A humorous and educational look at speech pathology.

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Musings on Pediatricians and Anti-Vaccine Parents

This was going to be a Facebook post, but it got very long for that, so forgive me if I ramble:

I’ve seen a lot of posts recently about pediatricians refusing to treat children whose parents choose not to vaccinate. The statements from the doctors have ranged from “sorry, but we need to look out for the well-being of all our patients, and we have many who cannot be vaccinated who we are trying to protect” to basically “eff you, you anti-science scum”.

At first, I was on board with the mentality that if you are unvaccinated by choice, your pediatrician is making a wise decision in excluding you from the practice (although I wasn’t really happy with the “eff you” presentation some doctors have – bedside manner is really important). After thinking about it for a while, I’m conflicted.

I agree that doctors have a responsibility to protect the unvaccinated-by-requirement from the unvaccinated-by-choice – I’d be super pissed if Dylan caught a disease she hadn’t yet been vaccinated against from an anti-vaxxer’s kid at her doctor’s office. But we also have to consider what we’re doing to the child whose parents choose not to vaccinate.

Everything that follows is based on the following beliefs/assumptions:
1. The goal of people who are pro-vaccine should be to get as many people as possible vaccinated rather than ostracize those who aren’t.
2. We should do everything we can to make sure a child doesn’t suffer from the sins of his or her parents.

Allowing pediatricians to bar unvaccinated-by-choice children from their practices does nothing to further either of these!
-If pro-vax pediatricians don’t see children of anti-vaxxers, they’re basically giving up on the possibility of the child being vaccinated. That may help at-risk children while they are sitting in their office at that moment in time, but the public health concern still remains – the unvaccinated children are still in the community and still likely to pass any vaccine-preventable diseases they have to at-risk children. Barring anti-vaxxers’ kids from the practice basically lets the doctor say, “not my circus, not my monkeys”. I don’t know if we should reward or accept that perspective.
-If pro-vax pediatricians refuse to see children of anti-vaxxers, these parents have two options for their children’s care – see an anti-vax pediatrician or seek no medical care at all. I don’t think either of these is desirable. An anti-vax pediatrician is likely to hold other views that conflict with medical/scientific research and put the child’s health in further danger, and no medical care is expensive to the child later in life *and* to us (because we’re likely to be subsidizing that care with either our health insurance premiums or our Medicaid taxes).

So if I’m saying that pro-vax doctors shouldn’t bar children of anti-vaxxers (and I hope I’m remembering well not to say “anti-vax children” because the children aren’t anti-vaxxers) from their practices, what are our alternatives?

First is persistence on the part of the pediatrician. Every time a parent brings an unvaccinated child into the practice (and I do mean every – this includes immunocompromised kids), the pediatrician should inquire as to why and do their best to get the kid vaccinated. For immunocompromised kids, this may not be possible. For kids who had a reaction to the vaccine, maybe there’s a new vaccine that the kid may not react to – but if you don’t ask the parent and just accept “unvaccinated kid”, you can’t know. For kids whose parents chose not to vaccinate, the pediatrician needs to engage that parent about the reasons they aren’t vaccinating (“I understand that you’re worried about the ingredients in vaccines – can we discuss which ingredients you’re concerned about?”) and educate and advocate with love and logic. And they need to do it at every appointment until that kid is vaccinated. If the pediatrician truly approaches the matter with compassion and parent gets still gets mad and leaves the practice, that’s unfortunate, but neither ignoring the elephant in the room nor banning the parent from the practice gets that child vaccinated. Persistent education and advocacy *might* get the kid vaccinated; telling the parent they aren’t welcome *never* will.

But what do we do about the presence of anti-vaxxers’ kids co-mingling with our unprotected kids in the waiting room? That’s one I don’t have a good answer for. Maybe pediatricians can have blocks of time where they only schedule anti-vaxxer kids and fully immunized kids (who, granted, don’t have guaranteed immunity, but have a much better chance than a 9-month-old infant or a third grader on chemo)? Separate waiting rooms for pro-vax and anti-vax families? It’s a tricky situation, I know. But I firmly believe that working it out to give these children access to quality medical care and their parents persistent reminders of accurate medical information regarding vaccines is both the practical way to peak vaccination rates and our responsibility as a moral and ethical society to make the most effective health care possible accessible to all children.


Board Games and Speech Therapy: Narrative Paradigm

As part of my efforts to start regularly blogging again, I’m branching out a little beyond what games I use in speech therapy sessions and spending some space discussing why I use games in speech therapy. This conversation is going to occur over a few months, one topic a month, and will be rooted in my study of communication theory as well as my experience as a speech pathologist. I’m starting out with the theory that is something of the background of my perspective in both communication theory and speech pathology – Walter Fisher’s model of the Narrative Paradigm.

Prior to Fisher’s development of the narrative paradigm, research in human communication focused on logic. It assumed that people used rational argument and discussion to develop their beliefs and perspectives. As a result, communication relied upon developing knowledge and understanding and reaching conclusions based on that understanding that the way the topic was discussed – scientifically, philosophically, legally, etc.

