Q&A with speech and language therapist Fiona Barry - ANSWERS BACK

[RachelMumsnet]

We're running a Q&A this week with Speech and Language therapist, Fiona Barry. Fiona will be answering any of your questions relating to children's speech, language and communication. If your child doesn't say much, mispronounces words, has a stammer, or you just want to boost their confidence and chatting skills, Fiona can provide practical advice on what to do at home. Post your questions to Fiona before midday on Wednesday 18th September and we'll post up her answers on 25th September.

Fiona has worked for the NHS with children who have speech language and communication needs. She also set up TalkingTipsForKids, a website and free app and Android app which helps parents boost their child's communication skills.

Fiona has developed a series of short films that give practical tips for parents worried about their child's communication skills, as well as for those who aren't but want to give their child the best start in life. The films are divided into age categories giving specifically geared advice for all stages of communication development. Starting with the baby in the womb and going right through to the 5 year old school child, Fiona shows how easy it is to fit language boosting tips into everyday routines. Each video also includes ideas for simple but fun games you can play with your child to help with their talking and listening skills. For more information see www.talkingtipsforkids.com

This Q&A is sponsored by talkingtipsforkids

@goonIcantakeit

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

I’m sorry to hear that you’ve found this a struggle, it shouldn’t be should it? Here are some resources - forgive me if I’m telling you things you already know, I’m not sure if you’re still looking or the age/specific needs of your child!

• Leeds Speech and Language Therapy Service has a super-duper website with a whole section devoted to receptive language difficulties.
• [[http://www.amazon.co.uk/Receptive-Language-Difficulties-Liz-Baldwin/dp/1855034417/ref=sr_1_1?ie=UTF8&qid=1379693537&sr=8-1&keywords=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.
• A recent campaign called RALLI (Raise Awareness of Language Learning Impairments) – it’s 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 4 or 5 key words including size concepts and positional concepts (not sure if this would apply for your child).

It may be that you’re not finding the information you want if you’re specifically looking for advice on ‘receptive language delay’. If you look at most sources of information for speech, language and communication needs (SLCN). Receptive language (understanding) and expressive language (talking) should both be included as well as 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 – receptive language delay being one area.

@StrawberryMojito

My DS, 2, has been slow to learn 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 I felt he always struggled academically.

Basically, do late talkers tend to be less intelligent?

Good question! There’s been lots of research into this. Some research shows the size of a child’s vocabulary at age 2 is a strong predictor of later language and literacy skills.

Other research states that vocabulary at 5 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 Maths - think of all the different words for maths concepts like ‘subtraction’ - take away, minus, less). Academic achievement is linked to language skills because we pass knowledge on using language.

Your DS had been late to talk but now seems to be catching up, great news. By 2 children should be able to say at least 50 single words and combine these into 2 word phrases like ‘more juice’ or ‘bye-bye mummy’. Jot down all the words he can say so you have a rough idea. Listen out for any 2 word combinations. Also check to see if he can understand simple instructions eg ‘Show me your nose’ or ‘Find me your hat and shoes’. Our Ages & Stages video is also a useful checklist. If you’re concerned that he‘s not doing this then seek advice from your local speech and language therapy service.

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

@hazeyjane

My ds is 3.2, he has sn - 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 some children develop to be completely non verbal). He has no words, no babbling apart from a monotone 'unh' sound. His mouth is always open and his tongue protrudes, he has poor oro motor skills and drools (which is controlled by medication).

His understanding, whilst 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, as he is so good at using the ipad, that 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. I don't feel he has ever had a thorough assessment, and apart from a videofluoroscopy, his oro motor skills have never really been dealt with.

He has now not seen a SALT since March when his GoTalk was issued, a lot of our provision has been to hand 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, are in light of this.

What should I be expecting in terms of support for ds?
How much SALT should be done by 1-1 at preschool?
Is there some sort of programme we should be following with the GoTalk (because frankly we are floundering!)
And finally - why do you think NHS SALT is letting down a child who has such severe needs in the area of speech and language?

Thankyou

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 (re: 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 p229 re: Augmentative and Alternative Communication (AAC) regarding the GO Talk.
Look at p321 for standards on supporting with children with dysphagia (swallowing difficulties) and p351 which discusses working with pre-school 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 ‘Go talk’ it’s best to ask for more support with this 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:
? ACE Centre Advisory Trust
? The CALL Centre

It’s good that you’ve got a meeting arranged with a new therapist – 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.

@Beckyandboys

Hi, my son is nearly 7 and has been seen by a SALT for the last 2 years ( with much persuasion on my part for him to be seen). They have managed to get him to produce his 'K & G' sound but I've noticed him having trouble with his 'R' sound too, mainly sounding like a 'w', any advice on how to correct this without the constant battle and months of waiting for NHS SALT assessment would be greatly appreciated.

The tricky ‘r’ sound! A real uphill struggle for kids sometimes. It’s one of the later sounds to develop, usually mastered by about 5 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.

You probably know the stages of speech sound therapy, 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 ‘raaaa’, he may be inadvertently using a good ‘r’ sound. If so, then get him to practise shortening the roar to the first sound ’r’. If his ‘raa’ is more of a ‘waa’ 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 ‘err’ so you get a neater ‘r’.

Practise in the mirror together so he sees how you do it and compares his attempts. Talk about how you make the sound, ‘my lips are round and my tongue lifts up to touch the roof of my mouth’. Keep it 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 (make the referral now if you feel there’ll be a long wait?).

