Tuesday, February 25, 2014

Identify the Signs - Struggles to Say Sounds or Words (3 to 4 years old)

Children at times may have difficulty getting out the words that they want to say. Even as adults we have moments where what we are intending to say does not come out as smoothly as we want it to. But when is this a normal disfluency and when is it considered stuttering and is a problem? This post is going to be a little bit different than my last few posts in that smooth speech does not "develop" in the same way as language does or as we acquire speech sounds. So, I will talk about disfluent speech, give you examples of stuttering and lay out some important risk factors to consider when determining if the stuttering is a concern or a normal, developmental stage and may go away naturally.

Facts about Stuttering

Stuttering may begin at any time in a lifespan but is most likely to occur in the preschool years between the ages of 2 1/2 and 4 years old. It may begin in a variety of ways. It may occur slowly, increasing gradually over a period of time. Or with in days or weeks could become significant. It may occur for a while, then go away, only to reappear again later in a cyclical pattern. It is important to note that about 75% of preschoolers who stutter will eventually have fluent speech. Some regain fluent speech within months and for some it may take years.

There is no known cause of stuttering. Based on recent research, we know that genetics plays a role in this disorder, but not all who are predisposed to stuttering will experience significantly disfluent speech. Some children begin to stutter as they are learning new vocabulary or are experiencing growth in their language development. So, they may have fluent speech at the two-word phrase level but when their language skills are developed and they could be putting together 4-5 word sentences, they may stutter on the longer sentences.

There are quite a different ways that stuttering may sound:

  • repetitions (sound, word or phrase repetitions) - I- I- I-want to go to the movies.
  • prolongations (sounds are stretched longer than typically produced) - Sssssssunday will be fun.
  • interjections (adding in extra words) - I um, uh like um you know, want the fries.
  • blocks (pausing or stopping of the sounds) - I w.........ill drop off the book at the library.
  • revisions (changing what was going to be said) - I need a, I'll get the silverware.
While many preschoolers are unaware of their stuttering, as they experience other children's (and adult's) reactions to their speech they begin to develop an awareness of their difficulties. Frequently there are physical signs in addition to the speech difficulties. These are called secondary characteristics and may include facial tension, body/limb tension, excessive blinking, head turning, lip tremors, facial tics or other unusual movements. These are signs that the stuttering is bothering the child or that the child is aware of the disfluent speech and is trying to "get out" of the stuttering moment.

Risk Factors

Family history of stuttering
Has occurred for more than 6 months
Continues to increase in severity
Strong concern about the stuttering (or frustration on the part of the child)
Child is avoiding talking
Presence of tension or other secondary characteristics (see list above)

If your child has any or all of these risk factors, the chances of the stuttering going away on it's own are much less than if your child has none of those risk factors.

If you are concerned about your child's stuttering, at any age not just preschool age, please contact a certified speech language pathologist. If you are in the central Florida area, feel free to contact me (here). If you are not, or if you would like more resources, check out The American Speech-Language Hearing Association's website for more information (here).

Monday, February 17, 2014

Identify the Signs - Says Only a Few Sounds, Words or Gestures (18 months to 2 years)

Babies' cooing and early babbling is one of the most delightful sounds in the world.  I remember saying "oooo" to my daughter when she was just a few months old and she said "oooo" right back. I cried. But as they grow older, their sounds should increase in number and frequency, words should develop as well as the use of gestures to help very young children communicate. Here is some information on early communication skills, some ideas of what you can do at home as well as some red flags to watch out for.

Typical Development of Early Sounds, Words and Gestures

Your infant (0-3 months) will begin to make little sounds like cooing and gooing that are soft and sigh-like. These sounds have no meaning and are just part of the way he is figuring out his mouth and how it makes noises.

After a few months (4-6 months), he will start to make clearer consonants, specifically p, b and m. Usually these sounds will be used in nonsense babbling like "muh-muh-muh" or "bah-bah-bah-bah." You'll probably notice different noises that indicate pleasure (giggles and chuckles) or displeasure. It was around this time that I told my husband that our son "found his voice!" He began to do a high pitch shriek that started off low and grew higher pitched. He began to play with the volume of his voice as well.

