5. speech disorders

Chapter 5: SPEECH DISORDERS

Speech disorders are those disorders related to the speech mechanism. This chapter reviews articulation or speech sound problems and stuttering (also known as stammering), as well as provides a brief introduction to apraxia (sound sequencing difficulties) and hypernasality which is common in children with cleft palate.

Objectives: Be able to identify the structures involved in speech production Be able to do a rudimentary oral mechanism examination Be able to identify children who have difficulties with speech Be able to generate simple activities to work on speech sounds Have a greater understanding of speech disorders and how to work

with them

5.1 Fact or Fiction? True or False Activity

Review the following statements. Which do you think are true? Which do you think are false? Talk about these statements with colleagues, what do they think? Why?

1. Speech is a fine motor skill 2. When assessing a child’s speech we might also ask the parent

about the child’s eating and feeding skills 3. If a child can’t speak they have a lazy tongue 4. If a child doesn’t speak, I don’t need to talk to them5. A child who talks a lot can’t have a speech disorder 6. Eggs can affect a child’s ability to talk 7. If a child is missing teeth, this can affect their speech 8. A child with a weak body might be able to talk better if given

physical support 9. Special educators should encourage all attempts at talking from

children who don’t have much speech or language 10.When a child can’t talk it is usually because they are tongue tied

There are a lot of misheld beliefs about speech, what causes speech disorders and why they occur. We begin with these statements to get you think about speech and the role of speech as it relates to communication and education of children. Many of these points will be discussed further in the chapter.

The Answers:

1. Speech is a fine motor skill - True

VSO Jitolee 2008 48.

We consider the movement of the tongue, lips and palate as a fine motor skill.

2. When assessing a child’s speech we might also ask the parent about the child’s eating and feeding skills - TrueWhen a caregiver can report about a child’s feeding or eating skills it gives us more information about the child’s oral motor skills.

3. If a child can’t speak they have a lazy tongue – FalseIn our experience very few children are actually lazy, usually if they can do it, they will do it. In a similar vein, children’s aren’t talking because their tongues are lazy though this is a common myth amongst educators and parents. A child’s tongue may have limited movement, ,or appear oversized but this is usually related to muscle tone or nerve damage in the brain. We will talk more about tongue movement when we move into the oral motor exam portion.

4. If a child doesn’t speak, I don’t need to talk to them – False

If a child doesn’t speak, and you DON’T talk to them it is unlikely that they will ever talk! Children learn to understand language before they use language.

5. A child who talks a lot can’t have a speech disorder - FalseA child may talk a lot but no one may understand him because of the way he pronounces words. If a child speaks but is unintelligible they probably have a speech disorder.

6. Eggs can affect a child’s ability to talk – FalseThis is a myth. Foods do not generally affect a child’s ability to talk. Food allergies may affect a child, but eating or not eating something will not stop your child from talking.

7. If a child is missing teeth, this can affect their speech- TrueWhen children are missing teeth this can affect their ability to speak clearly. Teeth form a natural barrier at the front of the mouth that is involved in the production of certain speech sounds including “s” and “th.”

8. A child with a weak body might be able to talk better if given physical support – TrueWhile speech is a fine motor skill it relies on the support of the big muscles in a child’s neck and trunk. Try talking while you are sitting slumped in a chair or in an awkward position. Children with particularly weak bodies like those with cerebral palsy can often better vocalize if they are placed in a supported seating arrangement. By sitting upright they can better stabilize the large muscles to control the small ones and they can better control their breath for speech.

9. Special educators should encourage all attempts at talking from children who don’t have much speech or language – True


Parents, educators and therapists should encourage all attempts at talking and communicating from children who don’t have much speech or language. Single sound production, or simple vocalizations are a step towards using words. If we discourage early attempts to communicate children might give up and not bother.

10. When a child can’t talk it is usually because they are tongue tied – FalseIf a child isn’t talking usually has very little to do with the speech structures and much to do with the child’s brain development. We will talk about tongue tie a little more in this chapter.

5.2 The Speech Structures:

When we consider speech disorders we must consider the whole child and the speech system.

What do we need to speak? - lungs, air, breath- voice box, vocal folds- oral cavity (mouth, tongue, palate, epiglottis etc.)- nasal cavity

Defining vocabulary: The following are some terms that can be helpful in describing structures and speech sound placement.

The Speech Structures:

The lips open and close to form different shapes such as ‘p’, ‘eee’, ‘ooo’. Sounds that involve the lips are often called bilabial sounds (literally ‘two lips’). In English, bilabial sounds include p, b, m, w.

Teeth also form an oral boundary. Sounds that involve the lips and the teeth together are called labiodental (literally ‘lip and teeth’). In English, labiodental sounds are f,v. Practice making those sounds and feel how the top teeth rest on the bottom lip during sound production. Interdental sounds (‘between teeth’) in English are a voiced and a voiceless ‘th’ (“think” vs. “bath”).

