Nanette - Lessons in Speech with Nanette

Why Visual Supports Make a Big Difference

July 8, 2024May 24, 2020 by Nanette

For children with speech and language delays, using visual supports like sign language, natural gestures, photographs, and digital pictures is incredibly empowering and educational in teaching comprehension and verbal expression. Imagine the frustration of a hungry toddler, unable to speak his needs, without any way to express his snack preferences. Having a visual support handy does not take the place of teaching your child speech skills. Rather, visuals enhance a child’s comprehension; help you identify the intended word to support your child in practicing saying it accurately; and reduce frustrations and negative behaviors. There are several ways that you can provide visual supports.

Using Sign Language For Visual Supports

Nowadays, it is very much in fashion to use sign language with young toddlers. Bookstores, libraries, apps, and mommy groups offer sign language resources for learning with ease and convenience. My favorite resources are produced by Signing Time. This company offers DVDs teaching sign language for babies and toddlers, featuring infant and toddler models. They’re highly recommended by many. The greatest thing about using sign language for communication is that unlike pictures, you always have your hands with you. Below are the top three reasons why caregivers and speech pathologists alike are using sign language.

It significantly reduces frustrations for both toddlers and caregivers. Toddlers often understand more words than they can express, demonstrating a larger receptive vocabulary compared to their expressive vocabulary. Your child knows what he wants to say, but he cannot get those words out just yet. Signing a word requires less effort and fewer steps than verbally producing the same word, making communication more efficient.
Teaching sign language supports speech development. Now that you have reduced those frustrating moments, there are naturally many more teachable opportunities in your day. For example, your child signs “milk” and you repeat the word “milk” a few times as you prepare the Nuby cup.
It supports receptive (comprehension) development. Children need to understand the meanings for words to bank those words into their spoken word repertoire. They may not say “milk,” but using the sign for it, they request it, reinforcing its meaning as they enjoy it.

Natural Gestures

In addition to sign language, you can use natural gestures with your child to help elaborate on communication. You are probably already doing many of these naturally (hence the term natural gestures.) Common examples seen with children between 9-21 months old are:

Waving hello and goodbye
Holding out your arm to show someone an object in your hand
Pointing to objects to express wants
Shaking your head to say “no” and nodding to say “yes”
Taking your hand and bringing you to a desired object
Making a movement to request an action (i.e., jumping to request trampoline play)
Giving a “hi-five”

Photographs: Dynamic Visual Supports

For some children, planning out a motor sequence to maneuver their hands to show a sign is incredibly difficult. I use sign language to enhance comprehension but rely on photos and digital images for effective communication of wants and needs. Photos of favorite items in a mini book or magnetic cases are handy. There are several goals in using these pictures:

Photographs narrow down the options and help you quickly understand your child’s wants. For example, if your child can make the first sound in a word, he may say, “guh” for granola, grapes, and gummies. If you have a photograph for each, he can continue to say “guh” and point to or look at the picture of the object he desires.
The natural progression in language development begins with comprehending names for objects. Children first learn that a three-dimensional object is called a “ball”. Using photos helps children understand objects. Show a picture of a ball to teach its representation. It enhances communication and comprehension.
Storing food and toy pictures in specific areas teaches categorization skills, aiding your child’s vocabulary development. We use this strategy to store new information and broaden both use and understanding for vocabulary words. Compiling food pictures in the kitchen and toy images in the family room teaches your child organization based on category.

Digitally Created Visual Supports

As your child becomes familiar with actual photographs of objects, you can transition to digitally produced pictures. These images are the creation of a digitally encoded representation of the visual characteristics of an object, such as an image of a ball that is not a photograph. Consult with your child’s speech pathologist to create a picture vocabulary, especially if your child has limited verbal skills or needs long-term support. If digital visuals are needed, then consider purchasing an iPad app. Custom Boards by Smarty Ears apps is well worth every penny!

In conclusion, integrating visual supports into your child’s learning journey can be transformative, offering a bridge between comprehension and expression. By utilizing sign language, gestures, and visual aids, you’re not only helping your child navigate communication challenges but also fostering a supportive environment where their needs are understood and met. Embrace the power of visuals as a tool to unlock your child’s potential and enhance their speech and language development journey.

Nanette

Nanette Cote is an ASHA certified speech pathologist, published author, and private practice business owner with 30 years experience.

Transform Communication with the Power of Floortime

October 8, 2024October 8, 2019 by Nanette

Embark on a journey of discovery as we delve into the transformative power of Floortime in embracing a child’s natural play inclinations. A while back, an Instagram photo inspired me to invite the photographer for a guest post about child-led play. Sara Roberts is an ASHA certified Speech-Language Pathologist based in New York. She received training in Floortime while in graduate school at Queens College. Floortime’s foundations greatly benefit her work with children on the Autism Spectrum in Early Intervention, preschool, and elementary school settings. You can follow her on:

Instagram: https://www.instagram.com/slptree/
Teachers Pay Teachers: https://www.teacherspayteachers.com/Store/Slp-Tree

Do you know how to play with children on the spectrum?

Playing with a child that barely or does not at all acknowledge your presence can be intimidating. It can make you feel lost. I have seen many adults (myself included at one time) try to interact by asking questions and get nowhere.