In the second half of his first year of life (7-12 months), he should start to combine different vowels or consonants in his syllables. You may hear short strings of babbling "be-buh-buh" "da! da!" or longer strings "da-bah di-di-buh-duh" It is in this stage that he will begin to use his voice purposefully. He will use these speech combinations and other sounds (not crying) to get your attention. My son likes to say "yah yah yah" when he wants something out of his reach.

This is also the stage where children use gestures more purposefully as well. He may lift his arms up to indicate he wants to be held. Or he may reach for something that is obviously out of reach to indicate that that is the item he wants. He may wave or gesture "bye-bye!" when he is leaving someone.

As they finish up this first year, right around his first birthday, he should have one or two real words. Some common examples are "mama" (more likely "dada!"), "baba" for bottle, "hi!" and "ball." He'll also be more able to imitate your sounds and babbling. If you say "buh-buh" he should repeat "buh-buh" if you switch to "buh-buh-buh" he should also switch to saying it three times.

After his first birthday, between ages 1 and 2, he'll go from those nonsense syllables to meaningful syllables (bah-bah to mean blanket, or mama to mean mom) to single words (doggie, duck, apple) to two word phrases as he approaches his second birthday. For more information on that check out this post on Combining Words (click here).

What You Can Do at Home

For your infant, one of the best things you can do is talk to him. Tell him stories as he is sitting in his bouncer or swing. I remember telling my 2 month old daughter the story of how my husband and I met (maybe I was bored or lonely that day, but I told her the whole story!) It is also important to just get right in their faces and make good eye contact and make silly sounds! It is a bonding experience first and a speech activity second :) I love it when my son has his hands on my face and explores my mouth and lips and teeth. He is focused on me and the sounds that I am making.

For your 4-6 month old, imitate his sounds. If he is making a "yah yah yah" sound, you make it right back. Be excited to be communicating back and forth with him. When you repeat him, you are acknowledging that he said something important.  You can also just converse with him as if he is saying something that you understand. If he says "yah yah yah" you can respond with something like "yeah! I like that idea. Let's play with cars!" Or if he says "dadadada" you can say "I miss dada too, he's at work. He'll be home soon."

As his sounds increase in complexity (between 7 and 12 months), you can name items that sound like what he is saying. If he says "buhbo" you can say "Bubbles! That's a great idea" or "ge-dih" you can say "Get it! Ok, I'll get the car!" Name the toys, foods, people and objects that are around him. You can use single words as you come across them. For example, if a firetruck drives by you can say "Firetruck! Look at the firetruck!" or if you are rolling a ball with him, each time you get the ball or roll the ball you can say "ball!"

From his first birthday to close to his second birthday, he'll be saying more and more, so he will need you to be telling him the names of all of the items he encounters. You can talk about actions and categories like foods or animals. Baby W received a few wooden puzzles for his 1st birthday. One of them has pets, so I say something like "Look at the pets! Bird. Bunny. Hop! Hop!" (while I pull the bunny out of his mouth and make it hop on the rug). I try to name the pieces that he is grabbing (and trying  to eat).

To be completely honest, I find that it is more difficult for me to work on encouraging gestures than it is for me to work on words - so this is taking purposeful action on my part! When Baby W wants to be picked up and he is just fussing I can say "up! Want up?" and then although his crying is telling me yes, I lift his arms and say "up!" then I pick him up. I do with his arms what I want him to do, then I follow through as though he did it to tell me.

It is also important to tell them how you know what you know. Kids don't get how you know what they are thinking. You'll have to tell them something like "I know that you want the cup of water because I see you are reaching for it." or "I see you looking at the book, I can tell you want to read it!"

