speech - Lessons in Speech with Nanette

PROMPT- Useful for Childhood Apraxia of Speech (CAS)

Nanette Cote Providing Tactile PROMPT to Toddler

What is PROMPT?

PROMPT is an acronym for:

Prompts for Restructuring Oral Muscular Phonetic Targets. This is a dynamic, hands-on program for children with apraxia of speech in which the trained clinician shapes the movement of a child’s jaw, tongue, and lips using our hands in support of sound production. Although the use of touch and movement is an integral component, PROMPT is more than just executing tactile support. It is a program that incorporates all aspects of a child’s processing, understanding, and interaction.

These areas of development, or domains, are known individually as: The Cognitive-Linguistic, (ability & language), Social-Emotional (socialization), and Physical-Sensory (muscle tone & senses) Domains. Together, these domains function in unison and influence each other to the extent that challenges in one area directly impact progress in another. This video for families on the PROMPT website visually explains the domains and PROMPT’s multifaceted treatment approach. Some children that may benefit from PROMPT include those diagnosed with motor speech disorders like apraxia and dysarthria, cerebral palsy, and autism. To determine if PROMPT is appropriate for your child, your clinician will begin with an observation and comprehensive evaluation.

Evaluation:

PROMPT is rooted in a Dynamic Systems Theory, meaning that clinicians must factor in cognitive, social, behavioral, sensory-motor, and physical influences on communication. Let us break these down into some specific questions that we as clinicians ask ourselves during a comprehensive assessment process:

Cognitive: What is the child’s ability to process sensory information and comprehend language? Does the child need visual schedules and/or other modifications and cues to learn new information? How should clinicians and parents’ scaffold, cue, and elicit language with the child?
Social: Do we need to work on establishing trust before diving into PROMPT? How does the child express his wants and needs (i.e., pointing, gestures, sounds?) How is the child’s non-verbal communication? What communicative intents does the child relay (i.e., greeting, requesting, commenting, responding to questions?) Is the child interested in engaging in communication and interactions with others?
Physical: What is the child’s skeletal system and muscle tone like? Do we need to provide additional supports in the environment to support skeletal and/or musculature issues? Does the child have difficulty with vision, hearing, tactile/touch?

System Analysis Observation (SAO) and Motor Speech Hierarchy (MSH):

In addition to collecting information from a parent interview, a PROMPT evaluation also includes analyzing the movements necessary for speech. These yes/no questions are based on typical speech development. Next, the clinician transfers the results to a visual representation to rate the severity of the speech disorder. The System Analysis Observation (SAO) and Motor Speech Hierarchy (MSH) provide us with practical information to develop a treatment plan.

Well-Built House

Marcus Neal, a PROMPT instructor, describes the Motor Speech Hierarchy as a well-built house with a strong foundation (jaw) necessary for sustaining the other structures (lips, tongue.) The jaw is the first articulator to develop, so we need to make sure that this foundation is ready to support sophisticated lip and tongue movements. Jaw stability and the ability to open our mouths in four graded levels (minimal to wide) helps us sequence movements for speech. In PROMPT, we incorporate vowels into a child’s practice because vowels shape jaw movements.

After completing a SAO, clinicians calculate percentages for each of these areas: tone, phonatory, mandibular (jaw), labial-facial (lips-face), lingual (tongue), sequenced movements, and prosody (inflections/intonation.) Next, we shade in the boxes for each of these areas on the MSH to help identify points of intervention. Given the fluid interaction between these Stages, we need to address three areas to work on immediately. While we cannot change a child’s tone, it is important to note limitations and consult with OTs and PTs for suggestions on improving posture.

After selecting three areas to prioritize, we develop goals and vocabulary lists to practice words/ phrases during functional activities. This list will include a variety of vowels, consonants, and blends with emphasis on core vocabulary. From the start, we blend words into phrases to work on prosody (intonation). So, we model and support with PROMPTs, “ma more!” or “go ma?” The reason for working on prosody early on is to help make speech movements fluid and vary communication intentions.

Service Delivery:

Typically, young children with apraxia of speech benefit from at least two, 30-minute sessions. Depending on the degree of severity, services may range anywhere from a few months to several years. Other contributing factors that can impact longevity of services are medical conditions, cognition, social/pragmatic skills, sensory/tactile defensiveness, and comprehension delays.

Typical PROMPT Therapy Session:

If a child with apraxia of speech has limited verbal skills, then sessions will initially focus on using vowel sounds. As vocalizations increase, then PROMPT support shifts to productions of consonant sounds/words/phrases/sentences.

