Q&A on speech and language with Fiona Barry

Fiona BarryFiona Barry answered your questions relating to children's speech, language and communication in September 2013. View the original thread here

Fiona Barry is a speech and language therapist. She has worked for the NHS and set up TalkingTipsForKids, a website and free app that helps parents boost their child's communication skills.

 

Speech and language skills

Q. GoonIcantakeit: Why do you think there is so little information available to parents who want to help their child with receptive language delay? 

A. Fiona: I'm sorry to hear that you've found this a struggle, it shouldn't be, should it? As I'm not sure if you're still looking or the age/specific needs of your child, forgive me if I'm telling you things you already known. Here are some resources that will hopefully be helpful:

  • Leeds Speech and Language Therapy Service has a super website with a whole section devoted to receptive language difficulties.
  • Receptive Language Difficulties by Liza Baldwin deals specifically with receptive language issues. It's really aimed at teachers but is also useful for parents, although not for very young children.
  • The National Literacy Trust has a useful summary and set of strategies.
  • RALLI (Raise Awareness of Language Learning Impairments) is a recent campaign that has been set up by leading academics in the field of specific language impairment to support parents and professionals. There are a range of films dealing with language impairments, including receptive language difficulties.
  • Have you thought about using an app with your child? I use the Splingo app, it's great for practising following instructions containing up to four or five key words, including size concepts and positional concepts. 
  • It may be that you're not finding the information you want if you're specifically looking for advice on receptive language delay. Try looking for information on speech, language and communication needs (SLCN), receptive language (understanding), expressive language (talking), phonology (speech), pragmatics (social skills) and fluency (stammering).
  • The recently formed Communication Trust has a great website containing information on all aspects of communication difficulties including receptive language delay.

Q. Jellysmum77: My four-year-old son has articulation problems and phonological disorder. We are feeling a little let down by the SLT we have had, so we are about to book some private sessions. We are also practising at home. After just one week of daily exercises using bigmouth and other tools I found on the internet, DS is beginning to say words he has never been able to pronounce. I would love some more ideas to try out. Have you got any tips or activities?  


Common errors he makes:

  • 
time = pime
  • pig = kig
  • tummy = pummy
  • 
jump = bump
  • 
jam = mam 


All of these he has said correctly this week, but his pronunciation is inconsistent. The ends of his words are mostly missing and some middle consonants. 
He also struggles with 's,' 'f' and 'l' at the start of words.

A. Fiona: It sounds like you're doing a great job. You're right that practising little and often is best. Speech work can get VERY repetitive and boring for little ones (and parents). My one word of caution is to make sure you discuss with the therapists exactly which order the sounds are being worked on. If he misses the sounds off the ends of words, the therapist may want to target this in a general way before working on any specific sound or vice versa, depending on his exact profile.

Here are some ideas for resources to make the work more fun:

  • For pictures of sounds within words Caroline Bowen has some excellent free resources.
  • SpeechTeach shows you simple games that make sound practice fun.
  • How about using an app? Find a range of speech apps listed and reviewed here. I use ArtikPix professionally and I think it's great, although it is a bit pricey for the whole range of sounds.
  • Use games involving movement such as a treasure hunt with the sound pictures dotted around the room or skittles with a different picture attached to each one.
  • Try an obstacle course in the garden where he has to say a sound/word before he gets to play on the next part.
  • Have you thought of using real objects for words instead of just pictures? I use this with children a lot and they love it. You could make your own 'p' or 'f' box with real objects beginning with these sounds and make a 'feely bag' with them.
     

Q: Sarahandemily: My daughter is 3.5 years old, talked early and well and is a real chatterbox. She has never pronounced her 'f' and 'v' sounds properly. 'F' is more like 's' and 'v' is more like 'b.'

We have recently started to correct her and try to get her to make the correct shape with her mouth and the correct sound. With a lot of effort she can get a near 'f' sound out at the start of the word 'fish' but seems to struggle with putting her teeth on her bottom lip. Is this anything to be concerned about at this age, or is she likely to get it in her own time?

Secondly, are we right to try and get her to say it properly or might this make her feel self-conscious and do more harm than good?

A. Fiona: The 'f' sound is usually mastered by about 3.5 years and 'v' by about six. They can be tricky for lots of children.

Let's talk about the 'f' sound here as this develops first and has the same type of lip and teeth placement as 'v'. Your daughter needs to be able to say the sound on its own correctly first.

Try the bunny teeth trick. Look in the mirror together and talk about having bunny teeth. Have a go yourself and you'll see that your top teeth sit on top of your bottom lip. Once your daughter has the correct teeth and lip placement, she just needs to blow. Try saying: 'bite your lip and blow.' This will keep the teeth in the right place but will get the air flow going, which is how the 'f' sound is produced.