As he gets closer to his second birthday, you'll want to take those single words that you've been saying and add action words to them. So if you've been playing with the ball, you can say "get ball!" or "roll ball" (you can add the word "the" at this point so you don't feel funny saying these incomplete phrases but remember that is what he'll be saying soon and you want to model the next step not modeling two or three steps down the road). If he is using action words, add a noun. So if he says "jump!" you can say "I jump!" or if he says "drink" you can say "drink water." You can also add an adjective (red car or green ball or jump up or more drink).

Red Flags

Infant - not making sounds
Toddler - not saying more than 5-10 words, not using gestures
Preschooler - not combining words

If you are concerned with your child's communication skills, if he is only using a few sounds, words or gestures, talk with your pediatrician and contact a certified Speech Language Pathologist. If you are in the central Florida area, feel free to contact me (here). If you are not, or if you would like more resources, please check out the American Speech-Language Hearing Association's pro-search feature and web page (here).

Tuesday, February 4, 2014

Identify the Signs - Does Not Combine Words (starting at 2 years)

Combining words into phrases and then later into sentences helps make what your child wants to say more precise. If a child say "ball" does he want to play with a ball, kick the ball, show you the ball, ask you where his ball is? But once he starts putting words together you get a better understanding of what he is thinking. Starting at 2 years old, your child should be combining words for conversational purposes. Here is some information on typical expressive language development, things you can do at home as well as some red flags to watch out for!

Typical Development of Expressive Language

Around your child's first birthday, he should have one or two real words. A real word is a combination of sounds that he consistently uses for that object or person. A good example is "baba" for bottle. If he says "baba" every time he wants his bottle then that is a real word. If sometimes he says "baba" and other times "moma" and other times he says something else, then that is not a real word for him (yet).

Throughout his next year, he will begin to name many objects in his environment and begin to combine words together. He may say "want ball" or "more juice" or "where mama?" In the beginning of this year, he may start to use intonation to indicate a question "milk?"

By his second birthday, he should be consistently putting two words together.  The word combinations should be a variety of noun-actions (doggie run, mommy go, book fall), action-nouns (drink juice, eat cookie, want car), adjective-noun (no milk, more snack, pretty leaf) or possessive-nouns (my toy, mommy spoon).

Between the ages of 2 and 3, your child will start to put 3 words together. "I go home" and "I want juice" and "more cookie, please" will be the types of simple sentences or phrases that you should begin to hear. Two word phrases are still fine for a 2 year old, but as your child approaches his 3rd birthday you'll want to hear longer sentences.

One easy way to see if your child is on track is to make sure that the majority of his sentences have as many words as he is years old. So, your 3 year old should say 3 word sentences. Your 4 year old should say 4 word sentences. Now, I am not saying that your 18 year old should only speak in 18 word sentences! But for young children this is a good rule of thumb to follow!

What You Can Do at Home

For your young child, you'll want to label the items that he comes into contact with. So, while you are getting a clean diaper, say "diaper! Diaper! I've got a clean diaper! Here's a diaper." You can show it to him and let him hold it while you get ready to put it on him. But the focus should be on the single word "diaper." The best thing to do for language development is to take where your child is and increase the difficulty by one step. Model that next language step. For example, my son only has a few signs and one word (his 1st birthday is next week), so he is needing me to model single words for him. We point to things as we go around the house or community and I name them for him. If he holds up a toy (or other object that he's found) I name that. If he attempts to say something in return I praise his effort.

Last night we went to get ice cream for my husband's birthday and there was a car next to ours with some little dogs in it. They were barking and drew our attention, so I said "dog! Look at the dogs! Dog. Dog. Dog. Do you hear the dogs? Arf! Arf!" Baby W was very interested in the dogs but did not respond or attempt to communicate anything. On our way out, the car of dogs was still there and they barked at us again. Again, I did a little labeling, then got him buckled into his car seat. He looked over at the car and made a little barking noise three times. We cheered and made barking noises, too!

Praising your child's attempts at communication is very important to let them know that you heard and applied meaning to what they said.

