I hate making clinical mistakes. They make me feel bad about my skills and myself. Mistakes may often be based on lack of information, which affects the development of a relationship. Sometimes the desire to make a difference as quickly as possible negatively affects the collection of comprehensive background information and prolonged rapport-building activities. Often mistakes can come from not knowing our clients as well as we should.
Lack of information can be in any area:
• Client history
• Client temperament, personality, and interaction styles
• Child preferences and interests
• Client communication and learning strengths
• Family understanding of communication disorders
• Family grief stages and fears
• Family expectations
• Teacher concerns
• Classroom curriculum and objectives
• Peer interactions and behavioral concerns
A lack of information combined with the false pride of “expertness” is a dangerous combination. We may know about communication disorders and be highly trained in providing intervention, but that doesn’t mean that we automatically know about the needs of every single client.
Gathering information takes time. Mistakes are often based on rushing to act before learning as much as you can about a client.
When I make mistakes, I move through stages:
• Discomfort: Something about that session or interaction didn’t feel right.
• Confusion: What made it feel off?
• Shame: I can’t believe that I didn't do a good job.
• Anger: Why is this so hard!
• Self-righteousness: I’m a skilled professional. What I do is important.
• Reflection: There are lots of different ways to accomplish a goal.
• Awareness and understanding: I know how I could have made it better.
• Remorse: I wish that I could go back in time and do it over.
• Learning and planning: I will design systems and strategies to prevent this from happening again.
• Apologies and amends: I will let the client and the client’s family know that I am sorry and provide suggestions about what might work better in the future.
Whether we are new clinicians or have many years of experience, we may still need basic systems and procedures to make sure that we aren’t skipping steps and starting with only limited information. We can create our own checklists, reminders, routines, forms, etc., that require us to slow the process and proceed methodically.
Rapport comes from knowing and understanding our clients and their needs. Although we may be able to intuit a great deal of information based on our clinical experience, we can also incorrectly assume that we know more than we do. Taking time to learn about our clients lets us create a therapy plan that matches who they are. I still make mistakes sometimes, though fortunately, mistakes help us learn. There’s always something new to learn because every client is a unique individual!
Everyone enjoys something. It might take us a while to find out just what will make another person smile, but if we watch closely, we can find it.
Some years ago I was working with a student who had significant cognitive delays and behavioral challenges. He attended his neighborhood elementary school, however, the staff was not sufficiently equipped to manage his needs. Teachers alternated shifts throughout the day providing one-on-one supervision. He would dart away from staff, run throughout the building, and one a few occasions, even run outside of the building. There were safety concerns that led to a discussion about increasing supports and/or changing educational placements to a new school.
A meeting was convened with the family, teachers, staff, and administration. The mood was tense. It was expected that I would speak first. I sat silently for a moment during the introductions and thought about this child. I thought about what he had been doing that day and I thought about what made him happy. He frequently walked in the hallway with a staff member. He always waved and greeted the other children and staff. Whenever he saw another person, he would smile with a wide grin. He was socially motivated and his greetings were sincere.
At the start of the meeting, everyone at the table turned to me. I said, “He has the most beautiful smile. Everyone lights up when they see him. He loves to visit with people.” The sense of relief was immediate. The parents smiled. The father laughed. It was as if we had all been holding our breath and we suddenly began to breath again. The child’s parents had expected to hear only negative comments. We did eventually share the extent of his needs, but we didn’t share that information first. The meeting proceeded well and everyone was in agreement about the child’s needs.
The way that we describe our clients shapes how they are viewed. This child demonstrated behavioral concerns, but these were not his only defining characteristics. When we are able to describe people from multiple perspectives, we recognize strengths and individuality.
SEE ALSO: Opinion Poll
Sometimes it’s difficult to recognize positive traits when you are overwhelmed or frustrated. We can find strengths, skills, and preferences through focused observation by looking for a smile. At some point during the day, in some interaction or within some activity, a child will smile, even if it is fleeting.
• Note when the child smiles: describe the activity and communication partners
• Note when a staff member smiles at the child: describe the style of engagement and type of interaction
• Note when a peer smiles at the child: describe the events leading up to this shared exchange
A smile shows you happiness. Find the smile and it will guide you to the positive moments!
All of our treatment materials teach cultural values and morals. The words, photographs, drawings, games and activities represent what society perceives to be important. They imply ways to behave and belief systems.