Fisher found purely logical constructs of human communication to be too limited and inconsistent with how people actually behaved. Recent examples of human communication and persuasion – one notable example being the Daisy ad from the 1964 US Presidential campaign – didn’t use appeals rooted in logical or philosophical thought, and were extremely effective in motivating action. What these acts of communication did, Fisher argued, was appeal to a more fundamental nature in human communication – our nature as storytellers. Instead of placing evidence into a structure of logical arguments, people instead experience and interpret their lives and others’ as a series of ongoing stories or narratives, each with their own characters, scenes, and plots with beginnings, middles, and ends. Using the example above, the Daisy ad didn’t appeal to any sort of evidence to construct a logical argument. It created a powerful narrative that began with an idyllic scene of a young girl picking flowers, transitioned to a sinister countdown, and ended with a literal end – of everything – followed by a statement that not “standing together” behind President Johnson would make this dreadful narrative become reality.

Core elements of the narrative paradigm include:

  • Values/Beliefs – The narratives we experience throughout our lives define our values and beliefs. Additionally, values and beliefs we’ve already formed tend to influence which of conflicting narratives we accept or reject in the future. If my father was a hardworking electrician whose union membership allowed him to gain access to better wages and benefits, I’ll develop a belief that unions are good. If your father was an independent contractor who couldn’t find work because local businesses use non-union labor, you’ll develop a belief that unions are bad. Those beliefs will greatly influence whether or not we believe the conservative politician who says that right-to-work laws protect workers from union bullying or the progressive politician who says they’ll hurt worker wages and benefits, regardless of whether the statistical evidence supports either narrative.
  • Good Reasons – We develop our own “good reasons” for accepting and interpreting information and evidence in the manner we do. In contrast to evidence and logic, which are objective and the same for all people, good reasons are based on our own history, culture, and perspectives about the character of the others involved – measures that are more subjective and less completely understood by a communication partner. When a new student enters your school from a neighboring school or district, your opinion of the quality of the students’ goals is influenced by your previous experience with that student’s school and the service providers at that school, even though those previous experiences provide no actual evidence regarding the quality of this student’s goals.
  • Test of narrative rationality – When we experience a new narrative, we assess, and then accept or reject, that narrative based on the narrative’s coherence, probability, and fidelity. Coherence refers to whether or not the characters in a narrative act reliably or consistently – someone who is kind to his neighbors will be deemed unlikely to rob them. Probability Fidelity refers to accepting a narrative that matches our own beliefs and experiences – if our experience and belief is that there is no God, we are unlikely to believe a story of miraculous healing and instead search for a scientific rationale.

Where does Fisher’s narrative paradigm become useful to speech pathologists?

1. The narrative paradigm does much to explain why it’s difficult for the field of speech pathology to move from treatment and assessment based on anecdote to evidence-based practice. As the more natural communicative form, it’s difficult to switch from the anecdote to something more structured.

2. The narrative paradigm suggests that our clients will respond better to treatment methods that present tasks in the form of a narrative or require responses in the form of a narrative. By using a natural communication form, we are asking clients to take fewer steps in developing their communication.

3. We must be mindful of cultural and social factors when developing treatment plans. If we present treatment activities or assessment items that are outside a client’s values, beliefs, or experiences, they’re not going to do as well on them. This is why students in low-income urban areas tend to do poorly on the Understanding Paragraphs section of the CELF – attending double features at movies and getting positive attention from emergency workers tends to be wildly inconsistent with their experiences.

4. We need to acknowledge that, even in the face of direct evidence to the contrary, our predisposition to use “good reasons” is likely to influence our therapy or assessment decisions – and the input of other professionals. Considering the influence of these narratives is critical (and the narratives may not necessarily be wrong – standardized assessments frequently do not present information in narrative form or ask students to respond that way).

Using the Narrative Paradigm in Therapy

Many games I’ve suggested in previous blog posts either present information in narrative form or require students to produce narratives in responses:

Games that present information in narrative: Dixit (a narrative in image form is still a narrative), Telestrations, Snake Oil, Storyteller Cards.

Games that require a narrative response: Apples to Apples (a great example of how values, beliefs, and “good reasons” influence choices), Rory’s Story Cubes, The Storybook Game, Who Would Win.

I hope this brief exploration of communication theory was useful. This kind of blog post is new for me, so I’d love to hear any feedback regarding what could use better explanation or what portions simply weren’t useful to you. At the end of next month, I’ll cover another communication theory, and you’ll see a couple more posts covering board games between now and then.


Wait… I have a blog?

Hey all,
It’s been a really long time since I made an update with actual content. Part of the reason for this is that I’m a lazy bum, but a bigger part of it is that I’m not doing much speech therapy at work anymore – I’ve taken on compliance and monitoring responsibilities at one of the districts my employer contracts with. While I totally plan to get back into the blogging habit – soon – right now my focus is on getting some new data systems up, which is really interesting only if you like spreadsheets and database management. I hope to have some speech stuff up soon (like within a couple weeks).


Call for assistance: Dysphagia2Go app translators

As some readers may already know, I’m one of the co-authors of the Dysphagia2Go app by Smarty Ears. The app is a tool to assist SLPs in writing diagnostic reports for dysphagia.