“You’re playing with the animals?” … No response.

“Which one is your favorite?” … No response.

“Can I have a lion?” … No response.

Strategies such as Following the Child’s Lead, Parallel and Self Talk, and Expansion are KEY to working on joint attention, engagement, as well as language and play development.

Here is an example of Floortime in action:

A child was playing with toy animal figures by silently standing the animals up and knocking them down repeatedly. I copied what he was doing while I modeled the words “up” and “down” both verbally and on his Augmentative and Alternative Communication Device (AAC). He did not pay too much attention to me, but he let me do it and he was being exposed to language (win!).

Then I added to his play idea by getting really animated when I said “down” and crashed the animals all over the table. This made him smirk and look up at me. We did the routine again and this time he imitated my crashing motion. After a few repetitions, I added the idea of the animals jumping over each other and he imitated that too! My hope is that he remembers this expanded play idea the next time the animal bin comes out and he will use the language I modeled for him.

Now what do you do with a child that does not play with toys?

A child was wandering the room and spinning around in circles. I copied him by spinning too while I modeled the word “spin.” After a few moments, I said “stop” loudly while I stopped spinning and put my arms up in the air. I kept repeating this, hoping that the child would establish eye contact with me and/or copy my action. He did not, so I copied his spinning and then fell to the floor while I said the word “down.” He never looked at me directly, but eventually he fell to the floor too! We kept repeating this until he let me hold his hands and we were playing a modified version of Ring Around the Rosie.

What about children who tend to focus on tactile stimulation?

Let us say a child is running his fingers along window blinds. First, copy his action by running your own fingers along the blinds next to him. Then narrate what you are doing with simple language such as “up, down” or “open, close.” After a few repetitions, expand on this idea by adding one new idea. For example, when the blinds close, you can say, “Goodnight!” and pretend to sleep. When the blinds open, you can say, “Good morning!” with an exaggerated stretch and yawn.

Let us say another child is running his fingers over a bumpy surface. Copy the action then narrate such as exclaiming, “Bump!” or saying, “bumpy, bumpy, bumpy” in a sing song voice. Then add a new idea such as introducing a toy car and having it drive over the bump.

Floortime: Takeaway Thoughts

These strategies may not give you results every single time, but you are exposing the child to language and different play ideas and that is always a success! Here is the bottom line when playing with children on the spectrum: copy what the child is already doing and then add to it! Sara Roberts, MA CCC-SLP

Nanette

Nanette Cote is an ASHA certified speech pathologist, published author, and private practice business owner with 30 years experience.

SEVEN Awesome Speech Therapy Toys for Summer

October 8, 2024July 13, 2019 by Nanette

Boy playing in the sand at the beach with his father using speech therapy toys

If you read my post on toy selection, then you already know the four important features that I consider in a toy for enhancing speech and language development. Speech therapy toys play a crucial role in engaging children and promoting their communication skills in an enjoyable way. Since I am a big fan of summer, I thought I would share some of my favorite summertime toys to support communication development for some fun in the sun. You will find that my recommendations are free of noises, bells, and whistles, so no need to stock up on batteries or worry about recharging something.

Speech Therapy Toys: New Sprouts Camp Out

New Sprouts Camp Out by Learning Resources is most appropriate for children between 2-5 years old. Here are some suggestions for building communication:

Expand your child’s pretend play skills while “roasting” a hot dog and marshmallow and then blow on these as they get “hot”.
Pack up all the goodies in the carry bag and bring it outside the next time you are going to roast marshmallows to help your child build longer play sequences and imitate actions.
Build comprehension by asking “Get/Give me” for designated objects.
Work on answering WHO, WHAT, WHEN, WHERE questions such as, “What do you do when you are hungry?”
Make comments about each item to model expanding speech development like, “I love eating roasted marshmallows!”

Smart Snacks Alpha Pops

Smart Snap Popsicles- speech therapy toys

Smart Snacks Alpha Pops from Learning Resources is appropriate for children 2 years and older. This toy collection contains a rainbow of make-believe frozen, Popsicle treats with uppercase & lowercase letters for learning matching, color recognition, fine motor skills and imaginative play. Below are some additional suggestions to foster fine motor and speech/language communication:

Pull apart all Popsicle sticks and hide them under dry beans, water beads, or any filling of your choice. Then, have your child build hand skills by pushing the pieces together as he/she locates matches.
Build phonemic awareness by asking your child to find the letters that make the sound “Buh.”
Increase speech skills by modeling sounds.
Talk about words that start with the targeted letter.

Speech Therapy Toys: Pop up Pirate

The Pop up Pirate game is suitable for 3 years and older as there are some small parts. I typically incorporate a pirate-theme sometime in my summer speech and language lessons while we talk about the ocean and the beach.

Build sharing and taking turns by having children use a gesture, sound, or word to make a request for “Me,” “My turn,” or “It’s my turn.”
Ask questions with “yes” or “no” answers such as: “Did the pirate pop?” or “Is that a red sword?”
Increase following directions with “Take two swords” or “Get a yellow sword.”
Practice simple to complex speech by modeling “pop,” “more pop,” “I want more pop!”

