Saturday, May 11, 2019

PROMPT Therapy for Mild to Profound Speech Delays

PROMPT: One piece in the puzzle
What is PROMPT?

PROMPT is an acronym for Prompts for Restructuring Oral Muscular Phonetic Targets.  This is a dynamic, hands-on approach in which the trained clinician shapes a child's jaw, tongue, and lips through facial manipulation in support of sound production.  Some children that may benefit from PROMPT include those diagnosed with: apraxia, cerebral palsy, and autism.  In order to determine if PROMPT is appropriate for your child, your clinician will begin with an observation and evaluation.  


How long will my child need PROMPT services?

Typically, children are scheduled for weekly services for up to an hour.  Younger children may benefit from two, 30 minute sessions, while older clients may attend once a week for 45-60 minutes.  Depending on the degree of the speech delay, services may range anywhere from 3 months for mild impairments to 3 years if delays are severe to profound.  Other contributing factors that can impact longevity of services are cognitive, social/pragmatic, sensory/tactile defensiveness, and comprehension delays.

What does a PROMPT treatment session entail?

If a child has limited verbal skills or is nonverbal, then sessions will initially focus on attending to tasks while working on using vowel sounds to make needs known.  Attention, focus, and eye contact are all necessary foundation skills for speech communication, so these targets will be addressed according to the child's needs.  As attention improves, then PROMPT support increases for productions of consonant sounds/words/phrases/sentences. 

As with any articulation or phonological approach, we start at the level the child can accurately produce, which may be a sound syllable like "ma" and progress in gradual steps to words.  It is not realistic to assume that once a child can produce a single word, that he/she will leap to using that word in a sentence.  Rather, we would progress to phrases and then simple sentences following word level achievements.

Should I see one private speech pathologist for PROMPT and another for traditional speech therapy?

PROMPT trained speech pathologists use this specialized approach along with many other strategies and cues, so it is not necessary to have more than one private speech pathologist on your treatment team.  As stated earlier, some children may not be suitable for PROMPT, while others could require time before they feel comfortable with a tactile approach.  In my experience, children typically benefit from a multi-modality approach to therapy that includes verbal, visual, and tactile cues.  As such, I would not choose just  a tactile approach like PROMPT in my treatment plan and solely focus on that one support.  Having said that, if you want to continue speech services with another private clinician with whom your child has established rapport, then collaboration between all professionals is considered best practice.  

Given the intensity of the PROMPT training, any speech pathologist interested in learning how to administer PROMPT would need to register for course work to both learn and demonstrate competence in PROMPT.  My level of training does not permit me to instruct another speech pathologist in PROMPT.  Therefore, as a PROMPT trained practitioner, I cannot model the supports for another speech pathologist to incorporate into his/her treatment sessions.

How do I locate a PROMPT trained speech pathologist?

If you want to find a speech pathologist in your area trained in PROMPT, then you can visit this link and conduct a search.

Will my speech pathologist train me in PROMPT for home practice with my child?

No, in fact the only professionals allowed to register for PROMPT intensive training are speech pathologists given the extensive foundation knowledge of anatomy and physiology of speech these individuals have completed at the graduate level.  The intent of PROMPT is to help develop a new motor plan for speech while eliminating error movement patterns.  Consistent attendance helps support that development and over time results in accurate motor movements for speech.  





Sunday, April 28, 2019

The Motor Speech Disorders: Apraxia and Dysarthria Defined




The late Pam Marshalla, a renowned Speech Pathologist, said it best in the opening to her book, Apraxia Uncovered- Seven Stages of Phoneme Development, "Children with apraxia and dysarthria do not respond well to traditional speech therapy methods and procedures, rather they need a therapy that actually teaches them how to make their speech mechanism function correctly." Let's take a more detailed look at the causes, theories, and characteristics that define apraxia and dysarthria.

Dysarthria is an impairment in muscle movements for speech caused by damage in the central or peripheral nervous system.  Speech productions may sound weak or breathy,
 or productions may sound strained; it all depends on the site of the lesion.  The articulators (lips, tongue) may be reduced in range of motion, speed, or coordination of movement.  Therapy sessions would be catered to the needs of the individual, be progressive in nature, and may involve oral motor activities.

