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Integrated Therapy

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Integrated Therapy

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An effective classroom approach for children with severe or multiple disabilities

By Abigail Scott

AN INTEGRATED MODEL OF service delivery works best in classrooms for children with multiple or severe disabilities, according to speech-language pathologists with the Easter Seal Society for Handicapped Children and Adults of Philadelphia, Bucks, Chester, Delaware and Montgomery Counties, headquartered in Philadelphia, PA.

Integrated teams serving in the Easter Seal classrooms include a speech-language pathologist, occupational therapist, physical therapist, nurse and teacher. Assistive technology specialists and music therapists also may participate when needed.

The Easter Seal Center in Philadelphia offers preschool special education for children ages 3-8. The Bucks County and Montgomery County Easter Seal centers in Levittown and Kulpsville, respectively, each have an approved private school for children ages 2-8. The Delaware County Easter Seal Society Center, in Media, PA, provides classroom services for children ages 0-3.

"We feel very strongly that integrated therapy is the most efficient method of service delivery because everyone is contributing to the classroom routine," said Susan Lantz-Dey, MS, CCC-SLP, who serves on several integrated therapy teams in the Philadelphia Easter Seal Center. "Our goals are coordinated among all the team members, so we are incorporating cognitive development as well as speech-language development and physical development."

The ultimate goal for students in an integrated classroom model is function, said Luanne Suplick, MA, CCC-SLP, head speech-language pathologist at the Bucks County Easter Seal Center. "You are giving meaning to what the children do. Rather than focus on isolated skills, we want them to be able to function in the classroom. Bringing in all the therapists into the classroom helps to focus on treating the whole child."

Nurses, teachers and teacher's aides then can learn first-hand how to solve problems of positioning, presenting material or feeding.

In traditional pull-out therapy, teachers may report a problem to the clinician, but they don't observe treatment and cannot provide input as to what works best for a particular child. "What looked right in the therapy room is not replicated in the classroom," Lantz-Dey said.

Co-treatment can make for richer therapy sessions, but the objectives for the different disciplines must be compatible, Lantz-Dey cautioned.

Cross-discipline planning and close interaction among team members will ensure completion of speech-language goals, reported Joy McGowan, MS, CCC-SLP, consultant speech-language pathologist for all five Easter Seal centers.

The children served by the Easter Seal Society have disabilities that include severe cerebral palsy (CP), muscular dystrophy and severe brain damage. All of the children have cognitive and developmental delays, and many have feeding issues.

Team members incorporate their goals into every activity that occurs throughout the day. For example, a physical therapist may hold a child during circle time to work on breath support, muscle tone and posture. Increased breath support and improved positioning enable the child to produce longer utterances, explained McGowan.

The primary role of a speech-language pathologist on the integrated team is to develop a functional communication system for a child, stated Joanne Van Horn, MA, CCC-SLP, who heads the speech-language pathology department at the Montgomery County Easter Seal Center.

Other team members are invited to give input on communication techniques as well, she said. "We try to develop an openness that considers everyone's creative thinking."

Speech-language pathologists instruct other team members how to improve communication with children, such as offering choices to a child or putting an object just out of reach so the child has to ask for it.

When communication is addressed throughout the day, children learn to recognize and respond to natural cues in their environment, Lantz-Dey said. Generalization occurs automatically, and the potential for carryover increases.

Much can be accomplished even when therapy is provided in small increments during the day, she said. "It may occur five minutes here and 10 minutes there. A lot of times we find that if you have the child for three minutes, you have their attention and interest better than if you had them for 20 minutes and they were inattentive."

Communication needs vary among the children in the Easter Seal classrooms. Many are nonverbal or have only limited vocalizations. Among the systems they use are augmentative and alternative communication (AAC) devices, picture boards and numeric encoding, according to Van Horn

"Communication is not always your traditional speech, sign language or pictures," Lantz-Dey pointed out. "You may be looking at proximity, eye gaze, facial expression or body language."

Proximity and eye gaze, along with positioning, are important considerations for children who use AAC devices. Occupational and physical therapists address positioning, and the integrated therapy model facilitates carryover and the generalization of AAC concepts, observed McGowan. "Training for a specific system can be enhanced and more responses can be elicited when all the team members are informed and aware of the goals that are worked on in therapy."

Isolated, structured therapy makes it difficult for children who use AAC to express spontaneous needs. When these children are in a classroom with their peers, however, clinicians can pinpoint their motivation and needs and decide on appropriate words or symbols.

Speech-language pathologists also assess behavior as attempts to communicate. Behavior patterns frequently translate into consistent messages of physical state, need for attention, or overstimulation. Children with brain damage and conditions such as pervasive developmental delay (PDD) or attention deficit hyperactivity disorder (ADHD) require an environment with low sensory stimulation and high predictability. Listening and responding to behavioral messages leads to significant improvement in subsequent behavior.

The Philadelphia center has designated classrooms for addressing specific issues, such as visual stimulation or sensory organization.