Once she can do this, then practise saying the sound with a vowel attached eg 'fee, foo, fah, fay'. She may need to do this with a gap at first eg 'f...ee' and it may take her some time to learn to blend to a smooth 'fee'. Give her loads of praise like "great 'f' sound". Also model the blending, so you do it first then she tries.

Next, try words beginning with 'f' like 'four' and 'feet'. Make sure you choose words that have 'f' followed by a vowel like 'fell', 'fork' and not ones followed by a consonant like 'fly' and 'fry'. These are more tricky and develop later.

Keep practice sessions short and sweet. Try this for a few weeks, but if you can't get past blending 'f' and vowel sounds, then see a speech and language therapist to get her started.

Q. U2rmysunshine: Our son is 4.3 years old and struggles with the 'r' sound in words like 'bread' and 'broken', for which he says 'bled' and 'bloken'. He has always mispronounced them and I have hardly ever corrected him but if I ask him to say them properly he is able to. He also pronounces words with an initial 'r' correctly. Is this something that will sort itself out in time?

A. Fiona: The good news is that he's already able to say the tricky sound 'r' when it appears on its own. In 75% of children the 'r' sound is not developed until about five, so he's doing well.

When 'r' appears in a blend or cluster (ie with another consonant such as 'br,' 'fr,' 'tr') it's more difficult to say. Clusters with 'r' emerge anywhere from 4.5 to six years old and sometimes even older. Often children reduce the cluster down to one single sound, eg 'bed' instead of 'bread'.

Your son is part of the way there, as he's actually using another consonant alongside the 'b' - it's just the wrong consonant. He can also say the 'br' sound in words when you ask him to try again. He just needs time to generalise this into everyday speech. Spend five minutes a day practising the sound in a fun way. Here are some ideas:

  • Play games where he listens to you saying lots of words beginning with 'br'. This is a technique known as auditory bombardment. There's a list here on Caroline Bowen's fantastic website.
  • Print pictures of the words and play hide and seek by placing the pictures around the room or play a matching game with two sets of the pictures. Every time he finds a picture or matches it, you say the word multiple times. This helps his speech sound system correct the way he says it. 
  • Play games where he has to say the words. He may have to say it with a gap first, eg 'br...ead' then try blending it. This is a very minor problem and should resolve itself on with time.

Q. Minimimimi: My son is 2.2 years. He is able to understand a wide range of vocabulary but is only able to speak about 25 words in English.

He has a tendency to invent vocabulary even when he knows it is not the correct word. For example, he calls aeroplanes 'eet eet', ducks 'quack quack' etc. How can this be corrected? We always say 'aeroplanes' and 'ducks' but he seems to ignore us. 

He does have difficulties pronouncing words. When he wants a treat, I always get him to repeat 'please' and 'thank you', which he attempts but he doesn't pronounce them correctly. 



We read a great deal and I limit his use of TV and iPads, though my MIL is convinced that he learnt all his words through those devices. Am I correct to limit the TV and iPads?
 


My husband speaks English to him and I speak Cantonese with him during the day with a 30-minute Mandarin session. He watches 20 minutes of CBeebies and 15 minutes of Mandarin cartoons each day. 
Should I be concerned over his lack of communication? Am I confusing him with the multiple languages? 

A. Fiona: You're doing lots of things right. Recent guidelines suggest no more than an hour a day of screen time for three to five year olds and less than half an hour for children under two years old.

Also speaking more than one language with your child gives him a great start in life. The benefits include:

  • Thinking advantages (bilinguals can think more flexibly because they're used to storing two or more words for each object/idea)
  • Increased employment opportunities (we now live in a global village and many employers actively seek bilingual candidates)

Many parents worry that speaking another language will make their child have a language delay but there is no evidence that bilingual children learn to speak later. Some children, whether bilingual or monolingual, learn to speak later than others.

By two years and two months, a child can usually say at least 50 single words and will be starting to join two words together eg 'more juice'. You say he has 25 words in English. It's important to know how many he can say in Cantonese and to establish his language levels in both languages, so refer him to your local service. 

Do not stop talking to him in Cantonese (as long as this is your first language). Children need to learn their first words in the languages of their home. The Mandarin sessions may be less useful at this stage, if it isn't your first language but they're fine as long as the sessions are fun and without any expectation on him to repeat words back to you.

Q. Bronteshoes: My son is four and has some issues with clarity of speech. His phonology and language are good but he speaks quietly and quickly and he tends to mumble. My husband and I are quite attuned to his speech, but children tend to ignore him and adults usually smile and nod without acknowledging (to my son) that they can't understand.

