Triangle School Therapies: How Therapists can help Classroom Teachers

■ Kathleen Cornell, M.A., CCC-SLP

■ Michele Diaz-LaManna, PT

■ Jacqueline Hughes, M.A., CCC-SLP

■ Noreen Koval, M.A., CCC-SLP

■ Colleen McCarthy OTR

■ Jennifer Perhac OTD OTR/L

■ Nicole Shahinian, M.A.,CCC-SLP

Occupational Therapists

What does an Occupational Therapist do in the school setting?

● Adapting activities and environments so all students can successfully participate

● Increase independence in daily living skills● Recommend assistive technology or strategies to increase learning

access and participation● Increase attention by recommending motor breaks and alerting activities● Addressing sensory needs ● Addressing deficits in motor skills that are impacting a student’s

education ● Visual perception/motor and handwriting skills

How might this look in your classroom?

● Specialized seating, recommendations for classroom layout or student specific ideas.

● Suggestions for fine motor development which impact use of classroom tools and also independence in self-care.

● Suggestions for use of Ipad/computer to increase independence and performance.

● Low tech ideas, such as; pencil grips, specialized paper, adaptations for independence.

● Developing simple motor breaks to do with the entire classroom, or ideas specific to an individual student. Recommending calming and alerting activities for use in the classroom.

How might this look in your classroom cont’d

● Addressing sensory needs for students with sensitivities that may impact participation in the school environment. For example, using headphones during individual work time or fire drills.

● Providing strategies to aid in development and improvement of handwriting; handwriting programs to teach letter formation. visual cues for line alignment and letter size, ideas for proper spacing between letters and words.

Fine Motor is more than using the correct pencil grasp….

Signs a student may have fine motor deficits

● Difficulty holding scissors and cutting shapes when age-appropriate

● Trouble with letter/number formation or reverses letters● Avoids fine motor activities● Trouble using an effective pencil grasp● Fatigue when coloring● Difficulty erasing without tearing paper● Writes too lightly or too dark and written work is illegible● Difficulty putting on coat, managing buttons/zippers/snaps, or tying

shoes (from what is age appropriate)● Switches hands during activities

Visual Perception/Motor Skills

Vision is much more than seeing. While our eyes see the world, our brain has to process this information to produce a meaningful and appropriate response. Students with visual processing deficits may struggle in many areas during the school day and impact them both academically and socially.

Signs that a student may have deficits in visual processing.

● May have reversals: b for d, p for q or inversions: u for n, w for m● Has difficulty negotiating around the school, may constantly bump into obstacles in the

environment.● Turns head when reading across page or holds paper at odd angles, may have poor

posture when writing.● Cannot copy accurately● Loses place frequently● Does not recognize an object/word if only part of it is shown● Holds pencil too tightly; often breaks pencil point/crayons● Struggles to cut or paste● Misaligns letters; may have messy papers, which can include letters colliding, irregular

spacing, letters not on line● Difficulty recalling things they have seen which may impact reading, spelling, and writing

performance.

Sensory Processing in the Classroom

Sensory processing refers to how we interpret and react to the multitude of sensory information that our body is taking in. Touch, sight, sound, movement, body awareness, taste, and smell are all senses that we are constantly in touch with during our day. To effectively work within our environment we must be able to functionally process all of this information. Students that are over or under sensitive to sensory information may present with behaviors are interfering with learning.

Signs of a student being overly sensitive

● Be unable to tolerate bright lights and loud noises ● Refuse to wear clothing because it feels scratchy or irritating-even after cutting out

all the tags and labels-or shoes because they feel “too tight.”● Be distracted by background noises that others don’t seem to hear● Be fearful of surprise touch, and avoid hugs and cuddling even with familiar adults● Be overly fearful of swings and playground equipment● Often have trouble knowing where their body is in relation others and bump into

people and things; or appear clumsy● Have trouble sensing the amount of force they’re applying; for example, they may

rip the paper when erasing, pinch too hard or slam down objects.● Have extreme meltdowns when overwhelmed

Signs of a student being under sensitive

● Have a constant need to touch people or textures, even when it’s not

socially acceptable

● Not understand personal space even when kids the same age are old

enough to understand it

● Have an extremely high tolerance for pain

● Not understand their own strength, may use excess pressure when writing

or coloring.

● Be very fidgety and unable to sit still

How can Occupational Therapy be implemented in your classroom or for a student?

• Direct, pull-out therapy - Therapist working directly with the student(s) in the OT room through IEP or 504 plan.

● Direct, push-in therapy - Therapist working directly with the student(s) in the classroom/educational setting through IEP or 504 plan.

● Consultation - Therapist observes student, contacts teacher regarding difficulties that are seen in the classroom and offers suggestions for improvement through IEP or 504 plan.

● ASK US!!! While we cannot work directly with a student without consent from a parent, we would be more than happy to provide general ideas and recommendations.

