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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



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:

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 childs speech we might also ask the
parent about the childs eating and feeding skills
3. If a child cant speak they have a lazy tongue
4. If a child doesnt speak, I dont need to talk to them
5. A child who talks a lot cant have a speech disorder
6. Eggs can affect a childs 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 dont have much speech or language
10. When a child cant talk it is usually because they are tongue
tied


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1. Speech is a fine motor skill - True
We consider the movement of the tongue, lips and palate as a fine
motor skill.

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

3. If a child cant speak they have a lazy tongue False
In our experience very few children are actually lazy, usually if they can
do it, they will do it. In a similar vein, childrens arent talking because
their tongues are lazy though this is a common myth amongst
educators and parents. A childs 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 doesnt speak, I dont need to talk to them False
If a child doesnt speak, and you DONT 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 cant have a speech disorder - False
A 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 childs ability to talk False
This is a myth. Foods do not generally affect a childs 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- True
When 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 True
While speech is a fine motor skill it relies on the support of the big
muscles in a childs 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 dont have much speech or language True

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Parents, educators and therapists should encourage all attempts at
talking and communicating from children who dont 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 cant talk it is usually because they are tongue tied
False
If a child isnt talking usually has very little to do with the speech
structures and much to do with the childs 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

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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 doesnt speak.

It seems to be a preferred diagnosis for children who dont talk and this may
be because it is easy to remediate. Parents should be counseled against
having a childs 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


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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

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Place and Manner Chart for English Consonants


Place of Articulation
Bilabial
(two
lips)
Labiodental
(lip &teeth)
Interdental
(between
teeth)
Alveolar
(ridge
behind
teeth)
Palatal
(roof of
the
mouth)
Velar
(the soft palate, feels
almost like theyre
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

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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 cant 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 someones 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 childs mouth getting the child to work with you becomes
very hard! PLEASE DO NOT FORCE A CHILDS 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 childs
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 childs range of motion or oral
motor strength. If a child has no volitional tongue movement at all, consider
again referring to a doctor.

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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 ______

Lips
Rounding (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





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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 childs 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 childs 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?














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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 DONT contain other sound errors
- words that dont contain the substituted sound (i.e. if the child
is replacing /k/ with /t/ dont 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 child
Stage 1 (0;9 1;6) m, p, b, w, n, t, d
Stage 2 (1;6 2;0) Stage 1 + (ng, k, g), h
Stage 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)


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In other words, if a child is having difficulties with both the sounds pand 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 childs 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


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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 dont 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 thats 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.


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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 childs
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. Dont 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.

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Here is a list of words that you can use for s in the initial word position:
Sad
Say
Some
Saw
See
Said
Sit
Soon
Sip
Save
Sing
Sand
Sound
Circle

If the childs 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.



hello blah blah
blah

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

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 childs mother tongue:
Yes
Less
Pass
Mess
Chess
Guess
Grass
Dress

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:
Muscle
Parcel
See-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

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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 ss 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 ss 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.













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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)











VSO Jitolee 2008 65.
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 childs 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.








VSO Jitolee 2008 66.
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 childs 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.




VSO Jitolee 2008 67.
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.









VSO Jitolee 2008 68.
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, dont 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
- dont finish their sentences
- pay attention and dont 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!



















VSO Jitolee 2008 69.
Advice for teachers and parents

It is important that teachers involve the childs 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.




VSO Jitolee 2008 70.
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 childs 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.






































VSO Jitolee 2008 71.
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 childs 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














VSO Jitolee 2008 72.
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 id
Teacher: you want it? You can have it

Later..

Child: I want id
Teacher: 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 childs speech in front
of the child or the childs classmates/siblings

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

If the childs 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.


VSO Jitolee 2008 73.
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)

















VSO Jitolee 2008 74.
5.12 Speech Goals

Recall that in chapter 4 we talked about writing goals. Lets 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.











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!




VSO Jitolee 2008 75.
5.13 Reflection on the material:

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 childs 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: