Children’s therapies the Pod (Medway)

Speech

When we use the term ‘speech’, we are referring to the production of sounds to form words.

Language

In the simplest sense, we think of language as being the understanding and use of words, sentences and grammar. This involves both receptive language (understanding) and expressive language (use of language).

Communication

Communication involves conveying thoughts, needs, wants and ideas to another person or people. Please refer to ‘Preschool core standards’ document pages 56, 75, 77, 88, 97, 104 and 106 to see what ages these skills develop in typically developing children. We communicate using language but also non-verbal means such as gesture, facial expression, body language, eye contact etc. Speech is not essential.

Children develop their Speech, Language and Communication skills at different rates and ages. Typically, children will do this through the development of the skills represented in the Communication Pyramid.

1. Speech sounds (top of pyramid)
2. Use of language
3. Understanding the language
4. Play
5. Attention and listening
6. Pre-verbal and early interaction (bottom of pyramid).

These core standards are aimed to help parents and professionals identify areas that a child may be having difficulties with and explore appropriate strategies through practise and play.

Core standards has a holistic focus and includes support with sensory, physical and communication needs.

Although these are labelled as pre school and school age documents, you can use strategies and ideas from both documents to support children, depending on what stage they are at with their communication development, irrelevant of their age. You may need to adapt the resources or activities to suit their individual needs, interests or motivations.

• Medway pre-school core standards
• Medway school age core standards

To be able to communicate with others we need to be able to focus and attend to what someone is saying. We also need develop skills to enable us to interact with those around us. These skills can include developing attention, sharing enjoyment and turn taking. The following resources can support children and young people with developing these skills.

Some of the videos may feature younger children or children with differing needs and diagnoses but the ideas and advice in them can be used to support children of all ages and abilities.

• View further information on foundation skills for communication

Videos

• Making choices
• Ready steady go
• Turn taking
• Making choices
• First and then
• Refocussing a child's attention
• Developing joint attention
  (opens in new tab)

Understanding spoken language can sometimes be referred to as ‘receptive language’ or ‘comprehension’ of language. In simple terms, this is ‘understanding what words mean’. Children develop their understanding of the meaning of words by hearing the word used at the same time as they experience it, for example, by touching, feeling or seeing an object, action, concept or feeling/emotion.

Using spoken language can sometimes be referred to as ‘expressive language’. This is the use of spoken words to name an object, concept, action or feeling/emotion. It also refers to the way that we put words together to form a sentence and the grammar we use which affects meaning, for example, tense markings, use of plurals etc.

Children can also develop their understanding and use of language without spoken words through a range of different communication systems such as sign language, use of symbols/pictures and through electronic devices. 

It is important to remember that children develop their use and understanding of language at different ages and stages in life. Read more information about ‘typical’ language development (page 76).(opens in new tab)

There is also growing awareness in the world of speech and language therapy that suggests some children may be processing and developing their language in a different way. Rather than starting with single words and building up to phrases and sentences, some children will start their language development by storing and using whole phrases or single words that they have picked up from their surroundings (either from adults, other children or media such as songs or video clips they have heard). This process of developing language is known as ‘Gestalt Language Processing’ or ‘GLP’.

‘Gestalt Language Processing’ is just a different way that some children develop language. Developing language as a GLP or through more traditional methods are both effective ways of children learning language. Many children will pass through the different stages of language development naturally without needing support. However, some children, whether they are developing language as a GLP or a through a more traditional framework, can get stuck at a certain point in their development. It is these children that may need additional help, from those around them, to help them move forward with their language development.

The following resources can support children and young people with developing their use and understanding of language through the traditional language development framework. Some of the videos may feature younger children or children with differing needs and diagnoses but the ideas and advice in them can be used to support children of all ages and abilities.

Read more information about supporting children who may be developing their language as a Gestalt Language Processor.

Videos

• Understanding and using language
• Vocabulary
• Communicating without words
• Modelling, commenting and expanding
• Using gestures alongside words
• Signing and gesture parent training session
• Asking for help
• Developing sentence structure
• Developing narrative skills

Augmentative and Alternative Communication (AAC) includes all forms of communication that supports or replaces speech. AAC enables children and young people to express their thoughts, needs and ideas. Using AAC will not impact on speech development. Research suggests AAC supports speech and language development. 

