1. Observation Hours:
COMPLETED HOURS: 20
John Hopkins Hospital
May 17, 2016: 9:00 am – 4:00 pm
Contact: Kate Holden (Head of SLPs at Johns Hopkins Hospital)
Worked under:
Eleni – Adult Acute Rehab:
1. 85 year old women
 Breathing through a trach
 Dysphagia
 Worked on swallowing
 Ice chips
 Neuromuscular electrical stimulation (NMES): The electrical
stimulation when applied in this manner accelerates muscle
strengthening, accelerates cortical reorganization (especially after
stroke), and increases the effectiveness of the exercise therapy.
 Worked on breathing and speaking with a valve speaking purple
trach ventilator
 On thickened fluids
2. 64 year old man
 Cancer all over body
 Tumor on Vagus (CN V)
 Dysphagia
 Breath-y – sounded like a whisper
 Weak left VF
 Worked on reading out loud to get the VF moving
 Checked tongue strength – low for age
 Tongue elevation strength is the maximum pressure of the tongue
pressing against the hard palate. The IOPI measures this when the
Tongue Bulb is placed in the “standard” position – agianst the hard
palate just behind the alveolar ridge. The image to the right shows
this position. You can simulate this placement if you suck on your
thumb: the pad of your thumb will be pressing against the hard
palate behind the alveolar ridge and your tongue will be pressing
on your thumb nail instead of a Tongue Bulb.
 Not aspirating – 3 liter water test
 On thickened fluids
Dana – Adult Acute Care, Surgery Service:
1. 65 year old women
 General acute care
 Progressive Aphasia
 “Yeah” for mostly everything, occasional “no”, but not able to
coherently communicate or understand direction
 Can follow a model: say, “stick out your tongue” – doesn’t
understand; if you stick out your tongue, they will copy

2.  Can recite days of the week and numbers (1-10) – in order
 Trach
 Dysphagia
 Only on thin purée and water
 Receives medicine with applesauce
2. 83 year old man
 Had a liver and kidney transplant
 Doctor asked to have a cognitive test: patient was having memory
problems, trouble focusing, saying strange things
 Result: Can’t encode or store new information – visual input was
better received and relied than auditory
3. 55 year old man
 Just checked in
 Dysphagia
 Saw his barium swallow test: A barium swallow is a radiographic
(X-ray) examination of the upper gastrointestinal (GI) tract,
specifically the pharynx (back of mouth and throat) and the
esophagus (a hollow tube of muscle extending from below the
tongue to the stomach). The pharynx and esophagus are made
visible on X-ray film by a liquid suspension called barium sulfate
(barium). Barium highlights certain areas in the body to create a
clearer picture.
 Trach: purple valve
 On thick purée – honey
Chain Bridge Speech & Language, LLC
May 19, 2016: 3:00 pm – 5:00 pm
Contact: Kristin Keller Daus (Founder of Chain Bridge Speech & Language)
Worked under:
Kristin Keller Daus
1. 17 year old boy
 Down syndrome and autism
 Non-vocal
 AAC: iPad - Augmentative and alternative communication (AAC)
includes all forms of communication (other than oral speech) that
are used to express thoughts, needs, wants, and ideas. We all use
AAC when we make facial expressions or gestures, use symbols or
pictures, or write. People with severe speech or language problems
rely on AAC to supplement existing speech or replace speech that
is not functional. Special augmentative aids, such as picture and
symbol communication boards and electronic devices, are
available to help people express themselves. This may increase
social interaction, school performance, and feelings of self-worth.
 Worked on syntax
 Verbs, adverbs, pronouns, commands – on iPad
2. 12 year old girl
 Worked on reading aloud
 Summary

