Tip elevation: Does your tongue tip lift to the top of your mouth, right behind your front teeth, to the little speed bumps of your alveolar ridge? The tip elevates and the right and left surface portions of the tongue push against the alveolar ridge causing a dip (narrow passageway) to form for airflow. The tip hoovers in space near the top of the mouth.
Blade elevation: Does your tongue tip point downward and lightly rest (stabilize) on the inside of your lower bottom teeth with the flat blade of your tongue contacting the alveolar ridge? The blade is the broad portion right behind the tongue tip. You can feel the blade resting on your alveolar ridge when your mouth is closed and your tongue is molded across the roof of your mouth. Blade productions may be considered mild distortions.
For typical speakers, fricative phoneme /s/, and its voiced cognate /z/, are produced at the alveolar ridge. The tongue is lifted forming a narrow constriction (tiny tunnel) for rapid airflow that causes friction. Air rushes quickly through a thin channel making a high frequency sibilant sound.
Sometimes it’s hard for children to control and balance the tongue to form and maintain a narrow opening. Speakers may develop any number of compensatory strategies for /s/ and /z/, such as changing tongue placement and airflow. Some individuals substitute a blade production, raising the broad section of the tongue with the tip contacting the lower teeth.
When treating /s/ and /z/, it’s beneficial to determine whether the client is producing all alveolar sounds with tongue tip elevation. In English /t/, /d/, /n/, /l/, and the tap sound, (middle consonant sound in “butter”, and “matter”, which is a fast sound that is something in between /t/ and /d/), are made with tip elevation.
We need to have the client’s mouth slightly open to see if their tongue tip elevates (rising movement) or lowers, or even if it tries to stick out, or move toward one side or the other. We need a window to view tongue movement. To make a window, you can use a flavored tongue depressor or the client’s pinky finger to keep the teeth slightly apart:
• Tongue depressor: Have the client lightly bite on the tongue depressor with one end at the molars and the other end sticking straight out of the client’s mouth.
• Pinky finger: Have the client place the very tip of their pinky finger on the back molars and lightly close their mouth (but don’t bite).
Shine a penlight flashlight into the client’s mouth. Have the client smile to increase the width of the window (so you can the sides of the mouth through the opening).
Check for tip elevation by having the client produce words for the alveolar consonants:
/t/: “ten”, “take, “talk”
/d/: “did”, “dig”, “dog”
/n/: “nine”, “net”, “neat”
/l/: “light”, “let”, “lock”
tap sound: “letter”, “kitty”
Remember that having your mouth open for a while can make you drool, so take quick breaks between words and have some tissues available. You can have the client watch their own productions in the mirror so that they can learn about their tongue patterns, e.g., “Let’s watch and see what your tongue likes to do for the /t/ sound. Look it lifted up high” (or “Look the tip went down”, or “Look it tried to stick out”).
Remember tongue placement is language-specific and it is important to review the phonetic inventory of every language to which a client has been exposed.
It helps to know whether or not all alveolar sounds are elevated before we ask for alveolar placement with tongue tip elevation for /s/ and /z/.
Children who have challenges with pragmatics and social language often struggle with recognizing that people have different perspectives on the same situation. People interpret actions, behaviors, and events from their own unique viewpoint. One of my colleagues recently shared an interesting technique to teach multiple interpretations through perceptual differences. Visual imagery can inspire a discussion of different ways to view the same stimuli. Optical illusions are designed to evoke variable interpretations. Using optical illusions provides students with specific examples of how we can see the same things differently.
The SLP began with a basic lesson on visual perception based on physical location. She sat across from the student and opened her laptop computer. She proceeded to exclaim loudly and theatrically, “Oh, that’s so awesome! That’s amazing!” She used Google images to search for pictures of the student’s preferred topic and began to comment on the details. The student, who could only see the back of the laptop, reacted to her statements about his favorite topic and said, “What? What is it?”
The SLP stood up and walked over to the opposite side of the table where the student was siting and said, “Oh, I guess from your perspective, all you can see is the back of the computer. From my perspective, I could see pictures of (student’s favorite things). Why don’t you come over to this side of the table and we’ll both have the same perspective of the screen?”
Next the SLP used a series of images of famous optical illusions with two interpretations, such as the duck or rabbit combination, and the old lady or young lady. The student would label what he saw in the picture and then the SLP would say, “Hmmm, well, from my perspective, I see (alternate image).” Soon, the SLP and the student were working collaboratively to find both possible images for the pictures.
The SLP then presented hidden animals artwork, which required flexible thinking to see how objects could represent other objects, e.g., how a cloud could be shaped like a horse in Jim Warren’s painting “Seven Horses”. The SLP repeatedly used the words and phrases, “perspective”, “my point of view”, and “from here, I can see X”. She periodically praised them both by saying, “Wow! I think we’re seeing this from the same perspective!”
We all have different sensory experiences. With food, music, art, etc., what is positive to one person, isn’t necessarily enjoyable to another person. Our sensory systems and our life experiences affect how we respond to stimuli. Optical illusions showed the student how two people could look at the same picture, one single shared stimuli, and construct different meanings.