My colleague and I were swapping stories about some of the outdated materials that we’ve found stored in the back of unused cabinets. Here were a few examples that we’ve seen:
· “An unmarried woman is called a “ ... ” as a sentence completion task
· “Go get a gun” to practice /g/ sounds at the short phrase level
· A picture of a woman’s hand, an engagement ring and the ring on her hand for three-part sequencing
· “Thong” (meaning flip-flop sandals) for “th” words
· A drawing of an ancient Egyptian bowing forward on the ground for “slave” to practice /s/ blends in CCVC combinations
· “What is this boy doing?” with a picture of a young boy sitting by the side of the road with his thumb out to represent hitchhiking to practice describing
It’s easy to see how these examples are inappropriate, dated and often amusing. Words change meanings, events change public understanding and habits shift generationally. The funny part is that no one thought that there was anything wrong with these materials when they were created, manufactured, sold and used in clinical settings. What if there is actually something inappropriate about the materials that you are using today? How would you even know?
ADVANCE Opinion Poll: How long do symptoms of speech or hearing deficits go undetected?
According to the 2015 American Speech-Language-Hearing Association (ASHA) Member and Affiliation Counts, 96.3% of ASHA certified Speech Language Pathologists are female, and 92.2% of ASHA members self-identified as non-minority (Caucasian/White).1 The National Center for Educational Statistics provides 2014 data on national public school enrollment for children: 62.1% White, 17.4% Hispanic, 12.4% African-American, 5.3% Asian, 0.2% Pacific Islander, 0.7% American Indian/Alaska Native and 2% two or more races.2 Children are rarely in leadership positions with adults. The power differential between children and adults likely prevents children from advocating for their cultural values or explaining why something is offensive.
Our professional organization does not mirror the populations who we serve. This may affect our ability to identify cultural appropriateness of materials and activities. Look at your materials in different ways:
· Are the drawings physically accurate or are they caricatures?
· Do the people featured in images reflect the diversity of your caseload?
· How do the activities and objects reflect the culture of the children and families you serve?
· Are the activities representative of what children would be doing today?
· Are the objects common to children’s experiences today?
· What are the underlying messages that are communicated by the images, activities, and objects?
· How do your materials reflect what you think is important in society?
· Do you agree with the values that your materials represent?
· Would families that you serve want their children to adopt the values that you are demonstrating? Have you asked them?
We don’t have to wait until our materials are laughably out-of-date and obviously offensive. We have the ability to partner with children and families so that what we teach honors a modern, diverse world.
1: ASHA Membership Profile: Highlights and Trends. (n.d.). Retrieved July 22, 2016, from http://www.asha.org/research/memberdata/
2: Digest of Education Statistics-Most Current Digest Tables. (n.d.). Retrieved July 22, 2016, from http://nces.ed.gov/programs/digest/current_tables.asp
Humans may be able to remember thousands of words, but we definitely can’t always find the word we want when we want it! We may have unlimited storage for words and concepts, but we definitely have limited retrieval.
We can make word recall easier through organization and categorization. When we think of with a word, we search through a large lexicon, like an internal database of words and concepts that reflect our understanding of the world. We typically store words through hierarchical relationships with increasingly broad superordinate categories, e.g., a poodle is a dog, which is an animal. We also store concepts together by similarities across key features, such as animals with paws, like cat, dog, lion, tiger, bear, etc.
When we recall a word, we search through specific categories stored in our brains. Scientists at the University of California in Berkeley have even charted the semantic maps that cover the cerebral cortex use fMRI data. Children who have language disorders often have difficulties with retaining, storing, recalling, and organizing words. Categorization activities are designed to illustrate meaningful relationships. Clinicians help children sort items into groups, describe group members, and explain exclusionary (doesn’t belong) and inclusionary (does belong) criteria.
Sorting may use one or more criteria. Dual sorting is when you need an item that matches two different semantic criteria, e.g., “What is a food that is cold?” or semantic plus phonological/orthographic criteria, e.g., “What is a food that starts with the letter A?” Dual sorting requires cross-referencing. You may access your entire list of foods, and then find foods that start with A. You might think of things that start with A, and then reference that list with foods. We see both of these strategies when we practice these activities with children.
OPINION POLL: How long do symptoms of speech or hearing deficits in children typically go undetected?
Categorization games can be cooperative. Children work together as a team using the letters of each child’s names as one of criteria. We write the first child’s name vertically along the left hand side of the paper, leaving room to add words across the page. If the child’s name is Thomas, we start with the letter T and pick one of the category titles for the first letter, e.g., a food that starts with T is tomato.