3.  Relying information
 Asking questions
Chain Bridge Speech & Language, LLC
June 27, 2016: 9:30 - 12:30
Contact: Kristin Keller Daus (Founder of Chain Bridge Speech & Language)
Worked under:
Kristin Keller Daus
Elliott:
almost 4
Post vocalic /t/ /d/ /g/ /p/
Trying to master the sounds that are typical for his age so he doesn't get behind
Very social
Get syntax
Just needs help focusing on closing sounds
Little bit of a lisp
Older Man (40s):
Working on accents
From South Africa
Self conscious
Especially on the phone
Working on /r/ pre, post and intervocalic
Wants to be understood better
/o/ and is
Worksheets
Chad:
15 year old
Down's syndrome
VERY social
Does all sorts of athletics
Very popular
Socially motivated
Articulation
Worked on reading out loud
Focusing on closing sounds
Talking slower
Spacing the words
Separating the words on paper
Ex: she | ate | the | apple
Different because you don't usually spend time working on artic with DS kids
because the muscles don't really improve because of the syndrome, but he has
come a long way
He wants to be understood and wants to communicate
Short stories
Worksheets

4. Bethesda Speech for Kids
July 20, 2016
9:30 am - 10:30; 10:30 - 11:30
Contact: Mandy Hart (Founder of Bethesda Speech for Kids; Pediatric SLP and
Drama Therapist)
Worked under:
Mandy Hart
Bran - 4 years old
9:30 - 10:30
/Th/ placement - movie /fi/er
Very talkative today
Lotion on hands then cheeks
Use towel on cheeks, lips and throat
Used a bee that vibrates on his cheeks and mouth
Use towel to wrap ice
Spray ice with flavored spray: strawberry, blueberry and apple
Goal - no hot dog bun tongue
Want flat, fat tongue
30 licks
Then he got his own treat of the ice cube sprayed with his favorite flavor
Blow into a balloon
30 blows into the balloon - struggled, only did 20
Nook add spray flavor so - Apple
Tongue movement
Top, sides, all around, inside cheeks
"Ca, Ca, Ca"
"Cry" "green" - tongue sit-up /r/
First time he has said green perfectly
25X tongue sit ups
10 sec rest
Nook is used for stimulation
/u/ /is/ - 30X
Chewing stick - 30X on both sides - molars
Puppy dog - shake stick to see strength
Bit, open and try to get the tongue in the hole
Bite all around with stick, Make sure tongue is in mouth
Lip stretch
Regular bite
Stretch mouth out all around
Push push push - presses on hard and soft palate chin and teeth
Note:

5. Mandy says:
**to get /r/ - backside with nook and tongue sit ups ~ always!**
Pixie Stick
Stick out tongue place the sugar on it
Work on swallowing
10X
Then put the sugar inside cheeks and between top teeth gums and lips, "dump
truck" scooping sugar under tongue and scooping it up to swallow, "front porch"
in front of bottom teeth
Work on tongue movement and placement to swallow
Working on /th/ /r/ with pixie stick - back of mouth!
Go to the table
Use cards
Lip and teeth discrimination
"Sit and do"
Words: categories
Teeth vs. lips - v vs. f and th
Thirteen
Thermometer
Thinking
Thermos
Thumb
Thread
Thigh
Thongs
Listening activity:
Paper with mouth, th vs. v or f - place the cards in the correct picture of tongue
placement
Thread
Vegetables
Vet
Thirteen
Fudge
Vest
Three
Thinking
Fork
Volleyball
Valcher
Thongs
Thermometer - finally perfect!
Vase

6. Thermos - perfect!
Feather
Feet
Thumb
Thermos
Thirteen
Thongs
Food
Thread (Fred)
Fur
Three
Thigh
Thermometer
Fan
Thief
/th/ can be hard because in out movement of tongue develops before up down
Need a certain tongue tone
**discrimination is great!**
**Next week: Working on consonant position - pre, inter, and post vocalic**
Nick - 12 years old
10:30 - 11:30
/s/ /z/
Skipped lotion, but still used towel for sensory prep
Tongue licks: 30
Working on tongue tone
Balloon blows: 30
Working on lip rounding and strength
Not distracted
Sitting up and straight
Nook add spray flavor so - strawberry
Tongue movement
Top, sides, all around, inside cheeks
Soft cheeks
"Ca, Ca, Ca"
"Cry" "crazy" "grace" "crease" - tongue sit-up post vocalic /s/
Chewing stick - 30X on both sides - molars
Slow down
Important to go slow
Doing double the work
Touch with tongue
Puppy dog - shake stick to see strength

7. Bite all around with stick, Make sure tongue is in mouth
Ta ta ta
Da da da
La la la
Slow down
It takes more control to do it slower
Open mouth
Na na na
Kata kata
Taco taco taco
Latka latka latka
Katala katala katala
Kit kat kit kat
Chin is nice and still
**speeds up - fatigue**
Lip stretch
Regular bite
Stretch mouth around
Push push push - presses on hard and soft palate chin and teeth
/u/ /is/ - 30X
Doesn't want to do anything says:
"Why do I have to do this?"
Side is easier than up down
Long /s/ 37 seconds - tongue blocked sound a little bit, breathing and
sound/voice support wasn't great
Pixie Stick
Stick out tongue place the sugar on it
Tongue not to touch lip
Work on swallowing
10X
Then put the sugar inside cheeks and between top teeth gums and lips, "dump
truck" scooping sugar under tongue and scooping it up to swallow, "front porch"
in front of bottom teeth
Work on tongue movement and placement to swallow
Long /z/ - 47 seconds
**/z/ is usually longer**
Use floss to get the small enough space needed to get a quality /s/
Did not want to do tongue sit ups;

8. claimed he already done them in the session
/ks/
Books
bakes
Tusks
Locks
Docks
Ducks
Kicks
Socks
Poxes
Box
Fox
Fix
Tricks
Tracks
Looks
Homework words:
Slippers
Slide
Sport
Springs
Start
Sled
Tusk
Nest
Is
Crust
Crease
Was
Said
Spider
4X over
Say the word and then make a sentence
/u/ /es/
Focus on stretching the lips - big smile
Silly sentences:
/s/ with cards

9. Bethesda Speech for Kids
July 13, 2016
9:30 am - 10:30; 10:30 - 11:30
Contact: Mandy Hart (Founder of Bethesda Speech for Kids; Pediatric SLP and
Drama Therapist)
Worked under:
Mandy Hart
Bran - 4 years old
9:30 - 10:30
/Th/ placement - movie /fi/er
Lotion on hands then cheeks
Use towel on cheeks, lips and throat
Use towel to wrap ice
Spray ice with flavored spray: strawberry, blueberry and apple
30 licks - could only do 25
Very distracted today
Then he got his own treat of the ice cube sprayed with his favorite flavor
Blow into a balloon
30 blows into the balloon - struggled
Chewing stick - 30X on both sides - molars
Puppy dog - shake stick to see strength
Bit, open and try to get the tongue in the hole
Bite all around with stick, Make sure tongue is in mouth
Nook add spray flavor so - strawberry
Tongue movement
Top, sides, all around, inside cheeks
"Ca, Ca, Ca"
"Cry" "green" - tongue sit-up /r/
25X tongue sit ups
10 sec rest
Nook is used for stimulation
/u/ /is/ - 30X
Lip stretch
Regular bite
Stretch mouth around
Push push push - presses on hard and soft palate chin and teeth
Pixie Stick
Stick out tongue place the sugar on it
Work on swallowing
10X
Then put the sugar inside cheeks and between top teeth gums and lips, "dump
truck" scooping sugar under tongue and scooping it up to swallow, "front porch"
in front of bottom teeth
Work on tongue movement and placement to swallow
Put sugar on teeth for /th/ spot

10. **next session do depressurization before session**
Go to the table
Use cards
Listening activity
Lip and teeth discrimination
"Sat and do"
Words: categories
Teeth vs. lips - v vs. f and th
Thirteen
Thermometer
Thinking
Thermos
Thumb
Thread
Thigh
Thongs
Listening activity:
Paper with mouth, th vs. v or f - place the cards in the correct picture of tongue
placement
Fish
Food
Thermometer
Vacuum
Thirteen
Thinking
Feet
Thermos - only one wrong
Fan
Fork
Thread
Vanilla
Fur
Thongs
Thigh
Pup pup pirate game:
Said a word right, put a fake knife in the barrel and a private jumps out when he
gets 5 - 10 right
2X
Pretty good at self correction
Says /fai/ instead of /(theta)ai/
/fermes/ not thermos
Nick - 12 years old
10:44 - 11:45

