Speech and Hearing Loss

Spoken language and healthy hearing go hand in hand.  Even a mild hearing loss may impact your child's ability to develop speech and language.  With the slightest inability to hear the different frequencies of our phonetic sound system, a child may not be able to receive the correct signal, interfering and corrupting the incoming message.  Additionally, if a child does not perceive the correct sound they will be challenged to replicate it correctly.  


There are two types of hearing loss; Conductive and Sensorineural Loss:

According to the American Speech, Language and Hearing Association (ASHA), conductive hearing loss occurs when sound is not conducted efficiently through the outer ear canal to the eardrum and the tiny bones (ossicles) of the middle ear. Conductive hearing loss usually involves a reduction in sound level or the ability to hear faint sounds. This type of hearing loss can often be corrected medically or surgically.  

The Inner, Middle and Outer Ear

ASHA defines sensorineural hearing loss (SNHL) as damage to the inner ear (cochlea), or to the nerve pathways from the inner ear to the brain. Most of the time, SNHL cannot be medically or surgically corrected. This is the most common type of permanent hearing loss. SNHL reduces the ability to hear faint sounds. Even when speech is loud enough to hear, it may still be unclear or sound muffled.If you suspect that your child is experiencing hearing loss, whether it is conductive or sensorineural, your pediatrician should be consulted and s/he will refer you to an Audiologist for an evaluation.  Additionally, you may be referred to an Otolaryngologist; (ENT) Ear Nose Throat medical specialist.  

An ENT is a medical doctor who specializes in the diagnosis and treatment of disorders of the head and neck.  They are medically and surgically trained to treat ailments of the inner, middle and outer ear. For instance they treat; perforated ear drum, conductive hearing loss, sensorineural hearing loss, weak tympanic membrane, otitis media and many more medical conditions.  

An Audiologist not only services hearing aids but they provide a complete diagnostic evaluation.  Audiologists are professionals who have received graduate and post graduate academic and clinical training.  They work in private practice, clinics, hospitals, Ear, Nose, Throat physician offices, industrial testing, and schools.

The scope of practice of an Audiologist include diagnostic evaluations, newborn and pediatric testing, sales and service of assisted hearing devices, tinnitus, vertigo (dizziness), balance, rehabilitation, industrial audiology, cochlear implants, recommendation and servicing of school FM systems, and counseling about hearing loss. 

I recommend a full hearing evaluation to all my families who are concerned about their child's speech and language development.  If you are concerned about any aspect of your child's development, contact your pediatrician.  S/he will be able to make the appropriate referrals and guide you through intervention and remediation. 

Communication Begins Day One of Your Child's Life

Language acquisition begins before your baby speaks his/her first words, before jargon, babbling and vocalizations. Communication begins day one of your child's life. First glances, touch, smells, sounds are all paramount in many facets of his/her development. There are several precursors to language that are essential for healthy development. 

Perhaps the most important is the relationship between you and your child. Most importantly, your child is dependent on you to make certain all his/her basic needs are met; nourishment  safety, health, comfort.  It is your responsibility to create a safe, loving, nurturing environment for your child.  In such an environment a child will feel comfortable to explore their surroundings. In the process of exploration, your child will begin to realize his or her impact on their world.  This valuable understanding is paramount in the development of language.  Once your child realizes that he or she could make things happen they will look to your response for validation.  This non- verbal connection to their caretaker, the ability to feel engaged and connected through facial expressions, eye contact, body language, touch, is your child's first experience with expression and communication.

Oral Motor Deficits

How does a parent know if their child has low muscle tone of the oral mechanism?

The muscles of the oral mechanism include the muscles of the lip, tongue, and jaw.  Very often when these muscles are weak your child will present with an open mouth position with the tongue placed anteriorly. They might experience severe drooling and have difficulty eating, drinking and maintain a closed seal around the straw,  Weakness of the lips, tongue and jaw will most certainly impact your child’s ability to produce the precise articulation (movements of the tongue, lips and jaw) and will likely result in your child’s ability to produce understandable speech.   Additionally, low tone may result in difficulty chewing, swallowing and  can result in an inability to stick the tongue out, or move it from side to side.  Drooling can also be caused by weakness in the muscles of the mouth.  Strengthening these muscles can be very important in improving both feeding deficits and speech intelligibility.

During mealtime, weakness of the muscles of the lip, tongue, or jaw can have a negative impact on the ability to maneuver the food laterally and posteriorly in the mouth as well as efficiently removing the food from the spoon or fork, and swallowing.   A heightened gag reflex and frequent choking may be caused by weak oral motor muscles, which make feeding your child quite challenging.    

Are there any quick fixes?

When a child presents with oral motor weakness, I recommend a structured oral motor program designed to strengthen the lips, jaw, and tongue.  Parents are asked to participate in these routines several times a day before feeding and to increase the difficulty as the child’s strength, awareness and range of motion increases.  The following are some activities and tools that I recommend to increase your child’s strength and abilities to feed and produce intelligible speech.