Hydro Hoops

Hydro Hoops is a new water play toy that I have been using in my speech and language pool group sessions this summer. Recommended ages are for 5 years and older, but I have used it with supervision with children as young as 3 years old.

Practice turn taking and sharing during pool play.
Model making appropriate comments when children make and/or miss baskets.
Build social comprehension by asking a child to throw the ball to another.
Role-play initiating asking to join a game with others.

Speech Therapy Toys: Ocean-colored Water Beads

Ocean colored water beads- speech therapy toys

Ocean-colored water beads! While the recommended age for these is 3 years and older, I have used them with children through 10 years. These make a great filler for sensory bin exploration! Here are some suggestions for objects that you can hide in a container of these delightful beads:

miniature ocean animals
Learning Resources Alphabet Popsicles
seashells
colored fish

Buckets

Using buckets in summer activities with young children not only provides entertainment but also serves as an effective way to develop comprehension and language skills. By giving children commands to place objects either inside or on top of the buckets, parents or caregivers can create engaging and interactive learning experiences. This activity allows children to follow simple to complex instructions, enhancing their ability to understand and express language while also promoting fine motor skills and spatial awareness. You can even build on this activity by using a variety of buckets such as:

one small and one large
castle-shaped
square and round
animal faces

Speech Therapy Toys: Bubbles by Gymboree

I’m not going to even try to sugar coat my feelings here, you NEED Gymboree Bubbles! These bubbles last longer, require less solution, and float on water, providing both entertainment and physical activity for children. The one downfall is that you can’t offer your bubble wand to little ones for sanitary reasons so they can work on some oral motor coordination. However, children can still try and blow the bubbles in the air, which often is a good starting place for toddlers trying to learn how to blow a bubble anyways. Once you break open the bubbles, here are some speech and language suggestions:

Ask if your child wants a “big” or “small” bubble to work on concepts.
Count the bubbles as you pop them with your finger.
Sing a song about bubbles to build rhythm and prosody (intonation) for speech.
See if your child can round his lips to blow the bubbles in the air. If not, then squeeze those cute, little cheeks in a bit to help him.

While I have deemed these toys to be ones you can use in the summer, all the above suggestions could be used year-round. There are no definitive rules when it comes to play, except of course to have fun!!

Nanette

Nanette Cote is an ASHA certified speech pathologist, published author, and private practice business owner with 30 years experience.

SPARK Cards: A First Person Review Of A Versatile Resource

November 3, 2024March 11, 2019 by Nanette

It’s always exciting for me to review a product, especially one as versatile as SPARK Cards! I can appreciate the hard work involved in creating educational items and the effort needed in promoting the tool. This is an honest review of how I found benefit in using SPARK Cards for sequencing in my private practice.

SPARK Cards Pros

Over the years, I have used SPARK Cards in my home office and teletherapy sessions with good success across a wide variety of ages, abilities, and settings. Some of my favorite features include:

Durable cardboard cards with a gloss finish to withstand being handled by many, little hands
Ability to use a dry erase marker to bring attention to teaching concepts
Functional stories that support making connections to daily living
Detailed descriptions for each card in a sequence to make session planning easier for the busy SLP and facilitate generalization of skills in the home setting
Hypothetical problem solving probes for each topic
Appropriate for children as young as four years old through middle school-aged clients

Teletherapy

I used these cards in teletherapy in two, different ways. One of my clients is working towards sentence formulation for functional tasks, so I scanned and loaded the Going to the Library deck in sequential order so we could address his goal without taxing the activity with sequencing. This particular deck is my favorite in the collection because we can talk about the library year round. I also like that the library itself mirrors a dated one that has patrons returning and checking out books the old fashioned way by handing them to a librarian. It’s a nice way to compare/contrast past and present features. I added some humor to the activity by joking about seeing a ladder. We addressed answering yes/no questions and problem solving in a lighthearted way that I feel improves engagement and attention in any task.

The second way that I used the sequencing cards was via my document camera. Another virtual client needs to improve sequencing skills, so I took three at a time from the Making a Lemonade Stand deck to provide choices while addressing sequential ordering. The three cards with kitchen backgrounds are my favorite ones in this series because I could again work on comparing/contrasting room features in the pictures to my client’s kitchen. Making these kinds of connections helps strengthen memory skills and brings much more meaning to our language activity.

Recommendations

While I LOVE the convenient portability of the SPARK collection and ease at which I can store it in my ever growing therapy closet, I would like to see the cards enlarged a little. Some of the smaller features are missed in my office sessions as I cannot magnify or zoom in on the cards as I can online. There is just so much fabulous detail in each card, that I would be saddened if my clients missed them.

I would highly recommend SPARK cards for home practice of all the above-mentioned language skills. Even children working on articulation goals could utilize this product, especially those needing drills at the sentence/conversational level. Specifically, the acronym SPARK stands for the following language probes embedded in each sequencing deck:

Sequencing and sentence formulation

Predicting, problem solving, picture interpretation

Analyzing and answering ‘WH’ questions (WHO, WHAT, WHEN, WHERE)

Retelling a story and reasoning skills

Knowledge of basic concepts and vocabulary

This comprehensive, affordable product promotes improving language skills at home. Since my original review, the developers launched more decks: SPARK collection 2 and SPARK Junior (appropriate for children 3 years and older).

