Focus on Communication

B Speech Therapy

Sometimes a child’s speech/language challenges can be obvious, as they were for Apex mom Christa Gala, whose son was diagnosed with “profound” speech articulation issues at age three. “Initially, the speech therapist thought he might have apraxia. We had to wait about six months to rule that out. They did determine he didn’t have any ‘language’ problems,” Gala notes. “I got him in speech [therapy] and we hit it hard from age 3 to age 8 — five solid years.”

But sometimes, the signs are subtler. Bridget Peacock of Holly Springs noticed that her twins, now 9, began having feeding issues when they were around 5 months old. “Food dribbled out. They had very low muscle tone. But it took me a little while to really notice what was going on,” Peacock says. “At pediatrician visits, they were never meeting milestones.”

Recognizing that a speech/language problem exists and understanding its source can be difficult for parents. As Traci Paxson, a speech/language pathologist at Innovative Therapy in Apex, explains, speech and language are made up of five domains: language, articulation, fluency, swallowing and voice. If there is a breakdown in language, articulation or fluency, then communication can be challenging and frustrating. Swallowing difficulties can cause feeding issues, while voice challenges can affect communication quality.

Components of Speech and Language

Here’s a breakdown of the domains of speech and language and the kinds of disorders associated with them.

Language. The building blocks of language are something many of us take for granted if they come to us naturally. However, in working to identify the nature of language disorders, experts break it down into its different aspects. According to Peg Haynes, a speech/language pathologist at Green Hope Elementary School in Cary, language comprises form, which includes the phonologic, morphologic and syntax/grammar systems; content, which includes the semantic system, or the meaning of words; and function/use, or the pragmatic system, which includes social language, the ability to communicate effectively with others.

Articulation. Articulation and speech-sound sequencing are directly tied to clarity of speech and intelligibility — in other words, how you produce your sounds and order them to be understood. Lisping is a speech disorder that falls under articulation, as does apraxia. “Apraxia is a motor planning breakdown. Although the individual still has muscle integrity in the mouth, he or she can’t be understood well. It involves ideation, which occurs when the concepts we wish to express are generated; motor planning; and speech sound production. In speech apraxia, you can’t make the sound on command,” Paxson says.

Swallowing. Difficulty swallowing, or dysphagia, can occur at any age. But it occurs more frequently in older adults, babies and people with brain or nervous system disorders, Paxson says. “Causes vary, and treatment is determined based on what’s causing the swallowing breakdown.” Peacock’s children, who showed early feeding problems, were eventually diagnosed with Fragile X, a genetic syndrome that is associated with a spectrum of physical, intellectual and behavioral characteristics. At 12 months, her son began receiving in-home services including physical therapy; occupational therapy, which was focused primarily on feeding; and some preschool education services. Her daughter started services the next month. Both children continue to receive a variety of supports for their developmental needs.

Fluency. This refers to the ability to express oneself easily and coherently. “The lack of fluency often results in poor communication. Stuttering and cluttering are examples of fluency breakdowns,” Paxson says.

Voice. This easy-to-overlook aspect of speech often goes untreated in children. Damage to vocal folds, or phonotrauma, can be caused by how much the voice is used or how it is used, says Hilary Bartholomew, a speech pathologist at the Duke Voice Care Center. Children can damage their vocal cords imitating different sounds; making harsh or squeaky noises while playing; or yelling and screaming during sports activities, on the playground or during tantrums. “Voice issues are nondiscriminatory and can affect children at any age, any developmental status, with and without behavioral issues. It’s child-specific with how they use their voice,” Bartholomew says. “Prolonged voice hoarseness, not that of a cold or other problems, is not part of normal development.”
Voice problems often aren’t discovered until language blooms around age 2 or when the child enters school, Bartholomew says. Usually someone outside of the immediate family — a neighbor, doctor or teacher — brings it to parents’ attention. “Parents can have trouble recognizing hoarseness themselves unless the change occurs suddenly,” she adds.

Aphasia. The loss of ability to understand or express speech/language, or aphasia, is caused by injury to the brain — most commonly a stroke. “There are different types or patterns of aphasia that correspond to the location of the brain injury,” Paxson says.

Interventions

While articulation problems can cause spelling or intelligibility issues, Haynes says, she sees more academic problems co-occurring with language issues.