Here are some sample categories:
• Things that smell
• Things that are cold
• Things in the water
• Things in the sky
• Things with wheels
We all contribute words that match the criteria for each letter of the child’s name, before moving to the next child’s name. We vary the game in different ways:
• Using one category for all the letters
• Using one letter for all of the categories
• Rolling dice to determine the number of matching words needed
• Making the words into silly sentences, e.g., Thomas’ pet turtle eats tomatoes
Children join together to complete each name. Cooperative and collaborative games help children create a personalized final product that reflect everyone’s contribution.
Fairies represent magic and wonder.
The word “fairy” is a magic because it helps students transition from consonantal /r/ to vocalic /r/. The intervocalic /r/ in medial position allows us to produce /r/ at the end of the first syllable and the beginning of the second syllable, “fairrrr-- -rry”.
We can teach the postvocalic /r/ through anticipatory placement of the upcoming consonantal /r/. After a child has mastered placement for initial /r/, such as “red”, “road”, etc., moving to vocalic /r/ may be difficult. Transitional words have a syllable ending and syllable initiating /r/.
Fairy words can become the basis for an articulation activity. Students and I created two rainbow fairy boards with nine pictures each: red fairy, blue fairy, orange fairy, green fairy, pink fairy, flying fairies, flower fairy, fairy crown, fairy wand, fairy forest, fairy castle, fairy wings, fairy garden, fairy dreams, butterfly, rainbow, mushroom house, and unicorn.
We compared the different types of /r/ sounds and practiced placement for each /r/.
Initial consonant /r/: “rainbow”, “red”
Middle consonant /r/: “mushroom”
- Practice pulling tongue to the back of the mouth and elevating the sides of the tongue toward the molars to make a cup shape
Initial /r/ blend: “green”, “dreams”
- Break the word into two syllables, “mush-- -- rrroom” to emphasize /r/
- “Green”: Tongue stays in the back of the mouth for “g + r”
- “Dreams”: Tongue likely starts in the middle of the roof of the mouth and quickly moves from “d + r”. We actually say the /d/ in the /dr/ combination with a sound that is more like “j” and “dg” in “judge”.
Therapy for Therapists: Download our coloring book for adults!
Vowel /r/ “air”: “fairy”
Vowel /r/ “or”: “orange”, “forest”, “unicorn”
- Underlying vowel is “ay” (like “hay”) with the mouth open and the lips spread in a slight smile. Hold the “ay”, and slowly retract the tongue and move it into the /r/ spot, “faaaaay-- -- -rrrrr—rrry”.
Vowel /r/ “ar” (like “car”): “garden”
- Underlying vowel is “aw” (like the East Coast dialect for “coffee”) with the lips puckered and rounded. Break the words into syllables. Hold the “aw” and slowly retract the tongue and move it into the /r/ spot
- “Forest”: “fawwww-- -- rrrrr—rest”
- “Orange”: “awwww—rrr-- -range”
- “Unicorn”: “uni-cawwww- -- -rrrrrr- n”
Vowel /r/ “er” (like “fur”): “butterfly”, “flower”
- Underlying vowel is “ah” (like at the doctor’s office, say “ah”) with the mouth open and the lips in neutral position (not rounded and not smiling). Hold the “ah” and slowly retract the tongue and move it to the /r/ spot, “gaaaahhh-- -- -rrrrr- -den”
We can capture the whimsy of fairies with engaging pictures, while using the power of anticipatory articulatory placement to teach vocalic /r/.
- This is one of the more difficult vowel /r/ sounds. The underlying vowel is “uh” (like“duh”).
- Butterfly: Break the word into syllables. Practice “bu-ttuh- fly” with the “uh” sound and slowly retract the tongue to the /r/ spot, “bu-- tuhhh-- -- rrrrrr-- -- fly”
- Flower: Separate the word and transition from “fl-- ow” to “uh”, “fl-- ow-- -- uuhhh-- -rrrr”
Cell phones and tablets allow for immediate audio and video recording. Students typically begin by making silly recordings of greetings and funny sayings.
Since most of us are initially surprised at how our voice sounds on a recording, we watch British Radio 1 Scientist, Greg Foot’s YouTube video, “Why does your voice sound different on a recording?”, which explains the inner ear and how vocal fold vibration causes the bones of the skull to vibrate. Students quickly become accustomed to hearing themselves and master skills operating the recording and playback buttons.
Students participate in generating word lists and sentences with their target words. We practice the sentences before recording, using a highlighter pen to underline target sounds on a cue card. Students make three recordings and choose the best recording to save. The QuickVoice app lets you label, store, organize, and send audio recordings.
For families who have access to technology, we send the recordings by email or text message. Students are encouraged to provide a description and directions to their parents/caregivers, such as, “This is me saying my /s/ words. Remind me to pull my tongue back, and lift the sides of my tongue to touch the insides of my top teeth.”