Nanette

Nanette Cote is an ASHA certified speech pathologist, published author, and private practice business owner with 30 years experience.

Mastering Teletherapy for Early Intervention

April 6, 2024February 27, 2019 by Nanette

Mother with child in Teletherapy Session

By: Janet L. Courtney, MS, CCC/SLP

Founder and CEO of Lighthouse Therapy LLC

Lighthouse-therapy.com

I am excited to introduce Janet Courtney, CEO of Lighthouse Therapy LLC, a teletherapy company. With over 25 years’ experience, she’s passionate about mentoring and supporting others. You can find Janet’s blog at https://www.lighthouse-therapy.com/blog, contact her at Lighthouse at contact@lighthouse-therapy.com or call 888-642-0994.

Teletherapy for Early Intervention

“My son is two and he isn’t talking yet, is that normal?” “Our one-year-old doesn’t feed herself and has trouble holding a spoon, is that normal?” A teenage mom with a 2-year-old and a 3-year-old is feeling overwhelmed and doesn’t know how to handle her children’s bad behavior. All these scenarios are great examples of children who will benefit from teletherapy for early intervention. The federal Individuals with Disabilities Education Act, Part C, (IDEA) covers services for children and families from Birth through age 3. The Preschool Program of Part B covers children for ages 3 to 5 (Section 619). These programs mandate special education services to be provided to families and their children with developmental delays or disabilities.

Referrals

Who plays a role in spotting these issues in students? Referrals can come from different sources. Parents are usually the first to notice issues, but teachers or doctors may also notice delays. Seeking help is crucial as these services greatly impact a child’s development and future education. The first 5 years are critical for physical, social, communication, and academic development.

Referrals for Early Intervention or Preschool involve a team of professionals who create an Individualized Family Service Plan (IFSP) or Individualized Education Program (IEP). The team composition depends on the child’s needs. Together with parents, team members outline concerns and services for the child and family. An IFSP, in particular, involves the entire family, emphasizing education and consultation. The program also sets goals related to the child’s development.

Groundwork for Success

Some parents and professionals may question how telepractice can meet children’s needs online and if it’s effective. Will it really work? How can therapists gather data for eligibility without being physically present? These are valid concerns that need addressing, especially regarding Early Intervention (EI) and Preschool services provided through telepractice. When a child is referred for these services, developmental assessments and parent/teacher questionnaires play a crucial role in understanding the child’s functioning. These assessments and interviews can be conducted via telephone or through the telepractice platform, often sent electronically. Lighthouse Therapy’s platform ensures safe and confidential sharing of information, reducing the risk of exposing Personal Health Information.

Online Video Conferencing

Portrait of cute girl listening to music on headphones while using laptop at home

Therapy sessions are conducted via online video conferencing, allowing flexibility for sessions in the child’s home or preschool classroom. Clinicians coach parents on targeted strategies, observe progress, and adjust techniques accordingly. In preschool, a support specialist or assistant aids the child in joining sessions. Through engaging activities and documentation cameras, therapists monitor and guide students effectively. Lighthouse Therapy’s platform is adaptable, ensuring a dynamic experience for all involved.

Parent Coaching in Teletherapy for Early Intervention

As therapists, it’s crucial to communicate clearly with parents and caregivers, offering practical strategies to enhance communication and learning at home. We teach parents how to emphasize key messages and directions, provide repetition and modeling for the child, and encourage recording interactions to track progress over time.

Wondering how to make teletherapy sessions successful for young children? SLPs plan multiple activities for a 30-minute session to maintain engagement. Themes, interactive videos, picture activities, and memory games keep sessions lively. Using stamps, drawings, and show-and-tell encourages communication skills.

For a FREE ebook that details parent coaching, please subscribe below:

Developmental Links

It is important for the professionals to have access to developmental norms, so I have included a couple links:

Many areas of the country desperately need these services. Engaging telepractitioners will provide key services crucial to children’s future academic success.

Nanette

Nanette Cote is an ASHA certified speech pathologist, published author, and private practice business owner with 30 years experience.

I Love You Daddy: Using Alexa to Help with Parkinson’s

July 19, 2024January 18, 2019 by Nanette

Parkinson’s Disease Diagnosis

Just prior to the 2018 national speech and language conference in Boston, the man who means the world to me, the one who sacrifices everything for his family, was formally diagnosed with Parkinson’s Disease. Learning about my father’s diagnosis of Parkinson’s Disease was a pivotal moment that deeply impacted our family’s journey.

For the last few years, my daddy has been losing weight and slowing down. We initially attributed it to old age, but in recent months, the hand tremors intensified, followed by a shuffling walk and breathy voice. Living in Illinois makes it hard to care for Pops, who still lives in the Rhode Island home I grew up in. I felt lost, sad, and guilty for not being closer to home. The 2018 ASHA conference was just what I needed, in a location where I could spend time with family. I could network with professionals closer to my dad, educating myself on his care and hopefully finding the best.”