The next step is combining words. It's best to start with the single words that they say and add a word to it. If you child knows the word "milk" you can add "want." So your child says "milk" you reply "want milk!" While I love the word "please" and think that socially it is a very important word, it is not the most important word to add to your child's vocabulary at first. Add an action to a noun. Or add a noun to an action. Later, when he is combining 3 words you can add "please" to say "want milk, please."

There are lots of words that you can teach your child that go along with the words that they already have. I am working with a little boy right now who knows "car" so we are adding actions to that noun. I say "push car" "get car" "want car" "drive car" "beep car" and "go car" while we are playing with cars. I model what I want him to say. When he says "go car!" as we are racing around the room I praise him and I give him opportunities to tell me what he wants. I may collect all the cars and put them up out of his reach and wait for him to say "want car" (right now it's "want" with a reach to the car, so I have him say "want" then "car"). Don't make your task super frustrating but do give your child opportunities to need to ask for what they want.

Once your child is combining two words consistently (at least 50-70% of the time), you can model the next step which is 3 words! "I want milk." or "Get car, please" or "Mommy, throw ball" Don't talk like this all of the time -you do want to demonstrate correct grammar - but during select times you can really focus on modeling the next step. The best way to model the next step is right after your child says something. So if he says "read book" you can say "I read book" or "please read book" If your child repeats the longer sentence, let him know he did a great job.

The next step is 4 word utterances. This is where your sentences will sound more grammatically correct! And you'll feel like you are actually speaking in sentences instead of that almost telegraphic speech from earlier. You can add in "the" and "to" and "a." Your child's sentences will start to sound more grammatically correct, too, which makes what he is telling you easier to understand! If you notice that your child is leaving out words, repeat the sentence back to him with all of the words that should be in there. So if he says "I go McDonald's" you can say "I go to McDonald's"

Just keep modeling what you want your child to be saying. Know where he is and what the next step is and you'll be on your way!

Red Flags

Infant - not making sounds
Toddler - not labeling objects or combining two words together
Preschooler - not combining 3 or 4 words together
School Age Child - making sentences that are missing many of the little words (a, the, to, on)

If you are concerned with how your child is using words or is not putting words together as he should, talk with your child's pediatrician and seek out a certified speech language pathologist. If you are in the central Florida area, feel free to contact me (here). If you are not, or if you'd like more reference information, please check out the American Speech-Language Hearing Association's pro-search page and their website (here).

Monday, February 3, 2014

Identify the Signs - Words are Not Understood (18 months to 2 years)

Speech sound development is one area that stumps many parents. When should your child be able to correctly say "f" or "g" or "m." Is it ok for your child to say "wawa" for water, and if yes, for how long is that ok? Or if he uses a silly word like "keekee" for your pet cat but at other times can say "cat" just fine, do you need to worry?  Here is some information on typical speech sound development, things you can do at home and some red flags to watch out for.

Typical Development of Speech Sounds

As an infant your child should begin babbling and making sounds with his tongue and lips for the purpose of interacting with you as well as just the fun of making sounds! You will likely notice a variety of consonants and a few different vowels. The combinations at first will be simple "dadadada" or "guh-guh-guh." Then the combinations get more complicated and he will vary the vowel or the consonant "mami" or "daga." About half way to his first birthday, he should be making a few consonant sounds like "p" "b" and "m." By his first birthday, he should have one or two words (some common first words are "dada" and "byebye") along with lots of babbling.

Between the ages of 1 and 2, your child should be increasingly saying more words. You should frequently think "wow! He knows that word?!!" Towards his second birthday he should be combining words (more on that in my next post).  He should be saying more and more consonants at the beginning of words. You should hear b, d, h, m, n and p with a variety of vowels. At this point you should understand about 25% of what your child says when the context is known. For example, you are talking about an airplane and your child says "ay-pay sigh!"  and you can guess that he said "airplane sky" All the sounds don't need to be correct, but you should be able to figure it out at least some of the time.