For example, children with limited vision benefit from a classroom that provides increased visual stimulation, such as low lighting and illuminated materials. A vision specialist visits weekly to instruct teachers and therapists in proper stimulation techniques, recommend appropriate materials, and teach team members how to enhance children's functional vision.

Another classroom addresses sensory disorganization and communication disorders that are associated with autism or PDD.

Lantz-Dey cited the case of a child with severe brain damage who made significant improvements in behavior and communication after a year in this special classroom.

The boy initially showed signs of PDD. He wore a helmet because he constantly banged his head, was physically aggressive toward other children and adults, and threw objects, she said. "He was quite a danger to himself and other children."

The interdisciplinary team worked with the child on sensory issues and emphasized behavior modification. He learned to initiate interaction appropriately and engage in purposeful play.

Today "he is starting to talk and uses 13 words productively," Lantz-Dey noted. "He is starting to use a picture communication board, is using purposeful verbal information, and no longer needs to wear his helmet."

The boy was allowed to choose whether to participate in activities, an approach used in the Easter Seals classrooms to reduce negative behavior. He could control interaction and his personal space and could back away from an activity at any time.

Speech-language pathologists, occupational therapists and physical therapists also collaborate on oral-motor and feeding issues.

"Eating is a function of daily living. An integrated therapy model allows the teacher and therapist to address feeding issues in a more typical mealtime environment," McGowan said. "Therapeutic feeding techniques may be demonstrated and implemented in a more practical manner that readily facilitates carryover."

To achieve feeding goals in the classroom, team members look for opportunities to make activities fun, especially if children are sensitive around the mouth. She recommended working on feeding issues around mealtimes with a child's peers present.

While most times services are provided in the context of classroom activities, pull-out therapy, at least to a corner of the classroom, is sometimes needed. Pull-out sessions increase the productivity of articulation and voice therapy and help highly distractible children to focus on a task.

McGowan prefers to conduct her consultations when the other team members are present. "Often I look at a specific child and the total therapeutic program, which takes into account positioning, speech and language goals, and how they are implemented in the classroom on a functional day-to-day basis."

Therapists have flexibility when providing services in the classroom, Lantz-Dey said. "If we are really moving in a session, we can keep going. That allows us to more effectively direct our time."

The speech-language pathologist should discuss how to train and formulate sounds within a classroom routine and how to generalize those sounds outside the classroom.

This is challenging because the daily curriculum may not always include specific sounds a child needs to work on, McGowan said. A curriculum may contain two words with those sounds, compared to 25 to 50 words that can be elicited in a pull-out session.

Parental contact is an important component of the integrated model. Parents maintain regular communication with team members by writing their concerns and questions in a daily communication log. They also can visit their child's classroom and participate in training sessions to learn therapeutic feeding and positioning techniques or specific activities to provide visual or verbal stimulation.

The interdisciplinary team maintains contact with a child's pediatrician and other professionals to advise them on issues such as whether a child should have a thorough feeding evaluation or modified barium swallow. A therapist may accompany parents on visits to these professionals and assist them in asking the right questions to receive appropriate answers.

"We can support parents and provide follow-up contact to clarify questions and reinforce recommendations," Lantz-Dey said.

Among the benefits of having all team members in the same classroom with the child are having questions answered as they arise and taking advantage of incidental teaching opportunities.

"Sometimes those are the best opportunities for teaching, rather than something that is planned," Lantz-Dey said. "Co-treatment and thinking out loud offer exposure to different perspectives and broaden our appreciation for the whole child."

Through team evaluations and treatment, therapists can learn to prioritize interventions. Sometimes speech-language pathologists do a co-evaluation with an occupational therapist to discuss whether independent feeding or an oral-motor focus is more important, she stated.

"The integrated model enhances overall communication among team members," she said. "That helps in assessing a child's challenges as a whole and in establishing solutions and goals to accommodate his or her specific needs."

Scheduling conflicts can arise in an integrated model. Scheduling time for specific therapies may be difficult, particularly toward the end of each month when therapists need to have completed a certain number of sessions.

Or, if a number of children are absent at a given time, the team members all may want to work with the few children present.

"Sometimes we have to get in line," Lantz-Dey observed.

Weekly team meetings can help resolve scheduling and therapy provision issues. They also help to prevent communication breakdown among the disciplines.

For More Information

Susan Lantz-Dey and Joy McGowan, Easter Seal Society, 3975 Conshohocken Ave., Phila-delphia, PA 19131; (215) 879-1001, ext. 259

Luanne Suplick, Easter Seal Society, 2400 Trenton Rd., Levittown, PA 19056; (215) 945-7200

Joanne Van Horn, Easter Seal Society, P.O. Box 333, 1161 Forty-Foot Rd., Kulpsville, PA 19443; (215) 368-7000

Abigail Scott is an assistant editor at ADVANCE.


Do you welcome scheduled visitors in the classroom to observe this integrated therapy model? If so, please contact me to schedule a visit. Also, are typical peers present in any of these classrooms?

Laurie Turtoro,  SLP,  Meadowood SchoolMarch 06, 2013
Newark, DE


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