The Mindful SLP Podcast: Permission to Play - 12

 The power of play therapy is real! In today’s podcast we talk about a client who overcame multiple challenges through play.

Music: Simple Gifts performed by Ted Yoder, used with permission

Transcript

Dan: Welcome to The Mindful SLP, the podcast for SLPs looking for simple tools and optimal outcomes. Your host is Denise, experienced speech therapist specializing in all things pediatric, and Dan, business manager for her private clinic.

Thanks for joining us. Today, we're going to be talking about play therapy. The title of our podcast today is Permission to Play, which, you know, sounds like a great thing to me. I've always loved to have a chance to play. And I know you speech therapists have an awful lot of toys. So Denise, take us through play therapy, just a brief explanation.

Denise: Sure. The play-based therapy I'm talking about today is what I do with toddlers and preschoolers mostly. Now we also incorporate play with older clients, but it looks different with the younger crowd. The reason we do it is to just boost the number of words they're saying, because the grammar, our real target goals, usually grows with the number of words kids put together.

So some of the really early grammar markers like prepositions, ING, and plural S they just start to happen as you do this play therapy and it looks like this, they say one we're like up and you say, go up when I say run and you say, you're running. And this works like magic for a lot of clients who don't have something else more severe going on, like maybe apraxia or autism and parents, they think you are magic because the child who only had 10 words is suddenly talking a lot. So there's a critical time of language expansion in the preschool years. And with these language expansion techniques that I just described where you just sort of expand on what the child says. You don't ask very many questions.

If you do ask a question, you would phrase it like, Hmm. I wonder what would happen if I did this. So you're not putting pressure on them to produce well, they start to talk. They start to catch this wave and their language just explodes. And this happens with normal kids. You remember it happening with our kids, right?

Dan: Oh, this is something that kids go through, right. They just hit this tipping point where suddenly they just start exploding and they become chatterboxes.

Denise: Yeah. In fact, I have one client, I think she's four now. And she has hit this point where her language is exploding. And the other day her mom said to me, I will never complain about her being able to talk, and then she said, but... and she just kind of trailed off...

Dan: Exhausted from listening to it. Welcome to parenting, you know, we all go through this play therapy is really just an easy way to get kids into that natural rhythm. It takes a little bit of time, but there is some special techniques going from playing into.

Denise: There are some special techniques, but truthfully, this is one of the easiest things pediatric speech therapists do. And you can use almost any toy that you have is, um, interesting to the child. In fact, I don't recommend this, but there have been a couple of times when a parent rescheduled the night, forgot to note it down. They come in the door and I'm like, dang come on in. Let's open up the toy box and no one was the wiser, because this is kind of easy.

Dan: If this is such an easy form of therapy, why are we spending an episode talking about play therapy?

Denise: Because I have learned recently to think of play therapy outside of the box, the therapy that I'm talking about that I normally do with preschoolers. I've got a client I'm going to call her Sarah, and I want to tell you about her.

It's going to take me a little time to go through her background, but stick with me because you're gonna understand why all this background is important. So when Sarah first came to me as a preschooler, she was apraxic. Really really apraxic. It was really hard for her to move her muscles to produce sounds.

Her behavior was beautiful, very responsive in therapy, same target words, but only the target words. She's very quiet. She didn't initiate conversation.

And didn't carry it on beyond the target word.

No, and at that point you think, well, maybe she only can say one word. So one of the things I like to do, if the parent doesn't happen to be in the session with me and they're in the waiting room is we go out in the waiting room and I say, oh, listen to what Sarah said today, this is so awesome, this is what she can do. And Sarah would never say anything. And one day her mom said to me, she's very selective about when she talks. So I go back in my room and a few minutes later, boom, suddenly a thought hits me. It stops me in my tracks. This is when you're very grateful that something in your mind makes you stop and observe something.

And the word selective, I thought selective, selective, selective mutism. Oh my goodness. Where are we going? It's a disorder that's associated with very, very high anxiety with talking. And children who have this will choose to only speak maybe in certain situations, in certain places, they won't talk at school, any place else, maybe they'll talk at home. Maybe they only talk to a couple people at home. And I just thought, oh my gosh, not on my watch. I mean, Sarah wasn't there yet to buy, like we are not going down this road of apraxia plus selective mutism. I mean, tragedy in the making, right?

Dan: That would be bad, yeah. Okay, you're worried about it, you recognize it now, what do you do to get Sarah away from the selective mutism?

Denise: I stopped doing artic(ulate?) therapy and we just began to move around a lot, blow bubbles, shoot baskets, make lots of sounds. As we were jumping around, I got lots of exercise. We were hopping, uh, we did all sorts of things and I have these little, uh, carpet markers, and we would say a word like maybe hop. She would say something as she was hopping around the room and I gradually would take the carpet markers out the door, and this is a very gradual process, but eventually I could get the carpet markers into the waiting room. And so she was saying her word as she hopped into the waiting room. And then she was saying a word in a different place, in the waiting room.