Chew Tube:  (textured and not textured)

• ·         Place laterally along teeth.  Allow your child to bite on each side. 
• ·         Place centrally on your child’s lips/mouth and allow him/her to round his/her lips while creating as tight of seal as possible for as long as s/he can maintain it.
• ·         Place laterally in-between cheek and teeth so child can feel the ridges/bumps on chew toy.
• ·         Swipe his tongue so he can feel the texture and receive sensation orally.
•  

Jiggler:

• ·         Start on child’s hands and move to his shoulders so as to prepare him/her for the activity. 
• ·         Using slight pressure, move the jiggler from ear to corners of the mouth several times or as long as s/he will tolerate it.
• ·         Allow your child to bite on the jiggler so s/he can receive sensory input orally.

Probe and /or Z-vibe:

• ·         Place laterally and posteriorly towards molars. 
• ·         Apply slight pressure and encourage your child to bite down on each side. 
• ·         Place laterally in-between cheek and teeth so your child can feel the ridges/bumps and vibrations on probe.
• ·         Swipe his tongue so he can feel the texture and receive sensation orally.
• ·         Put slight pressure against your child’s tongue and encourage him/her to push back with their tongue.

Straws and Sippy Cups: (using a straw will help stabilize your child’s jaw and keep it from shifting; build his/her strength and musculature)

• ·         Encourage your child to suck through the straw while holding his/her chin stable with your thumb and forefinger.
• ·         Discourage him/her from biting on the straw while drinking.  Very often a child will attempt to bite on the drinking straw to stabilize their jaw and keep their head from moving.
• Horns and Whistles:
• ·         Allow your child to explore the tools/toys orally. 
• ·         Place in between lips.
• ·         Discourage your child from biting on the tools/toys.
• ·         Encourage lip rounding around the horn for as for as s/he can maintain the position while blowing.
• ·         Model blowing for your child.

Oral Motor Games and Activities:

• ·         Fish faces – Use tactile prompts to bring your child’s cheeks together
• ·         Massage – With firm touch using one or two fingers, massage from their ears to the     corner of his mouth in a circular motion (along his teeth)
• ·         Lip smacking
• ·         Blowing kisses and raspberries
• ·         Bubble blowing  and popping on your child’s cheeks
• ·         Tongue clicking
• ·         Place something sweet around your child’s lips so he can attempt to use his tongue to lick it off.

As with any concern you may have about your child’s development, please contact you pediatrician and or a qualified speech language pathologist.

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Oral Motor and Sensory Tools

Children who have low tone around their mouths may benefit from oral motor activities.  Low tone and weak musculature can impact your little one's ability to speak clearly and eat efficiently.  Oral motor activities are paramount to successful development in the realm of speech, language and feeding.  A regular routine incorporating oral motor massage, and other oral motor activities will support your child's awareness, build the strength and range of motion of their oral motor mechanism for both speech and feeding purposes  The following items used regularly will promote intelligible speech and well as strong chewing, swallowing and overall good feeding protocols.

   

I recommend that a consistent program implementing these activities take place 3 times daily before each meal to bolster your child's healthy development. 

As with any issue regarding your child's speech, language and or feeding, you should consult your pediatrician and or a qualified speech language pathologist.

Auditory Processing Disorder and Your Child's Success

Auditory Processing Disorder, APD can be defined as the inability to recognize and identify sounds; primarily sounds that comprise speech.  It is the inability of the brain to accurately process the speech signal.  For instance, a person with APD may not be able to differentiate the sound /f/ from /th/ from /v/.   As you can imagine, when a student cannot easily distinguish between the word /feign/, and /vain/, or /fin/ and /thin/, the communication process becomes quite challenging and the classroom can become a difficult environment for a child to navigate.  Not only does APD impact the comprehension of the spoken word, but a fragile phonological/phonemic foundation can also impact negatively on academic success, reading comprehension and the child’s understanding of nuanced language.

While working with a qualified Speech Language Pathologist is paramount to develop and implement compensatory strategies, it is also imperative that child’s educators understand the unique needs of a child with APD. It will benefit the child if the classroom teacher implements the following strategies in the classroom.

1.       “Front and center” in the classroom.  Seating in the front of the room allows the child with APD to pick up on the non-verbal and visual cues such as facial expressions and articulation so as to comprehend the subtleties of the signal/message.

2.       A quiet classroom is paramount for success.  Research has been conducted that indicates that a classroom is many times noisier than healthy and acceptable levels.  NYC classrooms are probably worse and more worrisome.  A student with APD can become easily distracted by sound, and very often cannot prioritize the speech signal from other ambient and environmental sounds.  I suggest that the child with APD utilize an FM system.  However, many children are not eager to take this step.  Something as simple as closing the windows and curtains serve to significantly reduce the environmental sounds and will help tremendously.