I sometimes ask him to repeat himself slowly and louder but he doesn't seem to be able to monitor or adapt his speech. I've modelled fast and slow speech but it hasn't helped. He has no known issues with hearing. Do you have any ideas on what we could do to help?

A. Fiona: This is a fairly common issue. Are you sure he doesn't need a phonology assessment? Sometimes parents are so tuned in to their child's speech they may tune out speech errors. It's possible that he's making errors that are affecting his intelligibility but you're not hearing them. I really like this articulation guide by Linda Welsh. It is useful for parents to check where their child is at.

You state there are no known issues with his hearing but it may be useful to get this checked as sometimes children suffer with glue ear, an ear infection which causes fluctuating hearing loss. Periods where hearing isn't tip-top can affect speech development. Speak to his GP about this.

He's a bit too young to be aware of his speaking skills or how to modify them, even children in primary school can find this difficult. His speaking skills are likely to improve with age. You could try the following to work on his volume and rate:

  • Play games where you try being Mr Noisy and Mr Quiet. Read the Mr Men books and find pictures to help with this.
  • First let him see you being Mr Noisy and Mr Quiet and then let him try.
  • Lay out the Mr Noisy/Quiet pictures and drive a car nearer to Noisy or Quiet as he speaks to give him visual feedback on his volume.
  • Try the same games with pictures of a hare and a tortoise for rate. Read the story then practise talking fast and slow.
  • Once he can identify when he's being too quiet and/or fast, practise in pretend play, eg shopping.

Don't expect generalisation into everyday talking straight away, it's tricky.

Q. Lorajay: I am a bit concerned about my 17 month old's speech development. She occasionally babbles and she does seem to say one, two, three, go, but only we could understand it. She does point and say 'what's this?' but it's very unclear. Sometimes she doesn't even open her mouth to say it and just sounds it. I'm also pretty sure she can say 'hi' and 'bye'.

Why I'm concerned is she's unclear, doesn't have many words and very rarely wants to try talking. My three year old talked very early and has great language skills and vocabulary. Is it too early for me to be concerned? Should I be doing something to encourage her?

A. Fiona: By 18 months, children can generally say around 20 simple words such as 'daddy', 'ball', and can understand some single words like 'shoe' and 'car'. They can follow simple instructions like 'clap hands' or 'kiss teddy'.

Write down all the words she can say, even those that are mispronounced. If she consistently uses a sound for an item, then include it. Also include baby words like noises for animals, eg 'moo' for 'cow'.

Her speech sound system is in the early stages of development. The first sounds to emerge are 'p','b', 't', 'd', 'm', 'w'. Do you hear any of these in her babbling? Are you hearing strings of babble like 'bababa' or 'goo-ee-yah' with the sing-song style of adult talk? This is an important stage that comes before real words emerge.

"Sometimes children suffer from glue ear, an ear infection, which causes periods of fluctuating hearing loss and can affect language development."

It's good that she uses pointing alongside her babble. Is she starting to use early pretend play like mimicking to talk on the phone? If so, this is a good sign as pretend play is linked to language development.

Lastly, do you have any concerns about her hearing? Doe she have frequent colds? Sometimes children suffer from glue ear, an ear infection which causes periods of fluctuating hearing loss and can affect language development. If you're concerned, speak to her GP.

If she's not doing most of these things then refer her to your local speech and language therapy service. Our wise words video has lots of tips to encourage language at this stage. You clearly know what you're doing as your three year old is a chatterbox. Keep up the good work by playing, chatting, singing and sharing books with her.

Q. Sweetiepie1979: My daughter is 2.2 years old and has a vocabulary of 30 words. She can put two or three word sentences together and she babbles a lot. She loves speaking on the phone and pretending to have conversations. She has high comprehension but I am worried about her pronunciation. For example, she says 'milk' and 'cot' with a 'ch' sound at the end. (I have not counted these in the words she can say.) Do you have any advice?

A. Fiona: She's doing well. If a child is putting two to three words together in sentences, it's likely he or she has more than 50 single words. At her age it's important to include all words, even if they're unclear or baby-ish (eg 'choo choo' for train). We expect them to sound immature. It's great that she's using pretend play as it's linked to language development.

Speech sounds develop gradually over time, during the preschool years and have a set pattern of how they emerge. Most young children make mistakes and this is normal. Roughly speaking, by 18 months, parents can understand 25% of what their child is saying, 50-75% by two years old and 75-100% by three years.

At two years old, children use a limited number of sounds in their words and may miss the ends off words, eg 'cu' instead of 'cup'. By 2.5 they will add on a sound but this may not be the right one. This is probably what she's doing now.