A typical 30-40 minute PROMPT session for apraxia of speech would proceed as follows:

Greeting and set up (5-10 minutes)
Motor phoneme warm-up reviewing the targeted words embedded in the session’s activities with 3-5 PROMPT supported repetitions per target. (5-10 minutes)
Most sessions have 2-3 activities, each lasting 5-10 minutes. These activities incorporate pertinent aspects from the Domains reviewed above factoring in picture supports, timers, movement breaks, supported seating, and any other cues the child may need for success. Speech sound movements are worked on during play to help the child attach meaning and strengthen memory.
Review home practice plan (5-10 minutes)

Here are some examples of activities that I have used for children with varying cognitive abilities during my PROMPT sessions:

early childhood: Toy Vet Play Set with word targets to address needs in tongue control and jaw movements (go, goes, take, push, home, help)
preschool: Play-Doh Kitchen Oven with words to help work on lips-face control with movements that require rounding lips (no, two, dough, do, “mo” for more)
elementary school-aged: Pop the Pirate Game practicing words that support improving jaw control, lip contact (pop, Bob, up, “hep” for help)
middle school-aged: Knock, knock jokes to address improving prosody (intonation) and tongue control (Who’s there? cat, kitten, bike, show)

PROMPT Supports:

There are four levels of PROMPT (Parameter, Surface, Complex, Syllable) with clinicians using at least 2-3 of these in one session. Here is a breakdown on each level and the type of support it provides a child:

Parameter: provides the most support you can offer through stabilizing/ moving the jaw and lips. There are 13 sounds supported at this level some of which include: h, p, b, m, sh, and vowels in words like “cat”, “father”, and “eat”.

Syllable: only used for consonant-vowel (CV) productions such as “go”.

Complex: helps the child contract and/or tighten his tongue to produce consonants such as (r), blends (sh), and vowels.

Surface: these supports specifically help a child with placing articulators accurately, timing movements using rhythm and prosody, and transitioning from one sound movement to another to create words.

PROMPT and Teletherapy:

In 2020, PROMPT training for speech pathologists shifted from in person to virtual because of global shelter-in-place restrictions. The PROMPT Institute also developed specific training for clinicians using PROMPT via teletherapy. Parameter PROMPT offers the most support for a child and can be easily administered by a caregiver following a trained speech pathologist demonstration. Some surface PROMPTs can also be used in teletherapy with the clinician showing this support on herself, a doll, or willing assistant.

My hope in writing this post was to provide a thorough explanation of the dynamic intervention of PROMPT. This program is unlike any other that I have been trained in over the last two decades in the field of speech pathology, as I have witnessed tremendous success when applying this methodology with clients who have motor speech disorders. Both caregiver carryover and early intervention are crucial to these achievements, so please continue advocating for your child and seeking resources like the PROMPT website to further your knowledge and education.

If you want to find a speech pathologist in your area trained in PROMPT, then you can visit this link and conduct a search.

What are Phonological Disorders and Processes?

by Nanette Cote

Mastering Teletherapy for Early Intervention: Portrait of cute girl participating in auditory bombardment with headphones on

school teacher showing a book to the children

In this comprehensive guide, we’ll explore phonological processes, discuss age-related expectations, and outline your role in supporting phonological goals at home. Whether early intervention or the school system has identified your child for services, this post provides valuable insights.

Evaluation, treatment planning, and homework for phonological disorders differ significantly from articulation and childhood apraxia of speech due to their distinct nature. Please note that this post does not take the place of a comprehensive and diagnostic evaluation for your child. There are many factors that we assess when developing an appropriate treatment plan. Talk with your pediatrician, child’s teacher, and/ or speech pathologist if you have questions and concerns specific to your child.

PHONOLOGICAL PROCESSES

There are eight, phonological processes that we typically encounter in speech therapy: syllable reduction, syllable structure, cluster reduction, final consonant deletion, stopping, fronting, backing, and gliding. Below are definitions, examples, and age expectations for suppression of each of these processes.