We make audio recordings at regular intervals. We compare current speech and prior recordings to show progress, such as, “Remember when it was hard to say words with ‘s’ and ‘th’ sounds together? You can totally do this now!”
OPINION POLL: How long do symptoms of speech or hearing deficits go undetected?
Video recordings let us monitor articulatory movement. Using a cell phone or tablet camera, you can focus the entire video on the mouth. Students hold a flashlight to provide extra lightening to the mouth. Video recordings let us view the best productions and pinpoint placement differences that change the quality of the sounds.
Students can direct their own mini-movies using the Apple iMovie app. A video recording of target words can become a mini-movie with sound effects, a musical score, introductory titles, and fancy transitions between scenes. Students can be cinematographers, recording each other and splicing together scenes for a montage video.
Watching and listening to recordings hones our observational skills. We can attend to small details and change the rate of presentation (slow, speed up, or freeze the recording) to pinpoint specific examples. Observation is different from interaction. In an interaction, we are conscientious about the thoughts and feelings of the other person. We are simultaneously considering the needs of our communication partner and how we are presenting ourselves. We are busy organizing our thoughts and caring about how we are perceived.
Recordings free our attention from the burden of interaction. We can study recordings objectively in a relatively decontextualized manner without worrying about the requirement to respond directly to the speaker. Students are often able to recognize their most successful and most challenging productions when they focus on watching themselves. Recordings let us study our speech.
Every school year we learn new things. I recently took a few minutes to ask each student the question, “What have you learned about your talking and your speaking this year?”
Here are a few of the different responses:
• “I learned that I can do good R’s fairly consistently.”
• “I learned a different kind of R and to put my tongue back more.”
• “I made a document about stuttering that was really cool.”
• “If you slow down a lot, it’s better for you.”
• “I learned that I can help other people.”
• “I learned that my R’s became easier because I practiced more.”
• “I learned that repetition helps.”
• “I learned that warm-ups help.”
• “I’ve learned to be better at asking questions.”
• “What I’ve learned is that when you do your TH’s, you’re not supposed to keep it inside, and it’s supposed to stick out a little.”
• “I learned to add more details.”
Reflecting on what students have learned lets us celebrate successes. We talked about progress and the big changes that had occurred within one school year. I asked, “What did you do to make it better?” Students were able to identify how their behavior had changed. We saw how they had taken deliberate steps to improve their communication.
At the end of the day, I realized that it wasn’t just the students who were learning. We were learning, too. I asked myself what I had learned and suddenly, I knew that I had learned a lot. Each setting and each group of students shapes our skills. I asked myself a series of questions about learning across different areas:
• What did I learn about providing articulation therapy?
• What did I learn about providing language intervention?
• What did I learn about providing stuttering therapy?
• What did I learn about incorporating technology?
• What did I learn about student interests and contemporary media?
• What did I learn about creating student-specific intervention materials?
• What did I learn about culture and language?
• What did I learn about connecting with families?
• What did I learn about partnering with staff?
• What did I learn about working with administration?
Each question prompted positive memories and important lessons. I am grateful that I was able to spend time observing and analyzing tongue position and placement. I learned more about expanding personal narratives, eliciting thoughts and feelings with student interviews, audio/video recording, and a wonderful range of student interests from cooking to cinematography. I researched cultural and linguistic characteristics of Vietnamese, Arabic, native Hawaiian, and Russian. I met supportive and active parents and families. I collaborated with professionals, including Occupation Therapists, School Psychologists, Special Education Teachers, and General Education Teachers. I was able to provide valuable information to administrators about speech and language needs of students.
We are better clinicians and better people because of our clinical work. What did you learn this year?
“We need to write a letter to your tongue so that it will know what to do. What directions do we need to give your tongue?”
The students generate directions and tips that we write on a card. A “Dear Tongue” letter for /r/ might be:
• Remember to go to the back of the mouth
• Lift up the sides a little bit so you can feel the molars
• Relax just a little bit so you don’t get too stiff
• I believe in you. You can do it!”
Letters can be written to each of the active articulators, including the lips and the jaw. The directions will vary depending on the target sound. For /s/, a letter might be:
• Remember to lift up high right behind the front teeth
• Lift just the sides even more so that they can touch the inside of the top teeth
• Make a tiny dip in the center of the tongue so that the air can come through the middle
• You are strong. You can do it!”
