Strategies for dealing with anxiety, anger and low self-esteem

By Barbara Ellicott , EdD, CCC-SLP

In my early years as a speech-language pathologist, I sometimes was taken aback by difficult patients and tended to take their behaviors too personally. I came to learn that you actually can create roadblocks to solutions by doing this.

The majority of patient challenges have far less to do with you personally than they do with an inability to interpret and understand the underlying causes of behavior. It is extremely beneficial to maintain a receptive openness as well as a sense of humor.

Throughout the years, I have had to learn how to deal effectively with young patients who present special challenges. The following methods have been successful in dealing with children who have anxiety, anger, attention deficit disorder (ADD), and low self-esteem.

One common challenge is anxiety, which expresses itself in different ways depending on the age and/or maturity level of the child.

For example, young children may manifest anxiety through hyperactivity if they are not able to put their fear into words. Maintaining a calm, friendly and relaxed atmosphere in the waiting area and office is helpful. This can be achieved through soothing background music, toys, and a photo of Elmo or other easily identifiable characters on the wall.

Clinicians also can select games to address fears and concerns. For example, in Go Away Monster, by Gamewright Inc., in Newton, MA, each child is given a puzzle-like card with outlines of the items in a pictured room. The purpose of the game is to complete each puzzle. Children are asked to close their eyes, reach into a bag for an object, and say, "Go away, monster." If a monster is drawn, it is placed in a jail where it loses its capacity to scare.

Another favorite game is Not So Scary Things, by Educational Insights in Rancho Dominguez, CA. Children pick a card that corresponds to the scary picture on which they land. Later they land on a Courage Card, which illustrates that the scary thing, in actuality, is not scary after all.

I've found that the feeling of empowerment relieves stress in older children. Games such as speech chess and speech-opoly can stimulate cognitive solutions to problems. When children describe a solution to a problem on a game board with their best speech effort, they're awarded tokens.

Engaging children in some form of physical activity prior to commencing a scheduled speech activity can benefit the therapeutic process. Examples include doing simple stretching, shooting baskets into a mini-hoop, and playing ring toss.

When working with children who have ADD, it's helpful to combine physical activities with meditation and activities that require them to be still and focused. For example, ask a child to sit still with his hands folded for one to three minutes, depending on the maturity level of the child. When meditation time is over, allow the child to engage in a physical activity following each correct (or favorable effort) speech response. During the last few minutes, engage him in a more sedentary activity that requires focus, such as matching speech cards. This variety is the spice of a session, and the child feels rewarded for his modified behaviors.

When working with a young child who has low self-esteem, I encourage the parent who is participating in the therapeutic process to let the child win at most activities without being obvious. For example, I might take the parent aside and demonstrate how to misarticulate the targeted phoneme. The child then demonstrates awareness of the error and attempts the correct articulation.

Most patients who display anger are not angry at the speech-language pathologist. They may have issues with relationships or self-esteem or they may just be having a difficult day.

Simply asking "How are you today?" can create an opportunity for sharing. It's helpful to convey the idea that feeling vulnerable at times is a fact of life.

When dealing with challenging patients, it's important to remain calm, try to view things from the person's perspective, and be a positive problem-solver.

Barbara Ellicott, EdD, is a speech-language pathologist, learning consultant and school psychologist at Comprehensive Therapeutic Services in Madison, NJ. She can be contacted at drteddy2@earthlink.net.

With Challenging Adults, Spell Out Specifics

Every once in a while a patient is not content with the hours that therapy is available, the location of your practice, or payment procedures. The person may not understand the ins and outs of the managed care bureaucracy and offer to pay you up front, even after being told that this is not legal.

Having had several patients with these issues over the years, I learned the importance of taking the time, when responding to an initial referral, to spell out specifics. These specifics include location, therapy hours, waiting room rules when other family members are present, managed care sequential procedures, precertification and office policies.

If the patient appears to be in agreement, I mail out what I refer to as my "bureaucratic packet." It consists of forms requiring signature and spells out rules and responsibilities for liabilities, as well as brochures, appointment cards, etc.

One form in the packet that requires a signature indicates a charge for a missed appointment if the patient cancels on the same day. I do not charge patients if they are unable to attend due to illness, but I do charge if they cancel because "something just came up."

It took me years before I established such a policy. Why? Because I believe in adhering to the Code of Ethics of the American Speech-Language-Hearing Association (ASHA), which states that thou shall not charge for services not rendered. Feeling I was being taken advantage of and losing pay, I contacted the chair of the ASHA Ethics Committee, who informed me that although I couldn't charge the full fee for the session, I could charge "just enough to make it hurt." That is what I do now, and guess what? In more cases than not, the patient elects to come to therapy.

Taking the time to explain specifics and put them in writing ultimately saves a lot of professional time and prevents headaches in the future.

–Barbara Ellicott , EdD, CCC-SLP