Speech and language therapy addresses the communication needs of children. Speech therapists work on language comprehension and pronunciation skills. Alternative communication systems for non-verbal children can also be developed through speech therapy.

By Nicole Klimas
Assistant editor of ADVANCE, February 25, 2002

MALVERN, PA—Four-year-old Justin is filled with boundless energy. He comes into the gym area, tumbling onto the mat in the center of the room, while his mom reminds him to take off his shoes. He runs around giving high fives and hugs to the adults standing around watching him and then dives onto the swing hanging from the celling.

Cassidy is more subdued. She clings to her mom as they enter the large room, and the 2- year-old shyly looks around with big blue eyes. At first she's a little intimidated by all the adults standing around, but she eventually gets comfortable as a friend coaxes her away from her mom and into the center of the playroom.

Looking around the room, visitors see walls adorned with brightly colored crayon cutouts; corners crammed with toys, including a dollhouse, a miniature kitchen set and cardboard building bricks; and a small trampoline near the mat that dominates the center of the room.

However, this is not your typical child's gymboree. Justin and Cassidy have come for a play date with their speech-language pathologists at Theraplay, a therapy center that provides pediatric physical, occupational and speech therapy services in a play environment. Justin was diagnosed with Pervasive Developmental Delay-not otherwise specified (PDD-NOS) right before his third birthday, and Cassidy has typical language delays. Justin and his mom, Joanne, come two hours a week for speech and occupational therapy, while Cassidy and her mom, Maryanne, visit once a week for speech therapy.

Clinicians at Theraplay use toys, games, puzzles and books to provide speech, physical and occupational therapeutic services to children ages 0-21. Most are between the ages of birth and 12. Many of the children have autism, auditory processing difficulties, articulation problems or expressive language delays. Clinicians also see children with cerebral palsy and Down syndrome.

Incorporating play activities into therapy sessions helps to foster carryover into activities outside of the therapy room.

A typical activity involves using miniature figurines of characters, like Winnie the Pooh or Scooby-Doo, to create scenes that address linguistic concepts, according to Laura Ackerman, MA, CCC-SLP. For example, a child may be asked to hide a figurine and then use language to direct a parent or clinician to find the object.

Activities also may revolve around concepts such as "same" and "different." For instance, a clinician may have a child sit on the floor and hand all of the objects that are the same to the parent or a stuffed animal. This activity works well for carryover because the parent can easily do this activity at home, such as matching socks while the parent is folding wash.

Bamyard Bingo™ is a favorite game of many of the younger children at Theraplay, reported Dana Boettinger, MA, CCC-SLP, who is on staff at a Theraplay center located in Horsham, PA. She uses the activity in exercises that address matching, naming and following directions.

For older children she recommends Hi-Ho! Cherry-O and Clue Jr., which require the use of expressive language skills to explain the directions, comment on the game, or describe what is going on. Boettinger also may use the games to do some articulation drills with the children. In addition, books, puzzles, and arts and crafts are used with all age levels.

Speech-language pathologists at Theraplay do some co-treatment with physical and occupational therapists depending on the individual needs of a child. If a clinician encounters a problem, there is a free exchange of information among the various disciplines. For instance, a physical therapist may offer recommendations regarding positioning for a child with cerebral palsy to ensure the best possible outcomes.

Family involvement and home activities are a major component of the Theraplay philosophy, which advocates the carryover of skills outside the traditional realm of therapy.

"It's wonderful if the children can use their speech skills here, but the world is much bigger than that," Ackerman said. "Mom and dad are with them more often, and they're their primary teachers. We like to give parents tools and skills to work with and teach the child so the child is continually learning."

Parents are involved at all levels of the therapy process. They can address questions and concerns with therapists and are invited to take part in the therapy session.

"They usually have an opportunity to see me set up a game," said Ackerman, "then I bring mom or dad into the game so all three of us are playing. I then pull myself out so I have an opportunity to watch, observe, and give the parent some pointers."

Parents are encouraged to bring familiar or favorite toys from home to be incorporated into their play therapy sessions.

"Laura gives me suggestions for things to do with Justin," Joanne told ADVANCE. "It's easy to tell a child with autism what to say, but Laura recommended that I ask lead-in questions that force him to think."

Therapy in a play environment is more functional than drill work, Ackerman said. Children learn skills in the environments in which they will be used.