Letters have specific directions, based on guided feedback of techniques and strategies that were helpful during the session. Questions are used to highlight successes, such as “You lifted the tip of your tongue up high! Did that help you make your sound?” Letters have encouragement and affirmations. Using positive words provides a model of positive self-talk.
Personification of the articulators encourages clients to recognize the volitional control that they have to change movements in specific ways. Personification allows a client to separate their own identity from the challenges or difficulties related to approximations and error productions. The ability to alter a habitual motor pattern in precise ways requires an intense amount of concentration and vigilance. Making the tongue a partner in the intervention process helps clients focus their energies to monitor designated movements.
We congratulate our tongues when they are successful. We give pretend “high-fives” to our tongues, by making a “high-five” sign in the air near the mouth. We give ourselves a “pat-on-back” to celebrate the tongue’s movement and correct placement.
When you give human qualities to an entity, you are able to ascribe feelings and form understanding. We are able to have compassion and we do not place blame. We can give our articulators encouragement and direction. We can recognize that our articulators are doing the best that they can!
Let’s start with a virtual field trip to the zoo to watch the hippos eating watermelon, using multimedia.
With YouTube, we can bring entertaining videos of zoo animals to therapy sessions. The hippos, with their mouths wide open awaiting a large, whole watermelon, give us a way to build our describing skills.
We can start with a basic noun phrase that has an article (the) and a noun (hippo): “the hippo”. Here is our short sentence: “The hippo is eating watermelon.” Now we can grow our noun phrase element-by-element using guided questions.
Quantity: How many of the hippos love watermelon?
• Quantifier: All of the hippos love watermelon!
Specificity: Which hippo has his mouth open?
• Demonstrative adjective: That hippo has his mouth open.
Numerical term: How many hippos are eating watermelon?
• Number: Two of the hippos are eating watermelon.
Negation: How many hippos are sleeping?
• Negative: None of the hippos are sleeping.
Characteristics: What does the hippo look like? Is he big or small? Is he grey or brown?
• Adjectives: The big, brown hippo is eating watermelon.
Every time we add details to provide additional information, we are expanding the noun phrase, the syntactic complexity of the sentence, and the specificity of our descriptions. Describing doesn’t end there. Some of the best elements come after the noun phrase as post-noun modifiers.
Environment: Where are the hippos? They’re at the zoo.
• Prepositional phrase: The hippos at the zoo are eating watermelon.
Location: Where are the hippos standing? They’re by the fence.
• Prepositional phrase: The hippos by the fence are eating watermelon.
Characteristics: Tell me about the hippo’s teeth. Let’s count his big teeth. We can see eight big teeth.
• Prepositional phrase: The hippo with eight big teeth is eating watermelon.
We can even embed an entire clause into our noun phrase. All we need to do to transform our prepositional phrases into relative clauses is to add a relative pronoun (that) and a verb. With a relative clause (also called an adjective clause), a whole sentence is used to describe the noun.
• The hippos that live at the zoo are eating watermelon.
• The hippos that are standing by the fence are eating watermelon.
• The hippo that has eight big teeth is eating watermelon.
When you embed a clause, you combine two ideas. Two sentences become one sentence:
“The hippo has his mouth open” + “The hippo is waiting for watermelon” becomes “The hippo that has his mouth open is waiting for watermelon.”
Now let’s add in our first elements: “That one big, brown hippo at the zoo that has his mouth open is waiting for watermelon.” We produced a sentence with 17 words, multiple elements, and an embedded clause.
We can model the gradual building of elements through repetition of a simple sentence with one addition at a time. Our describing skills are more complex than color, shape, size, etc. We can embed a whole idea to share what we know about the subject.
How do you decide if a child needs articulation therapy? My colleague and I discussed different factors.
Does it sound like the child has an accent?
A mother shared with me that everyone thinks they’re from another part of the country.
Their son’s articulation disorder sounds like an accent. Whenever they meet people who have met their son first, they have to explain that they are really locals. What is the significance of sounding like you belong to your own speech community? Shouldn’t children have the right to represent their regional identity through their speech?
Do the errors affect language development?
Difficulty producing sounds that represent early developing grammatical morphemes and semantic relationships could affect expressive language growth.
• Inflectional morpheme ‘-s’ uses the sounds /s/ and /z/ for plural forms and third person singular present tense forms.
Listen to the difference to the ending of “cats” and “dogs”. Even though we use the grapheme (letter) ‘-s’ for both sounds, we say “catsss” and “dogzzz”. The same thing happens with the verbs “walks” and “sings”. Even though we write “s”, we say “walksss” and “singzzz”. Either voiceless /s/ or voiced /z/ is used depending on the voicing of the vowel that comes before it.
