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Dismissal – Destination or Dilemma

Sometimes it arrives like a clear day.  You’re sailing through the waters of words, phrases, and sentences with a child; and one day as you walk together to the therapy room your heart soars.  He is chatting about his upcoming family vacation and you’re happily realizing, “It’s over.”  His error-free effortless spontaneous connected speech screams to you that you have arrived at your destination.  The impromptu final therapy session confirms your suspicions.  You talk to his parents that day and predictably they agree that they had just been marveling over his speech clarity.  You’ll miss him you say, honestly, as you part ways.  Sure, you will run into Mom and him 10 years from now in the grocery store.  Mom will excitedly say to him, “Do you remember Miss Sandy?” and his blank look in the produce section will tell you “no, not really, kind of.”  It’s okay.  You will have served your purpose in his life.

Other times, Dismissal arrives in a foggier landscape.  You’re navigating through the waters of words, phrases, and sentences; and correct productions begin to emerge in spontaneous connected speech.   Encouraged, you complete every generalization activity known to man; and correct productions are still “emerging” in spontaneous connected speech. You back-up and re-plow forward.  Emerging but not stabilizing in spontaneous connected speech.  When the child self-monitors, he is accurate; and yet automatization eludes him.  “Can you say ‘plateau?’”  You’ll be heading into an ethical dilemma soon.  How long should you continue in this space?

I would love to hear how other SLPs handle scenario #2.*  I myself work in private practice with out-of-pocket payers, but I imagine it’s even more complicated in other settings. I present to you now rare “footage” of me in action under scenario #2:

With the child I very playfully make the point, “BRING IT HOME WITH YOU,” to supplement our generalization activities.  We brainstorm……What could we do to remind you to use your correct productions outside of this therapy room?  I know, I could move in with your family and remind you during dinner and weekends?  I could go to school with you each day and join you for lunch and recess too?  Is there an empty desk in your classroom I could use?  We could put a reminder sticky note on all of your friends’ foreheads, so that you remember each time you speak to them?   We giggle at the images that we are conjuring up together and determine that these solutions are not feasible.  “Nah, I’ll just try to remember,” he inevitably concludes.  “More home practice,” I silently conclude.

 There’s even more to my “silliness with a purpose.”  I ask the child if they could step away from the therapy table and continue to use their correct speech productions.  “Of course,” they answer and demonstrate.  Hmmm, let’s try it with the door open.  Let’s try it with one foot in the therapy room and one foot in the hall.  We both stand facing each other on the line where the two carpets meet, holding a highly intelligible conversation.  Let’s try it 10 feet from the therapy room.  Yep, you should be able to bring it with you.

 I also call the parents to explain that for several weeks now their child is 100% accurate in all structured activities regardless of utterance length/word position/phonetic context, etc. and over 90% accurate during therapy conversations when he “turns it on.”  We lament that his accuracy decreases outside of the therapy room when he neglects to self-monitor, and we are partially comforted that he has the tools to produce the sound correctly if and when he is so inclined.  Yes, he leaves with a toolbox, we agree.  He should continue to practice in the hopes of automatizing correct productions.  Do you want to take it from here and practice with him, I ask?  This is their dime, and I want them to opt-in or opt-out of my services at this point. 

Some parents will take on the challenge and cut the cord.  The door is always open, I remind them.  We agree to call it a “break,” leaving the door open just in case.  Others appreciate the honesty but prefer to outsource continued practice to yours truly.

What if there was a third option?  A home practice option with TikTalk monitored by the SLP.  TikTalk can be the bridge from direct therapy to independence.  After all, some children are past the point of instruction yet remain in need of practice, repetition, and self-monitoring outside of the therapy room.  I’m looking forward to offering a period of TIkTalk Practicing/Monitoring service to children who are dismissed from weekly direct therapy but would benefit from a period of continued practice directed and monitored by the SLP.

 

*I believe untreated myofunctional disorders can take you to the less-than-ideal place of scenario #2, and I therefore recommend that SLPs continue their education in that sphere.  Still this will not completely eliminate the hazy dismissal dilemma.

– Sandy

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