11. /s/ /z/
~ Sensory prep ~
Tongue licks: 30
Working on tongue tone
Balloon blows: 30
Working on lip rounding and strength
Not distracted
Sitting up and straight
Ta ta ta
Da da da
La la la
Slow down
Open mouth
Na na na
Kata kata
Kit kat kit kat
Chin is nice and still
Nook add spray flavor so - strawberry
Tongue movement
Top, sides, all around, inside cheeks
Soft cheeks
"Ca, Ca, Ca"
"Cry" "green" "grace" - tongue sit-up post vocalic /s/
Bite line ups
10 sec rest
Chewing stick - 30X on both sides - molars
Puppy dog - shake stick to see strength
Bite all around with stick, Make sure tongue is in mouth
/u/ /is/ - 30X
Long /s/ 43 seconds - tongue wasn't blocking sound at all
Tongue sit ups - 30
**speeds up - fatigue**
Counting teeth
Retract and lax tongue and have to control tongue tip
Long /z/ - 50 seconds
Lip stretch
Regular bite
Stretch mouth around

12. Push push push - presses on hard and soft palate chin and teeth
Pixie Stick
Stick out tongue place the sugar on it
Tongue not to touch lip
Work on swallowing
10X
Then put the sugar inside cheeks and between top teeth gums and lips, "dump
truck" scooping sugar under tongue and scooping it up to swallow, "front porch"
in front of bottom teeth
Work on tongue movement and placement to swallow
Put sugar on teeth for /th/ spot
/s/ vs. /z/
Say the word and out it in your own sentence:
Words
Inside
Bends
Soup
Fork
Box
Dice
Books
Bicycle
Boards
Fords
Bats
Worlds
Sends
Says
Mends
Ends
Rats
They all sounded great!
85% accuracy
Bethesda Speech for Kids
July 21, 2016
3:30 - 4:30; 4:30 - 5:30
Contact: Mandy Hart (Founder of Bethesda Speech for Kids; Pediatric SLP and
Drama Therapist)
Worked under:
Mandy Hart

13. Jonas
3:30 - 4:30
5 years old
Next floor instead of next door
Irregular plurals are off
Particular about what he plays with
Auditory processing issues
Not oral motor - some L
More focus on language
Drofts instead of drafts
Says this and that, need to push the vocabulary and language
No formal testing
Just play and talking
"They will have dinner and breakfast when they get back from school" - about
the dolls
"I(slight - d)know" instead of I don't know
"J: They live in the same house, have the same family
M: are they brothers?
J: yeah"
Had the last doll come out of the back door of the school bus instead of the side
door,
M: oh yeah you can sure but why not the side door?
J: well yeah it does open
M: where do they go?
J: into the school
M: in the classroom?
M: where's the teacher?
J: right here on the slide
M: oh the teacher plays on the slide before school starts
J rings the bell,
J: bell rings! Time for school!
M: what do they do in the school?
J: They have to do a lot of things
M: like what?
J: They come out and hop in the school bus
M: really? I thought that was after school. What do they do during school?
J: I don't know
M: do they read and learn?
J: Those things are all finished
Sometimes doesn't close his sounds
J: They don't have breakfast
Ignored the question, what's their favorite food
M: look there's the clown, what does the clown do?
J: That's the funniest that juggles
M: Is that a rooster?

14. J: It made that sound
M: do they take showers? Or wash their clothes?
J: no they just wipe their clothes off with their hands
M: Who lives here?
J: No that's apart of the house
Good turn taking in play, with dolls and with partner
Pretend and real life
Struggled:
Helicopter
Closet
Laid down - going down
J: My mom took me here
M: how?
J: in a car
This takes people back to their houses - looking at the car
M: Is there a driver?
J: No they just go in it
J: We don't have food for breakfast
J: because I can (ump) out the window
J: so he can told the boys to get ready for school
J: Maybe I'll have a (not) on the door
Then said knock correctly and with intention in the next sentence
J: They are going to wake up him.
We are going to have to yell to wake up him
J: it changes the vision (on the tv) - he meant channel
J: the airplane will land in the street
M: where will the cars go?
J: they will park behind it
M: what does appear mean
J: it came!
M: it appeared from far away; What does that mean?
J: It came from somewhere
J: I grew so big