Apraxia of speech is a condition that impacts one's ability to plan sequential movements for speech productions.  Like dysarthria, apraxia can be acquired or developmental.  Probably the most frustrating thing about a developmental apraxia diagnosis for some families is that it's cause is unknown.  Since there are no definitive answers in these idiopathic situations, there are a few theories for causation ranging from motor programming/planning theories to breakdowns in linguistic process theories.  The latter implies that language frameworks are inadequate and thus cannot support segmenting sounds into words.  Still another theory proposes that impairments in sensorimotor integration and/or sensory processing make it difficult for children to feel placements for articulators or interpret sensory feedback in the mouth.  While we can't always provide answers to causation questions, we can provide effective therapy by structuring programs that best meet your child's ability and needs.


Below is a list of characteristics common to many clients with apraxia of speech.  This information was adapted from an informative website, www.apraxia-kids.org:

  •  Errors on vowel productions
  •  Variety of errors for one sound target (For example, may produce "mat", "sat" or "hat" for the word "cat")
  •  Productions that are difficult to understand or distorted
  •  Increase in errors as length or complexity of words increases
  •  May be heard saying a target sound correct once, but not again 
  •  More successful with predictable, learned targets, like counting and reciting abc's, but not able to produce sounds in spontaneous conversations
  • Slower rates/speeds when talking because sequencing sounds/words is such a struggle
  • Awkward prosody with limited to no use of stress on words
  • Significant difficulty with repetitions
  • Clear, physical signs of difficulty talking
  • Age appropriate receptive/comprehension ability.  Your child knows what he or she wants to say, but can't sequence the complicated stages necessary for speech.

As speech pathologists it is within our scope of practice to diagnose and treat apraxia and there are several tools available for these purposes.  We also seek additional training to help us enhance our diagnostic and clinical skills in treating children with apraxia.  In addition to speech interventions, we may need to teach other effective means for communication, determine if there are comprehension needs, address social communicative concerns, and work at your child's level. 

In severe to profound motor speech disorders, speech pathologists support functional, effective communication for a child by finding the appropriate augmentative communication (i.e., pictures, voice output) that assist in making a child's needs known.  Once the method is identified, the next steps in therapy involve teaching both the child and caregivers how to communicate effectively with the new support system.

PROMPT therapy is an evidence-based option that may suitable for your child, but rigorous clinical training is necessary for this approach.  I will further discuss PROMPT in my next blog post. 



Sunday, April 14, 2019

Articulation or Phonological Therapy, that is the Question

Often, caregivers mistake an articulation disorder for a phonological one.  There is one distinct difference between the two and it is this:  a child with an articulation disorder substitutes or distorts one or more sounds while a child with a phonological disorder omits, substitutes, and/or distorts a process.  

Let's start with the term: phonological process.  This is something that all children demonstrate at various ages, but eventually suppress as they enter the preschool years.  For example, typically developing children may go through a period of time when they omit or delete final sounds in words (e.g. ca for car), but eventually, they suppress this process of final consonant deletion and use the final sound.  Children with a phonological disorder do not move on, rather, they continue to drop sound endings.  This makes therapy distinctly different between these two groups.  


In phonological therapy, we work towards helping the child learn to suppress the process.  So the child who needs to suppress the process of final consonant deletion will work on a different sound each session, BUT the sound will always appear at the end of the word.  In this way, we hope to teach the child to listen to sound endings, first, by listening to the therapist say a list of words, and then the child takes a turn.  


In articulation therapy, we typically address sound placement by teaching the child where to put his/her lips and/ or tongue to make a target sound.  We work in levels here by ensuring the child can produce targets in isolation, words, phrases, and sentences.  We also work on making these target sounds in various word positions: initial, medial, and final.  So someone working on the /s/ sound may practice "sun", "glasses", and "cats."  Typically, we look at mastery in one position before moving onto another.  Here, we target the same sound each session and increase the level as the child progresses.  We also need to ensure that we are targeting developmentally appropriate sounds, meaning sounds that are expected of a child by a certain age.  For example, we would not work on the /s/ sound with a three year old because most children this age can not master this sound.  A toddler's oral cavity may not be large enough to accommodate a large tongue to make those swift movements with finesse.  Since physical growth can vary from one child to the next, it is impossible to predict the exact age for sound mastery; therefore, we look at expectancy ranges to account for a larger population.  





Monday, March 18, 2019

Why Sippy Cups are the Nemesis for Speech Pathologists

The only thing worse than prolonged bottle drinking and excessive pacifier use beyond a year old is using the Sippy cup with your child.  One of the first things I advise when working with young toddlers is the total disposal of Sippy cups in the home.  Granted, this does not win me much favor with caregivers because we all know how portable and spill proof those Sippy cups are for families.  I will also be the first to admit that they are tempting because they make life easier for travel too, but there are other options that are just as spill proof and also help support adequate oral motor development for feeding and speech.  