"We try to make it as realistic as possible, but we give them the verbal cues and prompts they need to be successful communicators," Boettinger stated.

"For children with autism, environment is a big thing — it's the key to how well Justin is doing," said Joanne. "Children with autism won't progress as well if they are not comfortable."

"They learn a skill they can then practice on their own," Ackerman said. "They don't have an adult directing their play."

A major benefit of providing therapy in a play environment is that children tend to learn concepts more quickly and are less likely to get bored.

"They enjoy coming to therapy," she said. "Play is child's work; they get paid through verbal praise and tangible rewards."

Combining Work and Play to Help Children Communicate
by Darlene Alu

"Some cases are more difficult than others, so we're always trying new things in an attempt to keep the children interested but also meet their goals," explains Rolfe, who has been a speech therapist at Theraplay for almost a year. The majority of her patients are children with autism, Down's syndrome, Central Auditory Processing Disorder (CAPD) and apraxia. She also sees patients with fluency or general articulation disorders.

"The majority of my cases deal with autism," says Rolfe. Although her autistic patients range in age from two to eight, she says that many of them are preverbal. "Because they haven't started talking yet, we work on the prerequisites for language." Such prerequisite skills include paying attention, taking turns, making transitions, and maintaining eye contact. According to Rolfe, autistic children vary so greatly in their abilities, depending on the severity of their disorder, that treatment is never the same for any two of these patients. "There are so many different levels at which they can be. We might work on increasing their length of utterances, answering questions, formulating questions, telling about remote events, or grammatical training."

Rolfe's caseload also includes a significant number of children with Down's syndrome. For these patients, Rolfe says that finding ways to decrease the frustration they often experience in their attempts to communicate is a top priority. "Because Down's syndrome patients have a tendency towards low-toned facial structures, we work on oral motor activities and exercises that will strengthen their lips and tongues so that their clarity of speech will improve," she says. "A lot of articulation problems as well as language problems are associated with this disorder, so we also work on any specific sound errors the patients may have, as well as increasing their vocabulary and learning to use gestures to communicate."

Rolfe's patients in therapy for fluency problems are all of preschool age, so she incorporates a lot of fun activities into their sessions. "Showing them smooth, slow models of speech through books with characters like Snooky the Snail introduces them to different concepts that carry over into aspects of speech, like taking your time."

Another fun activity Rolfe uses is a treasure-hunt game for her patients with auditory processing disorders. "We work a lot with following directions, so the treasure hunt stimulates them to follow different commands we give them, which lead to an ultimate goal or prize," she says. "We just try to incorporate play into their therapy as much as possible," continues Rolfe. "For instance, in general articulation training, we may have them make up a story with certain sounds in it or play 'I Spy,' finding things in the room that begin with a particular sound."

As one of the newer therapists at Theraplay, Rolfe mainly evaluates children when they first report to the facility, then recommends and provides treatment. Treatment sessions usually last one hour, which includes a wrap-up session during which Rolfe instructs her patient's parent(s) regarding at-home activities for their child. "We always tell them what goals we're working on, how we are working on those goals, and how they can try to continue it [the treatment] at home," she says. "The treatment simply is not beneficial for the child if it's not carried over in the home. Goals can be met much more quickly if the children are working on them at home in addition to their treatment here, and carrying over their goals in the home helps them to carry them over in the real world."

Theraplay often employs "cotreats," in which the speech therapist and another therapist will work together in a session with a child. For instance, an occupational or physical therapist may collaborate with a speech therapist. "Cotreats not only maximize the child's therapy, [they] also enable the two therapists to learn techniques from each other's discipline. Sometimes what the OT does with a patient will motivate him to accomplish more of his speech tasks. I notice it especially with our autistic children. They have sensory needs that, when approached by the OT through movement activities, for example, [help make them] calmer, and their speech flows easier.

"Also during cotreats," Rolfe continues, "there are little things you can learn from the occupational therapist or the physical therapist that will benefit future treatment with a child. I also gain a better understanding of that child's disability when I see certain strategies from other disciplines working in therapy."