Background and Training

I’ve been a speech pathologist since 1995, primarily with pediatrics. After my practicum at RI Veterans Hospital, I worked per diem. Needless to say, it had been a while since I serviced adults. What better way to learn about the most current treatment programs for Parkinson’s than at the national ASHA conference? So, in between sessions on teletherapy, stuttering, and augmentative communication, I took courses in cognitive and voice therapy for people with Parkinson’s. I also spent some time researching Big and Loud therapy (LSVT) in poster sessions and at booths.

The most informative course was the very last one that I attended at ASHA on cognitive therapy. While this course was geared towards cognitive group therapy in a nursing home setting, I started thinking about ways to modify the plans for my daddy. To summarize the ASHA session, the presenters discussed functional lesson plans that incorporated conversations about recent and past historical events. The purpose was to help with memory and retrieval skills and facilitate making connections with personal accounts.

Amazon Alexa

It dawned on me that my daddy and I could use our Amazon Alexa to inquire about historical events by asking: “Alexa, what happened on this day in history?” You can even further probe with a follow-up question: “Alexa, what else happened on this day in history?” The plan has been for each of us to ask our respective Alexa’s this information and then I call Pops first thing in the morning to review the material. Later in the day, after completing my treatment sessions in Illinois, I call Pops in Rhode Island and ask him to recall 1-2 historical events we discussed that morning. When possible, I try to include personal perspectives to assist in recall.

This daily interaction supports goals like clear commands and increasing vocal volume. Talking with my dad lifts his mood. Since starting this interaction, my dad’s tone has improved. I hear glimpses of the man I’ve always loved.

Modifying Programming With Alexa

On some days, I assess conversations, especially if he skips meals, resulting in breathy voice and memory issues. Those days, language cues aren’t effective, so I just review the information again. He recalls more detail when he listens to Alexa’s recount. We accept it’s okay to listen multiple times or take notes. I periodically remind him that it’s not about recalling, but what he taught me growing up, avoiding making him sad. Be kind to loved ones whenever possible, avoiding regrets about not showing care when you had the chance.

Nanette

Nanette Cote is an ASHA certified speech pathologist, published author, and private practice business owner with 30 years experience.

Why Does My Child Need A Diagnostic Hearing Evaluation?

July 6, 2024November 8, 2017 by Nanette

Female doctor performing a hearing evaluation on a teenage girl

A comprehensive hearing evaluation is crucial for understanding a child’s hearing health. This article delves into the distinctions between hearing screenings and diagnostic evaluations, highlighting why a diagnostic hearing evaluation is important even if a child seems to hear well. We will explore various types of diagnostic hearing tests, different kinds of hearing impairments, and how ear fluid and pressure can affect hearing. By understanding these aspects, parents and caregivers can better appreciate the importance of thorough hearing assessments for their children.

This post collaborates with Dr. Eve Leinonen, an experienced audiologist serving clients ages four and up in Naperville, Illinois. Dr. Eve Leinonen earned her Doctorate in Audiology from Wayne State University in 2007. She has diverse experience in office and outreach settings. She has been the owner and principle audiologist of Affordable Hearing Solutions since 2015. Diagnosed with hearing loss at age 17, Dr. Leinonen can relate on a more personal level to the struggles and frustration that many with hearing loss face daily. She ensures patients select optimal treatment for their hearing loss and lifestyle, aiding their continued thriving in daily life.

Key Takeaways:

Hearing Screenings vs. Diagnostic Evaluations: Understand the differences and why both are essential.
Justification for Diagnostic Evaluations: Learn why thorough hearing tests are necessary even if a child seems to hear well.
Types of Diagnostic Hearing Tests: Discover the various tests used to evaluate hearing health.
Types of Hearing Impairments: Gain insight into different hearing impairments and their impacts.
Effects of Ear Fluid and Pressure: Recognize how ear fluid and pressure can influence hearing ability.

How is a hearing screening different than a diagnostic hearing evaluation?

It’s important to understand the difference between a hearing screening, and a diagnostic hearing evaluation. Schools and doctor’s offices typically conduct screenings to assess whether a child may have a hearing loss. This only looks at how the child hears via air conduction (how we hear with sound traveling through the ear canal to the middle ear, inner ear, and then the brain).

Diagnostic hearing evaluations look at all aspects of the hearing mechanism. It looks at how we hear via air conduction, bone conduction (how the auditory nerve itself is responding), word recognition scores (Speech Audiometry), tympanometry and/or otoacoustic emissions (OAE).

My child can hear me whisper, so why does (s)he need a diagnostic hearing evaluation?

One of the essential components to a dynamic speech and language assessment is a diagnostic hearing evaluation. If they haven’t already, I strongly encourage families seeking my private speech and language services to schedule a diagnostic hearing evaluation before I assess articulation, expressive, and receptive language skills. It is critical to rule out a medical factor for a speech and/or language delay that could negatively influence assessments and speech-language therapy.

Specifically, a hearing loss can impact vocabulary development, sentence structure, articulation, and academic performance. Our sounds are produced at many, different frequencies. Hearing difficulties affect a child’s ability to accurately produce certain sounds, especially quieter ones like /s/, /sh/, /f/, /t/, and /k/. It also impacts comprehension and expression. Insufficient information may hinder progress and communication development.