By three years, her speech should become clearer but she may shorten longer words, eg 'nana' for 'banana'. Clusters of sounds where two or three sounds happen together will be tricky, eg 'boo' instead of 'blue' as well as other sounds like 's', 'f', 'sh', 'ch', 'th', and 'l', 'r', 'w', 'y'. It sounds like her speech is within normal limits for her age. 

You can help by repeating back words correctly to her so if she says 'coch' you say: 'Yes, it's your cot.' Don't ask her to repeat the word back. A good rule of thumb is to refer her if unfamiliar people can't understand her by age three.

Q. StrawberryMojito: My two-year-old son has been slow at learning to talk. He is starting to pick it up but I think he is still behind his peers. I think he understands most things. Does being slow at learning to talk mean he will always be a slow learner? I am not bothered about him being brain of Britain but I would be sad for him if he always struggled academically. 
Basically, do late talkers tend to be less intelligent?

A. Fiona: Good question. There's been lots of research into this. Some research shows the size of a child's vocabulary at the age of two is a strong predictor of later language and literacy skills. 
Other research states that vocabulary at five years is a strong indicator of future qualifications and achievements.

Language is a fundamental skill that all children need to develop. Children with strong speaking and listening skills are more likely to make friends easily, do well at school, stay out of trouble and thrive in the workplace as adults. The whole of the school curriculum centres entirely on language. Teachers teach using words and sentences even in maths - think of all the different words for maths concepts like subtraction, eg take away, minus, less, etc. Academic achievement is linked to language skills because we pass knowledge on using language.

"The good news is that parents are the key to unlocking children's communication skills. Evidence shows that how parents play and chat with their children is more important to language development than class, ethnicity, education or wealth."

Your son had been late to talk but now seems to be catching up, which is great news. By two years, children should be able to say at least 50 single words and combine these into two word phrases like 'more juice' or 'bye-bye mummy'. Assess his talking skills by:

  • Jotting down all the words he can say so you have a rough idea.
  • Listen out for any two word combinations.
  • Check to see if he can understand simple instructions eg 'show me your nose' or 'find me your hat and shoes.' Our ages and stages video is a useful checklist.

If you're concerned that he's not progressing, then seek advice from your local speech and language therapy service.

The good news is that parents are the key to unlocking children's communication skills. Evidence shows that how parents play and chat with their children is more important to language development than class, ethnicity, education or wealth.


Speech impediments

Q. Mawbroon: How much do you know about tongue tie? Could you spot a posterior tie?

A. Fiona: There's a piece of skin called the lingual frenulum, which attaches the underside of the tongue to the base of the mouth. Children are said to have a tongue tie if this piece of skin is very tight.

About 3-10% of newborns have a tongue-tie and it affects more boys than girls. For some, the frenulum extends right to the tip of the tongue and restricts movement. In this case, children can't stick their tongues out past lips or clean food from the back teeth. The tongue can look heart shaped if very tight.

This topic is a bit controversial and advice can vary widely. Many say that the reduced tongue movement can affect latching on for breastfeeding in newborns, however there's a whole range of reasons why feeding may be tricky in the early days such as positioning, restricted head movements or reduced muscle strength/coordination in the mouth. If a tongue tie is present, many professionals automatically assume it's the culprit.

Many also say tongue ties can cause a delay with speech production or affect how well a child can say certain sounds like 's', 't', 'd', or 'n', which all need the tongue tip to be able to elevate to just behind the top teeth. In reality, even a tongue-tied chid will be able to make all the sounds in English. Their tongue positioning may be slightly different to an untied tongue but the resulting sounds will be accurate enough. A speech and language therapist is the only professional who can assess your child and offer advice on this.

A tongue-tie snip or frenotomy, a minor op, is often recommended. In newborns it can be done relatively pain-free and without general anaesthetic. With older children, a general is used as it's not possible to restrain an older child in a non-traumatic way.

Q. Kewcumber: My son is nearly eight and lisps 's' in all situations. He has other articulation problems (eg he pronounces 'bowl' as 'boule') but with practise, he seems to be improving. 
I'm almost certain it's not a physical issue as he pronounced the 's' sound in his first six months of speech then lost it. 



He was delayed in speaking until about three years old for a variety of reasons. He was very premature (26 weeks), he changed languages at 12 months from Russian to English and was adopted from an institution where speech delays are common. 


His school have agreed for two years running that he should probably be assessed but we still don't have a referral. He doesn't have any problems with general communication and is graded significantly above national average in speech in his speech and literacy testing.

He is terribly self-conscious about his lisp and to complicate matters his front teeth have recently fallen out.