Dan: In front of mom.

Denise: In front of mom. So anyway, we got past that whole danger zone, dodged that disaster of selective mutism. Sarah's articulation improves so much. A couple of years later, she was only working on KNG. She had some of the later developing sounds that weren't there yet, but that was appropriate for her age. And I thought, oh man, we are just good to go because now we just got to get her, her language up.

Dan: I sense an uh-oh. So what happened next?

Denise: Well she could talk in complete sentences, sometimes. She could sometimes kind of tell a story, but didn't. Sometimes, she would just stop talking. If you're trying to do get her language to move forward from where it was, she'd just be silent. Like she couldn't recall the words and she just didn't know how to do it.

And I was trying to bridge, take small steps. Okay. Well, here we are. Now, Sarah, let's get you to the next step so we can just get you moving on to talk like your peers. Cause that's the end goal, right? And I tried narrative intervention, she was just silent. She wasn't moving forward out when she could be very, very emotional sometimes, just break down crying and she wouldn't be able to tell anyone why.

Dan: And now she's in first grade.

Denise: Yeah. She's six years old and I thought, what am I missing? Am I missing phonological awareness? Am I missing auditory memory? I need to work on word recall, narratives. I was getting a little bit anxious.

Dan: And your anxiety. I'm sure it didn't carry it all over to her.

Denise: Well, I try not to let that happen, but I think she was feeling a little bit pushed. So then I remembered our three guiding principles at SLP pro-advisor, they are simplicity, mindfulness and depth of knowledge. And part of mindfulness is being able to step back and observe. And really figuring out what's going on. So that's what I did. And I remembered my early years with Sarah, where we just had to play around with sound.

Another thought hit me and stopped me in my tracks again. And I thought she never went through that period of language explosion. Like we talked about earlier in this podcast.

Dan: When little kids just start rattling on.

Denise: She never did that. She never turned into the chatterbox that we hear. So her well of language, if you want to call that is very shallow. I mean, she had these early grammatical structures and some later ones, and sometimes she could sort of tell a story, but it was all just very shallow, it was so surface. So I've got to build this depth. Here is where I learned to think outside of the box, because I had never imagined doing the kind of play therapy that I do with a preschooler, with a six-year-old. I might usually get more structured. And even though we're still playing, it's more structured.

I told their parents, you know what? I just want to play. No pressure. I want to play with her. I want to see what happens and they're on board. So that's what I started doing. Hello, play therapy.

Dan: So what's play therapy look like with a six-year-old? How's it differ from a three-year-old?

Denise: With a three-year-old because they're kind of impulsive, I usually have a bag with my toys out. We get out one at a time. A three-year-old would usually be totally enthralled with my nesting blocks and we can build them up a little bit. Sarah, she's interested in more mature themes and it did not hurt at all to have toys scattered all around the room. I mean, she, she's not impulsive, that is not her personality at all. We could move from one to the other. It helps to have a lot of stuff out. We have puppets and we have Play-Doh and we have the kitchen cooking stuff, what she loves and books, which really encourage her to talk. She loves books. If her language starts to dry up in one area, we just moved to another area.

Dan: But it's because she's more mature. She can actually handle that, and she can choose more what she wants to go do next.

Denise: And with preschoolers, I might like hold up two things to choose and they choose and I put the other one back in the bag just because they're so distractible. That's just not her personality. Now I might say some, not all six year olds have that level of maturity. This is part of her personality.

Dan: Back to knowing your client, yeah. So how'd that work for her?

Denise: Well, I've got to tell you. The first session that I try this, the first 20 minutes she said almost nothing.

Dan: She just silently played.

Denise: Oh, she might've said one or two words like we were doing Play-Doh plus she might've named the animal that she was cutting out with the cookie cutter on the Play-Doh. But nothing like what I was wanting and I had to keep telling myself to stay the course. I love poetry and there's this poem, the line from a poem that kept coming back to me: but at my back I always hear, time's winged chariot, hurrying near. Yeah. If you're not familiar with that poem, it's actually a seduction poem. It's called To His Coy Mistress. Someone who's trying to push someone further than she wants to go. It feels like coercion. And I thought, oh, okay. I can't have Sarah feel like this is coersion. You know, need to relax. Just need to relax, let it go. I have this overwhelming desire to prove to people that kids with apraxia are as capable as their peers.

And once they're past main part of the motor issues with apraxia, there's a lot of language learning that has to go on often and I have this drive to get them there. Um, so I had to just kind of like go with that and...

Dan: Step back and just let her be a child again.