Syllable reduction: eliminating a syllable in a word should cease by 4 years old. For example, “puter” for “computer”.
Syllable structure: inability to produce part of a syllable. There are four of these such shapes (CV, VC, CVC, CVCV) with “C” representing “consonants” and “V” meaning “vowels.” Some examples of these shapes are: (CV) “bee”; (VC) “up”; (CVC) “cat”; and (CVCV) “baby.” A child with a phonological disorder may have difficulty producing several of these combinations for an undetermined length of time.
Cluster reduction: occurs when a child omits part of a blend, most often /s/ blends /sk, sm, sn, sp, st/. You may hear him say “kin” or “sin” for the word “skin.” Children should be able to produce blends together between 4-5 years old.
Final consonant deletion: omitting the last sound in a CVC word (“ca” for “cat”) should suppress by 3 years old.
Stopping: producing a sound that should be stretched like /s/ with a /b, d, p/ (“bun”, “dun”, or “pun” instead of “sun”) should end between 3-5 years old.
Fronting: making sounds that are produced further back in the mouth more towards the front. For back sounds /k, g, ng/, the tongue lifts in the back while the tongue tip stays down in the front of the mouth. A child who fronts sounds lifts the tongue tip to touch his palate and substitutes /t, d/ for back sounds. You may hear “tan” for “can” or “tookie” for “cookie” if your child is fronting. This process ends at 3.5 years old.
Backing: the reverse of fronting. Here, your child continues producing sounds made with the tongue towards the front of the mouth, lifting the back of his tongue. So, you may hear “do” for “goo” or “gog” for “dog.” This process is often seen in children with severe phonological delays.
Gliding: substituting an /r/ with /w/ (“wun” for “run”) or /l/ sound with /w, y/ (“yeyo” for “yellow”.) This process may continue through 6 years old.

PHONOLOGICAL

Evaluation:

Speech pathologists observe and screen before evaluations, guiding test choices. Analysis and probes help develop treatment plans for phonological delays.

A phonological delay is when your child omits, substitutes, and/or distorts a process. This is something that all children demonstrate at various ages, but eventually suppress as they enter the preschool years. These errors occur at a young age because a child’s speech mechanism (lips, tongue, jaw) is not yet fully, physically developed to move swiftly and precisely. As children grow physically, their speech becomes more intelligible. Those with phonological disorders may need auditory training to improve accuracy.

A phonological delay means multiple sound errors. For instance, using /d/ for /th/ in “thumb” doesn’t signify a delay. This example would likely be an articulation delay. However, if he uses /d/ in addition to one of more of these sounds: /j, sh, ch, th/ (i.e., “padama” for “pajama”, “dells” for “shells”, “lund” for “lunch”, and/or “dum” for “thumb”), then he has not suppressed a phonological process of stopping and needs intervention, especially if he is five years old or older.

One of my most popular, phonological goals is: Reduce cluster reduction for /s/ blends (sk, sm, sn, sp, st) in initial positions of words with 80% accuracy given supports as needed.

Therapy:

In phonological therapy, we work towards helping the child learn to suppress the process. The speech pathologist prioritizes processes occurring over 40% in a speech sample. Unlike articulation issues, phonological delays vary contextually.

Cycles Approach:

Speech-language pathologists use the cycles approach, a systematic and evidence-based method, to address phonological disorders in children. This method organizes therapy sessions into cycles, targeting specific phonological patterns for a predetermined period before progressing to the next set of targets. This approach aims to facilitate generalization of speech sound improvements across a wide range of contexts. Through repetitive practice and reinforcement, children gradually internalize correct speech patterns and improve overall intelligibility. The cycles approach emphasizes a holistic approach to therapy, incorporating auditory, visual, and tactile cues to support learning and retention. By addressing underlying phonological processes rather than individual sounds, it provides a comprehensive framework for addressing speech sound disorders effectively.

Auditory Bombardment:

Auditory bombardment in phonological speech therapy involves exposing the child to a high frequency of correct target sounds in various contexts. This technique aims to increase the child’s exposure to the target sounds, leading to improved auditory discrimination and comprehension. By repeatedly hearing the correct sounds, the child’s auditory system becomes more attuned to the target phonemes, facilitating the internalization of correct speech patterns.

Auditory bombardment helps to create a strong auditory model for the child to imitate, aiding in the acquisition and production of target sounds. Additionally, this approach can enhance the child’s phonological awareness and contribute to overall speech sound improvement. Overall, auditory bombardment is a valuable tool in phonological therapy, providing intensive auditory input to support speech sound development and remediation.

Homework:

mother and son — Photo by cottonbro studio on Pexels.com

It is nearly impossible to skip homework practice and make progress in phonological therapy. Again, your child’s speech pathologist will want a certain level of mastery in the therapy room before assigning homework practice. Once targets are identified, clients with phonological delays can benefit from engaging in listening training at home. Ask for appropriate book suggestions. The sooner you start, the better.