 What exercises can we do at home to improve his speech? 


A. Fiona: Lisps can be a real issue for older children. There are three types of lisp:

  1. A lateral 's' which sounds a bit like the Welsh 'll'.
  2. The palatal 's' where the middle part of the tongue raises to the roof of the mouth instead of just the tip.
  3. The most common is the 'interdental' lisp where the tongue tip sticks out between the teeth instead of staying tucked behind the top teeth producing 'th' instead of 's'.

It's important to find out what type of lisp your son has. Lisps are very common and most children grow out of them. Sometimes the arrival of adult teeth stops the tongue poking out in the case of the interdental lisp. When his teeth arrive that may help and it might be a good idea to hold fire until they do. 

"Lisps are very common and most children grow out of them. Sometimes the arrival of adult teeth stops the tongue poking out in the case of the interdental lisp."

We don't worry too much about preschool children with lisps, but if it persists after this then it's wise to seek advice from a therapist. You may only need one or two sessions just to establish what type of lisp he has and to correct his tongue positioning.

A neat trick to see if he can say 's' accurately is getting him to say 't t t t t t' as fast as he can so it turns into a 'ssss' sound. This gets the tongue in the right place. 

Here's another test:

  1. Get him to close his mouth with his tongue behind his teeth.
  2. Then smile.
  3. Finally, blow out. The 'ssss' sound should appear.
 Q. Hedgerooni: My 3.2 year old son is outgoing, confident and chatty with an impressive vocabulary. Two weeks ago he started stammering and it has become progressively worse. At its worst, the words at the start of a sentence take over 10en attempts. The latter part of sentences come out fine, as does any singing or reciting stories from books. It feels as if this has come out of the blue. What should we be doing to help him?

A. Fiona: About 5% of young children experience some trouble with fluency as their language develops. For most of these children this will resolve, either with or without therapy. For about 1% of these children, the problems will carry on into adulthood.

Stammering can be really stressful for parents. It's painful for them to watch their child struggling. Stammering can come and go, so parents are often unsure of when to ask for help. It's common for stammerers to find their stammer reduces when they're reading aloud or singing (Gareth Gates is one of many examples).

We don't fully understand the causes of stammering but we do know that parents do not cause them. We also know that there are things parents can do that will help their child become as fluent as possible:

  • Listen to your DS and give him plenty of time to finish what he wants to say in his own time - don't be tempted to finish sentences for him.
  • Try to take the pressure off talking by avoiding asking lots of questions and making sure he has time and space to talk to you without being rushed or interrupted.
  • Set up five minutes in the day when you can play and chat with your child. Our champion chat video shows lots of these tips.

It's best to ask for advice sooner rather than later. Preschool children can go through a normal stage of dysfluency as their skills are developing, but if this continues for more than a couple of months or if there is a family history of stammering, then ask for advice from a speech and language therapist ASAP.

These sites are useful:

Hearing and speech

Q. Turkeyboots: My son has had severe glue ear and he now has grommets. He is almost four and has very poor speech. Do you have any suggestions on how to support him before starting school? 
 

A. Fiona: The advice I would give depends on whether your DS has had a recent speech and language assessment to establish if there is a delay.

You do say that his speech is poor so if he hasn't been assessed recently, then refer him again. Usually parents can self-refer but check your local service. Hopefully his hearing levels will be approaching normal limits again. Make sure this is monitored by the audiology team.

If his speech sounds are the problem and he mispronounces words, then always say words back to him in the correct way. Don't ask him to repeat the words, as he's likely to say then incorrectly again. Hearing a good speech sound model from you will really help but he may still need specific speech sound therapy, so do get this checked.

If it's his language (how well he can use and understand words and sentences) is the issue then the advice to get him reassessed still applies. You can still do many things to help with his language at home, which are explained in our talented talk video.

"If his speech sounds are the problem and he mispronounces words, then always say words back to him in the correct way. Don't ask him to repeat the words, as he's likely to say then incorrectly again."

Also practise lots of listening games. Even if his hearing levels have returned to normal, he may need to be retrained in listening.

Have quiet times in the day when you listen to sounds around you. Try making it a game, eg who can hear the most sounds and guess what they are (doorbell, car driving etc).

Focus on speech sounds with him. Lay out some toys and ask him to find a toy beginning with different sounds like 's' or 't'. I Spy is a good game to play, too. Encourage him to look at you when you talk to him so he can watch how your mouth makes all the different sounds in speech.