The ridge on the palate behind the teeth is also a structure we refer to when we talk about sound production. This is called the alveolar ridge and the tongue touches this ridge when you make the English sounds t,d,s,z,n and l. The palate is the upper part of the mouth (the roof of the mouth). The front part of the palate is known as the hard palate, the back part the soft palate. R and y are considered palatal sounds.

The soft palate or the velum is important for nasal sounds n, ng (these sounds are also known as velars). The soft palate is responsible for the control of airflow through the nasal cavity. If the soft palate cannot close the


nasal cavity completely air escapes through the nose when it should not (e.g. during non-velar sounds like p or b).

The tongue is a large muscle necessary for articulation. It moves up and down, in and out of the mouth, touching the palate. If the tongue has a problem movement can be affected then the sounds are distorted.

The frenulum is the visible bit of flesh that attaches between the tongue and the floor of the mouth. If a child is “tongue-tied” people are talking about this frenulum. When the frenulum is extremely short the tongue tip may be pulled back in the middle (see sketch) like a w.

A word on tongue – tie. Research shows that most children who have very short frenulums can still get enough range of motion to articulate properly. This is RARELY the reason why a child doesn’t speak.

It seems to be a preferred diagnosis for children who don’t talk and this may be because it is easy to remediate. Parents should be counseled against having a child’s frenulum cut if it is deemed unnecessary. As a rule of thumb if the child can get the tip of his tongue to their hard palate, this is sufficient movement for speech.

5.3 Consonant Sound Production

In talking about the speech structures, we have also talked about the place each of the English consonant sounds are produced. When we talk about sound production, in addition to place we consider manner and voice.

Manner of Sound Production or HOW the sound is produced. As you read through this portion of the text practice the sounds. How do they feel?

Stops – these are sounds that come out in a little burst of air (examples: p, b, t).

Fricatives – these are sounds that contain a lot of airflow (examples: s,z,sh)

Affricates – these sounds can be considered a combination of stop and affricate (example: ch)Nasals – these are sounds that are made using air through the nose

Liquids – these are sounds that are produced with very little obstruction of air

Glides – these sounds appear to glide off our tongue so are referred to as glides. Voicing


We might say a sound is ‘voiced’ when the voice is turned on (g, d) or ‘voiceless’ when the voice is turned off (k, t). If the sound is considered voiced, it means that the vocal folds are vibrating during the production of that sound. Feel your throat, can you work out if a sound is voiced or voiceless?

All this information is summarized again in the chart below.


Consider the vernacular you are working in with your children. Where might the sounds from this vernacular fall?

It is helpful to know where and how the sounds are produced in order to be able to instruct children how to produce them correctly. For example, if I want a child to make an “s” I can start by showing them how they need to hold their teeth together and get the air flowing through their mouth.

Speech Sound Activity:

Consider the sounds /k/, /r/, /l/ and /m/

1. Come up with a simple way to describe how and where the sound is produced in the mouth to a child

2. Come up with some ways you might use prompts to show appropriate tongue placement for a child who is not making the sound correctly

Place and Manner Chart for English ConsonantsPlace of ArticulationBilabial (two lips)

Labiodental(lip &teeth)

Interdental (between teeth)

Alveolar (ridge behind teeth)

Palatal (roof of the mouth)

Velar (the soft palate, feels almost like they’re made in the throat)

Glottal (space between vocal cords)

Examples

Manner of Articulation

Stops(Voiceless) p t k pat, tick, kite

Stops(Voiced) b d g bat, doll, go

Fricatives(Voiceless) f “th” s “sh” h

fine, thin, sun, shine, house

Fricatives(Voiced) v “th” z video, the,

zebra Affricates(Voiceless) “ch” cheese

Affricates(Voiced) “dj” jump

Nasals(Voiced) m n “ng” mouse, night,

ring Liquids(Voiced) l R lamp, ring

Glides(Voiced) w Y

well, yellow


5.4 What Are Speech Disorders?

Speech disorders are those related to the oral production of sound. Remember:

Speech is the production of sound, formed in the oral cavity

Language is the formal combination of symbols (words or signs) used to communicate and understood by members of a particular community.

So how do we identify a speech disorder versus a language disorder?

In general a child with a speech disorder:- may talk in sentences but be difficult to understand- may have difficulty with certain sounds- wants to talk, has the language to talk, but just can’t get the words out

If the child is NOT TALKING at all this is probably related to their language abilities and we should work on this first. 5.5 Oral Mechanism Examination

If you suspect a speech disorder, you may wish to do a simple oral mechanism exam. This is just a cursory examination of the mouth to see if there are any structural reasons why a child may be having trouble producing sounds.

DO NOT FORCE THE CHILD TO PARTICIPATE IN THIS IF THEY DO NOT WANT TO. Getting inside someone’s mouth is particularly intrusive. If you are to have a good working relationship with a child you need a level of trust. If you barge into the child’s mouth getting the child to work with you becomes very hard! PLEASE DO NOT FORCE A CHILD’S TEETH OPEN. Please also consider hygiene in this matter. If you do not have disposable gloves, wash your own hands very thoroughly both before and after touching the child’s face and mouth.

The information gathered during an oral mechanism exam can be included in their Individual Education Plan. But what next? How do you use the information to help the child?

If you see anything of medical concern, such as an open palate, yeast covering the mouth or dental problems, I encourage you to refer the child to a medical professional.

If the child has difficulty with tongue movements, perhaps you can practice these and note any changes over time with a child’s range of motion or oral motor strength. If a child has no volitional tongue movement at all, consider again referring to a doctor.


ABBREVIATED ORAL MECHANISM EXAM

Visual Examination:

Look in the mouth. - Do the structures look symmetrical (i.e. even on both sides?) yes no- Are the structures intact? yes no

If you notice anything unusual you should mark it down. This includes teeth that are literally falling apart and rotting, any mouth sores and any abundance of yeast/fungal growth in the mouth. You may wish to consider a medical referral if necessary.

Comments/concerns/observations:__________________________________________________________________________________________________________________________________________________________________________________________

Range of Motion:

Have the child try and imitate the following movements:

Tongue Protrusion (stick out) ______ Elevation (up towards nose) ______

Depression (down chin) ______

Lateralization (side to side): Left ______ Right ______

Lick lips all the way around ______

LipsRounding (kiss)

Retraction (grin/grimace)

Strength: Have the child push against a straw, clean finger or tongue depressor. Indicate good or poor strength.

Tongue: Protruded ______ Left ______ Right ______

Lips: Rounded ______

Have the child fill their cheeks with air. Can they maintain the lip seal when you push on their cheeks? yes no


5.6 Articulation Disorders

Articulation is the coordinated movement of the speech mechanism to produce intelligible sounds.

Articulation disorders may be caused by: Incorrectly learned motor patterns Poor movement of any of the speech structures (e.g. in children with

muscle tone issues such as Cerebral Palsy, Down Syndrome) Structural abnormality, e.g. cleft palate, open bite, missing front teeth

If you notice that one of the children in your class has difficulties producing certain sounds when he or she is talking then the first thing you need to identify is which sound(s) are causing problems. This can be done by listening carefully to the child’s speech and isolating the particular sound(s) that are not produced correctly. You can also pay attention to whether the sounds in question are always incorrectly produced or whether it it is only said incorrectly in certain words. You can also note whether it varies according to where the sound is in a word (at the beginning, middle or end).

What can be done?

In other words…

Before any treatment/remediation can be done it is helpful to identify the error patterns and a child’s stimulability of the sound (e.g. are there ANY contexts where she CAN make the sound?).

1. Write down the errors you hear in their speech

For example: Cat “tat”

2. Can the child make the error sound(s) in isolation (i.e. “s” versus “sun”)?

3. Can the child hear the difference between the correct and incorrect sound?


4. If you notice patterns (e.g. /k/ in the initial word position) probe this further by generating more examples for the child to imitate

Coat, can, cab, etc

Note down any the child can do successfully.

When selecting words for the child choose:- single syllable words- words that DON’T contain other sound errors- words that don’t contain the substituted sound (i.e. if the child is replacing /k/ with /t/ don’t choose a word that already has a /t/ in it as this makes it harder for the child- like “cat”)

Be sure to give the child IMMEDIATE FEEDBACK on the accuracy of their production (e.g. “that one was close”, “I saw your tongue on that one, try and keep it behind your teeth”)

What if there are multiple speech sound errors?If the child produces more than one speech error, you can decide which one to work on according to three things:

a. Start with the sounds that the child is able to produce accurately some of the time. If he is already producing it correctly on occasion then it should not be such a great step to producing it correctly all the time.

b. Start with the sounds that occur more commonly in speech as these will have the biggest impact on the intelligibility of the child. For example, work on the sound ‘s’ before the sound ‘r’ as this will have a much greater impact on how well you can understand the child.

c. Start with the sounds that occur first in normal speech development. Refer to the table below which has the order the speech sounds that occur in English speaking children.

Table of the order in which speech sounds occur in development of children with English as a first language

Stage of development (in years) Sounds produced by childStage 1 (0;9 – 1;6) m, p, b, w, n, t, dStage 2 (1;6 – 2;0) Stage 1 + (ng, k, g), hStage 3 (2;6 – 3;6) Stage 2 + f, s, (l), y, Stage 4 (3;06 – 4;06) Stage 3 + v, z, (r), ch, sh, j, Stage 5 (4;6 and above) Stage 4 + th, th (with voicing), sh

(with voicing)(adapted from Profile of Phonological Development, Grunwell 1987)


In other words, if a child is having difficulties with both the sounds ‘p’and ‘s’, work on the sound ‘p’ first as this occurs earlier on in development (Stage 1) than the sound ‘s’ (which occurs in stage 3).