A Sippy cup (like the one pictured above) is a bottle in a cup form.  It promotes the same suckle pattern that infants use to strip liquid from a bottle.  The suckle is the forward movement of the tongue to obtain liquid, which flows easily into the mouth.  So, if you are looking to advance your child from a bottle, you won't be making any gains if you use a Sippy cup.  As toddlers grow, we want to support transitioning them from this suckle pattern to a more mature movement.   Many toddlers, especially those with speech delays, will hold their tongues just passed their lips both when they speak and eat.  This tongue position mirrors the placement for suckle drinking.  Incidentally, the only sound that we make with the tip of the tongue just outside of the mouth is the /th/ sound and developmentally, toddlers are not expected to produce this target.  

Now that you are aware of the pitfalls of using a Sippy cup, let me offer two other options that not only secure liquids in a cup but also promote good oral motor development: a Nubby cup and built-in straw cup.  First, the Nubby cup looks like a Sippy, but has a flexible top that encourages sucking rather than suckling to drink.  The flow of liquid cannot drip out as easy as the Sippy cup; rather it requires some effort, or sucking on the child's part.  Similar to straw drinking, this sucking pattern pulls the tongue back into the mouth thereby supporting good oral motor development.  A built-in straw cup is another great option but can be a little challenging for beginners.  The major difference between the two is the straw requires sustained sucking while the Nubby can be tipped a bit to help move the fluid into the child's mouth.  For more information on straw drinking, head over to my post from 2012: The Powerful Straw.


One final point here that I once heard in a training supported by the TalkTools company, which by the way is a fabulous resource for oral motor supplies and trainings, is children do not need a Sippy cup or any cup for that matter in their hands during all wakeful hours.  Many children are filling up on these liquids and having trouble eating because their bellies are loaded with juices and the like.  Plus, it is far more challenging for children to drink while walking around, than it is when they are seated.  Moving toddlers need to focus on navigating environments and successfully getting the cup to their mouths while doing so is quite a mission.  As a result, a toddler may lose some focus stabilizing his or her jaw to drink adequately and could end up spilling liquid and/ or choking on it.  Seated postures for drinking are just more optional all around. That’s not to say that your children can't have drinks of water during the day, but let's get them safely seated first!

Monday, March 11, 2019

SPARK Cards: An Application Review



It's always exciting for me to review a new product, especially one as dynamic as SPARK Cards!  I can appreciate the hard work involved in not only creating educational items, but also the effort needed in promoting the tool.  While you can easily go on Amazon to find the details about SPARK Cards, I want to give you an honest review of how I found benefit in using these cards in my private practice.  DISCLOSURE: Other than a complimentary set, no other compensation was provided in exchange for this review.  Opinions expressed in this post are unbiased and solely mine.

Those of you familiar with my background know that I own and operate a private speech and language practice in my home office in Naperville, Illinois.  I have been treating clients of all ages from birth through high school since 1995 and over the last six years, have worked exclusively in private practice.  I see a variety of children locally who have delays in articulation, phonological processing, fluency, comprehension, and expressive language, so I am always on a hunt for a versatile product that can be used across multiple ages and abilities.

In addition to my home office visits, I have been working as a telepractitioner and independent contractor for the last three years.  During this time, I have uploaded all of my favorite activities to virtual platforms and I have purchased a document camera to utilize objects, sensory bins, and my iPad in teletherapy. 

Over the last month, I have been using SPARK Cards in my home office and teletherapy sessions with good success across a wide variety of ages, abilities, and settings.  Some of my favorite features include:


  • Durable cardboard cards with a gloss finish to withstand being handled by many, little hands
  • Ability to use a dry erase marker to bring attention to teaching concepts
  • Functional stories that support making connections to daily living
  • Detailed descriptions for each card in a sequence to make session planning easier for the busy SLP and facilitate generalization of skills in the home setting
  • Hypothetical problem solving probes for each topic
  • Appropriate for children as young as four years old through middle school-aged clients

I used these cards in teletherapy in two, different ways.  One of my clients is working towards sentence formulation for functional tasks, so I scanned and loaded the Going to the Library deck in sequential order so we could address his goal without taxing the activity with sequencing.  This particular deck is my favorite in the collection because we can talk about the library year round.  I also like that the library itself mirrors a dated one that has patrons returning and checking out books the old fashioned way by handing them to a librarian.  It's a nice way to compare/contrast past and present features.  I added some humor to the activity by joking about seeing a ladder.  We addressed answering yes/no questions and problem solving in a lighthearted way that I feel improves engagement and attention in any task.

