeds up - fatigue**

Counting teethRetract and lax tongue and have to control tongue tip

Long /z/ - 50 seconds

Lip stretchRegular biteStretch mouth around

Push push push - presses on hard and soft palate chin and teeth

Pixie StickStick out tongue place the sugar on itTongue not to touch lipWork on swallowing10XThen put the sugar inside cheeks and between top teeth gums and lips, "dump truck" scooping sugar under tongue and scooping it up to swallow, "front porch" in front of bottom teeth Work on tongue movement and placement to swallowPut sugar on teeth for /th/ spot

/s/ vs. /z/Say the word and out it in your own sentence:Words InsideBendsSoupForkBoxDiceBooksBicycleBoardsFordsBatsWorldsSendsSaysMendsEndsRats

They all sounded great!85% accuracy

Bethesda Speech for KidsJuly 21, 20163:30 - 4:30; 4:30 - 5:30Contact: Mandy Hart (Founder of Bethesda Speech for Kids; Pediatric SLP and Drama Therapist)Worked under:Mandy Hart

Jonas 3:30 - 4:305 years oldNext floor instead of next doorIrregular plurals are offParticular about what he plays withAuditory processing issuesNot oral motor - some LMore focus on languageDrofts instead of draftsSays this and that, need to push the vocabulary and languageNo formal testingJust play and talking"They will have dinner and breakfast when they get back from school" - about the dolls"I(slight - d)know" instead of I don't know"J: They live in the same house, have the same familyM: are they brothers?J: yeah"Had the last doll come out of the back door of the school bus instead of the side door, M: oh yeah you can sure but why not the side door?J: well yeah it does openM: where do they go?J: into the schoolM: in the classroom?M: where's the teacher?J: right here on the slideM: oh the teacher plays on the slide before school startsJ rings the bell, J: bell rings! Time for school!M: what do they do in the school?J: They have to do a lot of thingsM: like what?J: They come out and hop in the school busM: really? I thought that was after school. What do they do during school?J: I don't knowM: do they read and learn?J: Those things are all finished

Sometimes doesn't close his sounds

J: They don't have breakfastIgnored the question, what's their favorite food

M: look there's the clown, what does the clown do?J: That's the funniest that juggles

M: Is that a rooster?

J: It made that sound

M: do they take showers? Or wash their clothes?J: no they just wipe their clothes off with their hands

M: Who lives here?J: No that's apart of the house

Good turn taking in play, with dolls and with partnerPretend and real life

Struggled:Helicopter ClosetLaid down - going down

J: My mom took me hereM: how?J: in a carThis takes people back to their houses - looking at the carM: Is there a driver? J: No they just go in it

J: We don't have food for breakfast

J: because I can (ump) out the window

J: so he can told the boys to get ready for school

J: Maybe I'll have a (not) on the doorThen said knock correctly and with intention in the next sentence

J: They are going to wake up him.We are going to have to yell to wake up him

J: it changes the vision (on the tv) - he meant channel

J: the airplane will land in the streetM: where will the cars go?J: they will park behind it

M: what does appear meanJ: it came!

M: it appeared from far away; What does that mean? J: It came from somewhere

J: I grew so big

M: the shrinker can shrink you back to your right size

J: he was shrinkened too

When playing with the tellie tubbies- he said I when he was talking about the dollsAs if he was the doll

Struggles with together and apart

J: do you wanna see it,-me.

M: can I put the shrinker awayJ: no you can leave them out

Jessie4:30 - 5:30 years old

Lotion on hands then cheeksUse towel on cheeks, lips and throatUsed a bee that vibrates on his cheeks and mouthUse towel to wrap iceSpray ice with flavored spray: strawberry, blueberry and appleGoal - no hot dog bun tongueWant flat, fat tongue30 licksThen she got his own treat of the ice cube sprayed with his favorite flavor

Struggled with tongue not getting a ride from lower lip! Tongue needs to be tensing and curling

Nook add spray flavor so - Apple Tongue movement Top, sides, all around, inside cheeks"Ca, Ca, Ca""Cry" "green" - tongue sit-up /r/First time he has said green perfectly25X tongue sit ups10 sec restNook is used for stimulation/u/ /is/ - 30X

/r/OrEar

CryGreenCreep - struggled; tongue was too far backGreat

Ta ta taDa da daKatala katala katala Tick tock tick top tick tockLa la laKata kata kata

Tongue sit ups - 30X

Count teeth

Lip stretch Stretch mouth aroundPush push push - presses on hard and soft palate chin and teeth

The Red roller grows

Pixie StickStick out tongue place the sugar on itWork on swallowing10XThen put the sugar inside cheeks and between top teeth gums and lips, "dump truck" scooping sugar under tongue and scooping it up to swallow, "front porch" in front of bottom teeth Work on tongue movement and placement to swallowPut sugar on teeth for /r/ spot

Cards, say and match

GraduateGrapesGrassFriesCrownTrash canCribTricycleBroccoli- struggledDressBreakfast FriendsCrabsBear

CriesGrizzly bearRedGroundGrandfatherFrog - Crayons -BrowniesGrapesPresentBroomPretzelTruck -DrummerBrideGroomBreadFrying panTrumpetPrize Broom -Brownies -Creep -

Then put the words that came up into sentences

Struggled - homework:BrotherBrokeFrozenFrom Fro-yo

Bethesda Speech for KidsJuly 6, 20169:30 am - 10:30; 1:00 - 2:00Contact: Mandy Hart (Founder of Bethesda Speech for Kids; Pediatric SLP and Drama Therapist)Worked under:Mandy Hart