Always remember that we are referring here to the speech sound e.g. (‘sss’) and not the letter name e.g. (‘Es’) when we talk about sound production.

Example of how you might approach speech therapy for a child who is unable to make the sound ‘s’:

Stage 1: Discrimination

You need to make sure that the pupil is able to hear the difference between the sound that they are making and the one you want them to make before you can expect them to produce the correct sound. For example, if the child is making the sound ‘th’ instead of ‘s’ you need to know if they can hear the difference between those two sounds.

Before starting this (or any) speech sound activity, check to see whether the child has any history of a hearing impairment (make sure that the child wears their hearing aid if they have one). If you have concerns about the child’s hearing and they have not had their hearing tested, refer them to the appropriate professional for hearing testing.

In order to see whether a child can discriminate between sounds you need to get a piece of paper, draw a line down the middle of it and write the desired sound ‘s’ on one side (possibly with a drawing to represent the sound e.g. a snake for ‘s’) and the sound that the child is making in error on the other side (in this example ‘th’, again with a picture to represent the sound e.g. a thumb for ‘th’).

Example:

s th


Tell the child you are going to make a sound. Then say one sound at a time, pausing after each one. Ask the child to point to the letter/picture that corresponds with the sound they have just heard.

Make sure that you mix the sounds up and don’t have a predictable pattern of saying first one sound and then the other. For example you might say ‘s, th, th, th, s, s, th, s, th, th, s, s, s (making sure you pause between each sound so that the child has time to point)’ rather than ‘s,th,s,th,s,th,s,th’ so that the child is actually having to listen to the sounds and not just guess or predict what is next.

If the child is finding the task difficult, encourage them to look at your face and see the difference in the way your lips/tongue move when you say the two different sounds to help them to identify which one is which. If this still proves difficult for the child, make hand-gestures to support what you are saying e.g. point to your tongue when you say ‘th’ and make a wiggly line from your mouth with your finger to represent a snake for the sound ‘s’.

It is helpful to give the child feedback after EVERY SINGLE response. So.. if you say ‘ssss’ and the child points to ‘s,’ say “that’s right ‘ssss’.” If you point to ‘s’ and the child points to ‘th’ you might say “listen again, do you see my tongue peaking through my teeth or do you hear the air rushing like a snake? Ssssssssss. Do you hear the ssssss. Point to the ‘s’ and the snake.”

Stage 2: Producing the sound in isolation

When the child is able to hear the difference between the sound they need to make and the one that they are actually making instead, you can start on the production of the correct sound. You might consider using a mirror to help the child.

Get them to look at the way you produce the sound ‘s’ in this case (i.e. smile, teeth together, tongue behind the upper teeth and let the air out over the top of the tongue) and then ask them to look at their own mouth in the mirror and to try to imitate what you are doing and produce a ‘s’ sound.

This stage may take a lot of practice. Listen carefully to the sound the child is making and give them consistent feedback about the sounds they are making. For example: “that s sounded great. I could hear the way the air flowed right through your teeth.” or “Try that again, it sounded like the air was coming out all over the place.” Help them to make corrections until they are able to make a clear ‘s’ sound. Give lots of praise and encouragement when the sound is produced correctly but make sure that it is the correct sound and not one similar to it.


This stage needs to be practiced often (at least once a day) for a few minutes each time. Do not expect the child to continue doing this exercise for more than a few minutes at a time (boring!). Encouragement is very important so that you keep building the child’s self-esteem rather than making them feel like a failure. Only work on the speech sound when it is clear that you are doing therapy with the child, do not correct the child in their spontaneous speech at this stage or else he/she will be become reluctant to talk.

As the child becomes more proficient at producing the sound in isolation, start working on the sound in syllables or words. Word selection however is very important at this stage.

Stage 3: Producing the sound before a vowel

Some people advocate moving on to sounds in syllables as the next step. You can do this, though working on short consonant-vowel-consonant (e.g. sit) words can be more meaningful and functional for children. The stage is described below for those interested in this method. Once the child has mastered the production of ‘s’ in isolation, try putting it together with a vowel sound (a, e, i, o, u). First produce ‘s’ then ‘ee’ in quick succession and then run the two sounds together to produce ‘see’ i.e. say ‘s, ee, s, ee, s, ee, see’. Demonstrate this for the child first, then do it together and finally ask the child to do it on their own. Sometimes it helps to add a visual cue. Use two different coloured blocks. As you say ‘s’ point to one. As you say the ‘ee’ point to the other. Move these blocks closer and closer together until they are right next to each other.