From 2 until 3, your child will be saying more sounds, words and  2-3 word phrases. He should also now be able to say w, f, g, k and t. You should understand your child most of the time (about 50% of the time) and unfamiliar listeners should understand him some of the time, too. Parents have a natural ability to translate what a child says without even realizing we are doing it. Pay attention to how often you translate your child's speech to others. By the time he turns 3, he should be consistently putting the endings on words (so "cat" instead of "ca").

You'll notice that your 3-4 year old has a word for almost everything in his environment and wants to talk about everything! He should be able to say kw (q). You should understand him 75% of the time even if there are some sound errors. For example, "I wuv puhsketti" is fine for a 4 year old who wants to tell you how much he loves spaghetti!

Between the ages of 4-5, your child will continue to develop speech sounds like ng (at the ends of words), j, sh, l, s, ch, y and bl. While sometime these sounds will be correct you may notice some errors during conversation. You'll want to hear fewer and fewer errors as he ages. You should understand him almost 100% of the time (again, all of the sounds do not have to be correct, but you should be able to understand what he is trying to tell you).

Between 5 and 6 years old, he should start saying r, v, br, fl, fr, gl, dr, gr, kl, kr, pl, st and tr.

Finally, by the time your child is 7 and 1/2 he should be able to say all of the sounds including th, z, sp, sw and sl.

What You Can Do at Home

Honestly, one of the best things you can do to help your child develop his speech sounds is to model the correct production in your own speech. It's cute to say things like "wuv you!" but it won't be so cute when your 7 year old is still doing it. However, it is very good to do silly sounds with your infant - to blow raspberries and say "buh buh buh" to your baby is very appropriate. But you want to be modeling one (or two) step ahead of where your child is currently communicating when you are talking.

For infants and babies, making animal sounds, environmental sounds and silly sounds are great ways to encourage early speech production.

For your 1 year old, keep making those sounds but draw more attention to the fact that you are doing it. You may say something like "oh, I hear the clock. "t - t - t" and encourage him to say it too. Or if you are playing with a toy car you can tap on the car and say "beep! beep!" and ask him to say it while he taps on the top of his car.

For your 2 year old, encourage him to try new sounds. I like to talk about what my face and mouth are doing. "Look my lips go together and I can go mmmmm!" This is good for working on body parts too!

For your 3 year old, I would encourage him to try to say his sounds correctly not just in words but in simple phrases too. So if he can say "milk" when it's just the word, but says "I want ilk please" have him repeat it with a good "m" in a simple phrase "Milk please!" Also, if he can say a sound in one word, like a "k" in "car" but says "tat" for cat, you can encourage him to try a "k" in cat. Again, I would talk about what my tongue is doing when correcting errors.

For your 4 year old, you can start introducing letters and the sounds that they represent. So, if he is struggling with "s" you can show him the letter S and talk about how it represents the sound "sssssss."  I like to find things that make that sound and practice. Some things that make the "s" might be a snake or some kind of bug or the air coming out of a balloon and then act that out while you make the sound.

For your 5 year old (and older), you can demonstrate the differences in correct and incorrect production. I might say something like "you said 'sree'. Try to say it with a 't' at the beginning like this  'Tree" and really emphasize the sound that was in error.

Red Flags
Infant: not making any sounds
Toddler: making very few consonants and vowels, or uses mostly gestures and grunts
Preschooler: making many errors on most sounds or is very difficult to understand
School Age Child: making errors on sounds, spelling like he speaks, or is difficult to understand

A few things I'd like to add here at the end. If your child seems especially frustrated when he is not understood, it may be time to seek out help. Also, if while you are working on it, if he is not making progress, you may want to talk with a certified speech language pathologist. Finally, if your child has sounds that sound really slushy (a lateral lisp), you should seek help for that as soon as possible. A lateral lisp is never a typical speech pattern.

To get a copy of the sounds and at what ages they should be produced correctly, check out one of my earlier blog posts for a printable page (click here!)

If you are concerned with your child's speech sound development and you have questions, talk with your pediatrician and seek out a certified speech language pathologist in your area. If you are in the central Florida area, feel free to contact me. If you are not, or you would like more resources, check out the American Speech-Language Hearing Association's pro-search (here).

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