@FutureMum

Please can you provide some tips to help encourage DD (nearly 3, ASD dx) to talk/babble in places other than at home. At the moment, the few words/ very occasional brief sentences she says are at home, which means during her nursery time or out and about she hardly says boo. Any tips to encourage her to say 'more' for requests?

To encourage her use of ’more’ try toys which have a definite end point (wind up or push and go). Play ‘ready steady go’ games where you say ‘ready, steady’ and wait for her to say ‘go’ before you start the toy. When it stops pick it up but do nothing. Just wait and watch – see what she does. She may look at you as if to ask for more (depending on her eye contact skills) or reach for the toy herself. When she does, you say ‘more?... you want more?’. If you know the Makaton sign for ’more’ then use that at the same time, . Leave a pause for her and see if she attempts to copy your word or sign. If she doesn’t that’s fine.

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
eg don’t give her a whole biscuit (unless this will be distressing for her), give it bit by bit
When she finishes one piece wait and see if she indicates she wants more. 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, she may have a plan of targets already and 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.

Thank you to everyone who participated. There were similar questions, so I answered them together and have indicated this in my replies.

Fiona's answers have now been uploaded. Thanks to everyone who posted questions.

Thanks Fiona, interesting articles.

Hi Fiona, I have no idea if you will return to this or not. Thanks for your response to my query about tongue tie.

I need you to know that what you said about older children having to have revision under GA is not correct. There are a couple of dentists in the UK who have trained with Dr Kotlow who is a leading expert in this field.

They do laser revisions using only local anaesthetic. It is essential to have the patient awake during a revision, otherwise how can they assess tongue function? My son has had this done, so I have first hand experience of the procedure. He was fine, not at all traumatised and says he recommends that anybody needing revision should have it done because his tongue feels much better now.

I get the feeling that perhaps you are not up to date with developments in this field and are giving dated information to your clients which is a shame because as a SALT, you are in a prime position to spot tongue ties and help children who are struggling because of it.

You didn't answer my question about posterior tongue ties. Can you spot one? Often the tongue will look "normal" to the untrained eye and sadly many HCPs miss them.

I have had to dig and dig to find decent information for myself regarding DS1, basically the mainstream is woefully lacking in knowledge, sorry but it's true.

His ties went undiagnosed until he was 6yo and have caused no end of problems for him, including distortion of his orofacial structure and associated problems. There is a LOT more to this than speech and feeding.

If you are interested in further reading, I would recommend Carmen Fernando (she is a SALT), Dr Kotlow, Alison Hazelbaker, Dr Brian Palmer DDS, Catherine Genna Watson. For starters.

Yes, you say that tied kids can make the sounds required in English by positioning their tongues slightly differently. This is compensating. Compensating has knock on effects on the jaw/head/neck/shoulders in fact the whole body. Adults who have had revisions have talked about the instant relief of finally having the tension removed.

Imagine there was restriction in any other part of the body, I dunno, say your legs were tied together and only a doctor could free them. What would you think if a doctor said no, I'm not freeing the restriction,it's ok because you can shuffle along or maybe hop along with your feet together, OR WORSE STILL - no, the restriction in your legs is not the cause of your inability to walk properly. I don't know about you, but I'd be hopping and shuffling at top speed off to someone who could help me restore proper function in my legs!

It's no different with the tongue.

@mawbroon

Hi Fiona, I have no idea if you will return to this or not. Thanks for your response to my query about tongue tie.

I need you to know that what you said about older children having to have revision under GA is not correct. There are a couple of dentists in the UK who have trained with Dr Kotlow who is a leading expert in this field.

They do laser revisions using only local anaesthetic. It is essential to have the patient awake during a revision, otherwise how can they assess tongue function? My son has had this done, so I have first hand experience of the procedure. He was fine, not at all traumatised and says he recommends that anybody needing revision should have it done because his tongue feels much better now.

I get the feeling that perhaps you are not up to date with developments in this field and are giving dated information to your clients which is a shame because as a SALT, you are in a prime position to spot tongue ties and help children who are struggling because of it.

You didn't answer my question about posterior tongue ties. Can you spot one? Often the tongue will look "normal" to the untrained eye and sadly many HCPs miss them.

I have had to dig and dig to find decent information for myself regarding DS1, basically the mainstream is woefully lacking in knowledge, sorry but it's true.

His ties went undiagnosed until he was 6yo and have caused no end of problems for him, including distortion of his orofacial structure and associated problems. There is a LOT more to this than speech and feeding.

If you are interested in further reading, I would recommend Carmen Fernando (she is a SALT), Dr Kotlow, Alison Hazelbaker, Dr Brian Palmer DDS, Catherine Genna Watson. For starters.

Yes, you say that tied kids can make the sounds required in English by positioning their tongues slightly differently. This is compensating. Compensating has knock on effects on the jaw/head/neck/shoulders in fact the whole body. Adults who have had revisions have talked about the instant relief of finally having the tension removed.

Imagine there was restriction in any other part of the body, I dunno, say your legs were tied together and only a doctor could free them. What would you think if a doctor said no, I'm not freeing the restriction,it's ok because you can shuffle along or maybe hop along with your feet together, OR WORSE STILL - no, the restriction in your legs is not the cause of your inability to walk properly. I don't know about you, but I'd be hopping and shuffling at top speed off to someone who could help me restore proper function in my legs!

It's no different with the tongue.

Hi Mawbroon, we'll forward your mail on to Fiona and let you know if she responds. Thanks

Thanks Rachel