When the child has tried this, do the same for other vowels, e.g. ‘s, a, s, a, s, a, sa’ etc. Don’t worry if the ‘words’ you produce at the end are not actually real words. (In all these exercises, make sure that you and the child are producing the letter sounds and not the letter names i.e. ‘sssss’ and not ‘es’). You might find that the child has an easier time producing the sound next to certain vowels. Take note of these. This will be important in selecting your words for stage 4.

Stage 4: Producing the sound at the beginning of words

Use the same procedure as you did for stage 3, but this time use real words e.g. ‘s, aw, s, aw, s, aw, saw’. Start with single syllable words and then build up to longer words. Start with single syllable words with just 2 sounds (e.g. ‘saw’), then single syllable words with 3 sounds (e.g. said) and then move on to words with 2 syllables or more. If the child is having difficulties with other sounds in the target words choose a different word. Make a note of the other sounds he/she is having difficulty with but for this exercise only concentrate on the target sound – in this case ‘s’.


Here is a list of words that you can use for ‘s’ in the initial word position:

SadSaySomeSawSeeSaidSitSoonSipSaveSingSandSoundCircle

If the child’s name belongs with this sound you would DEFINITELY want to include that as a therapy word. Example: Silas

After practising these words by breaking them down first, try to get the child to say them as a whole word without producing the two parts of the word separately first. If the child has difficulty doing this, go back to breaking the word into onset (‘s’) and rhyme (the rest of the word e.g. ‘s’ then ‘aw’).

Think about making picture-word cards to help cue the child. These can be simple hand drawn articulation cards but allow for a greater variety of articulation practice activities

See below:

Say

Stage 5: Producing the sound after a vowel

Just as in Stage 3 but this time say the vowel before the ‘s’ sound e.g. ‘ee, s, ee, s, ee, s, ees’.

Stage 6: Producing the sound at the end of a word


“hello blah blah blah…”

This activity is the same as the one described in Stage 4 except that the words need to end in a ‘s’ sound rather than beginning with one.

Here are some words that you can use. Think also about using words from the child’s mother tongue:

YesLessPassMessChessGuessGrassDress

Stage 7: Producing the sound in the middle of 2 vowels

This is similar to Stage 3 except that you need to put the ‘s’ sound in the middle of two vowels e.g. ‘ee, s, ee, s, ee, s, ee, s, eesee’. Do the same for other vowels and use the same technique of modelling the sequence, saying it together and then allowing the child to say it on their own.

Stage 8: Producing the sound in the middle of words

When the child has mastered ‘s’ production at the beginning of a word, try ‘s’ production in the middle of a word – again break the word into parts to begin with e.g. ‘mu, ss, l, mu, ss, l, mu, ss, l, muscle’.

This is a list of words that you can use for this exercise:MuscleParcelSee-saw (note the s at the beginning as well as the middle of this word.)Sausage (note the s at the beginning as well as the middle of this word.)

Stage 9: Using s-words in a sentence

Using the words you practised in Stage 4, try making up short sentences or phrases

For example: The man bought a saw to cut wood.

The boy is sad

If the child has difficulty when it comes to the word ‘saw’ or ‘sad’, get them to say the word in isolation, breaking it down if necessary and then try saying the sentence again. Write the sentence down and highlight the ‘s’ of saw so that the child remembers to focus on the


sound before they get to it. Try to include only 1 ‘s’ sound in your sentence at this point.

Do the same for the s-final (Stage 6) and s-medial (Stage 8) words i.e. putting the words into a sentence and making sure that the child is able to say the target ‘s’ correctly, again taking the word out and breaking it down if necessary.

When the child is fully competent with the target words, you can start creating more complex sentences with many s’s and try to get them to produce all of them correctly.

For example: ‘Sometimes I use scissors to cut out squares and circles’

Note that not all written letter ‘s’s make a ‘ss’ sound – often they make a ‘zz’ as in the end of ‘sometimes’ and in ‘use’. Also note that even though the word ‘circle’ starts with the letter c, the sound we use at the beginning is ‘ss’. If in doubt, just say the sentence aloud to yourself and listen carefully to yourself to see whether you are producing ‘ss’ or ‘zz’ sounds. Only highlight the ‘ss’ sounds regardless of the written letter used.

Stage 10: Using the sound in spontaneous speech

When Stage 9 has been mastered with set sentences, ask the child to describe pictures (preferably with some ‘s’ words in them). Try cutting pictures out of the newspaper that you and the child can talk about.

If the child mis-pronounces any ‘ss’ sounds, ask them to say the word again, breaking it down if necessary, and then put it back into the sentence and try again.

With practice the child should generalize what they have learnt to their everyday speech.


5. 7 Sound Sequencing Difficulties (Apraxia/Dyspraxia)

“Sound sequencing” is being able to put sounds together to form a word. A child has a pattern in his head, which tells him how to put sounds in the correct order or sequence to make a word. Difficulties happen when the patterns of sounds that a child has in his head are either ‘lost’ or disordered. This means that a child is able to make the sounds, but he is not able to put them together in the correct sequence to make a word.