• Derivational morpheme ‘-er’ allows you to turn a verb into a noun, such as “dance” to “dancer”, or “teach” to “teacher”. We use ‘-er’ to compare “big” to “bigger”. We use ‘-est’ with a consonant cluster for the superlative, the “biggest”.
Are the errors on highly used sounds?
Some of the most commonly used consonants are /r/, /s/, /n/, and /t/. Given that these sounds appear in the most number of words, errors in their production affect speech intelligibility.
Are the errors odd or unusual?
Sometimes children produce atypical distortions. A bilateral lisp, made by spreading the lips and keeping the tongue flat, makes /z/ into a buzzing hum. Productions that don’t sound like speech sounds are highly noticeable to listeners.
Does the child have anatomical or motor muscle difficulties?
Any structural difference or functional difficulty has the potential to cause compensatory patterns that may become maladaptive and fossilized (resistant to change).
Can you say your name correctly?
• Safety: Stating your own name accurately is a safety issue if you are lost or separated from a group. Producing your name correctly reduces your risk in an emergency situation.
• Social: introducing yourself to make new friends requires stating your name
• Psychological: we have self-identify tied to our names
Does the child have medical needs?
• A young boy, who had asthma, was playing outside at recess. Sensing the need for his inhaler, he asked a teacher if he could go into the classroom to get it. The adult did not understand his speech and assumed that he wanted to go to inside for an inappropriate reason. Fortunately, other children intervened to explain the situation. The inability to state a physical or medical need is a potential safety issue.
Individuals are unique. Making decisions about when a child does or does not need services involves considering multiple factors. What factors would you want a clinician to consider for your own child?
How do you say, “Squirrel”? Does your pronunciation truly match the spelling of “squirrel”?
A bright student and I were practicing the postvocalic /r/ sound in “first”. I re-spelled the word (incorrectly) as “ferr—st” to show how it’s pronounced with an emphasis on the underlying vowel and a prolongation of the /r/. “Even though it has an ‘i’ in it, we say, ‘er’, like in ‘her’, or ‘fur’.” We began to generate a list of others words that had the “er” sound, which led to an interesting discussion about /r/ and spelling.
This student has been working on the vowel /r/ sound for “er” for a little while. The “er” sound is often difficult for clients to produce because the underlying vowel is “uh”, like the two vowel sounds in the word “above”. This “uh” vowel, like in “duh”, is produced with the articulators (lips, tongue, and jaw) in a relatively neutral position – almost like your mouth at rest. If you just open your mouth slightly and make a sound, you’ll probably get “uh”. To make “er”, we have to add /r/ to a relaxed mouth position.
We started a list of words that rhyme with “er” and were astonished at the spelling variations.
• “er” sound with “ir”: stir, girl, chirp, first, etc.
• “er” sound with “er”: her, paper, dinner, etc.
• “er” sound with “ere”: were
• “er” sound with “ear”: pearl, earth, heard, etc.
• “er” sound with “or”: worst, worry, world, doctor, etc.
• “er” sound with “our”: journey, courage, etc.
• “er” sound with “ur”: fur, nurse, purse, turn, etc.
If clients rely on spelling, it may be difficult for them to determine the underlying vowel for postvocalic /r/ words. Our orthographical system does not directly correspond to our phonological system. Approximately 44 phonemes (sounds) are represented with 26 graphemes (letters) combined in various ways.
Sometimes there are letters that we don’t even say. We tried the word, “February”.
“Do you know that most people don’t say ‘brew’ in the middle of ‘February’? They just say, ‘you’.” I explained. We then re-spelled “February” as “feb—u—air—ree”.
Articulation therapy may benefit from a focused exploration of sound-letter correspondence for /r/ and /r/ influenced vowels. We know that we don’t produce a /w/ sound for “write”. For conscientious, older students who are strong readers, their ability to use spelling to help them produce /r/ words may be highly misleading. Our spelling system does not consistently indicate which one of the underlying /r/ vowel sounds will be used. Generally, we have six /r/ influenced vowels: fear, fair, fur, far, four, fire. The “er” sound alone can be represented with seven different spelling combinations.
The student told me that “squirrel” is hard for him to say. We re-spelled the word as “sk—werr—ul”.
“I wish it was spelled that way,” he said.
“So do I,” I concurred.
Did you ever catch your friend’s eye from across the room at a crowded event and let her know that you were ready to leave? Briefly tilting your head to the side and a quick glance toward the door can represent an entire sentence.
We exchange thoughts and ideas through gestures, facial expressions, body postures, and physical proximity. Non-linguistic communication may often be just as important as spoken words.