Denise: Well, let her go through that preschool language growth that didn't happen. So after 20 minutes, what happened? I think she had, well, she had a cookie cutter and Play-Doh, and I think it was a pumpkin or something. And she started to talk about something that her mom cooks. And then she started to tell me about her Halloween costume. Then she told me about her sibling's Halloween costume, and then she just started to talk and the flood gates just opened up.

Dan: Oh, that's great. And then she became a chatter box from then on or was other sessions...?

Denise: She's not quite chatterbox yet, but it's a vast improvement, we're getting there. And in the other sessions, it took like two or three minutes before she started just talking, you know, this is what we need to do.

Dan: She is getting better. I mean, she, she actually was responding to that play therapy and is starting to use more words and to become more comfortable with talking.

Denise: Yes. And that's not all. So I'm seeing other things too, that show just how her confidence is improving. After about three or four weeks of doing this, she puts something inside an empty plastic egg I have.

So it made a little shaker and she shook it and she did a little dance move and made some little dancing sounds. Right. Okay. So for her, that is huge. And then later on in the session, for some other reasons, she just started dancing with her body. Really cool. Oh, when she started to self-advocate like, I had my box of puppets out and I was like, oh, who should we get out?

And she said, let me pick, which is big for her before she would've been more passive. And when she also went out in the waiting room and told her mom something we had done in therapy,

Dan: And so that's a real big step for her and her mom could even see that too. What does your mom think about all this?

Denise: Well, I asked her mom, I waited about a month before I said, are you seeing a difference at home? And her mom said, yes, we are. She is talking more at home, and she even had a friend over to play. Wow. I mean, if you don't talk...

Dan: Why would you have a friend over to play?

Denise: Why would you have a play date? So that was really cool.

Dan: How do you know when to start winding down play therapy and moving back into the other types?

Denise: I want to see before I move on, lots and lots of free talking, which for lack of a better word chattering going on, I want her well of language to be really deep, and to be filled with words the same way a preschooler's language well is filled with words.

But more specifically, I want you to have more readiness to tell stories. Let me explain that. So I'll just insert little things. Like if we are playing with the puppets, I'll make one of the puppets have a problem that we solve somehow and just tell this little story and they'll say, oh, what was the problem?

And so she'll be able to describe the problem to me. Remember the characters in the story. So not telling the whole story, but readiness to tell stories, I'm going to look for improvement in word recall. Cause that's been a really big problem for her just to remember the word she wants to say, because if you start to go and you don't know the word, you just get stuck, she doesn't know how to move forward from there. And I'm looking for more sentences that are more complete or have more elements to them. And then I think we'll be ready to move on.

Dan: As a speech therapist you're very, goal-driven, you're always looking to have your goals written out. Can you articulate some goals that you might have when you're doing play therapy with an older class?

Denise: You gotta have something to measure, right? Exactly. One of the goals I have hers to identify the problem in a story, remember character names, right? Another goal could be being able to refer to events that have already happened. A naming goal, which is just a, this is like a word recall, auditory memory, I found this to be really, really helpful with kids who just can't retrieve words is you just practice it, but we have practiced it in a very playful way.

For example, if we have the play food out, I might line some up and say, okay, let's see, what have we got here? Banana grapes, apple, kiwi. Oh, you know, can you do that? But I'm very, very low key about it. And then we might go to yellow banana, purple grapes, red apple, green Kiwi. And you can always have an articulation goal that you address in a playful way, 'cause that's what I'm doing with Sarah. She's still got that KNG so very laid back about it, but she's got the knife cutting the play food. Oh, cut. Cook those kinds of not grab. Sorry. That's gr oh gee, that's a blend. Sorry. You're not a speech therapist,

No I'm not, and I don't even play one on TV.

But go, yes, we did go.

Dan: Well, we've talked a lot about many different ways of applying this therapy. What's the concept you want our listeners to take into their own therapy this week?

Denise: The takeaway of this podcast is don't be pushed by our problems, be led by your observations.

Dan: That's really deep. Say that again.

Denise: Don't be pushed by your problems. Be led by your observations. I could tell you story after story beside Sarah's about how stepping back and observing has led me to solving a problem in therapy.

Dan: Thanks for listening to us today, please go over to SLP proadvisor.com. There are a lot of free ideas there as well as free materials that we have developed to help you in your therapy. Let us know what you think in the comment section, and we will be back with another episode of The Mindful SLP.

Thank you for listening to The Mindful SLP. We hope you found some simple tools that will have optimal outcomes in your practice. This podcast is sponsored by SLP pro-advisor. Visit SLP pro-advisor dot com for more tools, including Impossible R Made Possible, Denise's highly effective course for treating those troublesome Rs.

A link is in the show notes. If you enjoyed this podcast, please give us a five-star rating and tell your fellow SLPs. And please let us know what you think. Join the conversation at SLP pro-advisor dot com. .