A child who has sound sequencing difficulties is physically able to make sounds, but he does not have a pattern in the head of how to put the sounds together in the right order to make a word. Apraxia therefore is actually a motor planning disorder.

The cause of sound difficulties is usually unknown but assumed to be neurological.

How do we identify a child with apraxia/dyspraxia?

The biggest clue for identifying a child with apraxia is their inconsistency. These individuals may be able to say a word correctly one time, but the next time, the word is completely different. They may be able to make the sounds in isolation, but be unable to sequence them into syllables.

What can be done?

Try and assess the level of the breakdown. Where does the child run into trouble.. in 1 syllable words, 2 syllable words? Are there any discernable patterns? Because apraxia is a motor planning disorder, you want to choose patterns like:

Consonant-vowel-consonant also called a CVC (e.g. cat, kid, dog, bit) and practice the patterns until they are achieved at a successful level. You would then increase the complexity of the pattern you are working on. For example you might start with a CVC and move onto CVCV (mama), CCVC (black) or CVCVC (donut)


5.8 Stammering, Stuttering or Dysfluency

Stammering or stuttering (will be used interchangeably in this text ) is the term used for disfluent speech. It is a speech disorder whereby the individual has difficulty getting words or sounds out.

What causes stammering in young children?

There are different theories on the causes of stammering, but it is generally thought that one trigger of stammering is stress. This is supported by the fact that generally speaking a stammerer will have fluent (smooth) speech when talking to himself or when talking to a baby or child younger than himself and is not feeling under any pressure.

The stress that causes the stammer may be coming from an external source (e.g. a death in the family, a traumatic event etc) or it may be that the child is from a secure, stable, loving environment, in which case the stresses are almost certainly self-imposed by the child. If this is the case (that the child is causing himself to become stressed) then the advice given below should be effective in helping the child to stop stammering.

The two types of stresses that a child will create for himself are speed stress and the stress of uncertainty.

Speed stress means that as the child’s language is developing, he will try to imitate the rate of speech of adults around him, which is obviously too fast for his current stage of development. Because the child finds it hard to keep up with the rate of speech of mature speakers, he becomes stressed, which results in him stammering. Another cause for speed stress is that as the child moves from saying just single words to 2-3 words together and then short sentences, the speed at which he says each word will increase automatically. This, combined with his attempts to talk at an adult-rate of speech, will result in a significant amount of speed stress.

The other type of self-inflicted stress, the stress of uncertainty, comes as a result of the child feeling unsure of the pronunciation of unfamiliar words, the uncertainty on how to use new grammatical structures and the fear that he will produce them incorrectly.

When speed stress and the stress of uncertainty occur together the problem is made significantly worse. If, however, the child is able to slow down, he then has time to plan what he is going to say and how he is going to say it and this reduces both of the stressors.


Stammering in Early Childhood

During the normal course of language acquisition many 3-5 year old children experience periods of disfluency. It is believed that at this age their brains are moving faster than their mouths!

It only becomes a concern when:- the disfluency begins to have social implications (i.e. teasing,

refusal to talk), - the disfluency begins to have educational implications (i.e. stops

talking and participating in communicative interactions) or, - 2 or more of the following signs and symptoms are occurring related

to the child’s speech, he has a tense voice during the disfluencies and visible facial

tension, he repeats a sound 4 or more times before getting the word

out, he has “hard” blocks where he gets stuck on words, he is frequently changing words for fear of stuttering, he has disfluencies in every 2-3 sentences, he is very aware of his disfluency, but just keeps on trying to

get the words out, he becomes very upset by other listeners reactions, or the disfluencies continue in the next 3 to 6 months.

Treatment for stammering:

Much of stuttering therapy is related to:1. awareness of the problem (error patterns)2. awareness of the situations in which stuttering usually occurs (e.g.

high pressure situations such as speaking in class, talking to a girl they like, defending themselves verbally)

3. awareness and reduction of secondary behaviors related to stuttering (e.g. excessive tension, grimacing)

4. compensatory strategies to use to minimize the stuttering

But before we talk about therapy ideas, lets go over some vocabulary related to stammering.

Defining vocabulary: The following are some terms that can be helpful in describing stuttering

Blocks – When the speaker quite literally gets “stuck” on a word. Often there are specific sounds or words that cause these blocks. It is helpful to note these down, or have the parent or child make a list of words that frequently cause blocks.