Q. Halfwayupthehill: My son, 2.2 years, had a few words at around 16 months then he stopped talking except for saying 'mama'. He was eventually diagnosed with glue ear in the spring. This cleared up by the start of September but he has never recovered the words he was able to say and now only says 'me' or 'mummy'. The only consonants he pronounces are 'm' and 'b'. He does not repeat what he hears. His passive understanding is fine and he seems to hear OK, but 
I am very worried.

A. Fiona: I can imagine that you're really concerned. Firstly, make sure his hearing is being monitored by the audiology team to ensure normal hearing levels have returned. You say that the glue ear is resolved but once a child gets glue ear, they can be prone to recurrent bouts so do make sure your GP and audiology team are following up with you. We don't know if his hearing has returned to normal levels yet although you say he seems to hear OK. Some of the sounds used in speech are of a high frequency and only an audiologist can check if he is hearing within all the frequency ranges needed for speech.

Even if his hearing is fine, it could be that he hasn't had time to catch up since he had glue ear. By the age of two, a child should have at least 50 single words and be joining them together to make two-word combinations, eg 'daddy car' or 'more milk'. They should also be copying sounds and words from adults. You say that he's not doing this and only has a few single words.

Refer him to your local speech and language therapy service. In most areas you can refer yourself without having to go through the GP. They'll check his language skills and are used to seeing children with this type of problem. It's important to ask for support now rather than leaving it, as we know that early intervention is always best for language and hearing problems.

 

Socialising and speech

Q. StarlightMcKenzie: My son is almost seven and has ASD. He desperately wants friends and can start conversations with his NT peers by asking them how old they are and telling them his age, but then he gets stuck. 
Sometimes children put up with him for a little bit but quickly move away as he'll ask another question that makes him appear odd like: "What boring things are you interested in?" He often gets laughed at and picked on. 

He is extremely capable of learning and should I figure out what to teach, he'd work hard and practise but where do I start? What resources are out there to support him?

In addition to his ASD he has been diagnosed with a speech and language disorder over and above this. It manifests mainly in his expressive language,  which gives the impression that he understands a lot less than he does. His receptive language skills are very good.

A. Fiona: It sounds like your DS needs some direct teaching on how to start, maintain and end conversations. Have you tried commenting on his communication skills? Make your feedback kind but direct. This will avoid him not understanding a point that you are trying to imply or infer. Try not to compensate for his difficulties by struggling to make sense of what he's saying. Instead say outright: "I don't understand what you're saying" or "you've already told me about that". That way he'll learn ways to repair breakdowns in conversations.

Openly teach him how to choose children who might be compatible friends with similar interests. Some children with ASD assume that everyone is into what they are, so help him narrow down his search. You could teach and rehearse with him a bank of scripted questions to use in conversations, eg questions about people's weekends or music/sport/TV

Carol Gray's comic strip conversations are really useful to highlight good and bad questions. Keep the words in the questions simple if his expressive language is particularly affected by his language disorder.

How about using an app? There are many that work on conversational skills for children with ASD. Autism apps lists and reviews apps and would make your search a lot easier. The conversation builder is certainly worth looking at.

There are also lots of board games available to work on this such as The talkabout game by Winslow or Communicate junior by Super Duper Publications – here is one of their videos showing how it works.

Q. Dysgu: My youngest daughter is 4.8 years old and has just started reception. She is a happy, chatty girl at home but is very quiet in a school setting. This was the same for the two years she was at preschool. She is a very well-behaved child and no one at the preschool noticed that she did not tend to volunteer any speech. She would respond to a direct question and was never rude but was perfectly happy playing and doing what she was supposed to. 



Her speech development was fairly normal although we were concerned as she did seem to be behind but we were reassured that all was fine. (We were comparing her with a very verbal DD1 who spoke full sentences by 18 months.) She made huge leaps forward when she reached the age of two. She also started wearing glasses, so could this be linked to her progress?

She mispronounces many words and sounds and she misses off the beginning of words, eg computer becomes '-tuter'. 
She mixes up 'b' with 'v' so 'very' becomes 'bery'. 
These are just two examples but her speech can be hard to understand even for her dad, who lives with us and is very hands-on.


She is bright and taught herself to read CVC words this summer as she knows all the letter sounds and can say them all individually. 

She can count to 100, solve addition sums to 20. When I asked preschool about this in April of this year, they admitted that they had not noticed that she does not volunteer to speak. They did a lot of work, putting her in talk groups to build her confidence to speak. She quickly became the demo kid in these groups as she can say all the sounds correctly, she just doesn't/can't in normal speech. 

Her reception teachers are aware of this but what else should I be pushing for? Should I contact our GP and ask for a referral or wait and see what school thinks?

I don't want her to go unnoticed because she won't make a fuss and does everything she is told. Plus, there are some much more needy children in her class
.