Common Misconception

A common misconception is that intact comprehension negates a probable hearing loss. While this may be true, the only way to be certain that a child does not have difficulty hearing is to complete diagnostic hearing testing. It is very possible that a child with a temporary hearing loss can continue to follow routine, familiar directions; respond to subtle gestural cues such as eye gaze; and seemingly attend to conversational tasks. However, it would be challenging for this same child to imitate a variety of speech sounds, especially if they are hearing sounds as though they are swimming underwater.

There are some telltale signs and/or symptoms that indicate a need for a diagnostic hearing evaluation. Here is a list of the ones that I am most concerned about as a speech pathologist:

Delay in speech and/or language skills in comparison to siblings/peers
History of re-occurring ear infections or sinus infections
Difficulty imitating speech sounds
Trouble following directions
Excessively loud talkers

What types of diagnostic tests are included in a hearing evaluation?

There are also different types of diagnostic testing available depending on the child’s age and ability to task during testing. Visual reinforcement audiometry (VRA) engages children aged 6 months to 3 years or with developmental delays to respond to environmental sounds. It utilizes external speakers and toys for positive reinforcement. Tympanometry and OAEs check for fluid and inner ear hair cell responsiveness.

Play audiometry is utilized for children who are old enough (4 years or older) to task to a game or toys, but may not quite be old enough to raise their hand for each beep. Usually the game involves dropping toys into a bucket when they hear a beep to help the audiologist establish thresholds. Tympanometry and OAE’s can be performed as well as speech recognition testing.

Older children may be asked to raise their hand or push a button when they hear pure tone “beeps”, repeat words for word recognition score testing, and also tympanometry and OAEs (if necessary).

What are the types of hearing losses?

There are three kinds of hearing loss: conductive, sensorineural, and mixed. A conductive loss is often a temporary condition brought on by: fluid accumulation, ear infections, or a blockage of the Eustachian tube caused by an allergy. A sensorineural hearing loss can be the result of a viral infection such as measles, meningitis, or mumps. This damage to the middle ear may also be caused by head trauma or exposure to extremely loud noise. Some people are born with a sensorineural loss while others may acquire one in old age. These videos help explain causation for these losses and common interventions.

Conductive Hearing Loss

Sensorineural Hearing Loss

Mixed Hearing Loss

How does fluid and negative pressure in the ears impact hearing?

Understanding the effect of fluid on hearing is crucial, especially for young children. Fluid can give the appearance of normal air conduction levels at times, but the child is losing important speech sounds and cues. Though it appears normal on paper, to them it sounds as though they are hearing underwater. Speech and environmental sounds are muffled, thus effecting a child’s ability to hear and understand sounds correctly. It’s possible that their “normal” levels of hearing without fluid are even better than what is appearing with fluid.

This reduction of hearing can appear to the listener as a “hearing loss” despite showing normal response levels. Diagnostic testing is important as it will show whether the normal hearing thresholds reveal a conductive component (related to Conductive Hearing Loss and is a gap between air and bone conduction thresholds), thus indicating middle ear concerns.

Fluid and Development

Infants and toddlers are prone to excessive fluid build-up in the ear canals because the eustachian tube is parallel, giving fluids a cozy place to stay. As toddlers grow, the eustachian tube begins to slant, which supports natural fluid drainage from the ears. This is just one of the reasons why we encourage toddlers to sit upright while drinking to avoid adding more fluids into that ear canal.

Children can fluctuate in and out of temporary hearing loss conditions and even have this fluid in the ears without an infection. There are several misconceptions regarding children and hearing loss. One is that if your child has “normal responses”, then his hearing is fine. One aspect to look at is tympanometry, which analyzes middle ear function. Tympanometry can tell us if there is fluid or negative pressure in the middle ear, which can greatly impact hearing.

If you have any further questions about the impact of hearing on speech and language development, then please visit these links for more details:

Newborn Hearing Screening

Childhood Hearing Screening

How We Hear

Nanette

Nanette Cote is an ASHA certified speech pathologist, published author, and private practice business owner with 30 years experience.

Classroom Activities for Down Syndrome Awareness Day

July 6, 2024March 21, 2017 by Nanette

Nanette Cote's niece celebrating Down Syndrome Awareness Day

March 21st marks Down Syndrome Awareness Day, symbolizing the three extra chromosomes on marker 21 that cause Down syndrome. I’m dedicating this post to my niece, Ella, who is a social butterfly with diverse interests. Ella’s mom, Jennifer, is an English professor at Bunker Hill Community College by day and a supermom by night. Jenn’s supportive network, including family, neighbors, and educators, has been invaluable in caring for Ella and her sister, Abby. Recently, Jenn shared a presentation aimed at fostering empathy for children with processing challenges and low tone. The activities discussed in this post can be adapted for various populations. Thanks to Jenn for sharing her experiences!

Enhancing Socialization on Down Syndrome Awareness Day

After six years of worrying, I found myself in a unique situation. My concern was that my child would have difficulty making friends because she has a disability. She does not have the same language skills as the typical six or seven-year-old.