“Language is the medium through which all else is taught. It’s the basis for our conversations with people, our social interactions. It’s how we learn things, how we teach things. It just makes sense that a child who has language difficulties would have a greater likelihood of having problems with reading and writing,” she says.

For some children with speech/language disorders, learning what to say in different social settings is also a challenge. Peacock’s daughter, who spends most of the day in a typical classroom, is pulled out for resource help, specifically to work on social skills. She also attends a weekly social skills group in a private therapy setting.

“She’s very verbal and reads on grade level,” Peacock says. But because Fragile X can cause high anxiety in girls, “she clams up around strangers and doesn’t always know socially acceptable things to say. If she’s anxious, she gets very quiet and won’t say anything, or she gets really silly and yells out things to get people to interact with her.”

Because good speech/language development is essential to learning, the state provides early intervention services for young children as well as therapy for students already enrolled in school. To qualify, children must meet certain criteria established by the N.C. Department of Public Instruction.

When a teacher or parent has concerns about a child’s speech/language development, Haynes says, a Responsiveness to Instruction (RTI) process is initiated. “Before a child is identified (as needing speech/language services), the school will work to put regular educational interventions in place for a period of time, up to six weeks,” she says. “This is enough time for some students to show progress.”

The student is monitored, and the RTI team conducts follow-up meetings to discuss progress. The strategy may be tweaked, or the team may determine they need more information and go forward with a referral to the special education team to test for special education services. Parents of children who do not qualify for state services may choose to pursue private therapy.

Signs of Speech/Language Problems

By the time typically developing children are age 3, Haynes says, they should be able to:
• Say three- or four-word sentences.
• Be around 80 percent intelligible to strangers.
• Answer simple “who,” “what,” “where” and “what are you doing” questions.
• Understand concepts of in, on and under.
• Show communicative intent, either verbally or with gestures.
• Greet other people.
• Protest appropriately.
• Get your attention.
• Request items or actions.

Red flags, according to Haynes, include dropping word endings; using only vowel sounds or having vowel distortions; being unable to label pictures in a book; and echolalia — repeating a question instead of answering it. She recommends having your child’s hearing tested first. “The bottom line is that you cannot know if something is atypical unless you know what is typical. Knowing expected milestones and expected patterns of neurotypical development, paired with experience, allows me to determine whether there’s a problem with speech or language,” Paxson says.

Although Gala’s friends and family told her to let her son talk when he was ready, she felt strongly that early intervention was important. Her son qualified for speech services through the school system’s early intervention program, and during the summers she paid for private therapy. She says she asked herself, “Will this matter in 10 years?” She decided it would.

“He’s 11 years old now and has no sign of a speech impediment or learning delay,” Gala says. “It was all worth it. I’d do it again in a second. Never back down when it comes to your kid. Do the research, and don’t be afraid to be a steamroller when you need to be.”

Resources for Parents

• N.C. Early Intervention Branch: beearly.nc.gov
• Identify the Signs: identifythesigns.org/the-signs
• N.C. public schools’ services eligibility criteria: ec.ncpublicschools.gov/disability-resources/speech/language-impairments/speech-guide.pdf


Tools and Technology

“There are some fabulous things available in terms of technology. The key is to know how to use them,” says Traci Paxson, a speech/language pathologist at Innovative Therapy in Apex. “You still have to know if your child is a good candidate for any modality, and that’s where your professional is going to help you out.”

• Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT): a multisensory technique that gives tactile-kinesthetic cues to the jaw, lips, cheek or throat to guide the speaker through certain words, phrases or sentences. promptinstitute.com
• Sign language.
• Augmentative/alternative communication systems or devices:
      – TouchChat HD; touchchatapp.com
      – Picture Exchange Communication System (PECS) cards; pecsusa.com
      – GoTalk assistive technology device; mayer-johnson.com/gotalk-20
• Auditory programs:
      – Auditory Integration Training; ncbi.nlm.nih.gov/pmc/articles/PMC2082994
      – Therapeutic Listening®; vitallinks.net
      – The Listening Program®; a.advancedbrain.com/tlp/the_listening_program.jsp
      – Fast ForWord®; u.gemmlearning.com/fast-forword-at-home-service
      – Melodic Intonation Therapy; ncbi.nlm.nih.gov/pmc/articles/PMC2780359

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