The second way that I used the sequencing cards was via my document camera.  Another virtual client needs to improve sequencing skills, so I took three at a time from the Making a Lemonade Stand deck to provide choices while addressing sequential ordering.  The three cards with kitchen backgrounds are my favorite ones in this series because I could again work on comparing/contrasting room features in the pictures to my client's kitchen.  Making these kinds of connections helps strengthen memory skills and brings much more meaning to our language activity.  

While I LOVE the convenient portability of the SPARK collection and ease at which I can store it in my ever growing therapy closet, I would like to see the cards enlarged a little.  Some of the smaller features are missed in my office sessions as I cannot magnify or zoom in on the cards as I can online.  There is just so much fabulous detail in each card, that I would be saddened if my clients missed them.

I imagine that SPARK Cards would be a welcomed, educational tool in any Speech Pathologist's setting, especially in schools with mixed groups as you can cover so many speech and language goals with just one product!  Even students working on articulation goals could utilize this product, especially those needing drills at the sentence/conversational level.  Specifically, the acronym SPARK stands for the following language probes embedded in each sequencing deck:

Sequencing and sentence formulation
Predicting, problem solving, picture interpretation
Analyzing and answering 'WH' questions
Retelling a story and reasoning skills
Knowledge of basic concepts and vocabulary

Whether you work in private practice, school setting, or are looking for a comprehensive product to promote improving language skills at home, then SPARK Cards would be a affordable addition to your tool kit!  You can purchase this Amazon Choice awarded product at this link.








Monday, March 4, 2019

Spring Matching Worksheet FREEBIE and Extension Lessons


Happy almost spring!  Once again, the generous folks at Education.com have shared a complimentary activity for my followers!  Previously, I received crossword puzzles, but this time around, we went with something a little different.  I hope you enjoy this FREE Spring Matching Worksheet, perfect for early learners.

Learning fun will spring up for your kids with this matching worksheet. Kids can match the spring-themed words and pictures and practice their word recognition and spelling skills at the same time. Be sure to check out Education.com for lots more learning resources just like this one.

For SLP's: Send this activity home for carryover work by having clients practice target sounds or create sentences using the St Patrick's Day/ spring vocabulary terms.  Encourage clients working on language goals to also use targeted: pronouns, verbs, nouns, and/or descriptive vocabulary to address individual needs.


For Caregivers: Complete the attached worksheet together and then go on a scavenger hunt at home or in your community to find as many of the items as you can on the list.  


Wednesday, February 27, 2019

Early Intervention and Telepractice



By: Janet L. Courtney, MS, CCC/SLP
Founder and CEO of Lighthouse Therapy LLC

I am so excited to introduce my guest blogger, Janet Courtney.  She is the founder and CEO of Lighthouse Therapy LLC.  They are the newest online teletherapy company for schools.  Janet is a Speech-Language Pathologist of 25 years with the last 8 years spent servicing and assessing students PreK-12th grade via telepractice.   Her passion has always been helping students and professionals to become the best they can be through therapy, mentoring, and supporting those she serves. She currently lives in Michigan with her husband and three mostly grown children. Janet was working as a lead therapist for a telepractice company when we met a few years ago.  We have a mutual respect for each other's skills and abilities as therapists and leaders in the field of telepractice.  You can find Janet's blogs at https://www.lighthouse-therapy.com/blogcontact her at Lighthouse at contact@lighthouse-therapy.com or call 888-642-0994.
"My son is two and he isn’t talking yet, is that normal?"  "Our one-year-old doesn’t feed herself and has trouble holding a spoon, is that normal?"  A teenage mom with a 2-year-old and a 3-year-old is feeling overwhelmed and doesn’t know how to handle her children’s bad behavior.  All these scenarios are great examples of children who will benefit from Early Intervention.  The federal Individuals with Disabilities Education Act, Part C, (IDEA) covers services for children and families from Birth through age 3.  The Preschool Program of Part B covers children for ages 3 to 5 (Section 619).  These programs mandate special education services to be provided to families and their children with developmental delays or disabilities.

So, who is responsible for identifying these students?  Referrals for students can come from a variety of people and places.  Parents obviously are the first to notice difficulties that their children are having, but not all parents will recognize these delays in their own child.  Physicians, social workers, daycare providers, preschool teachers, relatives, and family friends may be the first to recognize developmental delays or disabilities in this population. By seeking out assistance for a child, parents and educators can get crucial services that a child and their family needs. These services will significantly impact a child’s development and future educational achievements. Critical physical, social, communication, and academic development occur in the first 5 years of a child’s life.   

