A-Z of speech, language and communication

What is AAC?

AAC stands for augmentative and alternative communication. AAC includes a wide range of techniques used to support or replace spoken communication.  It can include low tech systems such as signing, gesture, symbols, books, and boards as well as high tech devices such as voice output communication aids. 

AAC may be used by children, young people or adults who find communication difficult because they have little or no clear speech.  It can help them communicate and be better understood by others.

What to look out for

In order for AAC to be considered the following criteria needs to be met:

• A need for AAC. The person will be non- verbal or have difficulties with intelligibility of speech or writing. 
• A desire to use an alternative form of communication.
• Motivation to interact with others
• Opportunities to communicate
• Support within their usual environments to maintain, update, and encourage use of AAC

How you can help

When interacting with someone who uses AAC try to remember the following tips:

• Try to find somewhere quiet to have your conversation, cut down on the distractions around such as switching off the TV
• Ask the person if there is anything they need you to do to support their communication. Ask them if they can show you how they answer ‘yes’ and ‘no’
• Allow more time for the person to respond. There may be silences, but don’t be tempted to fill them.  Ask one question at a time, and allow them time to answer this before moving on to the next question.  Try not to ask too many closed questions. Where possible use open questions to encourage the person to tell you more.
• If you don’t understand what the person has said, let them know and see if they can tell you in a different way.  If you still can’t understand, say you can come back to that later, or ask if there is someone who knows the person well who can help you understand.
• Confirm with the person what you think they have told you. This will lessen the risk of misunderstanding.
• The person using AAC may not pick up on your nonverbal communication such as facial expression, or gestures if they are busy looking at their AAC.  You may have to explain things again if they have missed some information by not looking at your face. 
• Some people who use AAC may find it tiring and may need a break during a long conversation
• Talk to the person directly, not their supporters

What do Speech and Language therapists do?

Speech and Language Therapists are able to assess the person’s communication skills and can advise on the most appropriate AAC system for them.  They will link with other members of the team to support with this assessment such as the person’s family, other professionals involved such as teaching staff.  They will also advise on how to develop the person’s  use of the AAC, and will be involved in training the team around the person in how to use the AAC.

Further reading and resources

Communication Matters is a national charity involved in a wide range of activities supporting those who use AAC.
Accessible from: http://www.communicationmatters.org.uk/

CALLScotland is an organisation primarily funded by the Scottish Government to provide support to children across Scotland who require access to technology I order to fulfil their potential. 
Accessible from: http://www.callscotland.org.uk/home/

Augmentative and Alternative Communication Scotland provides straightforward access to a range of practical AAC resources commissioned by NHS Education for Scotland (NES)
Accessible from: http://www.aacscotland.org.uk/Home/

What is Autism?

Autism is a lifelong condition affecting many areas of development that include:

• communicating with others
• relating to others
• relating to the world generally

Autism covers a wide spectrum therefore while all those with autism share certain areas of difficulty, their condition will affect them in different ways. Typically, a child on the autistic spectrum would display the following:

• difficulties with social communication and interaction
• restricted and repetitive behaviours or interests
• hyper, or hypo-reactivity to sensory input. This can lead to difficulty processing the sensory world can affect a person’s ability to communicate and function independently in social situations. It can also have a negative impact on education, recreation, employment and social integration.

What to look out for?

Children may present differently, however some of the following would be indicators for further assessment:

• No babbling by 12 months 
• Poor unusual/eye-contact
• Does not consistently respond to name
• Does not try to attract adults attention e.g. by pointing, raising arms to be lifted
• No gesturing (pointing, waving, bye-bye, etc) by 12 months 
• No single words by 16 months 
• No two-word spontaneous phrases by 24 months 
• Any loss of any language or social skills at any age. 
• Play is limited and often repetitive
• Echolalia (echoes verbal utterances)

How to help?

There are many approaches to supporting children with Autism. No two children are the same, so choosing the right ones can be a challenge. The National Autistic Society suggests many strategies and approaches which may be helpful.

Strategies and Approaches: National Autistic Society: https://www.autism.org.uk/advice-and-guidance/topics/strategies-and-interventions/strategies-and-interventions

Some children may benefit from using alternative means of communication such as sign language or visual symbols. Others have good language skills, but they may still find it hard to understand the expectations of others within conversations, perhaps repeating what the other person has just said or talking at length about their own interests.

It often helps to speak in a clear consistent way and to give children time to process what has been said to them. It can help to supplement verbal information with visual information e.g. gestures, real objects, or pictures. 

Consider putting families in touch with local support groups or the National Autistic society Helpline.  
Accessible from: https://www.autism.org.uk/

Further Reading/Useful Websites

NHS Education for Scotland: Knowledge Network: Autism http://www.knowledge.scot.nhs.uk/home/learning-and-cpd/learning-spaces/autism-spectrum-disorder.aspx

Autism Spectrum Disorders (ASDs)For General Practitioners and Primary Care Practitioners. http://asd.nes.scot.nhs.uk/

National Autistic Society
http://www.autism.org.uk

The Autism Toolbox
http://www.gov.scot/resource/doc/266126/0079626.pdf

Early Support Booklet for Families: Information about Autism https://councilfordisabledchildren.org.uk/help-resources/resources/early-support-information-autistic-spectrum-disorders

What is Bilingualism?

In the UK, ‘bilingualism’ is used to refer to the ability to understand and/or use more than one language (this therefore includes ‘multilingualism’)

The languages involved can be any languages, including sign languages. 

The majority of the world is bilingual, meaning that globally, it is the norm to have more than one language.

Any individual with more than one language should be considered bilingual, regardless of the relative competency in any of the languages.

Bilingualism is NOT a disorder and being bilingual does NOT cause or contribute to any speech, language or communication disorder.

What to look out for:

Bilingualism can be achieved in different ways:

1. Simultaneous bilingualism
Where 2 or more languages are used with the child from birth

2. Sequential bilingualism
Where one language is acquired and an additional language is introduced later (often when English or another language of education is introduced)

Where languages are introduced sequentially, there is sometimes a ‘silent’ period when the second language is introduced. However, this should be monitored carefully if it lasts for more than one month to avoid missing a profile of Selective Mutism.

Being bilingual does not necessarily slow down language development.  If there are concerns about first language (or simultaneous language) development, where the child is receiving a good model and amount of language exposure, this is a concern.

A range of terms are used to refer to how languages are used, for example:
• Home language,
• first language,
• mother tongue, L1 (first language acquired),
• L2 (second language acquired sequentially)

This can lead to confusion, therefore it is useful to include a description
e.g. Mum speaks Mirpuri with the child and Dad uses Urdu.  Mum is the main carer.

Any speech, language and communication difficulty can co-occur with being bilingual, so it is important not assume that any difficulty is ‘because’ of bilingual development.

Key messages

• Bilingualism is NOT a disorder and being bilingual does NOT cause or contribute to any speech, language or communication disorder. (DeHouwer  2009)
• There are now thought to be wider cognitive benefits from being bilingual in terms of flexibility of thought (eg Bialystock 1999).
• Parents should use the language in which they are most proficient and all languages used should be valued and treated as important.  Home languages have huge importance to culture and identity as well as for communication. Once lost, it is very hard to regain previous language proficiency. 
• Parents must NEVER be encouraged to prioritise English over home/ native language (s)
• Children need to acquire a good language model whatever their home language(s). Therefore it is best for children by hear a good model of language from proficient speakers. 
• The most important thing is to ensure all languages are presented as being valuable and and children exposed to languages across a wide range of contexts talking while playing, using books in each language, accessing TV in each language.
• Language should be presented at the right level for the child’s ability.
• Code switching (switching between languages) within sentences is normal for both bilingual parents and children growing up in bilingual families. The ability to integrate two languages and follow language rules can be a marker of language proficiency.
• Support from interpreters should be used at every opportunity. Some of the concepts involved in child development involve high level vocabulary which may be unfamiliar.  Make sure you have identified the correct language

What do Speech and Language Therapists do?

Speech and language therapists (SLT) do not teach English and do not address concerns regarding the learning of English (or any other) additional language.

Speech and language therapists can offer and advice and support:
• Where there are concerns about a child’s language development in their first language or development in ALL languages. The SLT can help identify whether this reflects a disorder or normal bilingual development.
• To colleagues and families on how to support bilingual development and reduce the risk of language loss in favour of majority languages.

References:

De Houwer, A. 1999. Two or more languages in early childhood: Some general points and practical recommendations. Washington, DC: Center for Applied Linguistics. https://www.cal.org/content/download/1857/20796/file/TwoorMoreLanguages.pdf

Bialystok E.,1999. Cognitive complexity and attentional control in the bilingual mind. Child Development. 70:636–644

Resources:

Bilingualism matters
Available from:  http://www.bilingualism-matters.ppls.ed.ac.uk/

National Literacy Trust:
https://literacytrust.org.uk/early-years/bilingual-quick-tips/
NLT top tips for parents bilingualism
NLT bilingualism parents frequently asked questions

 Advice leaflets from the National Literacy trust are  available in Arabic, Bengali, Chinese, Estonian, French, Gujarati, Norwegian, Panjabi, Polish, Portuguese, Romanian, Somali, Swedish, Tamil, Turkish, Urdu, Welsh.

Talking Point
Available from: http://www.talkingpoint.org.uk/directory/free-resources-parents/multi-lingual-factsheets
ICAN Talk together bilingual
Talk Together booklet available to down load in:

Arabic - Czech - French - Polish - Punjabi - Somali - Urdu - English

Top tips leaflets in Arabic, Bengali, Gujarati, Hindi, Punjabi, Urdu, welsh & English.

What is Cleft Lip/ Palate?

Cleft lip and/or palate is the most common congenital abnormality of the craniofacial complex. Around one in 700 babies are born with a cleft around the world. This group includes individuals born with syndromic and non-syndromic cleft palate (with/without cleft lip) which is confirmed at birth. The type and severity of a cleft can vary involving only the lip or palate or both lip and palate together (Watson 2001). Antenatal diagnosis of cleft lip can be made at time of mid – pregnancy anomaly scan. Most clefts of the palate are identified immediately after birth or during newborn physical examination, as routine scanning does not generally detect cleft palate. A proportion of clefts are associated with syndromes. Some cleft palates may not be detected until sometime after birth as they are ‘hidden’ (known as a submucous cleft palate), and are identified when feeding difficulties emerge or later when speech is affected. When an infant is given a diagnosis of a cleft, they are referred to their regional cleft lip and palate service for further assessment, advice and management by the cleft team.

Key Messages:

Children with cleft palate are at risk of (RCSLT 2009):
  • articulatory problems
  • abnormal hypernasal resonance
  • hearing problems
  • feeding difficulties

• Impaired communication may have an adverse effect on literacy, social skills, peer relationships, self-confidence and behaviour.

• Perceptual assessment and investigation of speech disorders associated with cleft palate require highly specialist skills and investigations available within regional cleft lip /palate centres.

• A multidisciplinary specialist team will support children with a cleft lip/palate

• Repair of the cleft palate increases the likelihood of normal speech development. Surgery normally takes place in the first year of a child’s life.

What does a  Speech and Language Therapists do?

• Speech and language therapists (SLTs) are integral to the decisions made regarding management, be it surgery, prosthetics or speech therapy treatment, with the objective of normal speech.

• Speech therapy management and intervention extends from infancy to adulthood, tailored to the needs of the individual, and shared as appropriate with parents, local SLTs and social and education authorities.

References:

Watson, A., Sell, D., and Grunwell, P. 2001.(Eds). Management of Cleft Lip and Palate. Whurr, London and Philadelphia. Pp 3-15.
The Royal College of Speech and Language Therapists ., 2009. RCSLT: Resource Manual for Commissioning and Planning Services: Cleft Lip and Palate. Available at: https://www.rcslt.org/wp-content/uploads/media/Project/RCSLT/resource-manual-commissioning-planning-slcn.pdf 

https://www.rcslt.org/wp-content/uploads/media/Project/RCSLT/resource-manual-commissioning-planning-slcn.pdf

Resources

Cleft Lip/Palate Association (CLAPA)
https://www.clapa.com/

What is developmental language disorder?

Developmental language disorder (DLD), previously known as Specific Language Impairment is a condition where children have problems understanding and/or using spoken language. Children with DLD present with spoken language difficulties without any obvious explanation and they often go unrecognised.

A child can be diagnosed with DLD if:
• Their spoken language has a negative impact on their daily interactions and learning
• Their language difficulties have not resolved by 5 years of age.
• The problem is not associated with autistic spectrum disorder, learning difficulties, brain injury, hearing loss, Down’s Syndrome etc.

Children with DLD may present with co-existing difficulties such as attention difficulties, motor difficulties and dyslexia. Children who do not meet the criteria for developmental language disorder should be referred to as having ‘language disorder or language difficulties’.

What to look out for?

Children with Developmental Language Disorder have difficulties learning, understanding and using spoken language.

Look out for children who:
• Have trouble understanding instructions
• Take longer to learn new words and have a limited vocabulary
• Struggle to find the words they want to use
• Find it difficult to join in with conversations
• Use very simple sentences

How can you help:

• Keep your own spoken language simple
• Give one instruction or piece of information at a time
• Give the child time to process what you have said and give them time to answer
• Show the child what you mean rather than relying on words
• Help to support communication by using pictures and gesture
• Focus on the child’s strengths
• Do not put pressure on the child to speak
• Notice what the child is interested in and talk to them about their interests

What do Speech and Language Therapists do?

Every child is different so there is no simple approach to supporting children with Developmental Language Disorder (SLD).  The speech and language therapist will have a conversation with a family member to ascertain the impact of the difficulty and what is important to the child and the parent or carer. 

The speech and language therapist can also assess the child’s expression, comprehension, speech sounds and social communication if that is appropriate. 

If the child requires additional input the speech and language therapist will aim to empower the parents or people close to the child to facilitate successful communication techniques/ strategies and improve the child’s communication skills. This could involve developing the knowledge and skills of key people in the child’s life such the parents, wider family, and nursery or school staff. For example, this may include indirect coaching, modelling and training, or more direct interventions focussing on particular aspects of the child’s communication such as developing vocabulary or sentence structure. 

Further reading/resources

• Raising awareness of Developmental Language Disorder
Available from: https://www.youtube.com/user/RALLIcampaign

• I CAN
Available from: https://www.ican.org.uk/

• Talking Point
Available from: http://www.talkingpoint.org.uk/

Development Speech Difficulties

What are Developmental Speech Dificulties?

The term Developmental Speech Difficulties is used to describe the difficulties that some children have with their articulation and/or phonological development. Other terms also used include speech sound disorder, speech sound delay, phonological disorder, phonological delay, speech impairment and in some cases, dyspraxia.  

• Children with developmental speech difficulties make errors by omitting or substituting speech sounds. The patterns of these errors may be observed in typically developing younger children (delay) or may be non-developmental (disordered).

• A key characteristic of children with developmental speech difficulties is that their intelligibility (speech clarity) is often significantly less than other children of the same age.

• Most children with developmental speech difficulties have no identifiable cause for their problems. However, speech difficulties can be associated with other conditions such as cleft palate, cerebral palsy, childhood dysarthria and global developmental delay.

What to look out for?

• Children typically vary in their speech development. Younger children may make errors and substitutions in their speech, however these may be within the normal range, depending on their age.  Refer to the speech sound development guide to review typical speech sound development. 

• The extent to which  parents understand what their child says. By the age of three, parents can normally  understand 75% to 100% of their child’s speech output. 

• A developmental speech difficulty can prevent a child from communicating effectively, causing frustration or withdrawal from social situation.

How to help?

• Don’t correct the child or tell them they are wrong.  The child may think their speech/ sounds is the same as yours. Do say the correct word, clearly.

• If you cannot understand what the child is saying, encourage them to show you or tell you another way. If you have understood some, repeat it back to the child to check you have got it right.

• For children with developmental speech difficulties causing unintelligibility and/or frustration/anxiety, discuss a request for assistance with your local speech and language therapy service.

What does a Speech and Language Therapist do?

Following referral, the speech and language therapist carries out a screening assessment to determine the presence and extent of developmental speech difficulties and to decide whether or not intervention is indicated.

Further diagnostic assessment and analysis will guide the speech and language therapists decision about which type of intervention to select and which phonemes or speech patterns to target in therapy. 

Resources

• Norms for Speech and Phonological Development In Children under 7 years
Available from: https://smartandstatic.com/speechcare/files/speech_norms.pdf

• Speech and language therapy dot com
Available from: https://speech-language-therapy.com

Do dummies affect speech development?

There is a lot of conflicting advice available about the use of dummies, which can be confusing for parents and health professionals.

Some feel that there are some advantages to using dummies in the early months of a child’s life. Dummies may be useful in settling young babies and encouraging strong sucking patterns, especially those born prematurely (American Academy of Pediatrics 2000). 

Some studies have also looked at a theory of whether there is a correlation between dummy sucking and Sudden Infant Death Syndrome (SIDS) and whether when settling a baby down to sleep, using a dummy lowers the risk of SIDS (Mitchell et al 1993).

Not all experts agree, however, that the use of dummies should be promoted. Some professionals feel that dummy use may lead to difficulties in establishing and maintaining breastfeeding although others argue that this link is not necessarily causative and that other factors should be considered such as mothers motivation to breastfeed (Dodds 2011).

The use of dummies/ pacifiers has been linked to an increased risk of ear infections and dental problems (Niemela et al 1995). They may also restrict opportunities for babbling and experimentation with sounds (Baker 2002). When an infant has a dummy in their mouth they are less likely to copy sounds adults make or to attempt to babble and play with sounds themselves which is important in the development of speech and language skills. It is felt by some professionals that overuse of a dummy may lead to difficulties producing certain speech sounds, especially those that require the tip of the tongue (t,d,s).

Parents preferences for dummies should be respected. Professionals often advise parents to limit the use of dummies after 6 months old, and especially after one year. This is particularly important during the day and when children are talking and interacting with other children and adults.

References

American Academy of Pediatrics., 2000. Prevention and management of pain and stress in the neonate. Committee on Fetus and Newborn Committee on Drugs, Anesthesiology and surgey. Canadian Paediatric Society. Fetus and Newborn Committee. 105 (2): 454-61.

Baker, E. 2002. “The pros and cons of dummies: what a speech pathologist should know,”        Acquiring knowledge in Speech, Language and Hearing , vol.4, no.3, pp.134-136.

Mitchell EA, Taylor BJ, Ford RPK, et al. Dummies and the sudden infant death syndrome. Arch Dis Child. 1993;68:501–4. [PMC free article] [PubMed

Dodds, J., 2011. The impact of Dummy use on breastfeeding: The Cohrane findings. Perspective. NCT Journal

Niemela, J., Uharim M. & Mottonen, M. 1995. “A pacifier increases the risk of recurrent acute otitis media in children in day care centers,” Pediatrics, Novermber 1995.

Resources

Bumps to Bairns- Dummies
Available from: https://bumps2bairns.com/dummies/

What are eating and drinking difficulties?

Eating and drinking difficulties can include a difficulty with swallowing, or with coordinating lip, tongue and jaw movements to chew and move food around the mouth. 

Children may have eating and drinking difficulties for a variety of reasons such as:
• Premature birth
• Having Down's Syndrome, or cleft lip and/ or palate
• Diagnosed with Cerebral Palsy
• Having a heart condition or a condition that affects their breathing.
• Having gastro- oesophageal reflux
• Complex medical conditions

Not all children with these difficulties will have eating and drinking difficulties. There may also be children that do not have the difficulties on this list that experience eating and drinking difficulties.

Some children have feeding difficulties that may relate to sensory difficulties. This can happen with children with ASD (Autism Spectrum Disorder) or with children who have previously had reflux or a difficult start with feeding. 

What to look out for?

These signs may seem more obvious at some times and may also change depending on the type of food your child is eating. Children with eating and drinking difficulties may experience some of the following symptoms:

• Coughing and/ or choking during or after feeding
• Changing colour and/ or noisy breathing during or after feeding
• Refusing foods
• Difficulty chewing or difficulty moving onto more challenging textures
• Gagging
• Prolonged feeding times
• Weight loss or lack of weight gain
• Trying to swallow a single mouthful of food several times
• Difficulty coordinating sucking and swallowing
• Arching or stiffening of the body during feedings
• Congestion in the chest after eating or drinking
• Wet or raspy sounding voice during or after eating
• Frequent respiratory infection
• Spitting up or vomiting frequently
• Food or liquids coming out of the nose during or after feeding
• Irritability or lack of alertness during feeding

How to help? General Advice on Eating and Drinking

• Children need lots of practice to learn new chewing skills and coping with new textures
• Introduce changes to tastes and textures gradually
• Let children explore foods with their hands and mouth
• Keep the environment calm and relaxed when feeding
• Consider child’s positioning when feeding/eating
• Include the child in family mealtimes, keep the experiences positive
• Consult with child’s primary caregiver if there are any signs/symptoms of eating and drinking difficulties

What does a Speech and Language Therapist do?

Some speech and language therapists have undertaken training to assess and support children with eating and drinking difficulties (dysphagia). This will be alongside other professionals, such as dieticians, paediatricians, occupational therapists, physiotherapists, health visitors and nurses.

Resources/Further Information

RCSLT Dysphagia Factsheet: Available from: https://www.rcslt.org/speech_and_language_therapy/docs/factsheets/dysphagia

What is Inclusive Communication?

Inclusive communication seeks to create supportive and effective communication environments, using every available means of communication possible to aid understanding and expression of need and choice.This includes spoken language, written language and all forms of non-verbal communication.

Inclusive communication is vital to equality of access to services, person-centred care and increased participation and social interaction.  Inclusive communication is about reducing barriers to communication.

The Scottish Government definition of Inclusive Communication (2011) means “sharing information in a way that everyone can understand. For service providers it means making sure that you recognise that people understand and express themselves in different ways.”

How to help?

Everyone is responsible for communicating in ways that include others and creating supportive environments. Inclusive communication demonstrates that, as a society, we value, respect and include people with communication support needs.

The Scottish Government (2011) developed six communication support principles to help ensure that communication is more inclusive and that services are delivered more effectively for people with communication support needs.

1. Communication accessibility and physical accessibility are equally important.All people who use public services have the right to access them on an equal basis.

To make your services fully accessible means considering communication accessibility as well as physical accessibility in the traditional sense.

2. Every community or group will include people with different communication support needs.You should presume that every group you are working with, or expect to work with, includes people with communication support needs. This includes members of the public and your colleagues.

Inclusive communication should be considered at all times, whether providing information or planning an event, meeting or activity. Good communication practice will help you reach your target audience more effectively and allow people to access services on an equal basis.

3. Communication is a two-way process of understanding others and expressing yourself.Quality service delivery is when the service provider and person who uses the service understand each other, and the person who is using the service is able to express their needs and choices effectively.

Everyone communicates differently. When somebody has communication support needs, it may take more effort and time to ensure that the service provider and the person who is using the service understand each other.

You need to:
• Match your communication to the needs of the people who use services
• Recognise and respond to the variety of ways that individuals may express themselves

4. Be flexible in the way your service is provided

In order to match the way you communicate to the needs of all the people who use services do not take a ‘one size fits all’ approach.

It is important to consider how changes to the way services are delivered will affect the people who use them. A ‘one size fits all’ approach will not work, as one system will not meet the needs of the all the people who use services.

5. Effective user involvement will include the participation of people with different communication support needs

To help you identify the full implications of service changes for all members of the community, involve people who use these services, including people with communication support needs, from the beginning of the change process.

Services delivered around the needs of the people who use them will be more cost effective, user friendly and fit for purpose.

It is important that people with communication support needs have the opportunity to participate in the change process in the same way that others can.

6. Keep trying

Small, simple changes to the way you communicate will make a big difference to your service delivery. Some changes may take longer, but will deliver positive outcomes, resulting in cost efficiencies and an increase in user satisfaction.

Source:

Scottish Government (2011). Principles of Inclusive Communication An information and self-assessment tool for public authorities.
Available from: http://www.gov.scot/Publications/2011/09/14082209/0

Resources:

RCSLT videos
Set of five videos exploring inclusive communication, produced by RCSLT Scotland.
Making communication even better  NHS Education for Scotland learning resource for health, education, social work and voluntary sector staff
Available from: https://test1.nes.digital/media/2036508/mceb_workbook_interactive.pdf

Include us All: Scotland’s Inclusive Communication Hub:
Available from:  http://includeusall.org.uk/resources

What is ‘screen time’?

“Screen time” is an expression used to describe activities carried out in front of a screen such as watching TV, using a mobile phone, tablet or computer, playing online electronic games.

As technology continues to develop children are accessing digital content at a younger and younger age. Digital media is now a ubiquitous part of children’s lives perhaps from even before they are born. This growing presence of digital media has led to an increasing interest in how use of this media influences children’s development in both positive and negative ways. As we collect further research this will enable early years practitioners to achieve their shared responsibility for improving the well-being of children. It is important to consider both the context and content of what the child is viewing; considering what the child is watching not merely the length of time that the child is using a smartphone, tablet, computer or TV.

Neurological development in the early years is significant and children need many opportunities for interaction with their caregiver to achieve optimal development. Playing and talking together with a sensitive adult not only builds language skills and vocabulary, but also lays the foundations for attention, emotional wellbeing and reduces the risks of later behavioural issues. Background noise and images such as those from the television or other devices has been shown to disrupt sustained play and reduces the quality of the parent-child interaction. In particular the background noise from the TV reduces the quantity and quality of the language addressed to the child (Christakis, Gilkerson and Richards et al 2009).

Research suggests that children gradually come to understand child directed television content though this is dependent on the quality and content of the programming (Anderson et al 1986). Children continue to require support and interaction from a sensitive and responsive adult well into the toddler years. (Anderson & Pempek 2005).

Early years practitioners often witness infants and toddlers using touch screen devices however little is known about their understanding of the content viewed.  This area of research continues to grow and evidence is mixed about the impact on cognitive development. However, parental use of mobile devices has consistently been shown to reduce parental interaction with young children with the resultant negative impact on cognitive skills particularly language and executive function (Radesky et al 2014).

Key messages

• Children need opportunities to interact with their world and the people in it. It is important that parents respond to their children’s attempts to communicate with them. Screen time and digital media use may reduce parent’s responsiveness
• It can be helpful to include some “screen free” time each day with no distractions or background noise to support and encourage interaction
• Research suggest that harm occurs when screen time crowds out playing time and interaction with adults. Encourage parents to share screen time with their child and use it as a foundation for play and interaction extending the play beyond the screen
• Encourage parents to be selective about what they allow young children to watch on screen, taking time to check the content is suitable for their stage of development. For children under 2 years of age there can be negative impacts on cognitive development, particularly in relation to language and executive function, largely due to exposure to content programming produced for adults (Anderson & Subrahmanyam 2017)
• Encourage parents to establish boundaries for their child’s use of screens using parental controls as appropriate.
• Getting out and about is important for children’s physical development and wellbeing and to prevent issues with weight. Parents should be encouraged to be mindful that screen time does not reduce opportunities for other play experiences
• Use of digital media can be used to build and maintain relationships with absent adults (e.g. grandparents, parent working away, parental shift working pattern, parent in prison)
• Children are influenced by the screen time habits they see around them. Encourage parents to review their own screen use to consider if this could get in the way of positive interactions with their child. Encourage parents to put their phone/tablet down when their child attempts to communicate or interact with them.

References

Anderson, D. and Pempek, T. (2005).Television and very young children. American Behavioural Scientist 48 (5) 505-522
Anderson, D., Pugzles, Lorch. E., Field, Collins, & Nathan, J. (1986). Television viewing at home: Age trends in visual attention and time with TV. Child Development  57 1024-1033

Anderson D.R., & Subrahmanyam K (2017) Digital Screen Media and Cognitive Development. Pediatrics 140 (supplement 2) S57-S

Christakis, D.A., Gilkerson J., Richards, J.A., Zimmerman, F.J., Garrison, M.M., XU, D.,Gray ,S., &  Yapanel, U. (2009). Audible television and decreased adult words, infant vocalizations, and conversational turns: a population-based study.Archive Paediatric Adolescent Medicine  163 (6) 554-558

Radesky,J.S., Kistin, C.J., Zuckerman, B., Nitzberg, K., Gross, J., Kaplan-Sanoff, M., Augusty, M., and Silverstein, M. (2014). Patterns of Mobile Device Use by Caregivers and Children During Meals in Fast Food Restaurants
Pediatrics 133 (4) 843-849

Resources

Literacy Trust:
Available from: http://literacyapps.literacytrust.org.uk/links/

Children often stop, pause, start again and stumble over words when learning to talk (e.g. ‘um’/‘er’) and repeat words or phrases (e.g. “can we go, can we go to the shop”).  This can be part of typical development and is most common between the ages of two and five years old.  For the majority of children non-fluency is temporary and often associated with a rapid spurt in language development. For some children these difficulties can persist and impact on their ability to express themselves.

What is Stammering?

• Stammering or stuttering is characterised by unusually frequent repeating or prolonging (stretching) of sounds or words or blocking on these (no sound coming out). The child may struggle to speak which can sometimes lead to anxiety, distress or reluctance to speak.
• Onset is usually between 2-5 years of age but can be earlier or later.
• Boys are four times more likely to stammer than girls.
• Stammering can vary in severity over time and can come and go.
• It can vary in different situations and with different people

When a child stammers you may notice that s/he:
• Repeats part of a word several times (“mu-mu-mu-mu-mummy”)
• Repeats  single syllable words several times (“I I I I want to go”)
• Stretches sounds in a word (“sssstory”)
• Cannot seem to get started, no sound comes out for several seconds (blocking, “… dog”)
• Adds sounds before certain words (“n, n, n, Jackie”)
• Uses other non-speech sounds before getting started (e.g. coughing, throat clearing, sniffing)
• Shows struggle when trying to say a word
• Has unusual associated body movements when speaking (e.g. clenching hands, jerking the head, tapping a foot)

What to look out for?

The following factors have been shown to be characteristic of those children at greater risk of developing a persistent stammer.

• A family history of stammering
• Age of onset is after 3 ½ years
• Child has been stammering for 6-12 months without any improvement
• Child exhibiting other speech and language difficulties

How you can help: Key Messages

• Slow down your own rate of speech and include more pauses in your talking so that your child feels less rushed. Modelling a slow speech rate is much more helpful than telling a child to ‘slow down’.
• Give your child time to finish what s/he is saying.
• Try not to ask your child too many questions. Give time for him/her to respond.
• Show your child that you are interested in what s/he is saying and not how s/he is saying it. Look at your child to show that you are listening and attending to him/her.
• Don’t try to anticipate what your child is saying and complete his/her sentences.
• Try to avoid a hectic environment. Some children who stammer respond well to routines and structured environments.
• If your child gets particularly stuck, it may be helpful to acknowledge this but in a positive way e.g. “That was a hard word but well done you for trying”.
• Particularly for older children, it may help to reduce any anxiety about talking in a group by giving them their turn at the start or near the beginning of an activity.

What does a Speech and Language Therapist do?

A referral to Speech and Language Therapy should be made if there is parental/carer concern and/or if stammering is having an impact for the child/young person.

The speech and language therapy (SLT) can:
• Evaluate the risk of persistent stammering and the need for monitoring and intervention
• Provide support for parents, carers, children and young people
• Empower parents and other key workers

Resources:

The British Stammering Association
Available from: https://www.stammering.org/

What is selective mutism?

Selective Mutism (SM) is an anxiety disorder where the child speaks little or not at all in some situations, while in other situations the child talks freely. This doesn’t mean they are always anxious but at times when there is an expectation for them to talk, their anxiety levels rise. The pattern is predictable and has persisted for at least a month. It is not to be confused with ‘traumatic’ or ‘reactive’ mutism which is a symptom of post-traumatic stress disorder.

Indicators towards a diagnosis of Selective Mutism:
• The child has a consistent pattern of not speaking to, or in front of, certain people.
• The child talks comfortably to at least one other person, but stops talking, whispers or becomes visibly tense when aware of anyone else approaching.
• The failure to speak has a significant impact on educational or occupational achievement or social communication.
• The child has described, in the absence of stammering, a sensation of ‘freezing’ or their voice getting stuck or not coming out.

Children with selective mutism appear to be shy in many situations but are not necessarily shy by nature. Shy children may be worried about talking whereas children with selective mutism are terrified and won’t just grow out of it. Children with selective mutism may also have other diagnosis or speech and or language impairments.

What to look out for?

Some children are just shy but they do not show the aversion to speaking that characterises selective mutism. Children with selective mutism are not stubborn and need support to find ways for them to participate in non-stressful ways. Children who are shy, however can become selectively mute.

Look out for children who:
• Swing from relaxed and chatty to wary and reticent
• Stiffen their body and face and their communication becomes non-existent or reduced to whispers, single words, short phrases or gestures in certain situations.
• Talks happily to their peers or some family members but when a teacher or less familiar adult approaches they clam up or, they find it easier to talk to someone they barely know
• Become so anxious in talking situations that their muscles become tense and it can interfere with their ability to point, handle objects, walk or run

How can you help?

• Early identification and management of selective mutism is important
• Ensure there is no pressure on quiet or reluctant speakers to speak. Also do not ask them direct questions
• Provide gentle support that enables the child to participate at their own pace
• Ease into communicating with the child by chatting with parent/ carers first, then slowly increase your non-verbal communication with the child, and perhaps give them something to play with before talking to them without any expectation for them to reply e.g. comment on something about what they are doing
• Look to more detailed advice to offer the parent from the Speech and Language Therapy Department.

What does a Speech and Language Therapist do?

Speech and language therapists work with a wide range of communication difficulties stemming from a variety of causes including psychological causes. Given the wide range of possible contributing factors and the changing presentation of selective mutism, various professionals may be involved in assessment process. This is to ensure that the most appropriate and effective interventions and be planned.

The speech and language therapist can offer specialist advice and support, and liaise with other professionals if needed to help manage selective mutism effectively. The speech and language therapist can offer advice on how best to adapt the communication environment for the family, carers and those supporting the child on a daily basis to ensure they have management strategies to try out.

Further reading/resources

• Johnson, M. and Wintgens, A. (2002) The Selective Mutism Resource Manual, Speechmark Publishers.

• Johnson, M. And Wintgens, A. (2012) Can I Tell You About Selective Mutism? Jessica Kingsley Publishers.

• Selective Mutism Information and Research Association (SMIRA)
Available from: http://www.selectivemutism.org.uk/

• Afaisic
Available from: https://www.afasic.org.uk/download/6/

• Talking PointAvailable from: www.talkingpoint.org.uk

What are voice disorders in Children?

Voice Disorders are when the voice sounds different persistently or intermittently to what might be considered typical. This may be considered a change to the individual child’s usual voice or different in comparison with their friends or siblings.

The voice can be affected in different ways:

Quality 

e.g. the voice may sound hoarse, husky, breathy or rough.

Pitch 

e.g. the pitch may be habitually too high or too low for the age, or build of the child.

Loudness 

i.e. the child does not control the volume of their voice.

The most common voice problems in children include laryngeal strain, vocal cord nodules and vocal cord polyps.  When the voice is misused this is referred to as ‘vocal abuse’.

What to look out for?

Dysphonia: 

may present as total voice loss (aphonia) or partial voice loss.

• Straining of the voice, shouting and screaming.
• There may be excessive use of whisper which should be avoided. Whispering does not protect the voice and may damage the vocal cords.
• The quality of the voice may be hoarse/husky/breathy or strained/rough.
• Voice loss may occur at different times in the day.
• Voice loss can follow shouting e.g. at a football match/concert/night out/singing
• Voice loss can occur due to emotional upset reflecting tension and poor breath support

Pitch:

• Pitch control may be difficult leading to ‘pitch breaks’ in conversation or persistent high or low pitch.
• Consideration should be given as to whether the pitch is an acceptable pitch for the child’s age and build.

Loudness:

• Volume control is important for the health of the vocal cords.  It requires adequate breath support and co-ordination to be effective without damaging the vocal cords.
• Trying to raise voice and straining the vocal muscles is exhausting and is not necessary.
• When a child uses a loud voice all the time it can be damaging. There is a high risk of vocal cord damage when the cords are hit together forcefully to raise volume.
• When a child uses a whispered voice.  Being too quiet is a strain on the vocal muscles and can lead to further problems e.g. vocal nodules.
• If a child is unable to raise volume there may be difficulty co-ordinating breath support for voice production.

How you can help?

The voice can be an indicator of how we feel.  Both physical and emotional changes in a child can have an effect on their voice production.

Be aware of common bad habits:
• Talking too long and running out of breath, talking too loudly, straining voice.
• Straining caused by shouting/screaming/emotional outbursts crying or laughing.
• Excessive voice use speaking/shouting/singing resulting in voice loss.
• Coughing which is unproductive.  Consider if the child uses an inhaler with spacer and regularly rinsing following use of inhaler.
• Imitating noises from TV programmes or creating their own e.g. grunting or voicing when breathing in.
• Dryness from medications, allergies or mouth breathing.
• Inadequate fluid intake.

Be aware of the child’s home/school situation:
• Is the family a loud family?
• Sitting in front of games can be stressful and result in shouting.
• Sports activities football/ swimming/athletics if shouting involved.
• Stress or tension.

Be aware of the child’s general health which may increase risk of voice disorders:
• Asthma or allergies
• Acid Reflux
• Frequent upper respiratory infections leading to chronic cough and inadequate breath support
• Behavioural problems resulting in shouting/screaming/being constantly loud

Encourage good vocal hygiene care:
• Drinking adequate fluid such as water or diluting juice. 
  o Young children should typically drink between 1-1.5 litres per day depending on their size
  o Children over 14 years should drink 1.5-2 litres per day
  o Avoid fizzy drinks and caffeine
• To avoid shouting and whispering.
• Encourage positive family support such as no smoking around the child or in rooms where the child may play
• Encourage quiet play activities

A referral to Ear, Nose and Throat (ENT) may be made if you have concerns for the child’s voice.ENT will refer to Speech and Language therapy.

Phone Speech and Language Therapy for advice if required.

What does a Speech and Language Therapist do?

Following an ENT examination, speech and language therapists assess the child taking a detailed history and, if appropriate, offer a voice therapy course for the child and their family/carers/school.

The results from the ENT examination would be discussed. Education for voice care would include talking with the school, if appropriate.

Therapy covers an explanation of normal voice production and vocal hygiene care.  Normal voice production involves relaxed breathing to support voicing and volume control, as well as relaxed laryngeal muscle movement to enable easeful phonation (vocal cord movement).

All factors which are harmful to the voice should be identified and these behaviours modified or stopped. Diaphragmatic breathing, easeful voicing and projection of voice are practised.

Vocal hygiene care teaches the child how to maintain a healthy voice though adequate hydration and avoiding irritants. The management of inhaler use to reduce side effects would also be discussed if appropriate.

References:

Speech therapy information and resources
Available from: www.speech-therapy-information-and-resources.com