We use conventional gestures to share familiar ideas, such as pointing or rolling one’s eyes. Coding and transmitting ideas non-verbally is actually a complex process. Communicating an intention with gestures and facial expressions, without speaking at all, requires multiple steps:
Generate an intention: decide what you want to communicate
Plan: decide how you will communicate your message
- You can watch your partner until they look at you
- You can wave at your partner
- You can move a little closer to your partner (lean forward)
- You can tap your partner lightly on the shoulder
Give your message: combine your gestures and facial expression to convey your intention and share your message
Check for understanding: watch for your partner’s response
- If your partner doesn’t understand you, you can repeat the gesture or try a new gesture
- Validate your partner’s correct understanding of your message: nod, smile, etc.
We can teach the sequential steps involved in a non-verbal communicative exchange as a game. We can model and demonstrate the multiple steps required for each stage of the interaction with cue cards that use words and/or pictures.
Each card has the command “No talking” and/or an icon of an X across the mouth to remind players that the message has to be shared non-verbally. The entire exchange will take place without talking at all:
- Let your partner know that you think it’s hot in here
- Let your partner know that you think it’s cold in here
- Let your partner know that you are hungry
- Let your partner know that you are thirsty
- Let your partner know that you like their shoes
- Let your partner know that you like their shirt
- Let your partner know that you need a pencil
- Let your partner know that you want to play a game (like Rock, Paper, Scissors)
- Let your partner know that you want to know what time it is
When we communicate, we observe the behaviors of our partner to gauge their understanding of our message and if there is a communication breakdown. Individuals with speech and language disorders may have difficulty with pragmatic judgments of listener responsiveness, and limited perseverance to overcome misunderstandings.
Showing the turn-taking steps in an interaction without using spoken language may provide a fun way to recognize the roles and responsibilities of both the sender and the receiver.
Do you have an emotional response to consonant mastery charts for age
of acquisition for speech sounds? I do. Just the mere mention of late mastery
of sounds makes me bristle.
Do you use the Poole study from 1934 or the Templin study from 1957 as
a means to determine whether or not a child is demonstrating an articulation
delay? The 1934 Poole study examined 65 children ages 2;6-8;6 at the University
of Michigan, and mastery was defined at 100% accuracy for consonants in
initial, medial, and final position in words. The 1957 Templin tested 480
children ages 3-8, and mastery was defined at 75% accuracy for consonants in
initial, medial, and final position in words.
In the Poole study, /r/ and /s/ were not considered mastered until 7; 6.
In the Templin study, both were considered mastered by ages 4;6. There is a three-year difference in mastery between
these two studies. (Neither of these studies was specifically designed to
serve as a form of eligibility criteria for the provision or the denial of
special education services and therapeutic intervention.)
This past week I met with a new student and his family. The student was
a second grader, age 7;8. He had recently transitioned from another school
district. He had difficulty producing /l/ and /r/. His mother shared that she
had advocated for services at his prior school and was told that his errors
were typical. She had become concerned and had sought a medical evaluation for
I tested the student and found him eligible for services. He was
friendly and eager, and readily attempted all tasks presented. When his mother
asked me why no one had helped her son before, I said, “Everyone has different
opinions.” There was nothing else I could say, because educational agencies
form “opinions” by extrapolating certain elements of data for specific purposes
that are then used to determine policy.
What if we conducted action-based developmental research on other
- Age at which beginning intervention requires the least amount of
services in order for child to achieve goals
- Age at which child is most stimulable to intervention (modifying
- Age at which maladaptive compensatory patterns become fossilized
(highly resistant to intervention)
- Age at which speech articulation affects perceptual skills (ability to
differentiate between targets, approximations, and errors)
- Age at which speech sound disorders affect socialization and peer
- Age at which speech sound disorders affect literacy development
- Age at which family, staff, or student are initially concerned about
In this case, the student presented with a mild restricted lingual
frenulum (tongue tie), an anatomical and structural difference that may affect
his development of speech production for /l/ and /r/. Waiting for a normative
age of mastery may not have been appropriate, as underlying lingual range of
motion was atypical, but we can talk more about tongue tie later…
Question mastery charts and their appropriateness to policy.
1. Prather, E.M., Hedrick, D.L. & Kern, C.A. (1975). Articulation
Development in Children Aged Two to Four Year. Journal of Speech and
Hearing Disorders, 40, 179-191
2. Bauman-Waengler, J. (2016). Articulation and phonology in speech
sound disorders: A clinical focus (5th ed.). Boston, MA: Pearson.