Conclusion

In conclusion, grasping the nuances of phonological processes is vital for effective intervention strategies. With thorough evaluation and targeted treatment plans, accompanied by diligent home programming, children can overcome phonological challenges more effectively. Encouraging parental involvement in home practice reinforces therapy gains and fosters lasting progress in speech development.

Daily Oral Motor Routines: Developing Awareness & Improving Feeding

by Nanette Cote

Portrait of shocked young girl with mouth open against red background

“Speech is movement made audible…, oral-motor therapy, as it is practiced today, can be defined as the process of facilitating improved oral (jaw, lip, tongue) movements.” Oral-Motor Techniques in Articulation & Phonological Therapy by Pam Marshalla, M.A., CCC-SLP

Sometimes, children need a little more than auditory and visual cues to make sequenced movements for speech. We know that making these movements brings them one step closer to pairing sounds with those motions. Adding tactile learning can be an essential piece in the puzzle for children who need to feel more information in and around their mouths before producing a sound.

Developing a new speech movement takes time, successful practice, supports, and extinction of inaccurate movements. This comprehensive oral motor wake up routine for home intends to support caregivers in using oral motor tools sold through Ark Therapeutic to prepare the mouth for feeding and/or speech.

Years ago, I connected with Ark and they graciously gifted me several products to try with clients on my caseload. I do not advocate purchasing or implementing oral motor products unless a speech pathologist has recommended these specifically. Comprehensive assessments support appropriate treatment planning and identify other medical, contributing factors like hearing loss or tongue tie that may need intervention prior to initiating speech-language therapy.

Oral Awareness

Before a child can develop sequenced movements for speech, he needs to be able to feel and attend to the structures of his mouth. Without this knowledge, he may not be able to perform tasks like putting lips together, moving the tongue, or chewing. As a result, these children do not comprehend an auditory (verbal) direction to “Lift the tongue up and make the /d, t, n/ sound,” even when you show them how it is done.

Oral awareness through “wake-up” practice helps children feel the boundaries in and around their mouths. One tool that I have used over the last two decades in private practice is the Z-Vibe by Ark Therapeutic. You can purchase this instrument alone or as part of a grabber in the form of the Z-Grabber. For more information on the Z-Grabber, please see my post on jaw work.

Oral Motor Tools

Ark’s Z-Vibe Oral Stimulator

This single probe tip instrument provides intense vibration input to support stimulation, improving awareness, and exploration. In other words, it helps “wake-up” the mouth before feeding and/or speech practice. While you can only use one tip at a time, there are over 35 different ones that you can twist and secure on the Z-Vibe.

Ark’s 10-Tip Kit Set for the Z-Vibe

This kit includes the following tips for the Z-Vibe:

Preefer
Probe
Mini
Hard Fine
Bite-n-Chew
Textured Bite-n-Chew XL
Hard Spoon
Soft Spoon
Hard Brush
Soft Brush

I will be describing a “wake-up” routine using the first, four tips in the list above: Preefer, Probe, Mini, and Hard Fine. You can read more information on the Bite-n-Chew and Textured Bite-n-Chew XL in my post about the jaw. The hard and soft spoons are helpful in transitioning infants to textured foods. These spoons are especially useful if your child stuffs his mouth full as this is a sign that he needs more information and input before being able to chew and swallow.

The Z-Vibe vibration with spoon tips give oral musculature appropriate sensory input and ensures safety while eating. Finally, the brush tips support oral hygiene and dental care. These are both good options for getting ready to use a regular toothbrush. Consult your child’s speech pathologist about appropriate tips.

Wake-Up Routine

ALWAYS maintain control of the Z-Vibe and refrain from letting your child hold the tool itself to place on his face. We do not want the child to use this tool like a toy and/or place it on bones like the nose or ears as this is a useless, sensory stimulation experience. You may allow your child to hold the device with you, but never independently.

Step 1:

When you first introduce oral motor tools, you will need to begin by having your child feel the gentle vibration on his hands, gradually moving up his arms and towards his mouth. We want to make every step of this stimulation a positive experience and starting at someone’s face is too intrusive. Hold and count from 3-5 on your child’s hands, arms, then cheeks using the Z-Vibe with Preefer Tip.

Preefer Tip: This particular tip was designed to roll along inner cheeks and/or lips to increase oral awareness. The ridged surface of this tip was a brilliant idea because it provides the perfect amount of stimulation without being overbearing.