Physical Therapist

What do School-Based Physical Therapists Most Often Address?● Assist students in meeting educational goals and accessing all areas of their

environment● Functional Mobility● Adapting the environment for student success● Positioning/Seating/Assessment of desks and chairs to promote optimal learning● Address foundational gross motor skills● Address balance and its effect on school functional skills● Provide consultation regarding emergency evacuation of students● Provide vestibular activities to soothe and increase attention● Increase Mindfulness and attention

Physical Therapist

Physical therapy classroom strategies may include:● Desk/Chair adaptations ● Mobility adaptations● Activities to increase endurance and balance● Class gross motor groups● Adapted yoga poses, mindfulness and breathing activities● Push-In to gym class

Physical Therapist

Students who take several MOVEMENT breaks during their day are most SUCCESSFUL!

Speech Therapists (Speech Language Specialists/Speech Language Pathologists)

In class presentations on:• Using Clear Speech (with a chart for classroom use) • Using Appropriate Speaking Volume (with a chart for classroom use)• Using Appropriate Rate of Speech (with a chart for classroom use)• Social Thinking and Self-Regulation in the Classroom

Teacher training in:• The Visualizing and Verbalizing Program • The Zones of Regulation Leah M. Kuypers

Referrals for Speech Concerns

What are the speech related issues that get referred to the speech language pathologist?

• Articulation issues (mispronouncing sounds, not saying the beginning or ending sounds in words, distorting sounds in words)

• Voice issues ( hoarse voice quality, harsh voice quality, losing the voice a lot of the time)

• Speech Fluency Concerns (stuttering)• Selective Mutism ( a student who is refusing to speak at all in one or more

environments)

If a child’s speech pronunciation is hard to understand, what do I do?

• Listen to the child’s speech and write down exactly how they are misarticulating sounds

• A good way to analyze a student’s speech is to have them read aloud to you, and you write what sounds they are actually saying above the mispronounced sound in words.

• Once you have a good list of the sounds the student is mispronouncing during reading aloud, then you will see if he/she is mispronouncing the same sounds in conversation.

I am not sure what I am hearing?

• If you know a child is saying a sound incorrectly, but you are not sure what he/she is saying, just put a question mark over the sound to indicate that it is not being pronounced correctly.

• If a child leaves out a sound or syllable, just cross it out to indicate the child did not say it at all.

What if the child is not reading yet?

• You can show a child some pictures of common items and have him/her verbally label the items by answering, “What is this?”

• Then you write down the sound the student is saying instead of the correct sounds

• use a question mark over any sound when you are not sure what is being said• use a slash if a student is not saying a sound or syllable in a word.

Now you have a list of the sounds the child is not pronouncing correctly, what’s next?

• You will look at the district’s accepted developmental norm document and circle the sounds the child is mispronouncing.

• Then you will check to see if any of the sounds are beyond the age at which 90% of the population has achieved mastery.

• The male and female ages of mastery are different so you will need to take note of which age/gender applies to your student.

• If gender is not mentioned for a sound, then the age of mastery is the same for both male and female students.

• If you have questions, you can contact me at any point. Ext. 2960 or nshahinian@htps.us

The child’s age is beyond the age of mastery for a sound(s), what’s next? • You will fill out part of the pre-referral

intervention form. You will fill out the parts seen in the example on this page.

• For Speech Language Specialist, you can put Nicole Shahinian.

• You can ask Nurse Kim to give you the screening date for hearing and vision and note whether or not the student passed. Also, you will need to document any medical concerns or allergies.

• You should also attach the document you created with the student’s mispronounced sounds.

• You will also need to describe how the student’s pronunciation problems are affecting him/her in class.

The child’s age is not beyond the age of mastery for a sound(s), what’s next?

• You will still fill out part of the pre-referral intervention form. You will fill out the parts seen in the example on this page.

• Even if a student is not at the age of mastery for speech sounds, you will still be able to work with him/her on pre-referral strategies that can help encourage proper speech development.

After you fill out your portion of the pre-referral intervention form, what is next?

• Contact the speech language specialist to meet with you about your concerns regarding the child’s pronunciation.

• Once we meet, I will fill out the date of pre-referral meeting and the projected date of review.

• The date of review will be based on the amount of time the child will receive pre-referral strategies in the classroom to improve speech pronunciation.

• The time frame of pre-referral strategies will usually be a minimum of several weeks and will vary depending upon the success and speed at which the student is able to improve speech pronunciation with pre-referral strategies and how close they are to the age of mastery for the target speech sound(s).

After you fill out the front portion of the pre-referral intervention form, what is next?

• I will go over the students pronunciation errors with you so I understand what he/she is doing, so I can explain to you the proper strategies to help you work with the student on improving his or her speech sounds.

• We will take the appropriate strategies from the list above and write their number below along with any dates that we meet to discuss strategies that can help the student improve pronunciation skills in the classroom.

• I will also write a description of the student’s status on the day of the meeting.

• Any of the meetings regarding pre-referral strategies can also include the student’s parents, especially if they are willing to work on speech sound stimulation at home. If they are interested, I would be more than happy to give them worksheets to work on at home to encourage speech sound development.

Once you understand what strategies you need to use in class with a student, what is next?