I’ve just learned that the app is in the process of being translated into Portugese, and Smarty Ears is interested in translating the app into as many languages as possible. To do so, they need translators. Translators need to be practicing SLPs and will be compensated with a free copy of the app. Interested parties should send an e-mail to contact AT smartyearsapps DOT com.


Board Games and Speech Therapy: Returning Next Week

It’s been a while since I’ve posted in this blog, but the summer vacation was needed (and my work schedule got a little crazy for the first couple weeks of school). Next week, I’ll be restarting weekly blogging (on Tuesdays, probably) with a brief overview of the games I’ve already reviewed, a preview of what games are to come, and a list of things not to write on a student’s IEP (something that’s been on my mind at work a lot over the last few days). The following week, board game reviews will start appearing again in the same format as before.

Board Games and Speech Therapy: Origins 2012 Round-up

The games added to our collection last weekend (mouseover for list). No, we did not pay for all the games. Yes, we paid for all the ones I’m going to talk about.

As I mentioned in my previous post, my wife and I attended the Origins Game Fair last weekend. We had a lot of fun, played a lot of board games, and lamented that we could not come for the entire convention due to its overlap with the school year. While most of the games we played didn’t relate to speech pathology or the use of board games therein, I did find some gems I wanted to share:

Dixit: Journey – I mentioned this expansion for Dixit when I discussed the game itself, but I finally got my hands on a copy. The artwork is of very high quality and less “cartoony” than previous Dixit games, and it comes with updated 3-6 player rules (although I haven’t had a chance to review those yet). Unfortunately, it doesn’t come with storage for the previous expansions, so I’ll have to see if all the cards fit into my Dixit: Odyssey box.

Get Bit! – I discussed this game in an earlier blog post, but I wanted to bring it up again because it won this year’s Origins Award for Best Family, Party, or Children’s Game. So, if your administrator questions using a game about sharks eating robots in therapy, you can respond by saying that you’re using an *award-winning* therapy tool – and then deflect the follow-up question about which award.

Hike – A small-press casual card game I had never heard of before this convention. It’s similar to Uno in that your goal is to get rid of the cards in your hand by matching, but differs in that all the matches are nature-themed (tree, water, bug, bird) rather than just color and number. There’s some literacy, too, but I’m considering it as an option for lower elementary students who are working on ecology units in class (gotta address that NCLB-mandated curriculum relevancy, after all).

Say Anything – Say Anything is a game I didn’t buy at the convention, but will be ordering soon based on a demo in the dealer’s hall. The best way to describe it is free-answer Apples to Apples – instead of picking a card, each player writes a response on a markerboard.

Telestrations – Telestrations is my big find of the convention, and the subject of my next full post. It’s Telephone plus sketching. Each player in the group has a markerboard pad with multiple pages. The players get a prompt (usually a one-word or two-word phrase) and one minute to draw it. The pads are passed to the player next to them, who has to guess what the picture is. The pads are passed, and the players then have to draw the previous player’s guess. Continue until the pad reaches its original owner. In one game, we got to see, through a variety of miscues, “wig” become “belly button”. The educational aspect of the game is learning about where the communication breakdowns occur and how they can be prevented. I’m very excited to try this one out.

Timeline: Inventions – Timeline is a sequencing game in which players need to put a series of cards in chronological order. The first version of the game, Inventions, features various innovations throughout history including writing, the corkscrew, and the compact disc. It’s a good sequencing game for older students, especially if you can get them to talk out their reasoning behind where a certain invention should go.

Wits and Wagers – Wits and Wagers is a spin on trivia games in which you don’t necessarily have to know the correct answer – you can guess what the correct answer is. Each player is asked a question with a number for an answer (for example, “How many people signed the Declaration of Independence?”) and writes down their answer on a markerboard. Then, the answers are arranged from lowest to highest, and the players place a bet on which answer they think is correct. The answers nearest the middle get the lowest payout and the answers at the extremes get a higher payout. Because the scoring is based on the wager and not having the correct answer, even students who don’t know the facts can still try to guess what the correct answer is. This is another game that’s on order after a demo, but I’m very excited to take an in depth look at it afterward.

I’m sure there were many other good therapy games there that I didn’t see, but we were only two people, and it was a pretty large convention. If there’s something you think I might have missed, let me know and I’ll look into it next time…


Follow-up on Critical Reasoning Post re: CNN Article About AAC and iOS

Hey all,
I promised that I’d post an update if I heard back from AssistiveWare about the figures cited in the CNN article, and I heard back this afternoon. Short version: AssistiveWare’s white paper was misquoted, and their survey was deliberately designed to be a self-selecting report from those interested in AAC on the iOS (and clearly reported by AssistiveWare as such. David at AssistiveWare also was very helpful in providing a reference to their actual survey, which, from my reading, describes its methods well and reflects figures that seem far more reasonable with my expertise and other consultations.

I hope this provides a fair picture of what was reported by CNN and what AssistiveWare actually found and emphasizes the importance of critical thinking when reading news reports on AAC and speech pathology (or topics in general).