Parents are often hesitant to make an appointment to have their child evaluated for fear that his/her speech may be normal and they will be charged with a big bill "for nothing". The purpose of the free screening is to determine whether the child is developing speech and language at a normal rate or whether something is wrong. This is especially useful for preschoolers.

A screening is about 15 to 20 minutes in length. It involves playing with the child and listening to *him talk. With older preschoolers ages 4 to 5 and young elementary age children we give abbreviated language and articulation screening tests.

If a child fails the screening, an evaluation should follow. There is a charge for an evaluation based on the time needed to test the child and generate a report. Because of its brevity, a screening can never take the place of an evaluation. Try to think of a screening this way: the screening answers the question, "Is the child’s speech normal for his age or is there a speech-language problem?" The evaluation is based on the premise that there is a speech-language problem present and we need to answer the question, "What specifically is wrong with the speech or language an how easily can it be corrected?"

* it is very clumsy to keep using "him/her" throughout this document. We are not trying to be sexist by using one pronoun or another. Please read this document using the pronoun appropriate for your child.

Speech and Language Evaluations

During the speech and language evaluation the therapist tries to answer the following questions:

1. What are the relevant antecedent events that occurred prior to the communication disorder? We look at whether anything unusual happened prior to birth, at the time of birth, or shortly thereafter. We want to know whether the child had difficulty with feeding, choking, or breathing? Was she hospitalized and for what reason? When did you become concerned about the communication? What did you do about it?
2. Since the development of speech is dependent on the ability to hear, we want to know if the child has had a history of ear problems. Did the child ever have an ear infection? How were the ear infections treated and did they recur? Has the child had a recent hearing test? Do you suspect a hearing loss and why?
3. How does the child relate socially? Is she very quiet and shy with new people? Is she self-conscious about talking? Will she separate easily from you and comfortably interact with the therapist?
4. How cooperative is the child? Will she interact appropriately with the test materials and toys? How typical is the behavior elicited here to that which is exhibited at home?
5. What types of speech problems are detected? How is articulation, or the ability to produce the vowels and consonants of our language? How intelligible is the speech? Do the parents have to interpret what the child is saying? Does the child speak too fast? Is there a stuttering problem? How is the child’s voice (does it sound hoarse or raspy)? In the adolescent, is the pitch appropriate for age and sex?
6. Are there problems with language? How appropriate is vocabulary and sentence structure for age? Is the child able to clearly relate stories and events that are of interest to her? How does she respond to questions? Does she seem to have difficulty understanding what is said to her? Can she follow directions; how many? Are there problems with use or comprehension of pronouns?
7. How well can the child control the muscles of speech? Does she have good range of motion with the tongue, lips, and jaw? Does she have feeding problems? Does she choke a lot when eating or drinking? Can she imitate the therapist’s movements to produce individual speech sounds or a string of varied speech sounds? Does she have oral habits such as thumb-sucking or a pacifier? Is she able to drink from a glass or with a straw?
8. What are the recommendations for treatment and how many treatment sessions will be needed to reach the desired goals?

A speech and language evaluation is written up in report form and a copy is sent to the insurance company if filing with them for coverage. With your permission we also like to send the pediatrician a second copy so that he can be aware of all aspects of your child’s health. We also give you a copy of the report for your personal files.

Therapy

Speech and language therapy is individualized to meet the needs of each child. It is the natural outgrowth of the comprehensive evaluation. The amount of time scheduled for your child’s therapy is based on the age and maturity of the child and the perceived severity of the disorder. Generally preschool children are seen from 20 to 30 minutes, while older elementary and secondary students can be seen for 45 to 60 minutes. The majority of children are seen here once a week; however, those with disorders that are severe in nature may be seen for two to three times a week.

Our philosophy of therapy is to involve parents in the treatment process. We view the parents and child as members of our "team" and in that respect we give everyone a role. The therapist is the team leader, the parents are the coaches, and the child is the leading player. We always ask the parent to sit in on at least some, if not all, of the therapy sessions. We feel it is our job to teach parents how to implement the treatment at home and we give you all the materials that you will need to do this. We also ask parents to make a commitment to spend at least 30 minutes a day, seven days a week, working with the child on the assigned exercises. With older children and adolescents we stress that they must also make this commitment to practice each day.

The type of therapy given is based on the disorder that is being corrected. Some of the more common ones will be briefly described here:

The most common speech disorder is an articulation defect. This can be as simple as an inability to produce one speech sound, or phoneme, such as an "r" or "l". A common disorder that everyone is familiar with is the lisp, where the tongue protrudes between the teeth and a "th" sound is used in place of the "s". A child can also have problems saying multiple phonemes and sometimes these children are unintelligible to everyone (except maybe their parents). We refer to these children as having a phonological disorder.

A less common problem is one in which the child may be able to make all of the individual phonemes in isolation, but has difficulty with the motor planning needed to coordinate several phonemes into a single word and single words into phrases and sentences. This motor planning disorder is called verbal dyspraxia. Some children with verbal dyspraxia may have difficulty saying even the easiest words like "bye-bye".

Children with neurological impairments like cerebral palsy may have a condition called dysarthria. Words are slurred or indistinct; the child may have difficulty speaking loudly because he cannot control his respiration; there may be drooling; rate of speech may be laboriously slow and intonation pattern may be monotonous.

Children born with a cleft lip and /or palate will often have articulation problems as well as hypernasality. They may have air escaping through their noses during speech resulting in nasal snorts and distortion of many of the plosive sounds like "p", "t", and "k" and the stridents like "s" and "ch".

Stuttering, or what is often referred to as a fluency disorder, is characterized by whole or part-word repetitions("the, the, the" or "ba-ba-ba-ball"), silent blocks (pauses), prolongation of sounds ("sssssoap"); often there is obvious tension in the face and neck. Generally children with fluency problems have the most difficulty at the beginning of sentences. Often "wh" words like "where", "when", "what", and "why" are difficult to say when starting a question. They may speak very rapidly when they can get the words out. Older children may avoid saying certain words or phonemes that they personally feel are too hard for them. Children with a stuttering problem generally are shy and hesitant to speak aloud in class; sometimes they have difficulty making friends.

The majority of children with a fluency problem have a history of speech difficulties that began in the early preschool years, usually between ages 2 and 5. In addition to the stuttering, as preschoolers they may also have had a phonological disorder or a language delay. Sometimes it is difficult to discern whether a young child is indeed stuttering or just going through a normal period of dysfluency. It is true that many boys between the ages of 2 and 3 have a lot of "starts and stops" in their speech; this usually corresponds with a period of rapid language development. However, if the dysfluency persists over six months, becomes progressively worse, or the child appears frustrated, then he needs to be seen by a speech-language pathologist. The good news is that the majority of children diagnosed with a fluency disorder in the preschool years can achieve normal fluency with treatment. The longer stuttering is left untreated, the harder it is to achieve and maintain normal fluency in later years.

Language Delays and Disorders

When we refer to " expressive language", we mean the vocabulary and grammar that the child is using. We also talk about "pragmatics" or the social reason for the use of speech. Language develops in a rather orderly fashion: between 9 and 12 months most children begin to use real words, such as "mama" or "bye-bye". Around 18 months there is an explosion of speech and the baby really takes off and acquires a vocabulary of words, mainly nouns, that reflect his interest and needs (e.g. "up", "eat", "no", "car", "ball", etc.). By 24 months the average baby has a vocabulary of about 50 words and is starting to make "sentences", e.g. "Daddy car" and "Eat cookie". Here is where pragmatics come into play: the baby uses his words for a variety of purposes: to protest something ("No bath"), to indicate possession ("My car"), to indicate location ("Here car"), to question ("Were mama?"), to comment ("Big ball"), etc. Between 24 and 36 months the toddler’s speech continues to develop. Not only does he acquire nouns, but now he also begins to get more verbs, adverbs, and adjectives so that sentences have a more mature format of : agent + action ("Doggie eat"); action + object ("Push car") ; agent + object (Daddy’s car); etc.

"Receptive language" refers to the child’s comprehension of what he hears. Before 12 months the baby understands routines and comes to expect certain things to happen in a specific order. Closer to 12 months the baby will understand single words, such as "bottle" , "bath", and "cookie", if they are used frequently in familiar situation. During the baby’s second year there is an increase in his understanding of short sentences that are used frequently, such as "Go get your shoes" or "It’s time to eat". Babies generally understand more than they can say. By 24 months most babies can point to familiar objects in the house or in a picture book when told, "Show me the ______". They will respond appropriately to single commands, e.g. "Come here" or "Sit down". They know many of their body parts and can point them out when you ask, "Where is your _______ (nose, feet, ears, legs, etc.)". By the third year most children can correctly answer "wh" questions (who, what, where) and yes/no questions.

Children with delayed speech and language development are slow in achieving the above language milestones. The causes for these delays are many and varied. Some of the causes are hearing losses, mental retardation, cleft lip and palate, Down’s syndrome, cerebral palsy, attention deficit hyperactivity disorder, dyspraxia, and learning disabilities. In many instances we are unable to find a reason for the delayed onset of language, or we find it in retrospect several years later, such as when a severe learning disability is diagnosed at school.

Disordered language is a bit different. In this type of problem, the child may use language, but not pragmatically. An example is the child who can parrot a McDonald’s television commercial but is unable to ask for what he wants to eat or drink. Often these children also have severe problems in comprehension of language. At age three they still may not be able to follow simple commands like "Come here". A child with disordered language might have a diagnosis of autism, Asperger’s syndrome, Pervasive Development Delay, a Central Auditory Processing Disorder or a severe learning disability.

Voice Disorders

A voice disorder is usually caused by misuse of the voice. Screaming and stage whispers over time can result in nodules or polyps on the vocal cords. The voice will sound hoarse or raspy; with repeated abuse the voice will be breathy and it will be difficult to increase volume beyond a whisper. Anyone having these symptoms that persist over a week should have a consultation with an otolaryngoligist (ear, nose and throat specialist). The medical doctor needs to evaluate whether surgery is indicated or whether a period of voice therapy should be undertaken first. Sometimes vocal rest (abstaining from speech for a period of one to two weeks) can eliminate the symptoms and reduce the inflammation of the vocal cords. However, if the child continues to misuse the voice, the problem will quickly reappear. This is the reason most doctors prescribe voice therapy.

In voice therapy the child will learn the reasons for his hoarse voice and will learn how to use the voice properly without straining the vocal cords. The entire family is asked to help the child identify when he is misusing his voice; a reward system is also used to reinforce him when he uses his voice properly. The child is encouraged to use non-speech methods as a substitute for yelling, such as a whistle to get attention.

Children with cleft lip and palate may also have voice disorders. Generally children with clefts have hypernasal speech or nasal air emission. Some children with repaired clefts have hyponasal speech (unable to produce "m", "n" and "ng" as nasal consonants). Children with dyspraxia and cerebral palsy may also have problems with nasal resonance. All of these children benefit from a period of voice therapy.

Auditory Processing Problems

A central auditory processing disorder (CAPD) is a term used to describe children who have normal peripheral hearing but who have difficulty processing or generating meaning from spoken communication.  The problem may lie in one or more of the following areas: sound localization; auditory discrimination; auditory recognition;  speech in noise; memory and sequencing of auditory events.  Children with auditory processing problems often have difficulty hearing the fine differences between similar speech sounds, e.g. “s” and “z” as in “sue” and “zoo”.  They may also have difficulty remembering the sequences of individual speech sounds or syllables in words; this can thus result in problems with spelling and reading.  Some children with CAPD have difficulty remembering and following 2-and3-stage directions, such as “Take out your math book, turn to page 53, and do all the even numbered problems from numbers 4 to 16.”  Other children with auditory processing difficulties listen well in a quiet environment, but have a great deal of difficulty when there is competing background noise, such as a radio or television on.  The teacher may comment that the child has poor listening skills or gets very restless and fidgets a lot when the main task is to listen to auditory information.  Children with CAPD typically do poorly when they have to attend to rapid speech or someone with an accent.  They may also have poor musical ability, difficulty keeping rhythm or clapping to the beat, and their speech may be choppy and lack normal prosody.

 At Cary Speech Services our staff have been trained to assess central auditory processing disorder using  the SCAN-C.  The SCAN-C  is an imitative test for children between the ages of five and twelve years.  It  requires the child to repeat stimulus words or sentences in the presence of background noise, filtered words that distort speech and competing signals that are different in each ear.  After a diagnosis is made, therapists design and implement a treatment program that addresses the child’s weaknesses.  This may also include suggestions to the child’s classroom teacher to improve listening in the school environment.

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