15. M: the shrinker can shrink you back to your right size
J: he was shrinkened too
When playing with the tellie tubbies- he said I when he was talking about the
dolls
As if he was the doll
Struggles with together and apart
J: do you wanna see it,-me.
M: can I put the shrinker away
J: no you can leave them out
Jessie
4:30 - 5:30
years old
Lotion on hands then cheeks
Use towel on cheeks, lips and throat
Used a bee that vibrates on his cheeks and mouth
Use towel to wrap ice
Spray ice with flavored spray: strawberry, blueberry and apple
Goal - no hot dog bun tongue
Want flat, fat tongue
30 licks
Then she got his own treat of the ice cube sprayed with his favorite flavor
Struggled with tongue not getting a ride from lower lip!
Tongue needs to be tensing and curling
Nook add spray flavor so - Apple
Tongue movement
Top, sides, all around, inside cheeks
"Ca, Ca, Ca"
"Cry" "green" - tongue sit-up /r/
First time he has said green perfectly
25X tongue sit ups
10 sec rest
Nook is used for stimulation
/u/ /is/ - 30X
/r/
Or
Ear

16. Cry
Green
Creep - struggled; tongue was too far back
Great
Ta ta ta
Da da da
Katala katala katala
Tick tock tick top tick tock
La la la
Kata kata kata
Tongue sit ups - 30X
Count teeth
Lip stretch
Stretch mouth around
Push push push - presses on hard and soft palate chin and teeth
The Red roller grows
Pixie Stick
Stick out tongue place the sugar on it
Work on swallowing
10X
Then put the sugar inside cheeks and between top teeth gums and lips, "dump
truck" scooping sugar under tongue and scooping it up to swallow, "front porch"
in front of bottom teeth
Work on tongue movement and placement to swallow
Put sugar on teeth for /r/ spot
Cards, say and match
Graduate
Grapes
Grass
Fries
Crown
Trash can
Crib
Tricycle
Broccoli- struggled
Dress
Breakfast
Friends
Crabs
Bear

17. Cries
Grizzly bear
Red
Ground
Grandfather
Frog -
Crayons -
Brownies
Grapes
Present
Broom
Pretzel
Truck -
Drummer
Bride
Groom
Bread
Frying pan
Trumpet
Prize
Broom -
Brownies -
Creep -
Then put the words that came up into sentences
Struggled - homework:
Brother
Broke
Frozen
From
Fro-yo
Bethesda Speech for Kids
July 6, 2016
9:30 am - 10:30; 1:00 - 2:00
Contact: Mandy Hart (Founder of Bethesda Speech for Kids; Pediatric SLP and
Drama Therapist)
Worked under:
Mandy Hart
Bran - 4 years old
9:30 - 10:30
Articulation
Just acquired /l/ with 100% accuracy last session and over the last few weeks at
home and such
/Th/ placement - movie /fi/er
Lotion on hands then cheeks

18. Use towel on cheeks, lips and throat
Use towel to wrap ice
Spray ice with flavored spray: strawberry, blueberry and apple
30 licks
Then he got his own treat of the ice cube sprayed with his favorite flavor
Blow into a balloon
25 blows into the balloon
Practiced "who is" with rounding mouth then closing teeth - 25X
Chewing stick - 30X on both sides - molars
Puppy dog - shake stick to see strength
Bite all around with stick, Make sure tongue is in mouth
Nook add spray flavor so - strawberry
Tongue movement
Top, sides, all around, inside cheeks
"Ca, Ca, Ca"
"Cry" "green" - tongue sit-up /r/
25X tongue sit ups
10 sec rest
Nook is used for stimulation
Lip stretch
Regular bite
Stretch mouth around
Push push push - presses on hard and soft palate chin and teeth
Pixie Stick
Stick out tongue place the sugar on it
Work on swallowing
10X
Then put the sugar inside cheeks and between top teeth gums and lips, "dump
truck" scooping sugar under tongue and scooping it up to swallow, "front porch"
in front of bottom teeth
Work on tongue movement and placement to swallow
Put sugar on teeth for /th/ spot
Then tried /thumb/
Go to the table
Use cards
Lip and teeth discrimination
"Sat and do"
Words: categories
Teeth vs. lips - v vs. f and th
Football
Vet
Vacuum cleaner
Vanilla ice cream
Fur
Thermometer
Fudge
Three
Fan

