Velopharyngeal Insufficiency

Velopharyngeal Insufficiency

Technically defined, Velopharygneal Insufficiency (VPI) is a disorder where the soft palate does not form complete closure during speech which allows air to flow through the nose instead of only the mouth.  

Essentially, when you speak (especially saying consonants like b, p, d, t, k, and g), air comes from your lungs and out of your mouth, stopped briefly by your tongue or your lips to form the consonant sound.  The reason the air comes out of your mouth is that your soft palate (the top of your mouth toward the back of your throat) moves to block air from coming up your nose.  Ever take a drink and have milk come out your nose? Your soft palate wasn't closing off your nose.  That is a case of VPI, basically, your soft palate didn't close off your nose from your mouth.

Here are some pictures from the Seattle Children's Hospital which hopefully illustrate what I just explained above:

Soft Palate during typical speech. 

Soft Palate at rest.  See how air comes up from your lungs through your mouth and nose? That is how the soft palate rests in those with VPI during speech as well.

 The main symptoms of VPI are:

• Nasal sounding speech
• Nasal emissions (essentially snorting air out of the nose especially when producing "stop" consonants like p, b, t, d, k, and g)
• Substituting glottal stops (like the sound in between "uh-oh") for consonants
• Unusual productions of sounds like using your tongue to produce "b" instead of just your lips.

Many of the people who have VPI are those with a history of cleft palate.   Additionally, those with recent adenoidectomies, recent traumatic brain injuries are susceptible.  Occasionally, there are people who have VPI with no definable cause. 

When a child (or adult) is suspected of having VPI, the speech therapist will refer them to an ENT to get a full evaluation.  In some bigger locations, there are teams who are specialists in this area (may be cleft palate teams) who are also able to evalute.  When you go to the ENT appointment, the ENT will look through your nose and down your throat, possibly with a cool fiber optic tube to see how the soft palate is working.  Additionally, you may be asked to take part in a special x-ray to monitor soft palate use during speech. Occasionally, during diagnosis, you may be asked to see a team of specialists including an ENT, surgeon, and speech language patholgoist.

Speech Therapy cannot cure VPI alone.  While speech therapy can assist in learning techniques to help speak after the main treatment which is either a speech appliance or surgical intervention.  

A speech appliance, called an obturator, is somewhat similar to a retainer, and is worn in the mouth and used to help keep the soft palate up where it needs to be. The obturator can be used before surgery, after surgery, or instead of surgery. Additionally, some patients opt to not use it at all and wait for surgery.

Surgical Interventions are either a Furlow palatoplasty, which moves muscles in the throat to be better positioned for moving the soft palate into the position it should be for speech, or a sphincter pharyngoplasty which places tissue in the back of the throat to close the gap between the back of the throat and the soft palate. Speech therapy can be provided before and after surgery to help the child learn proper positioning of consonants and to help the child correct incorrect speech patterns.


 
References:

• Pictures and Information from Seattle Children's Hospital Velopharyngeal Insufficiency 
• Cincinnati Children's Hospital has some great pictures and explanations
• Velopharyngeal Disfunction just in case you want to get your research on! 

If You Give a Mouse a Cookie

If You Give a Mouse a Cookie

If You Give a Mouse a Cookie by Laura Numeroff is one of the most fun books to read in speech!  I love the whole series (including If You Give a Pig a Pancake and If You Give a Moose a Muffin). This book is one of the best books for simple sequencing, vocabulary, and fun related activities. 

With one of my clients, I am focusing on building basic vocabulary.  On each page as you go through the book there is a picture of what the mouse wants attached with velcro.  While at first, this will just emphasize the words that I want the child to learn, as they improve, we will increase to matching the picture to the word, using the pictures to sequence the book, and mixing them up to allow the child correct me using yes/no.

With every book I like to use "thematic learning" so that my whole session revolves around the book we are reading. I enjoy using coloring activities to learn the words for the colors, give them choices (I typically have them choose between 2-3 color choices), and to give a break of focused language attention.  When we color, I sing the song "This is the way we color the _____, color the ______ color the _____. This is the way we color the _____. We're coloring it ______" I fill in the blanks with whatever we're coloring (in this case the mouse or the cookie) and the color the child chose. 