We moved to a town where kids took an interest in my child, becoming friends who sometimes overwhelmed Ella with attention. So I took it upon myself to help my child’s peers understand her. I arranged activities in her classroom, letting students experience her perspective firsthand, thanks to her teacher’s support.

Understanding Auditory Processing

First, we divided the class into groups of four. Within each group, someone needed to volunteer to stand in the middle. Three participants received slips with information: birthdate, favorite meal, and favorite toy and shared details with the person in the middle. They all tried talking to the person in the middle at the same time. After about a minute of this exercise, we stopped and asked the children how they felt trying to communicate and listen. Those in the middle commented that it was difficult to listen to everyone, and they felt overwhelmed. It was equally frustrating for those who were trying to share their information to the person in the middle.

I then transitioned to discuss how this exercise could apply to my girl. We talked as a group about how sometimes she would respond with an automatic “no.” Sometimes she would push people away. I asked the group what did they think they could do to help lessen these behaviors. And the children had some insightful answers. “Approach her one at a time.” “If she does say ‘no,’ then just say ‘OK,’ but wait for about five minutes and then go back to see if she wants to play then.”

Increasing Compassion on Down Syndrome Awareness Day

The other exercise I did with them was a practice used by the Down Syndrome Society of Rhode Island. After making sure no one had food allergies, I handed out large marshmallows to the children. I cut the marshmallow in half because they were so large. Children stored marshmallows in their cheeks, realizing speech was difficult. They discussed understanding peers with low tone, suggesting repetition and slowing speech.

Concluding Thoughts

Overall, I was so happy with the way these exercises went and the children’s responses to them. I knew these exercises were effective when a parent approached me at the end of the year and said that her son had come home the day we did them and with enthusiasm, told her that he now knew how to talk to his friend at school. The fact that he offered this information freely, gave me the sense that he was listening that day. If these exercises helped him to communicate better with my daughter, then it was not only a fun venture, but also an effective one.

Nanette

Nanette Cote is an ASHA certified speech pathologist, published author, and private practice business owner with 30 years experience.

Speech Teletherapy- Your SLP Questions Answered

July 7, 2024January 24, 2017 by Nanette

As you navigate the landscape of speech teletherapy, it’s essential to narrow down your options to a few companies that align with your goals and values. Once you’ve identified them, thorough research is key. Delve into their websites, seek input from colleagues, and leverage social media platforms to gather insights before scheduling interviews. Now, let’s address some common queries about teletherapy.

How many hours a week do you work in speech teletherapy?

I have worked for two companies and both required I work directly with clients for at least ten hours weekly. Additionally, I receive compensation for time spent on billing, consulting with parents, writing IEPs, documenting, and planning sessions. I am compensated for late cancellations or no-shows. Typically, I bill 10-13 hours weekly for therapy and related tasks.

How many kids are on your caseload?

I have worked with children in virtual school settings, meaning that they are either home-schooled and/or participate in charter schools with fewer hours than traditional school settings. Therefore, I typically have 9-10 clients on my caseload of 10 direct hours weekly.

How often are you paid for speech teletherapy?

I submit my bills on the last day of each month and then receive a direct deposit two weeks after invoicing.

Do you need to find your own clients?

No, if you contract with a company, then they assign you clients. This was important for me when I first started in teletherapy. I knew I could do telepractice independently, but entering this new world, I preferred starting with a reputable company and relying on them for assignments.

How does speech teletherapy work?

Clients meet me in “my therapy room” by logging into a HIPPA-secured space. We both need to use a device (laptop, iPad, Chromebook) with a webcam to see each other.

In addition to facilitating activity loading and data collection during sessions, most platforms offer a variety of interactive tools for engaging therapy experiences. These include circling answers, playing games with stamps, utilizing timers, and accessing video content for diverse speech and language tasks. Clients consistently find these features motivating and engaging, making it difficult to conclude sessions.

Do you need to be certified in other states?

Yes, as of right now, I need certification in the state I reside in and that of the client’s. The companies that I have worked for reimburse me for certification and renewal fees for licensure in states where my clients reside.

What are your contracted rates?

I can’t discuss salary, but some companies negotiate fees more than others. As a contract therapist, I anticipated lower reimbursement rates. My goal was to fill daily gaps and ensure steady income. Thus far, my contracts have fit both of those bills.

Nanette

Nanette Cote is an ASHA certified speech pathologist, published author, and private practice business owner with 30 years experience.

FAQ: Playing with Water in Speech Pool Groups

November 3, 2024April 4, 2016 by Nanette

In December 2015, the ASHA Leader honored me in their Limelight section. Months later, emails flooded in with excitement and questions about playing with water in speech pool groups. Messages from SLPs globally, including Germany, and locally, such as Illinois, have been received and appreciated. In true SLP fashion, professionals asked poignant questions, inspiring a FAQ post about speech and language pool groups. This post later turned into a guide book: We Talk on Water (available on Amazon.) For detailed guidance on lesson plans, materials, billing, participant recruitment, documentation, and low-tech AAC, this book is essential!