A. Fiona: Yes, the quiet child can get overlooked in the classroom. She sounds like a bright little button with some age-appropriate speech sound errors occurring. It could be that she's finding it hard due to shyness. As you know her best, what do you think?

She may be displaying some features associated with selective speaking or selective mutism. Have you heard of this or considered it yourself? This is where a child fails to speak in specific social situations, eg school, even though they are able to speak in other more familiar settings, like home. It's only diagnosed once a child has failed to speak for at least a month after they've started school/nursery. It's widely thought to be linked to anxiety rather than stubbornness, which was the old-fashioned view. It usually starts between the ages of three and five.

It can have a gradual onset, starting as shyness but can also be sudden when triggered by an emotional event. It may be that she's showing a mild form since she positively responds to direct questions.

We're seeing an increase in selective speakers clinically. This may be due to an increased pressure to get our kids talking in schools. Children start school very young and teachers have targets for speaking in groups. Some children are just not ready for this and need adults to expect less but support more.

Early support is essential. Talk to her teacher and share the leaflets on The Selective Mutism and Information Research Association or The selective mutism resource manual by Maggie Johnson and Alison Wintgens.

Ask for a referral to see an educational psychologist to find out the root of the problem and advice on support, as SLTs do not usually treat selective mutism.

"We're seeing an increase in selective speakers clinically. This may be due to an increased pressure to get our kids talking in schools... Some children are just not ready for this and need adults to expect less but support more."

Q. NeoMaxiZoomDweebie: My nephew is 3.5 years old and is currently being assessed for high functioning autism. He's very bright and can count and recognise numbers to 30.

He is starting to read but his functional language is behind. He can't ask for a drink or join in a game as he has no real grasp of 'under' or 'on'. He loves people and is sociable.
 
How can we help him to begin communicating his needs more?

Plus, how do we help him learn to approach other children? He currently just plays close to other kids and if they leave, he might grab them. This doesn't help make friends. 

A. Fiona: His functional language is not good and he can't join in play, which is a common issue for children with ASD. The National Autistic Society has some great advice on how to support social skills so this is a brilliant starting point.

Everyone in your nephew's life needs to be involved in this, so encourage his parents to involve nursery staff, if he attends.

Social skills are something that most children just pick up along the way but he's likely to need skills like sharing and playing together explicitly taught and practised with him. His nursery probably has some experience with this. Once given a diagnosis of ASD - or not, as the case may be - the health and education systems have teams in place which would support him, eg speech and language therapy or nursery visits from specialist teachers to help staff support him.

You can help by:

  • Using clear and simple language with him.
  • Don't use jokes, sarcasm or idioms like 'cry your eyes out' because he may not understand these.
  • In everyday situations, talk about the differences in what people like and think. This is tricky for children with ASD, eg ask him to help you pick snacks out from the kitchen based on what he knows about family members' likes/dislikes. This helps him think about what others think and like.
  • Read books together and talk about what the characters are thinking/feeling.
  • If a difficulty arises when he's trying to play with others, talk to him openly but kindly about why it went wrong, eg Sam is sad because you grabbed him. He wants to stop playing now. It's OK he's still your friend.

Q. FutureMum: My daughter is nearly three, ASD, and diagnosed. At the moment, the few words or occasional short sentences she says are at home, which means during her nursery time or out and about she hardly says boo. Can you provide some tips to help encourage her to talk in places other than at home?

A. Fiona: To encourage her using more words, try using toys which have a definite end point, eg those wind-up or push-and-go features and play ready, steady, go games. Here's how to play:

  1. Say 'ready, steady' and wait for her to say 'go' before you start the toy.
  2. When the toy stops, pick it up but do nothing. Just wait and watch to see what she does. 
  3. Depending on her eye contact skills, she may look at you as if to ask for more or she may reach for the toy herself. When she does, you say 'more, do you want more?' If you know the makaton sign for 'more' then use that at the same time, shown here.
  4. Leave a pause for her and see if she attempts to copy your word or sign. If she doesn't, that's fine.
  5. Now model the phrase 'I want more' before you start the toy again.

Keep practising this and always leave a gap for her to copy you. Try the same in everyday routines like snack time:

  1. Don't give her a whole biscuit (unless this will be distressing for her).
  2. Give it to her bit by bit.
  3. When she finishes one piece, wait and see if she indicates she wants more.
  4. You can then model the 'more' and leave a gap for her to copy. You may need to observe carefully if she doesn't initiate communication much, like many children with ASD. If so, start with something you know she finds highly motivating. 

To encourage her to use verbal language outside the home you could start with nursery. Discuss this with staff. They may already have  planned targets so this could be incorporated. Nurseries should have access to local health and education teams which would have all the advice needed to help her in their setting. 
 