For one of my language activities, I made a cookie jar.  Each cookie in the "jar" has one of the objects from the book on it.  We will use the jar to review vocabulary and build sentences.  For each cookie we'll place it on the square and say, "There's ______ (scissors, a cookie, a napkin, etc.) on my cookie!" and then place the cookie IN the jar.  I want to work on IN and OUT and this will be one of the ways that we work on the word "in." Every time we finish with a cookie, we'll place it in the jar.  There is a sandwich bag on the back of the jar set up to catch the cookies.  This activity could be used with other vocabulary, actions, directions, etc. What you put on the cookie is up to you.

 We've been working on yes and no questions for a while, so now we'll be working on questions with cookies.  The kiddo will use the spatula to flip over the "cookie" and then we'll ask the question.  The questions currently are about the child's likes and dislikes for yes and no, but can be expanded to any wh- question or more difficult yes/no questions. Some of our questions include "Is this a plane?" and "Are you a boy?" We're using both sign language, body language (head nodding or shaking), and verbal cues to talk about yes and no.  Additionally, we've been reading the Sandra Boynton book "Are You a Cow?" for some extra practice.

We are also still working on generalizing big and little, so I have some pictures of big and little cookies and mice to keep placing in the big and little boxes that I used in Go, Dog. Go. 

References:

• Rock Chalk Speech Talk
• LCSLP blog 
• Speech Room News

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Body Parts

Body Parts

Body parts are some of the most important labels we can teach children.  Body parts help answer important questions like, "What hurts?" or "What did you hit?" Think about how many times we tell children instructions like, "Use your fingers to paint." or "Don't use your fingers to eat." If a child doesn't understand the word "fingers" they will have a very difficult time using or not using them appropriately.

Developmentally, children between one and two should be able to point to simple body parts when they are asked to, which means they receptively understand those words. By two and a half, a child should be able to expressively identify many body parts.  This means that by 2 1/2, your child should be able to both point to and say the name of a body part.  The body parts they are able to name will vary slightly depending on what you teach them.  For example, I had a speech teacher that taught all of his children to point to their throats and say, "larynx." Obviously, that isn't super common among parents.  Your child should know the basic parts of their face (eyes, ears, mouth, nose) and their limbs (arms, legs, feet, hands, head) by 2 1/2.

For me, I use two songs to talk about body parts--head, shoulders, knees, and toes, and the hokey pokey.  Head, shoulders, knees, and toes is a quick and easy way to get kids to both hear and touch 8 parts of the body.  I use a handy visual that I found while google searching one day that looks like this:

When I use this visual in therapy, I point to each picture as we go through the song the first time we sing it together.  The second time we sing it, I place the visual where my client can see it and then I do the motions for the song with them.  I sing it at least 2 times, but up to 4 or 5 times if the kid really likes the song.

The second song I love to use is the Hokey Pokey.  The Hokey Pokey is great because I can emphasize any particular body parts I want to!  If we just want to talk about eyes, feet, and knees, that is all we sing about!  Initially with kiddos I try to use body parts that are far away from each other (like nose, tummy, and feet) so that they don't get confused (like saying ear for eye, etc). Kids love to shake it all about! If you are in a big enough space with kids who really need some movement, getting to shake and turn is great for the kids!  It's a super fun song and emphasizes exactly what I need it to.  Man, I love the Hokey Pokey.

When I sing Hokey Pokey, I use easy clip art pictures to show the kid what body part we're talking about.  Like these for example:

To talk about one body part in particular, I like to sing something like, "This is the way we touch our nose" (This is the way we touch our nose, touch our nose, touch our nose. This is the way we touch our nose, early in the morning) or "[kid's name] has a little nose" to the tune of Mary had a little Lamb (Jessica has a little nose, little nose, little nose. Jessica has a little nose and this is how we [touch, tickle, poke, etc] it.)

I love the Sandra Boynton book Horns to Toes, and In Between which goes through all sorts of different monster body parts.  I also love her book Let's Dance Little Pookie which shows a pig and his mom doing things like putting shoes on their feet, hopping around, and is an easy and quick book to label body parts in.

 References

• All images from google images
• ASHA on speech development for 1-2 year olds
• Toddler Developmental Milestones

Go, Dog. Go

Go, Dog. Go

One of the very best ways to develop language is through reading stories, or what we in the biz call "narratives." All children can benefit from reading aloud, whether you are reading something simple like Go, Dog. Go or something much more complex like the Harry Potter series.  For early readers, especially children under 6 or so, Go, Dog. Go by PD Eastman (the same author as Are You My Mother) is one of my very favorite books. 