Step 2:

Continue proceeding with caution and positive acceptance by alerting the outside of your child’s face before moving inside the mouth. Stroke the outside of your child’s cheeks in a downward motion, starting near his ears and moving towards the lips in three rows on each cheek, counting from 3-5 each time.

Step 3:

For lip awareness, you can continue using the Preefer tip or switch to the Probe or Mini Tip.

Preefer Tip: Hold vertically at one lip corner and roll it moving towards the opposite corner. If age appropriate, you can sing a song while you move back and forth 3-5 times or simply stretch out your counting.

Probe/Mini Tip: These removable tips have three surfaces: bumpy, striated, and smooth. Start out introducing the smooth side and then take baby steps towards trying the textured ones. Stroke the lips using one surface at a time applying gentle pressure and counting for 3-5 seconds. Please note that the Mini Tip is great for smaller mouths and infants.

Step 4:

Start moving inside your child’s mouth using the Preefer, Probe, or Mini Tip to alert the inner cheeks. This area is a boundary cue for moving foods towards the molars for chewing.

Preefer Tip: Roll the tip inside each cheek with an up-and-down motion while and counting for 3-5 seconds.

Probe/Mini Tip: Position the Z-Vibe Probe or Mini Tip horizontally on the bottom of your child’s cheek inside his mouth and then walk it up using counting or a song.

Step 5:

The last step is to alert the tongue. You may use the Preefer, Probe, Mini, or Fine Tip for this final part of the routine. The only area overly sensitive to vibration is the palate, or top of your child’s mouth.

Preefer Tip: Roll this across the middle of the tongue from side to side while counting from 3-5 repetitions.

Probe/Mini Tip: Start with the bumpy side for the first round of 3-5 repetitions and then repeat this count using the striated end. Place the Tip of the Z-Vibe a few centimeters from your child’s tongue tip, holding and gently pressing as you move the tip vertically back and forth. The Z-Vibe should maintain contact with the tongue during each of the 3-5 repetitions.

Fine Tip: To build awareness at the sides of the tongue, use the Fine Tip to gently stroke with a back and forth motion for 3-5 repetitions on each side.

Take Away Points

1. I use a variation of the “wake-up” routine at session starts to build muscle awareness for feeding and speech.
2. Tactile sensation is part of my comprehensive plan for children with feeding and speech delays.
3. A multi-sensory approach includes auditory, visual, and tactile cues, supporting overall progress with caregiver training.

SIX Ways to Improve Vocabulary

by Nanette Cote

Why is vocabulary improvement crucial in speech therapy, and what are six effective strategies to achieve this goal? Explore our comprehensive guide to discover practical techniques and activities tailored to enhance vocabulary skills in speech therapy sessions. Caregivers can help improve their child’s vocabulary by practicing categorization, association, using themed-units, identifying attributes, and understanding context clues together.

The title: speech pathologist is rather misleading as it implies that we only work on speech. Whether we work in private practice, hospitals, or school settings, speech pathologists address language delays just as much as speech and articulation disorders. One aim of this post is to enhance expressive and receptive vocabulary skills, considering comprehension’s significance for meaningful language use. Some children excel expressively but require receptive skill development. Others need more focus on expression. Still, others can show a delay in both areas. After formal evaluation, a therapy plan is designed to best meet your child’s needs.

CATEGORIZATION

fruit stand — Photo by Clem Onojeghuo on Pexels.com

There are a few strategies that we can use to help improve vocabulary skills. The essence of this work is to teach children how to store vocabulary concepts like a filing system. Categorization activities may involve asking the child to name or identify members of a target group. For example, three items that belong in a zoo group include: lions, tigers, and bears (oh my!) On the flip side, we can also ask the child to provide or find the category name for a group of its members. We address categorization skills every day in our functional routines when we put away groceries, laundry, and toys.

HOME ACTIVITY:

two paper tote bags — Photo by George Dolgikh on Pexels.com

I had the good fortune to work with some exceptional Speech-Language Pathologists early on in my career. During one of my observations, I watched students play a lively, category game using just brown paper lunch bags and small sheets of paper. This game can easily be adapted for children in 1st through 5th grade. If your child is younger and has a hard time reading, then you can always put pictures on the bags in place of words.

Before you begin, get at least 10 paper bags, and write the names of various category groups on each one. Then, make a list, using a small piece of paper or half of an index card, of 4-5 group members. For pictures on bags, create and attach them. Make groups like Colors challenging by listing specific members, not just primary colors.