When I talked with my colleague about this creative approach, she laughed and said, “How could I start telling him that people have different thoughts about something without physically showing him that people actually see different things?”
We know that we make positive changes in the lives of our clients, but our work can also make a meaningful difference to the next generation of speech-language pathologists.
Many years ago, when I was learning to be a clinician, I observed Dr. Bob, a speech-language pathologist in private practice. Dr. Bob specialized in working with children with Autism Spectrum Disorder (ASD). On the day that I observed, he spent 30 minutes with a precocious five-year-old boy who had ASD.
Dr. Bob and the child sat side-by-side at a table to complete a wooden alphabet puzzle. Each puzzle piece was a letter of the alphabet and had a colorful drawing of an animal that matched the letter. They took turns placing the alphabet pieces into the board. With each turn, they alternated between multiple tasks:
• They looked at the puzzle piece together, and looked at each other while Dr. Bob made expressions of interest and curiosity about its design
• They pretended to put the piece in the wrong way before fixing it, or pretended to give the animal the wrong name
• They traced the letter’s shape
• They made the sound of the letter
• They labeled the animal, e.g., “that’s a giraffe”
• They described the animal, alternating between physical characteristics, habitat, actions, etc.
• They pretended to be the animal or pretended to see the animal in the room, raising their hands up to their eyes as hand binoculars
This one simple puzzle was used to address social, language, and literacy goals:
• Social reciprocity and turn-taking
• Problem solving and absurdities
• Letter and sound correspondence
• Orthographic knowledge
• Phonological awareness
• Naming and describing
• Asking and answering questions
• Imaginative and dramatic play
Dr. Bob was laughing. The child was laughing. It looked like fun. They were both having fun throughout the session. The half-hour passed quickly. I saw how the therapy was engaging, interactive, and enjoyable. It took years before I understood how much had happened within that short time frame. It wasn’t until I learned more about intervention, disorders, and clinical management that I fully realized the complexity of the session.
My observation was just a moment of time within his busy day, as new clients arrived every half hour. I was one of countless students who observed, as teaching and clinical training were foundational values of the clinic. Allowing university students to observe is a form of generosity. When our therapy sessions are open and welcoming to university students, we are giving ourselves to our clients and to the future of the field.
I am grateful that Dr. Bob taught me essential skills:
• Incorporating multiple goals into a session
• Managing therapy time efficiently
• Using materials in creative ways
• Infusing social development into every activity
Even though no one is as skilled as Dr. Bob was, we still do have a lot to offer. We have clinical experience. We provide intervention that benefits clients and can enrich university students’ education. Open the therapy room doors and let everyone observe the fun! Our work changes lives and Dr. Bob’s work changed mine!
Are you new to a school building this year? There are, of course, the obvious tasks:
• Make friends with the secretaries and custodial staff
• Connect with administration and share how happy you are to be at the school
• Complete a monthly calendar for annual IEP and re-evaluation due dates
• Access or create a caseload spreadsheet with student names, grades, service minutes, communication domains (articulation, language, fluency, etc.), and additional special education services
• Begin the on-going process of scheduling students (magically triangulating student needs, school/class schedules, special activities, additional services, teacher feedback, etc.)
• Start a data collection and attendance system to document services
There are a few more activities that might be beneficial:
• Clean-out the space
• Look at the room from a child’s perspective
• Thank the prior clinician
Clean out the space: Colleagues have recently spent hours cleaning out neglected speech rooms. There were file cabinets with materials from the 1980’s, including moldy felt board storybooks, and mimeograph worksheets for an old paper-duplicating machine that was discontinued with the invention of the photocopier. There were two nonfunctioning Language Master Systems (early recording and audio systems that used magnetic tape) and prior editions of standardized tests that are no longer valid. As tempting as it is to just close the file cabinet drawers and leave the mess for another 10 years, don't do it. By leaving piles of already worthless materials untouched, you may be subjecting a newly hired clinician, who just graduated from college, to start the year completing an archeological exploration into the history of Speech Language Pathology. Recycle, donate, discard, or repurpose materials!
Child’s Perspective: Adults are not the same height as children. Sit on the floor. Sit on your knees. Change your height and look all around the room. Think about what you notice, what you can and can’t see, and what you can and can’t access. Design the room from the point of view of the child.
Thank the Prior Clinician: Every child can make a card for the prior clinician.
• Use blank cards or construction paper and art supplies to have students make cards
• Provide a model of the typical layout and format of a card with the correct spelling of the clinician’s name and common words
• Provide a choice of three different writing prompts:
o Thank you: “Let’s think about speech class last year. What kinds of things did you do? What kinds of things did you learn? This is a thank you note. What’s one thing that you want to say thank you for?”
o Advice: “Your speech teacher from last year has a new job. What is some great advice that you want to give your speech teacher for their new job?”
o Summer news: “You might have done some interesting things this summer. Let’s think about what fun/interesting/funny things happened this summer. What summer thing do you want to share with your old speech teacher?”
• When all the cards are completed, you can send them as a packet to the prior clinician
We can start the year with closure, with gratitude, and with an organized fresh start!
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”.
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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.