Confidence is widely regarded as an important trait for success, and insecurity is often considered a liability.
Recently, a colleague who is transitioning to a new team shared her fears with me about her position change. She will soon be working alongside Occupational Therapists and Physical Therapists to serve children who use Augmentative and Alternative Communication. Many of the children have complex medical needs and the position requires coordinating services across multiple professionals.
“I feel like an imposter,” she confided to me, implying that she didn’t feel qualified for the job. The imposter syndrome describes when people with strong skills do not appear to believe in their own abilities. I know her and I know her work. She is qualified for the position, and it will also require her to expand her knowledge base.
After reassuring her that most professionals feel uneasy when they change settings and begin working with new clients, I told her that a little insecurity is actually a good thing. Insecurity can make us better clinicians. Insecurity often occurs when we are not sure how to proceed. When we are unsure, we may take deliberate steps to increase our understanding.
Self-doubt may be a form of self-reflection. If we entered every clinical situation with such a heightened sense of confidence, that we didn't question our own decision-making, then how would we learn new things? We might even inadvertently make incorrect assumptions about the course of treatment. Obviously, too much insecurity can be debilitating, but too much confidence can be detrimental. A balance of just enough insecurity to recognize our current limits may prompt self-improvement.
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When we have moments where we feel like an imposter, we may be recognizing that we have areas that need growth. We are acknowledging that we have more to learn. Our field encourages life-long learning, which is another way of saying that we have a life-long lack of knowledge. The manifestation of disorders, disabilities, and constellations of needs in communication and swallowing that exist within the entire human condition is too broad for any one person to ever reach expertise.
Insecurity is a shadow form of humility, which may be an asset as we interact with clients and families. Self-improvement may come from recognizing present limitations, followed by a purposeful plan of action for positive change. We can welcome threads of insecurity to enter our practice in the form of functional questions:
• How was I prepared for this client’s needs?
• How was I unprepared for this client’s needs?
• How did I interact with the family?
• How could I change my interaction style to foster improved rapport?
• What additional information do I need to access?
• What resources could help me?
• What is the expertise of the other professionals around me?
• How can I learn more about the scope of related professionals?
• What new research is available pertaining to this client’s needs?
Skilled services may include the instability that comes from seeing strengths along with current weaknesses. Insecurity can be a force that challenges us to be better.
A child who is substituting /w/ for /r/ makes progress producing /r/. He is now using /r/ in initial position in words. Surprisingly, he is also now substituting /r/ for /w/. He is producing “right” correctly, but now he is no longer saying “white”.
My colleague shared this story with me and explained how she needed to provide specific directions to the child, e.g., “It’s OK for you to still say /w/. ‘Wing’ starts with the /w/ sound. You can still pucker your lips for the /w/.”
What happened? We could simply assume that the child overgeneralized production of /r/. Perhaps it is much more complicated. Substitution of the /w/ phoneme for the /r/ phoneme may have altered his phonemic inventory. One sound, /w/, represented two distinct phonemes /w/ and /r/. Untreated speech sound errors may have the ability to affect a child’s phonological understanding.
We each have a phonemic inventory, which is the total number of phonemes that we use contrastively. This means that we recognize that when one phoneme changes, the meaning of the word changes. “Rich” is not the same as “which”. One phoneme change in the minimal pair means that we have said two different words. For a child who is using one sound for two phonemes, this contrast may be lost.
A teacher shared that one of the students was writing “thun” for “sun”. She was concerned that articulation had affected spelling. Speech sound production had likely affected more than spelling, it may have altered the child’s phonological development.
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In articulation therapy, we often begin with ear training to help the child differentiate between target sounds and substitutions or distortions. Children often have difficulty recognizing when they have produced the target sound correctly and the closeness of their approximations.
Parents and caregivers may also report that they are unable to hear the difference between their child’s errors, approximations, and correct productions, e.g., “It’s just how he talks. I don't hear it anymore. ”How many years of substituted productions would it take for a child to become unable to hear the difference between phonemes? How many years of substituted productions would it take for a parent/caregiver to become unable to hear the difference in their child’s speech?
We listen for meaning. As typical communicators, the message is more important than how the speech sounds were produced. We generally focus on the content of what was said, instead of how it was said. Children with articulation disorders and their families are likely listening for meaning to the extent that they may lose the ability to hear production.
Extended ear training exercises and contrastive pairs may be essential for many more children with articulation errors than we realize. We could question if more years of inaccurate production leads to increased risk of phonological involvement. We can advocate for children by sharing the benefits of initiating articulation therapy with young children to prevent possible phonological disorders, which could, in turn, affect literacy development.