Support for parents

Q. Beckyandboys: My son is nearly seven and has been seen by a SALT for the last two years, with much persuasion on my part for him to be seen. They have managed to get him to produce his 'k', and 'g' sounds, but I've noticed him having trouble with his 'r' sound too. It mainly sounding like a 'w'. Do you have any advice on how to correct this at home? 

A. Fiona: The 'r' sound is tricky and a real uphill struggle for kids sometimes. It's one of the later sounds to develop and is usually mastered by about five years of age. Until this point, most children use a speech process known as gliding, where 'r' is pronounced as 'w'. This is a normal developmental speech sound process. It seems your son has not quite grown out of this stage yet, which makes sense if his speech sound system has been delayed.

He has to be able to say 'r' on its own before he can start practising it within words so bear this is mind.

My favourite tip is to ask him to roar like a lion, eg 'raaaa'. He may be inadvertently using a good 'r' sound. If so, then get him to practise shortening the roar to the first 'r' sound.

If his 'raaaa' is more of a 'waaaa' then try getting him to say 'errr,' then add a vowel sound to the end eg 'erraah' or 'erroo'. If his 'r' sounds good, then you have a starting point. Get him to practise shortening the lead up to the 'errr' so you get a neater 'r'.

Practise in the mirror together so he sees how you do it and then copy you. Talk about how you make the sound, eg 'my lips are round and my tongue lifts up to touch the roof of my mouth'.

Keep practise sessions short and sweet. Stay with the 'r' plus vowel for a week or so then try words beginning with 'r'. Don't push this too much, he may need to see an SLT to get him to a point where you can carry on. You could make the referral now if you feel there'll be a long wait.

Q. hazeyjane: My son is 3.2 and he has special needs - GDD, hypotonia, severe reflux, swallowing problems (he aspirates causing frequent lung problems) etc. He is part of a study into a genetic condition called kleefstra syndrome, which he has a lot of genetic markers for. 


He has a severe speech delay, which is consistent with kleefstra syndrome where in some cases children develop to be completely non-verbal. DS has no words and doesn't babble apart from a monotone 'unh' sound. His mouth is always open and his tongue protrudes so he has poor oro motor skills and drools (which is controlled by medication). 


His understanding, while delayed, is much better than his expressive language. I have been signing makaton with him since he was 10 months old and he now has quite a few signs.

He was issued with a Go Talk communication device since he is so good at using the iPad. His SALT thought that AAC may be a good way forward if he remains non-verbal. 
I feel that DS has been sorely let down by the speech and language service.Talking Tips for Kids

I also feel that he has never had a thorough assessment. Apart from a videofluoroscopy, his oro motor skills have never really been dealt with.
 
He hasn't seen a SALT since March, when his GoTalk was issued. The previous SALT handed me a pile of signs and picture symbols and just get on with it. 
After many phonecalls and letters, we are finally meeting a new SALT next week.

So the questions I would like to ask you, in light of this:

  1. 

What should I be expecting in terms of support for my son?
  2. How much SALT should be done by one-to-one at preschool?
  3. 
Is there some sort of programme we should be following with the GoTalk (because frankly we are floundering!) 
  4. Why do you think NHS SALT is letting down a child who has such severe needs in the area of speech and language? 
 


A. Fiona: It's really sad to hear this. Of course, I'm unable to comment on your specific situation as I don't know your child or the area you live in regards to SALT provision.

However, I can recommend this publication from The Royal College of Speech and Language Therapists (RCSLT) entitled Communicating Quality 3. It sets out the professional standards that all SALT services should be adhering to. You may want to take a look at page 229 on augmentative and alternative communication (AAC) regarding the GO Talk.

Look at page 321 for standards on supporting with children with dysphagia (swallowing difficulties) and page 351 which discusses working with preschool children.

It's not that reader friendly but does set out the standards expected and you could use this in your discussion with the SALT service, if you feel there is a mismatch between the guidelines and what you're receiving.

This RCSLT position paper on videofluoroscopy may also be useful.

With regard to the GoTalk, it's best to ask for more support as it's not something that can just be switched on and off you go, as you've obviously discovered. The following places may be useful for you:

It's good that you've got a meeting arranged with a new therapist as it's an opportunity to ask all these questions and find out exactly what your child should be receiving.

If you're still unsatisfied after this you could contact the NHS Patient Advice and Liaison Service (PALS). One of its functions is to represent patients who have a complaint or query about the care they're receiving. This would be a good place to go if your discussions with the SALT service do not result in a solution you're happy with.
  

Last updated: 23-Oct-2013 at 1:17 PM