3.       Allowing significant time for the child with APD to process a question or statement; whether written or verbal is imperative for their success.  For instance, when you interact with this child you may need to rephrase your question or statement in order for them to fully comprehend it.  Working with children with APD, I have found that, at times, they do not understand some of the nuances of complex language.  For instance, some older children with APD do not easily understand analogies without an explanation and have difficulties with metaphors.  You may find that this type of language may present a challenge and may need to be rephrased. Questions that include analogies and metaphors can be very tricky and may not be the best indication of their understanding of a topic.  A child with APD may understand more direct language and will be more successful at answering direct questions.

4.       During classroom lectures and tests, providing handouts, and using visual tools and illustrations very often support students with APD.

5.       Also, allowing extra time for testing will significantly help a child with APD.

As with any concerns you may have regarding your child’s speech and language, consult with your child’s doctor or a qualified SLP.  Referrals can be made for an assessment to determine whether your child has APD.  Please be aware that APD is not diagnosed in young children.  However, if it is suspected, a qualified SLP will be versed in treatment.

Pervasive Developmental Disorder (PDD)

According to the NIH, Pervasive Developmental Disorders (PDD) refers to a group of disorders including Autism, Asperger’s Syndrome, Childhood Disintegrative Disorder, and Rett's Syndrome. PDD is characterized by delays in many areas of development. While symptoms of PDD may appear as early as infancy, the typical age of onset and diagnosis is around 3 years of age. A child with PDD may demonstrate delays and problems across all realms of development including receptive and expressive language, social and emotional interactions, sensory motor, and play. A child with PDD may also exhibit difficulty transitioning from one activity to the next, s/he may also appear to be unable to attend to a communication partner, activity or task, demonstrate repetitive body movements, and may be unable to sit in one position for any length of time.


Children with PDD will vary greatly in their abilities. While some children may not speak at all, others may have limited language, and still others may appear to have typical age appropriate language. Many children with PDD will exhibit limited play skills and will not interact socially nor will they play collaboratively with other children. Rather they will exhibit peripheral parallel play. Some children with PDD may exhibit sensory defensiveness and react unusually to light, touch, and sounds, while others may seek out and desire these sensory stimuli.

Early intervention services are paramount in the treatment of PDD. If you suspect that your child has PDD it is important that you express your concerns to a qualified pediatrician. S/he can refer you for a proper evaluation which can determine the need for early intervention services. Very often, speech-language therapy when paired with occupational and physical therapy, and special instruction can serve your child’s needs and support him/her in his/her journey upon a successful life.

What Do Toddlers Talk About?

The development of speech and language can vary between children -- and often does. However, there is a natural progression that typical development follows. Simply speaking, easier skills must be mastered before more difficult ones. Nonverbal benchmarks before verbal. Vocalizations typically emerge before babbling. Shorter utterances come before more lengthy ones. Sounds that require an open vocal tract such as ah come before sounds that require complex coordination of the articulators such as b or p. B and p come before s and z and so on. Additionally, children will typically tell you that there is an apple before they tell you that they eat apple and they will tell you they eat apple before they tell you that they eat apple on table.
While many of us may know when single words start to emerge in a child’s communication, other benchmarks are not so straight forward. When determining language development in your infant and toddler, the following points of reference can help frame typical development from birth to three years of age.
· At 6 months a child should be responsive to his/her name. S/he should vocalize and babble with intonation, respond to different emotional vocal tones and facial expressions, and turn his or her head towards sounds.
· At 12 months a child may be using one or more words with meaning such as mama, or baba. This is when a child begins to express intention. S/he should also understand simple directives when accompanied by visual cues and gestures.
· At 18 months a child’s vocabulary should be approaching 25 word; mostly nouns. S/he should use jargon with intonation, repeat a lot of what s/he hears, and follow simple directives without supporting gestures or visual cues.
· At 2 years of age a child should be able to verbally identify common objects with approximately 65% intelligibility. S/he should produce 1 and 2 word utterances combining nouns with verbs such as “eat cookie”. Verbs and adjectives are emerging in their lexicon and their vocabulary is growing larger approaching two to three-hundred words. Prepositions will also emerge such as on and in. S/he will begin to refer to him/herself as I or me. Their voice quality (pitch and amplitude) will not be well regulated at this time. Receptively, your child typically will follow directives such as “show me” “give me” and the most important “clean- up”
· At 3 years of age, your toddler should communicate with close to 90% intelligibility. S/he should use pronouns correctly. You may notice temporal markers such as the past tense “ed” are emerging in their language. Their vocabulary could be between 500 and 1000 words and s/he produces 3 word utterances. S/he will identify body parts and will be able to answer some “wh” questions such as, what do you do when you are tired? Additionally, a 3 year old child will relate better to their environment and they will begin to comment on their surroundings.
Do not fret, it does not necessarily mean there is a delay or impairment if your child has not met all of these milestones. Language development is influenced and dependent upon so many other factors. If you are concerned, contact your child’s pediatrician or a licensed Speech-Language Pathologist with your questions. They will help you to determine if a full language evaluation is necessary.