Rolfe enjoys Theraplay's small, close-knit atmosphere because it promotes helpful communication between disciplines. "It's a great environment for any therapist, but especially for new therapists because all of the disciplines are right in the same facility. That allows us to bounce questions around or give support to each other, and we all learn so much from one another," she enthuses. "Having other speech therapists here as -- well as multiple people from other disciplines every day -- I feel as though I've learned more in the time I've been at Theraplay than I learned in the year I spent at my previous job." Several home care therapists also work out of Theraplay, and they often provide support as well. "The home care therapists are more experienced and are very helpful when we call them with questions," says Rolfe. "They usually get back to us within 24 hours and always have time to talk to us as they travel between appointments."

Rolfe chose speech-language pathology as her vocation because she "wanted to have a career that focused on helping people." Since she knew that communication is such a vital part of everyday life, she decided to concentrate on helping people habilitate and rehabilitate in that area.

In addition to continuing to study speech disorders, Rolfe is interested in learning more about swallowing and feeding disorders in infants and preschool children. "We have some children in our caseload with dysphagia. The more patients I see, the more I have found that there are many children below the age of three who have speech and language problems as well as feeding problems. That is very interesting to me. [Dysphagia] is different than any of the disorders I've really treated so far," she continues. "Trying to determine why some children prefer certain foods or textures and reject others, and how it relates to their speech and language development really interests me, and I'd like to know more about it."

Continuing education courses specific to dysphagia and numerous other topics are available to speech therapists: Rolfe says she takes advantage of these whenever she can. "There are in-depth training seminars out that enable us to learn more about different disorders," she says. "Having gone to some of the seminars that deal with feeding disorders and working with a therapist who is here from Children's Hospital of Philadelphia, I've learned a great deal in the area of feeding, but would still like to learn more." Rolfe credits her experience at Theraplay with expanding her knowledge of sensory integration which has, in turn, helped her better understand and more effectively treat her feeding patients.

Another of Rolfe's ambitions is to attain further training in behavior therapy and therapy techniques with autistic patients. "Because of the nature of autism, behavior issues exist in treating those patients. All autistic children are different, so a lot of techniques are trial-and-error in overcoming their decreased attention. I just feel that if I have more knowledge in that area, it would help me to find ways to go about getting past that block and beginning treatment, which would make the therapy more efficient. What works in one situation doesn't necessarily work in another, so I take time to read up on autism a lot in journals to see what others in the field are trying."

Rolfe has not narrowed her scope of interests to the study of autism alone, however. "We're seeing an increase in the amount of Down's syndrome patients at the clinic," she says, "so I also look for courses that deal with speech and language problems with Down's syndrome children and speech therapy techniques for these children." Although speech therapists are required to take continuing education courses in order to maintain their certification, Rolfe feels that continuing education would be necessary even if it were not mandatory. "I couldn't imagine not taking them [continuing education courses] because it is such a diverse field with so many disorders and there are always new diagnoses and treatment techniques coming about. I just think that these courses allow me to keep up on everything in the field."

Although Rolfe thoroughly enjoys her time working with children, she naturally experiences the occasional frustrating case. There have been times, she explains, that a patient simply doesn't respond to the therapy being administered. "You'll find you're doing all the different therapies you can, you're trying different techniques, other therapists are doing the same things you are in trying to get the goals met, but for some reason or another, progress isn't being made. You want to see your patient getting better, [but] sometimes he doesn't, so you have to decide whether to keep him on a little bit longer or to discharge him.

"It's challenging as a therapist, because you just don't want to let anyone go who has a communication problem," she continues. "However, it's really not appropriate to continue therapy that isn't making any progress. You wonder if it's really beneficial for that child to go on getting therapy -- or are you just causing him more frustration?

"I got into this field to try and help kids communicate better," Rolfe states. "I really like working with the kids and seeing them make progress and eventually meet their goals. It's so rewarding to discharge a child because he's met all of his goals and is functioning age-appropriately. I have a great feeling to know that I helped them through all of that, and they have a great feeling when they get to graduate from speech class!"

Although Rolfe is committed to increasing her knowledge in several areas of her field, she has no aspirations at this time to pursue a position in management. "I feel that as a manager or administrator, you lose time with the patients," she says, "and I so enjoy my time with the children." Rolfe is confident that she will not change her mind about this. "Even when I am older and have more experience, "I truly feel that I will prefer to be a staff speech therapist. The best thing about a job as a speech therapist is getting to work with the kids and that is what I want to continue doing. The more time I have with the patients, the happier I am."