Nanette Cote holding beach ball and spreading the word about the benefits of playing with water in pool groups

FREQUENTLY ASKED QUESTIONS ABOUT SPEECH
AND LANGUAGE POOL GROUPS

Coursework and Training

How did you got started in doing treatment sessions in the pool? In 2003, I observed a pool group at a Jewish Community Center in Rhode Island. Soon after, I requested insurance coverage. It took a couple months before my job site hosted speech and language pool groups at the Jewish Community Center. My tasks were promoting the pool group, collaborating with a PT, and writing weekly service notes for billing submission.
Do you have any special certifications to help with your sessions in the pool? I acquired all of my training through experience. Hosting my first pool group with an exceptional PT taught me about water positioning and improving stability and attention.
Is there coursework or training for providing aquatic speech therapy services? One of the emails that I received following the ASHA Leader article was from Susan Nachimson who shared that she has been teaching a course titled: Speech Therapy in an Aquatic Setting since 1/2002 [California Board of Speech Pathology (PDP#129)].

Securing a Facility for Playing with Water

How would I go about looking for other facilities that offer aquatic speech therapy services? If you are not interested in starting your own group and would rather observe pool group therapy, then begin by calling rehabilitation facilities. Many of these locations have heated pools that they use for physical therapy with clients.
How did you secure the pool? Six months before the services were slated to begin, I actively researched for the pool group session I wanted to offer through my private practice. First, I called three facilities and ask to speak with the aquatics directors. I followed up by meeting receptive individuals who rented their pool to rehabilitative agencies. I chose Rush Copley Healthplex
Do you think a neighbor’s pool with an outside shower and bathroom work? I’m not a strong swimmer, so I’d feel uncomfortable using a neighbor’s pool and taking on liability for the group. I also like being in the community and being able to offer pool group services to up to 10 families. Having the ability to invite several participants also increases opportunities for peer modeling and expands socialization.

Billing, Insurance, and Liability Coverage

Do you bill for it like a normal group speech therapy session? Yes, I bill my speech and language services using the speech group CPT code 92508. This code is an “un-timed” one, meaning that you can expect the same reimbursement whether you spend ten minutes in the water or sixty.
Did you bill to insurance companies or do the group sessions private pay? If you did private pay, what were your rates? I do a little bit of both depending on the insurance carrier and my network participation. I advise families with high co-payments near reimbursement limits not to use coverage, to avoid taking away sessions. Research insurance reimbursements and set charges accordingly, ensuring rates align with coverage and state regulations. You can expect to make significantly less for group services than for individual sessions.
How did you go about getting liability coverage to work with clients in the pool? I asked the pool facility what they required and in my circumstance, I only needed to add the location name to my existing liability policy. This addition did not require any additional fees. You should ask this question while researching pool facilities as this may vary depending on your state.
Do you pay pool rental fees? There are non-refundable pool rental fees at the facility that I use for group services; however, I ask families to cover these costs. Families are expected to pay a designated amount per group for each of the six weeks of my program. This fee is not prorated if they miss a session. I cannot afford the risk of paying for weekly services for each family without being able to bill for a session if the family misses or decides not to continue for whatever reason.

Playing with Water: Goals and Session Outline

Do you have specific goals for each child while playing with water or is it more a general group therapy targeting various aspects of language (engagement, imitation, vocalizing, following directions)? Years ago, an EI PT and I devised a service form for pool group tasks, now adapted for my private practice. New students are offered a free consultation to align goals. I designed the SOAP note to allow me an opportunity to comment and expand on tasks and I used a local printing store to make carbons of the note so I can quickly provide families with feedback about the session. I also wrote an outline of all the developmental goals that you can address with children aged two through seven years old during pool group therapy.
Have you ever used pool therapy for middle school and high school students with autism? And if, what kind of activities did you do? No, I have only worked with children aged 2-7 in the pool.
Would you mind sharing more details about a typical pool therapy session? For more details about my group agenda, you can follow this link.
What songs do you use in pool groups? The most popular songs are: The Wheels on the Bus, If you’re Happy and You Know it (I use this tune for a directions game to sing, “Put the duck on your head, on your head”), Head, Shoulders, Knees, and Toes, Five Green and Speckled Frogs, Hello and Goodbye songs, All the Little Fish were Swimming in the Water, One Little, Two Little, Three Little Bubbles.

Miscellaneous Questions

Did you have an ongoing day/time for a number of weeks? Yes, my summer groups are weekly at the same day and time for six weeks total.
Did you have the parents in the pool too? A caregiver at least 18 years of age is required to remain with each child before, during, and after pool group sessions.
Were your classes 30 min or one hour? My water sessions are 30 minutes long, but “therapy” begins in the changing room both before and after water play. We talk about our sessions, what we wear in the water, and temperatures that day just to name a few.
Did you co treat with a PT? I currently work as a solo facilitator for my pool group sessions, but highly recommend working with a motor specialist when possible, especially if you are just getting started with pool group therapy.
How do you advertise (word of mouth, flyers at your clinic, etc.)? I bought local ad space but got no clients. Last summer, participants found me on social media, through ABA meetings, and referrals.

Nanette

Nanette Cote is an ASHA certified speech pathologist, published author, and private practice business owner with 30 years experience.