Bran - 4 years old9:30 - 10:30Articulation Just acquired /l/ with 100% accuracy last session and over the last few weeks at home and such/Th/ placement - movie /fi/er Lotion on hands then cheeks

Use towel on cheeks, lips and throatUse towel to wrap iceSpray ice with flavored spray: strawberry, blueberry and apple30 licksThen he got his own treat of the ice cube sprayed with his favorite flavorBlow into a balloon25 blows into the balloonPracticed "who is" with rounding mouth then closing teeth - 25XChewing stick - 30X on both sides - molarsPuppy dog - shake stick to see strengthBite all around with stick, Make sure tongue is in mouthNook add spray flavor so - strawberryTongue movement Top, sides, all around, inside cheeks"Ca, Ca, Ca""Cry" "green" - tongue sit-up /r/25X tongue sit ups10 sec restNook is used for stimulationLip stretchRegular biteStretch mouth aroundPush push push - presses on hard and soft palate chin and teethPixie StickStick out tongue place the sugar on itWork on swallowing10XThen put the sugar inside cheeks and between top teeth gums and lips, "dump truck" scooping sugar under tongue and scooping it up to swallow, "front porch" in front of bottom teeth Work on tongue movement and placement to swallowPut sugar on teeth for /th/ spotThen tried /thumb/

Go to the tableUse cardsLip and teeth discrimination "Sat and do"Words: categories Teeth vs. lips - v vs. f and thFootballVet Vacuum cleanerVanilla ice cream FurThermometerFudgeThreeFan

ThreadThinkingFoodForkFishThermosThreadThongs Thirteen FoodFeetFiveThighFeatherThermometer

Could tell he was manipulating the tongue movement that he used to get the sugar for /th/ sound

Willie - 4 years old1:00 - 2:00Articulation Both parents are foreign - mom Asian, dad middle easternSpeak English at home but their English isn't the bestWent straight for play microphones in the roomPlayed and sang ma ma ma, la la la, ba ba baMics are great for imitation Bench work was a little challenging because not used to itStruggled with yellow (yellow fish on the towel on the bench)But corrected on the third tryFinal constant deletionone eye - "one die"Little lotionSometimes unintelligiblePoints doesn't use words(Same for Bran):Lotion - chocolate chips or smiley faceRub cheeksUse towel on hands and face, lips and throatYellow towelWork on saying yellowSensory prep! (Lotion and towel)

Toy BeeVibratesOn cheek

Ice in the towel for lickingWith flavored spray - strawberry, blueberry, AppleGoal: 20 licksShaking of tongueMuscles are weak, tiredNot very aware of tongue - he is but trouble moving it up, not realizing its still in their mouthLicks like a Popsicle, moves ice rather than tongueUses lips a lotSays Willie as widdie Whistle not as loud more like a kazooLess tension than brans balloon whistle and pipe21 plus 4 he took a breakVs. last session 10 plus 5LispTongue really sticks outNook with AppleNook outside mouth has to use tongue to touch the nookHead compensation Put tongue on the wrong side, opposite side she had it on, he still didn't realize it was wrongCheek compensatingHas to demonstrate mouth open for him to realizeCa ca ca doesn't work for himHe doesn't repeat it backSometimes just stops speakingHe drops his tongue backSoft cheekOn hard palateOn soft palate/u/ /i/ - 10X focuses on lip rounding and closing constantsCongestedSometimes can only breath through nose but you can hear some obstruction when he breaths through noseCheeks are tightta ta ta - tongue sticks outla la la - was able to keep tongue inDa da daNa na naWorking on tongue tip up and in his mouthStill moving whole tongue instead of just the tip but now his tongue stays in his mouthNo more droolingLip stretchesMoving the lips around and make sounds with her kids Utah while she moves his around with a gloved handLots of oral stimulationShe firmly believes it makes a differencePush push on palates and teeth and chin

Pixie stick exerciseOn tongueStick tongue out - 10XTongue thrustGreat gesturing but needs to use words more oftenNeeds to do more describing of what he needs and what is happening around himIn cheeksTense cheeksDoesn't really use articulators everything just stays in one placeNever been to dentistNeeds a palate expanderDidn't get ta ta ta last time but did todayMotor planning difficulty Intimating hand motor is hard for himVery smart just strugglingHolds cheeks to stabilize jawWorking on soft cheeks so he can move his tongueScooter - suder Lots of tongueDoesn't close soundsBall of string - bad swing La la - la lieGets excited and pointDipsy - tipsyOn the String - on the swingTurn the page was okayFell down - fell townHe's spanking - his pickinStopped - not grammar that affects the soundsAgain - AgainstPo - Poy Flowers - FliesFlower - fly or fryOr floway when corrected he corrects it in this waySay new new to work on the word blueEyes is fineString - swingElephant - enafent Up - dup Po is happy was fineNo - noySad - saidHappy - happy-a or happy-eye (both added after the word is said correctly. It's added on to the end)Ball of yarn - ball yardScissors was okayPull - yull I – bye

Pull - poolPiece of - pizzaWind up was goodBall - byeYes - lots of tongue, tongue is completely out of mouthLarry - loudy Tuck it in was goodWhen starts drooling mom says close mouth and swallow and he does as suchHis homework:/u/ /i/Lip top lipTa ta taDa da daLa la laNa na naAll 10-20 times