When a child is referred for Early Intervention (EI) or Preschool services, many different professionals will be involved in developing an Individualized Family Service Plan (IFSP) until the child turns 3 and then the team will develop an Individualized Education Program (IEP).  The team may include a school psychologist, neurologist, speech-language pathologist (SLP), physical therapist (PT), occupational therapist (OT) or other professionals, depending on the areas of concern for the child.  The team, including the parents, will develop an IFSP or IEP that defines the areas of concern and the services that the family and child will receive.  An IFSP specifically includes the entire family; education and consultation are a key component in the IFSP.  Goals related to the child’s development are also an important part of this program.

Some parents and professionals wonder how telepractice can address these children’s needs in an online setting?  Will it even work?  If the therapist is not there, how can they get data to determine if a student will qualify?  These are all excellent questions that should be answered to address EI and Preschool services and telepractice services.  When a child is referred for EI or Preschool services, developmental assessments and parent/teacher questionnaires are crucial to get a caregiver and teacher’s perspective on where the child is functioning.  These questionnaires and interviews can be conducted via telephone or on the platform.  Many questionnaires are also sent via email.  Lighthouse Therapy’s platform allows for safe and confidential sharing of information through the security of our platform, thus decreasing the risk of exposure to Pertinent Health Information.

Therapy services are conducted via online video conferencing services.  These services can be performed in the child’s home with the caregivers/parents or in a preschool classroom in an individual or small group setting.  The clinician can coach parents on strategies and activities specifically designed to promote development in deficit areas.  The therapist can observe the caregiver/parents with the child to continually monitor progress and adjust strategies that are being recommended. In the preschool setting, a student support specialist or classroom assistant can assist the child to join the therapist in the session. The session is conducted via the platform with engaging and interactive activities.  The student may also perform tabletop activities and, using a second documentation camera or external camera, the therapist can observe the student’s activities and guide the student and assistant from there.  A wide-angle lens is great for group settings or observation of the student performing with peers or in a classroom activity.  At Lighthouse Therapy, our platform can easily adapt to all these environments and provide a dynamic and interactive experience for the students, parents, and other professionals engaged in assisting the student.

When coaching parents or caregivers, we as therapists must speak in layman’s terms.  It is important to give those most involved in the child’s education practical tips to enhance communication and learning opportunities.  Teach the parents how to use highlighting in their speech to emphasize the message or direction they are working on with the student.  Using repetition and modeling for the child by giving them the words they are missing or giving them the correct production of the words they are trying to communicate.  Another tip I always recommend to parents or primary caregivers is recording the child at the beginning of the year.  When they interact with the child daily, they will not notice the progress their child is making.  By going back 3-6 months later and listening to that recording again, it will be much easier for them to recognize and identify the gains their child has accomplished.

So how do I integrate these ideas into a successful teletherapy session?  With children this young, it is always a good idea to have at least 3 or more activities planned for a 30-minute session.  This will allow you to move from an activity that has lost their attention without losing the child’s attention completely.  Some examples of activities I have prepared would have a theme related to a holiday, a concept we are addressing, or favorite types of toys that the child responds to (i.e. trains, animals, princesses, etc.). With the topic or goal in mind, I include a song or YouTube video with lots of action to get the student excited and engaged at the beginning of the session.  I can stop and start the video and use annotation on the video.  This also lays the groundwork for what we are working on that day.  Then we do an activity with pictures, a story, or a book related to the child’s goals.  I incorporate the use of stamps and drawing to help the child interact with and talk about the pictures using highlighting and modeling for the student and as a demonstration for the parent.  Then we transition to a simple memory game or flashcards again giving praise and excitement about the activity.  If this is too difficult, I will use my documentation camera and have a time of show and tell.  This is a great way for the child to use his communication skills to tell me about something that they are excited about. For some of my ASD students, I make sure to include social greetings at the beginning of the session and goodbye before they can end the session.  When used consistently, my students become accustomed to these requirements and start to spontaneously produce them with minimal prompting and carryover.

It is important for the professionals to have access to developmental norms, so I have included a few links related to Developmental Norms for Speech and Language, Occupational Therapy Developmental Milestones, and the National Association of School Psychologists position statement on Early Intervention Services.  Many of you already have your favorites, but it is always nice to have other resources available.

These services are desperately needed in many areas of the country.  By engaging in the use of telepractitioners, these children will be given services that will be key to their future academic success.