Circumlocution – When a client identifies a sound or word that causes blocks and goes out of their way to avoid it in their speech (e.g. has difficulty with the sound K so says “I live in the town on the lake” to avoid saying Kisumu)

Compensatory strategies – these are strategies we teach our students to use when they are stuck or having a stuttering moment

Disfluency/dysfluency – the speech is not fluent

Secondary behaviors – these are the behaviors that occur when an individual realizes they are going to stutter, or when they are stuck in a stutter. Often the secondary behaviors are more noticeable than the actually stuttering. Some secondary behaviors could include excessive tension in the neck and throat, facial grimacing, etc)

Sound prolongations – when one sound is held/stuck (e.g. throw me the b---------------ball)

Sound repetitions – when one sound is repeated (e.g. throw me the b-b-b-b-b-b-b-ball)

Word repetitions – when one word is repeated (e.g. throw me the ball- ball- ball- ball- ball)

Assessing the Problem:

To some degree everyone has some disfluency to their speech. When a child is referred to you or you notice a child in your class that stutters. Think about:

- does the child seem aware of the behavior?- how frequently does the disfluency occur? (every sentence? Once a day?)- what is the pattern of disfluecy?

What can be done?

Awareness of the problem and situations:Awareness is the key. First we have to make the child aware of the disfluency so they can begin to learn to anticipate and control it. When they are aware of their disfluency then we can start looking for patterns of occurrence or potential triggers. Then we can move towards handling the disfluency when it occurs.


Awareness and reduction of secondary behaviors Most secondary behaviors are related to tension. Therefore it is important to work on relaxation. When clients are aware we can begin to have them recognize the secondary behaviors and start relaxing. Relaxation causes a decrease in the stuttering.

Consider advising a client:- when they experience a block, don’t push through just stop. Take a breath and start again. - when they anticipate a stressful situation slow down their speech and take slow deep breaths - try and release tension in their neck, face, and shoulders

Compensatory strategies There are strategies we can recommend to a child:

- stop when they are experiencing a block- add the sound mmm before a sound they know they usually get stuck on (e.g. ,mmm kisumu). This seems unnatural but actually a listener is less likely to pick up the addition of mm than the sound prolongation of k. We call this an easy onset. - put the difficult word at the beginning of the sentence (e.g. Kisumu is where I live)- practice what it is you want to say in a safe environment

For the listener:

- do not hold your breath! - give the individual the time to say what they need to say- don’t finish their sentences- pay attention and don’t comment or react when they get

stuck/flounder- if it is a friend in a social situation, cover for them if you notice they are stuck!


Advice for teachers and parents

It is important that teachers involve the child’s parents when helping a child not to stammer anymore. If the problem is only being tackled at school and not at home, the results are likely to be slower and less effective.

Quite simply, the child needs to learn to speak more slowly. This will reduce the amount of speed stress and have a positive knock-on effect on the stress of uncertainty thus eliminating the need for the child to stammer. To help a child to speak more slowly, parents and teachers need to:

Slow down their own rate of speech . They should speak at a rate of 80 words per minute (you can practise this by reading an 80-word passage from a book, taking one minute to read the passage, keeping your pronunciation and intonation the same as normal as you read). Making sure that every word is said slowly, particularly the first word in each sentence. This type of speech can be referred to as ‘stretched speech’.

Use short sentences with basic vocabulary and simple grammatical structures. Think about talking to a foreigner who does not understand English or Kiswahili, you would talk slowly and use simple vocabulary in order to be understood. This is the type of speech you need to use with a young child who is beginning to stammer.

Introduce the ‘stretched speech’ game in which each child takes a turn sitting in a certain chair and has 5 minutes to describe an activity or something that happened in the day or at the weekend using stretched speech. Children in the stretched speech chair cannot be interrupted, but parents/teachers can use gesture to indicate that the child needs to slow down, if necessary.

After the child has played the stretched speech game for one or two weeks on a daily basis, his speech should be smooth when he is playing the game. You can then begin to generalize the use of stretched speech to other situations. For example, if he is very excited and is talking quickly trying to tell you something in class or at break-time, you can ask him to sit in the stretched-speech chair and to tell you using the stretched speech that he has been practicing.

When the child has mastered stretch speech associated with sitting in the stretched speech chair, you can begin to ask him to use stretched speech in other situations when he is under stress and is not sitting in the chair. It is intended that he uses stretched speech to substitute stammered speech until he has matured enough to be able to cope with more adult vocabulary and rates of speech.


If you have an older child in your class who has already been stammering for some time, the methodology will not be as simple and it is recommended that you seek professional help, where possible. Above all, do not increase the child’s anxiety about his stammer as this will only make it worse. IT IS NEVER ACCEPTABLE TO FORCE A CHILD WHO STUTTERS TO TALK IN FRONT OF THE WHOLE CLASS. NOR IS IT OKAY TO MAKE FUN OF THIS CHILD, OR ALLOW OTHER CHILDREN IN YOUR CLASS TO MAKE FUN OF THIS CHILD ABOUT HIS SPEECH.

Children with a stammer can still participate in whole class activities. Think of other ways to help them communicate such as writing their response on the board.