I find Go, Dog. Go to be one of the best "simple" books that both has a connected story, but can also be used for very specific tasks.  For example, the entire story is about the dogs all going to a big dog party in a tree, but there are several running themes throughout the book as well.  For example, the pink poodle and the yellow dog talk about their hats several times throughout the book.  These pages are fantastic for practicing greetings during a speech session.  Each time the poodle shows the yellow dog her hat, they both say, "Hello" and "Goodbye." The pages are full of prepositions and descriptions including color and size.  Additionally, the dogs are doing such fun kid-friendly activities like playing games, going to a party, stopping for birds crossing the street, and swimming that kids tend to keep attention much better than in other books on the same reading level.

While any reading is beneficial, reading to really help develop language is important.  In my practice, I do that in a variety of ways. One of those is thematic sessions in which the majority of the session revolves around the narrative, even though I work on different goals.  For example, let's pretend I'm working with a 3 year old boy with around 50 total words.  I might be working with him on following directions, greetings, attention, using expressive language, and also introducing some new vocabulary. How can I possibly do this with just one book? Well, I would use the book as a center of our activities.  We might work together on Go, Dog. Go for a month with several or all of the following activities:

• Use visuals and activities for big and little
• Great site for visuals that go with can be found here.
• Wear hats, put hats on, take hats off, etc.
• Count the dogs
• Match colors with trees or dogs
• Some good visuals can be found here.
• Color Go, Dog. Go coloring pages (for older kids we would follow specific directions like, "Color the dog's head purple." or "Draw stripes on the dog's feet"
• Coloring pages can be found here.
• Some of my favorite coloring visuals can be found here as well.
• Act out sleeping and awake
• Talk about fast and slow, play the game "Red light/Green light" during therapy
• Make crafts that associate with the book like a stoplight collage, gluing cotton balls to a poodle for hair, make cars out of cardboard boxes, etc.
• Practice "stop" and "go" with stop lights
• One blogger made adorable stop lights during an entire preschool Go, Dog. Go activity, find it here.
• Watch youtube videos of readings of Go, Dog. Go for homework to further familiarize the child with the story
• Two of my favorites can be found here and here.
• Give parents some dog activities to do for homework at home.
• Some great ones are found here and here.
• Make a sensory bin with Go, Dog. Go themed objects to find and discuss.

Also, I wanted to show some pictures for how I used some of the above resources recently.  I used them addressing several different goals, and my kid had a blast!  Although we've moved on to another book, the kiddo requests Go, Dog. Go almost every session.

After reading the book, we used a big and a little tupperware and then separated the big and little dogs into the appropriate container.  I've extended this activity with other visuals like planes, firetrucks, etc. essentially whatever will get the kid's attention.

We use these crayon visuals to have the kid request which color they want.  I've used this when matching colors to dogs or colors to trees in the book as well.  Additionally, with more advanced kids, I've used the visuals as a reminder of instructions (e.g., I would place a visual when the instruction was something like, draw pink polka dots or purple stripes).

Here is my sweet, sweet sensory box and visuals that I use.  We have several elements from the book including dogs, cars, hats, party blower/horn things, and balls of various colors (ever tried to find mini trees? Much harder than you'd think...) We use this box mostly for receptive language and trying to find specific elements.  We tested it out without the objects in the beans first to make sure that the kid could identify the elements.  After the initial test, we used the sensory box for an increased element of difficulty.  Sensory boxes are great for speech because they add a kinesthetic element that is hard to really get otherwise.  (Learn more at this great blog! or this one! or this one!) 

Hope this is helpful to you in your speech therapy journey.  Enjoy and Happy Speeching!

References

• All Go, Dog. Go images were taken from google images.  Additionally, the visuals I pictured were taken from the various references I posted above. 

Speech, Disabilities, and Church

Speech, Disabilities, and Church

Many families have adults and/or children with with special needs. Many of these same families also attend church.  While some big churches have programs for children and adults with special needs in the church, I believe it is safe to say that most churches do not have such programs in place.  Some difficulties that families of those with special needs face during church are:

• Loud microphones for sermons, choirs, prayers, etc.
• Quick speaking with complex language during sermons, sunday schools, children's meetings, etc.
• Very few visuals other than text (for example, in a sermon, they may use flash a scripture on a video or presentation, but they very rarely will have a visual of that scripture or scripture story)
• Required quiet attention of an hour or more with very few sensory breaks
• Loud music from organs, pianos, or instruments
• Lots of people in very little space, often families share pews or sit close together in chairs

Church congregations often have some advantages for those with special needs as well:

• People tend to be more forgiving of those with special needs 
• Teachers, Church leaders, Pastors/Reverands/Bishops/Preachers typically want to help
• Most churches have a very routine order to their services, classes, and activites

Families of those with special needs can help their church help their family member with a lot of education and some assistance to help teachers, leaders, etc. know how to help the family member.  Here are some examples:

• For family members of Deaf individuals: you can provide American Sign Language classes to help your church members communicate with your family member.  You can help them understand how to communicate through sign or writing, you can also help them understand how to get their attention, how to make sure that your family member understands, and talk about the wonderful culture that they are a part of.
• For family members of those with Autism Spectrum Disorders: You can wear headphones during services if the noise gets to be too much, you can hep the teacher learn how to make visuals for sunday school lessons to help the child or adult understand the lessons, ask the church to provide an aide for lesson times that can go with the individual and help them during lessons, ask the church to provide an area where the individual can go where it will be quiet should they require a break, and provide education to the church members of the specific struggles of your family member.
• For family members of people who stutter: You can provide education to the children about what stuttering is and what strategies they can use to help the individual (like waiting for them to finish speaking instead of speaking for them), you can allow the individual to participate in choirs or singing which will help them overcome their stutter during church and focus on their strengths.
• For family members of those with language difficulties: You can ask teachers and leaders to repeat important parts of lessons and stories before asking questions of the individual, supply teachers with pictures that correspond with lessons and stories to help the child understand the lesson, you can ask for the lessons beforehand to go over with your loved one before church to improve their familiarity
• For family members of those who struggle with articulation: help teachers and others in the classroom understand your family member's particular difficulty and also to clarify what was said by repeating it back and being clear when you don't understand
• Look at pinterest for some great boards with visuals, schedules, story pictures, etc
• For example: Great Pinterest Board for church visuals

Family members and those with disabilities can have a great time in their church family.  Be open to how you can help those around you help you. 

Here are some additional resources.  I don't have every church (because I don't know them all), but I tried to get a fairly representative sample.

• Strength in Weakness: The Bible, Disabilties, and the Church
• Disability Resources
• The Church and People with Disabilities
• Pastoral Statement of US Catholic Bishops on People with Disabilities
• Muslims with Disabilities
• Disability Inclusion

Apraxia

Apraxia

Apraxia of speech is a motor speech disorder in which a child or adult has difficulty speaking syllables, words, and sentences with motor-planning instead of muscle movement.  Essentially, the brain (which is healthy) has difficulty telling the muscles (which are healthy) what to do. Some doctors also refer to apraxia as verbal dyspraxia. CAS (Childhood apraxia of speech) is prevalent in about 1 out of 1000 children (or somewhere between 3 and 4% of children diagnosed with speech disorders.  It is typically found more often in boys than girls and is associated with a few diseases including Fragile X syndrome.  As a speech disorder, it is fairly rare. 

Symptoms

Some symptoms as explained by the American Speech Language Hearing Association (ASHA) are:

• inconsistent errors on consonants and vowels in repeated productions of syllables or words
• lengthened and disrupted coarticulatory transitions between sounds and syllables
• inappropriate prosody, especially in the realization of lexical or phrasal stress. (Reference)

While these are not the only symptoms, these are the most indicitive of apraxia. Severe phonological disorders which use consistent patterns are not apraxia of speech, however apraxia can occasionally have patterns of difficulty with specific sounds or patterns.  Additionally, apraxia of speech also is seen in apraxia of limb movement (inconsistent movements of arms and legs) as well.

Apraxia can also affect a child's language development.  Children with apraxia frequently have difficulty with grammar, expressive language, reading, and writing. 

Causes

ASHA has identified several causes of CAS (Reference).  Neurological difficulties such as stroke, infection, brain surgery, etc., neurobehavioral disoders including autism, epilipsy, and other syndromes, and idiopathic speech sound disorders.  Essentially, should a child have some sort of trauma to the brain or a syndrome or disease which affects the brain they are at higher risk.  Additionally, like all speech and language disorders, occasionally there are some children who are just born with these difficulties and will require therapy in order to resolve their problems.

Treatment

Treatment is focused on increasing intelligibility using both articulation and language therapy together.  Traditional articulation approaches may be used in conjunction with therapy focusing on increasing general intelligibility and language abilities. Treatment can also utilize tactile and visual cues to help increase motor planning skills. Children with CAS also benefit from using melodic tones when speaking to improve speaking functions. 

