therapy - Lessons in Speech with Nanette

Why Did My Child Qualify For Articulation Therapy?

Woman holding the letter S with child imitating a touch cue in speech therapy

ARTICULATION

Why is understanding the journey of speech sound development crucial, and what is the basis for evaluation and treatment in articulation therapy? Making progress in speech development starts with understanding the evaluation and treatment process for articulation delays, as discussed in this post.

In this comprehensive guide, we will navigate the journey of speech sound development and discuss the basis for evaluation and treatment in articulation therapy. Understanding the milestones and stages of speech sound acquisition is crucial for identifying potential delays and designing effective intervention plans. Articulation therapy, distinct from phonological and childhood apraxia of speech therapies, targets specific speech sound errors to enhance clarity and pronunciation. We’ll explore the various assessment methods used to evaluate speech sound production and discuss evidence-based treatment approaches.

Additionally, we’ll highlight the pivotal role of home programming in reinforcing therapeutic gains and supporting speech progress beyond the therapy room. Join us as we navigate through the fundamentals of speech therapy and empower caregivers with practical strategies for facilitating speech development in children.

Milestones and the Evaluation Process:

Speech pathologists assess speech sound development using a test battery containing all consonant sound targets. Most of the time, a child with an articulation delay can produce vowels accurately, but not consonant sounds. If your child hasn’t mastered age-expected sounds, their score may indicate therapy is necessary. The chart pictured below is my all-time favorite speech development reference tool from 1972 for parents. I particularly like how it displays the wide range for development of each sound target.

Some children need more time to master sounds with any number of factors influencing that timeline. Ear infections, fluid buildup, wax, growth, attention issues can delay sound mastery for months or years in some children.

In 2018, McLeod and Crowe published a study updating developmental expectations for speech sound development. Note that these researchers suggest that all speech sounds are acquired by six years. Under these guidelines, more children may qualify for speech services.

McLeod-Crowe-2018-English-consonants-Treehouse-A4

After the Evaluation:

You just learned that your child is eligible for speech services due to an articulation delay. If you are in early intervention, then you likely will not see specific sound targets in your treatment plan, but that all changes in an IEP- Individualized Education Plan.

Let’s walk through the meetings that lead to an IEP in the school system. First, attend a brief referral meeting at the school to determine testing needs with the team. A couple months later, you will reconvene and review all test results. If your child qualifies for speech, then you will create an IEP at that eligibility meeting. Listen carefully to the goals for speech articulation, which are written to be met in one year. Given that these goals must be achieved in a year, they should be concise, measurable, and appropriate for your child’s age.

Here is an example of an achievable objective, focusing on an early sound production: Increase accuracy of /b/ in all positions (i.e., ball, cowboy, web) of words with 85% accuracy.

Here is an example of a lofty goal which should be divided into smaller components as there are 18 objectives in this one example: Increase accuracy of /p, m, h, n, w, b/ in all positions at the word level with 85% accuracy.

In summary, you have the right to ask questions during any meeting, be it for eligibility or treatment planning. If goals seem unattainable, express concerns during IEP meetings. Parents are one of the most important team members because you know your child best!

Therapy:

Your child needs articulation therapy when he substitutes or distorts one or more sounds. For example, he may substitute the /w/ for /r/ in the word rabbit or distort the /l/ in the word ladybug such that the /l/ does not sound clear and crisp. In articulation therapy, we teach lip and/or tongue placement for target sounds. Here, we progress from isolated sounds to sentences and practice sounds in all word positions: initial, medial, and final. So, someone working on the /s/ sound may practice “sun”, “glasses”, and “cats.” Typically, we look at mastery in one position before moving onto another. We target developmentally appropriate sounds and increase the level as the child progresses.

Homework:

Your speech pathologist will want your child to practice sound targets at home once progress is noted in treatment sessions. Waiting for accuracy is crucial; clients who practice at home generalize skills, reducing therapy time and ensuring error-free practice.

Conclusion

In summary, understanding speech sound development lays the foundation for effective evaluation and treatment of articulation disorders. By incorporating home programming into therapy plans, caregivers can play a crucial role in reinforcing progress outside of sessions. Consistent practice in natural environments enhances therapy outcomes and promotes long-term speech proficiency.

PROMPT- Useful for Childhood Apraxia of Speech (CAS)

by Nanette Cote

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.

Mastering Teletherapy for Early Intervention

by Nanette Cote

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.