• You will be doing the pre-referral intervention strategies with the student for a period of time to stimulate proper speech development.

• Then around the review date, I will contact you and we will meet to discuss what the next steps are.

• If the student is progressing with increase correct production of the sound, we may continue classroom strategies for a while.

• We can add new strategies from an attached document if needed at any point.

• We eventually may refer the student for speech services, if the student does not improve pronunciation with pre-referral strategies.

• A fair amount of the time, pre-referral strategies are sufficient to resolve the speech difficulties! Your hard work with the student shows!

1/15/17

What do you do if a student has a consistently unusual voice quality?

• Examples are: a hoarse voice, a scratchy voice, a voice cutting on or off, or often having no voice to speak• First, you must keep data for a few weeks regarding the student’s daily voice quality and fill out pre

referral form and contact me.• Then you would need to email/call the parent to give them your data on the voice concerns and ask if

they have spoken to the pediatrician about the child’s voice issue.• If the voice issues persist, without any news from the parents for a few weeks, it would be important

to express your concerns again to the parents along with your data regarding how long the student has had the voice issue in your classroom. You will need to ask the parents again if they have taken their child to see the pediatrician regarding the voice issue.

• Parents taking the child to the pediatrician is the first step in dealing with a voice issue.

• The child would need to be seen by an otolaryngologist, an ENT, before a speech language pathologist could do an assessment for voice issues.

• The ENT would need to give the parents a prescription for voice evaluation/ voice therapy with a medical diagnosis so the SLP can address the voice disorder.

What do you do if a student stutters?

• See the parts of the pre-referral for speech services fluency form that you need to fill on this page.

• On the date that you write on the form, you need to speak with me.

• I will clarify any questions you have about presenting concerns and behaviors.

After you fill out the top of the fluency pre-referral form, what’s next?

• I will review the suggested pre-referral intervention strategies with you and we will decide which are most appropriate for your student.

• The strategies will be implemented and reviewed depending on the amount of progress the student is making, he or she may continue with classroom strategies or the student may be referred for a possible speech evaluation.

What if a student will not speak at all in one or more environments in school?

• Selective Mutism by definition is when a person is not speaking in one or more environments

• Initially, contact Nicole Shahinian (ex2960), I will discuss with you/help you with deciding which strategies will best help your student function in the classroom.

• Also, an IEP/504 plan is sometimes beneficial in order to define ways to lessen anxiety while encouraging mainstreaming.

What if a student will not speak at all in one or more environments in school?

• First gather information, speak with the teachers who deal with the student in specials and speak to the lunch aid to see if the child speaks in those environments.

• Fill out the parts of the pre-referral form noted on this page.

After you fill out my portion of the per-referral form, what’s next?

• Please try to seek me out the same day or day after you fill out your portion of the form.

• I will review the information filled out with you and find out about the issues the student is having with communicating, and then I will review the suggested pre-referral intervention strategies with you. We will then decide which are most appropriate for your student.

• The strategies will be implemented and reviewed depending on the amount of progress the student is making, he or she may continue with classroom strategies or the student may be referred for a possible speech evaluation.

General question: When are parents notified about concerns with students’ speech during any step in the pre-referral process?

• With any issue with a student’s speech, the parents should be notified at each step.

• Teachers should describe objectively what the concerns are and what recommendations have been made such as pre-referral strategies.

• If parents are interested, I am more than happy to meet with them as well, to explain the strategies to them so they can stimulate proper speech development at home.

• Notifying parents at each step:• makes parents feel comfortable in the long run with the speech

pre-referral/referral process • allows the parents an opportunity to work on speech issues at home, which only

further helps proper speech development

Call me or email me anytime with questions.

• Nicole Shahinian MA CCC-SLP ext. 2960 or nshahinian@htps.us

• Please feel free to give my information to parents of students anytime, if they have questions.

• I hope this was helpful and informative.

What if I have major concerns about a student’s communication skills/behavior, and the problem isn’t related to pronunciation/voice/fluency?

• You take your data and documentation of the student’s significant difficulties with communicative functioning in the classroom to I&RS, if you see significant issues with the following:

• The student does not make sense when speaking or when writing sentences, not because of pronunciation issues, but due to significant difficulty with using the proper word order, specific vocabulary, and/or appropriate grammar.

• The student cannot follow orally given directions or listen to verbally given information and answer verbally given questions with appropriate answers.

• The student uses non-specific language and has significant difficulty: sequencing events/parts of a story, reasoning/problem solving, comparing/contrasting, inferencing, predicting, and understanding/expressing the main idea.

• The student is having difficulty understanding: peer interactions, the emotions or body language of others, other people’s point of view “perspective,” and/or both posted and implied rules, and the student is having difficulty self-regulating

Appendix of Forms (next few pages)

• Speech Developmental Norms• Pre-referral Intervention Form Speech and Language Services: Articulation • Pre-referral Intervention Form Speech and Language Services: Fluency • Pre-referral Form Speech and Language Services: Selective Mutism• Pre-referral Form Speech and Language Services: Voice