Treatment is also more beneficial when given intense treatment more frequently (3-5 times a week) alone rather than in groups. 

References:

Childhood Apraxia of Speech

ASHA Technical Report

Building Vocabulary

Building Vocabulary

 

Vocabulary.  Vocabulary essentially is a list of all the words that we know.  For adults (and children over 12), that vocabulary can extend to an amazing 50,000+ words.  We use vocabulary every day to talk about the world around us and get our wants and needs met.  We use vocabulary to communicate and without it, we would very much struggle to do so.  There are four basic types of vocabulary:

1. Expressive Vocabulary: These are the words that you use when you speak. 
2. Receptive Vocabulary: These are the words that you understand when someone else speaks to you.
3. Reading Vocabulary: These are words you understand when reading them
4. Written Vocabulary: These are words you are able to use in writing.

Think about the following words and what category they might fit in: cup, explain, expedition, therefore, and peacock.  Some of those words might fit into multiple categories, while some might only be used by you in one.

How many words should my child know?

Well, that is a fairly difficult question, but we can estimate a child's expressive vocabulary.  Keep in mind that typically, people's receptive vocabulary is slightly larger than their expressive vocabulary. Here are some numbers according to the Linguisystems Milestones Guide.

12 months: 2-6 words
15 months: 10 words
18  months: 50 words
24 months: 200-300 words
30 months: 450 words
3 years: 1,000 words
4 years: 1,600 words
5 years: 2,200-2,500 words
6 years: 2, 600-7000 words
12 years+: 50,000 words+

 How to Help

Read. Read. Read. Read.  I can't reiterate enough that reading is the most important thing you can do to help build your child's vocabulary.  Recently, the Barbara Bush Foundation posted on their Facebook page quoting, "Reading aloud is recognized by experts as the single most important activity parents can engage in to develop strong language skills in their children." 

"We can model reading, keep them reading independently, and just teach them more and more vocabulary in a contextualized, functional way through text and stories so they can connect it to what they know."--Dr. Carolyn Ford

Here are some additional ideas from the American Speech Language Hearing Association (Reference):

• Build on your child' s vocabulary. Provide definitions for new words, and use them in context: "This vehicle is riding on the highway. It is a car. A bus is another kind of vehicle. So are a train and an airplane."
• Encourage your child to ask for an explanation if he or she does not understand what a word means.
• Point out things that are the same or different. Play games incorporating these concepts that he or she will encounter later in the classroom in reading readiness.
• Sort items into categories. Now try to sort them by pointing out more subtle differences between objects (e.g., rocks that are smooth vs. those that are rough, heavy vs. light, big vs. small). Again, have your child identify the object that does not belong in a given category, but now ask him or her to explain why the item does not belong.
• Expand on social communication and narration skills (telling a story) by role-playing. Play house, doctor, and store using dialogue, props, and dress-up clothes. Do the same with a dollhouse and its props, acting out scenarios and making the dolls talk.
• Read stories with easy-to-follow plots. Help your child predict what will happen next in the story. Act out the stories, and put on puppet shows of the stories. Have your child draw a picture of a scene from the story, or of a favorite part. You can do the same thing with videos and television shows, as these also have plots. Ask "wh" questions (who, what, when, where, or why) and monitor his or her response.
• Expand on your child' s comprehension and expressive language skills by playing "I Spy": "I spy something round on the wall that you use to tell the time." After your child guesses what you have described, have him or her give you clues about something that he or she sees.

Introduce  New Words

For older children, you can use new words like "frustrated" in place of "mad." When a child asks what it means, you can briefly explain that it is a feeling when you're trying to do something, but can't. Continue to expand upon a child's sentences. For example, if a child says, "I want the dog" ask if they want the big dog, the giant dog, the tiny dog, or diminutive canine, etc.

Read a book that has a humongous hippo or an enormous elephant and discuss other words you know for big like huge or gigantic. You can also build word webs which connect words that mean similar things. There are tons of pen and paper ideas for vocabulary expansion.

Reinforce Words They've Learned   

Keep using new words.  Talk about being frustrated cooking dinner because the oven isn't cooking as fast as you want.  Talk about being frustrated when you have to clean up over and over because the house keeps getting dirty.  

You can play some vocabulary games (like hangman, scattegories, etc.) to help reinforce words you've learned.  

References

• Vocabulary Resource Page 
• Evidence-Based Vocabulary Instruction 

• Build Your Child’s Vocabulary! Top Speech Therapy Activities