19. Thread
Thinking
Food
Fork
Fish
Thermos
Thread
Thongs
Thirteen
Food
Feet
Five
Thigh
Feather
Thermometer
Could tell he was manipulating the tongue movement that he used to get the
sugar for /th/ sound
Willie - 4 years old
1:00 - 2:00
Articulation
Both parents are foreign - mom Asian, dad middle eastern
Speak English at home but their English isn't the best
Went straight for play microphones in the room
Played and sang ma ma ma, la la la, ba ba ba
Mics are great for imitation
Bench work was a little challenging because not used to it
Struggled with yellow (yellow fish on the towel on the bench)
But corrected on the third try
Final constant deletion
one eye - "one die"
Little lotion
Sometimes unintelligible
Points doesn't use words
(Same for Bran):
Lotion - chocolate chips or smiley face
Rub cheeks
Use towel on hands and face, lips and throat
Yellow towel
Work on saying yellow
Sensory prep! (Lotion and towel)
Toy Bee
Vibrates
On cheek

20. Ice in the towel for licking
With flavored spray - strawberry, blueberry, Apple
Goal: 20 licks
Shaking of tongue
Muscles are weak, tired
Not very aware of tongue - he is but trouble moving it up, not realizing its still in
their mouth
Licks like a Popsicle, moves ice rather than tongue
Uses lips a lot
Says Willie as widdie
Whistle not as loud more like a kazoo
Less tension than brans balloon whistle and pipe
21 plus 4 he took a break
Vs. last session 10 plus 5
Lisp
Tongue really sticks out
Nook with Apple
Nook outside mouth has to use tongue to touch the nook
Head compensation
Put tongue on the wrong side, opposite side she had it on, he still didn't realize it
was wrong
Cheek compensating
Has to demonstrate mouth open for him to realize
Ca ca ca doesn't work for him
He doesn't repeat it back
Sometimes just stops speaking
He drops his tongue back
Soft cheek
On hard palate
On soft palate
/u/ /i/ - 10X focuses on lip rounding and closing constants
Congested
Sometimes can only breath through nose but you can hear some obstruction
when he breaths through nose
Cheeks are tight
ta ta ta - tongue sticks out
la la la - was able to keep tongue in
Da da da
Na na na
Working on tongue tip up and in his mouth
Still moving whole tongue instead of just the tip but now his tongue stays in his
mouth
No more drooling
Lip stretches
Moving the lips around and make sounds with her kids Utah while she moves his
around with a gloved hand
Lots of oral stimulation
She firmly believes it makes a difference
Push push on palates and teeth and chin

21. Pixie stick exercise
On tongue
Stick tongue out - 10X
Tongue thrust
Great gesturing but needs to use words more often
Needs to do more describing of what he needs and what is happening around
him
In cheeks
Tense cheeks
Doesn't really use articulators everything just stays in one place
Never been to dentist
Needs a palate expander
Didn't get ta ta ta last time but did today
Motor planning difficulty
Intimating hand motor is hard for him
Very smart just struggling
Holds cheeks to stabilize jaw
Working on soft cheeks so he can move his tongue
Scooter - suder
Lots of tongue
Doesn't close sounds
Ball of string - bad swing
La la - la lie
Gets excited and point
Dipsy - tipsy
On the String - on the swing
Turn the page was okay
Fell down - fell town
He's spanking - his pickin
Stopped - not grammar that affects the sounds
Again - Against
Po - Poy
Flowers - Flies
Flower - fly or fry
Or floway when corrected he corrects it in this way
Say new new to work on the word blue
Eyes is fine
String - swing
Elephant - enafent
Up - dup
Po is happy was fine
No - noy
Sad - said
Happy - happy-a or happy-eye (both added after the word is said correctly. It's
added on to the end)
Ball of yarn - ball yard
Scissors was okay
Pull - yull
I – bye

22. Pull - pool
Piece of - pizza
Wind up was good
Ball - bye
Yes - lots of tongue, tongue is completely out of mouth
Larry - loudy
Tuck it in was good
When starts drooling mom says close mouth and swallow and he does as such
His homework:
/u/ /i/
Lip top lip
Ta ta ta
Da da da
La la la
Na na na
All 10-20 times