This is how you play:

Have your child set up bags with category titles. Then, read category members aloud for your child to listen. Then, have your child take the paper and place it in the correct bag. At the end, I always go back and take a paper out of the bag and practice recalling category members. You can make it into a game by giving a point for every correct placement for the word list and a point for each member he or she can recall from the list.

ASSOCIATIONS

black car — Photo by Sarmad Mughal on Pexels.com

Word associations are another example of teaching a “filing” system for word retrieval. These word pairs express a relationship that comes in many forms such as:

Opposites (night and day)
Synonyms (large and big)
Part-Whole (wheel and car)
Attributes (yellow and bees)
Functions (sleep and bed)

THEMED-BASED UNITS

close up of leaves in autumn — Photo by BREAKS OUT on Pexels.com

Themed based units typically follow seasonal events, activities, and familiar sights throughout the year. You can even build categorization and association strategies using themed units. This approach can be effective because you teach what the child is exposed to in his or her everyday life, which can make these terms become more functional as the child can apply therapeutic learning naturally in other settings.

ATTRIBUTES

close up photography of different type of colors of paper — Photo by Pixabay on Pexels.com

Another strategy for improving vocabulary is teaching attributes for target words. Here, we incorporate games, worksheets, and homework lessons that focus on describing items according to their function or use, color, shape, and size. We can also use other senses like taste and touch to define words. In this way, we have taken one vocabulary word and taught up to six more while formulating definitions.

HOME ACTIVITY:

Here’s an association activity based on seasonal themes and incorporating attributes that you can do for each season of the year with your child.

SUMMER: First, make a yellow circle and write in the middle, “Things that make me think of summer.” Then, cut up to 10-15 strips of paper to make the rays for the sun. Finally, brainstorm associations together and write down answers on rays. Some associative words my son helped me come up with for this task included: pool, beach, lake, water, hot, heat, ice cream, sunscreen, vacation, and swim.

FALL: Create a tree with different colored leaves for association words: colors, windy, apples, pumpkins, football, leaves, Halloween, Thanksgiving, hayrides, and scarecrow.

WINTER: Use snowflakes for association words and form these into a giant snowball. Some suggested terms: cold, ice, snow, coats, hot chocolate, holidays, snowman, sledding, ice skating, and boots.

SPRING: Create a giant center to a flower and write these words on petals and stems: warm, crisp, rainy, bloom, flowers, green, jackets, growth, new, and muddy.

CONTEXT CLUES/ WORD PARTS (PREFIXES, SUFFIXES)

Utilizing curriculum vocabulary with older children poses challenges in language goals due to progress assessment difficulties in my experience. However, we can measure improvement in a child’s ability to interpret vocabulary meaning in context or demonstrate knowledge of word parts. One of my most treasured purchase from Teachers Pay Teachers (TpT) is product called: Context Clues Packet using Tier Vocabulary by Nicole Allison. It is engaging and comprehensive for both elementary and middle school students. I especially like having answer choices for determining vocabulary meaning in context because it teaches another strategy of eliminating less obvious selections.

As support staff, we are challenged with helping foster independence with our students. We will not be there during their classroom instruction or testing to provide cues and probes to increase comprehension, so we need to teach strategies for unaided success. Incorporating the above mentioned techniques into daily activities at home can significantly boost your child’s vocabulary development. Remember, even just reading together is a great way to expand language skills!

Why Visual Supports Make a Big Difference

by Nanette Cote

For children with speech and language delays, it is incredibly empowering and educational to use visual supports via sign language, natural gestures, photographs, digital pictures 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.

SIGN LANGUAGE

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

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 PICTURES

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.

Transform Communication with the Power of Floortime

by Nanette Cote

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 what this looks like 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.

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

A First Person Review of Versatile SPARK Cards

by Nanette Cote

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. You can purchase your set at these links:

Original SPARK set 1

SPARK collection 2

SPARK Junior (appropriate for children 3 years and older)

I love you, Daddy

by Nanette Cote

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.

Going with the Flow

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.

Classroom Activities to Enhance Empathy for Down Syndrome

by Nanette Cote

October is Down Syndrome Awareness Month, and I’m dedicating this post to my niece, Ella. She’s 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!

Socialization

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.

Talking All at Once

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.”

The Marshmallow Test

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.

Telepractice- Your SLP Questions Answered

by Nanette Cote

As you navigate the landscape of 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 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?

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 therapy 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.