5.9 Hypernasality and Speech Issues Related to Cleft Palate

Speech difficulties related to cleft palate are usually related to nasal/oral air flow. A cleft palate occurs when the child’s palate did not fully fuse together pre-natally. What people usually think of when they think of a child with cleft palate, is those individuals who also have a cleft lip and an opening between their mouth and nostrils.

How do we identify a child with cleft palate?You may notice:

- a bifid uvula (the uvula- that funny thing that dangles down at the back of

your throat is split in two)- a translucent white line along the palate- a hole in the roof of the mouth - a baby that gets excessive milk in their nose- a child who has an excessively nasal voice quality- the child may be in your class/referred to your EARC with a diagnosis of cleft palate

If you suspect cleft palate, refer them to your local Association of Physically Disabled Kenya (APDK) or other appropriate medical professional (perhaps an ear nose and throat doctor or otolaryngologist). ADPK usually has information on the international cleft palate teams that come to Kenya and perform surgeries at Kijabe in October/November of each year.

What can be done?If the child is having cleft palate surgery, you may wish to do a detailed assessment of their speech and language skills. However, do not begin treatment until after the cleft palate repair.

Treatment for cleft palate is typically related to awareness and redirection of airflow. Activities might include:

- using a mirror to demonstrate when the child is producing air through her nose vs. mouth- activities related to blowing and increasing oral air flow- working on specific sounds


5.10 General advice to teachers and parents regarding speech sound disorders:

Give the child the same opportunities for talking as the other children in the class, but do not force a child to speak if they do not want to.

Accept any attempts the child makes to speak. Do not draw particular attention to her speech. Remember, it is what she says that is the most important, not how she says it.

Be Encourage and provide feedback and modeling:

Child: I wand idTeacher: you want it? You can have it

Later..

Child: I want idTeacher: you want it? Wow. You know what I heard a nice /t/ sound when you said “want”

Do not talk negatively about the child and the child’s speech in front of the child or the child’s classmates/siblings

Do not allow teasing about speech and language difficulties in your classroom

If the child’s difficulty is interfering with her progress at school go to your local education office for help. Find out what services are available in your area to help these children.

Any intervention should aim at making talking enjoyable and avoid the frustration of knowing people cannot understand what they are trying to say.

With all individuals we recommend that communicating continues to be a positive and reinforcing experience. This can be encouraged by providing pleasurable speech experiences such as reading, telling simple jokes, having them describe during play, helping them express themselves verbally, and giving them the time and attention they need while they are talking.


5.11 Activities to work on speech disorders in a classroom setting:

Generated by Speech and Language Trainer of Teachers (ToTs) at a related conference

Showing mouth shapes for each of the different sounds

Demonstrations by the teacher (e.g. /sh/ /z/ /k/)

Imitation of sounds

Verbal prompting

Singing simple songs and skits that contain the sound

Turn taking

Peer tutorials

Practice sounds in words and sentences by using them in role play and drama

Practicing sounds in words in songs, rhymes, poems, tongue twisters, story telling and riddles

Warming up for speech sound practice by having children imitate environmental sounds as well as doing activities related to airflow such as blowing whistles, blowing balloons, or blowing straws in water

Using hand signs to cue the speech sounds

Oral activities: bubbling, sucking, blowing balloons, use of articulatory mirror, blowing, whistling and shooing away exercises (e.g. candles)

5.12 Speech Goals


Recall that in chapter 4 we talked about writing goals. Let’s integrate this information with what we just learned in chapter 5.

Below is one long term and several short term speech goals (adapted from www.speakingofspeech.com) Sample speech and articulation Goals: Please note that I have included these goals written for the /s/ sound. They could however be adapted for any sound the child is having trouble with.

Long Term Goal: Mukema will produce the /s/ speech sound with 90% accuracy.

Short Term Goals: 1. Mukema will produce /s/ in isolation with 90% accuracy. 2. Mukema will produce /s/ in syllables (“sa” “so” “see” etc) with 90% accuracy. 3. Mukema will produce /s/ in all positions of words with 90% accuracy. 4. Mukema will produce /s/ in sentences with 90% accuracy. 5. Mukema will produce /s/ in oral reading tasks with 90% accuracy. 6. Mukema will produce /s/ in structured conversation with 90% accuracy. 7. Mukema will produce /s/ in spontaneous speech with 90% accuracy. 8. Mukema will improve self-monitoring skills for the target sound /s/ with 90% accuracy.

5.13 Reflection on the material:


Activity:

A child in your class has difficulty producing the sound /s/. You are working with him on producing the sound correctly in initial word position.

Write down a goal for the child?

Make sure it is measurable!

http://www.speakingofspeech.com/

Now that you have read through this chapter on speech sound disorders, answer the following questions:


What is a speech sound disorder?

1 reason I might want to look in a child’s mouth…

1 thing I can do to help a child who is stuttering:

1 activity I could do with my class to work on speech sounds:

5. speech disorders

Documents

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speech disorders chapter

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speech disorder eggs