AAC includes low tech paper-based systems such as Communication Boards and Communication Books, light/mid tech systems such as Big/Little Macs, E-Tran Frames and Go Talks as well as high tech systems such as Voice Output Communication Aids (VOCAs).

Children with Speech, Language and Communication Needs benefit from a total communication approach which incorporates the use of spoken language, sign/gesture, picture and symbols to support their language development.

Speech sounds are the building blocks of words and are the top of the communication pyramid. Speech sound development is important because a change in a single sound can completely change the meaning of the word.  For example, if a child hasn’t yet developed their “k” sound, then they are likely to call a “key”, a “tea” – this completely changes the meaning of the word and may cause confusion to the listener.

When thinking about speech sounds, we consider the following properties:

• To be able to use speech sounds first we need to be able to discriminate (hear the difference between sounds). We then need to be able to process them and be able to store them. Only then will a child be able to produce the sound accurately.
• Noisy or Quiet? For some sounds our vocal cords vibrate which makes them noisy (for example, b/d/z) and for some sounds our vocal cords do not vibrate which makes them quiet (for example, p/t/s)
• The place of articulation is where the sounds are made in the mouth.  Some sounds may be made at the front of the mouth (for example, p/t/s) and some are made at the back of the mouth (e.g. k/g/ng)
• How is the sound made? This considers how the air escapes to make the sound.  Some sounds are long and hissy (for example, s, f, v, sh); some sounds a short (for example, b, t, g); some sounds are made by the air being directed through the nose (m, n, ng).

Read more about when children develop different sounds (page 109)

Infants and children and young people (CYP) seen in MCH’s Children’s Feeding Clinics can have difficulties with feeding and/or swallowing and/or have difficulties with gaining adequate nutrition and hydration in order to grow and develop in a safe and healthy way.

Speech and Language Therapy Feeding Clinic

Infants and CYP seen in this clinic may have delays/difficulties with feeding, such as eating age appropriate textures/consistencies or difficulties drinking from certain receptacles.

Infants and CYP are also seen in this clinic if they have disordered feeding and swallowing (called dysphagia) which means a child is unable to prepare and swallow food/drink safely so that it goes down towards their stomach, rather than heading towards their lungs. Dysphagia usually occurs as a result of a primary diagnosis for example, neurological/ neuromuscular disorders, anatomical/structural differences, genetic disorders, secondary to systemic illness (illnesses that affect the body’s respiratory/gastrointestinal/ cardiac systems) and from being born prematurely.

Dietetic Feeding Clinic and Joint Feeding Clinics

Depending on the severity of the feeding difficulty and/or dysphagia, a child may need to be solely/additionally fed via a tube (aka. enterally-fed) directly into their stomach (PEG/PEJ) or through their nose (NG). If this is the case, a child may require sole/ joint input from a dietitian in order to make sure that they are able to receive enough nutrition and hydration in order to grow and develop healthily.

Please see the below presentation which details what to expect in each of the feeding clinics:

If you have concerns that your child is having difficulty or has a disorder of feeding and/or swallowing, please ask a health or educational professional to complete the feeding clinic referral form, giving as much information as possible. Once received, the feeding clinic team, consisting of speech and language therapists and dietitians will look at the referral and allocate to the appropriate feeding clinic.

How to access the service

Your GP, Consultant, Health Visitor, School Nurse or other Health Professional may refer to the service.

• Feeding clinic referral form

What is deafness?

Deafness is different for every child.

• Some children can hear louder sounds (for example, a dog barking) but not softer/quieter sounds (for example, birds outside).
• Other children have a greater hearing loss and do not hear louder sounds
• Some children have difficulty hearing high pitch sounds (for example, a whistle) while others have difficulty hearing low pitch sounds (for example, cars rumbling along the road)
• Some children have difficulty hearing both high and low pitch sounds.

Children with hearing loss typically miss out on hearing others speaking or don’t hear the words clearly. Children learn spoken language from hearing other people speaking. Children with hearing loss can be given extra support with communication by their families and adults who work with them.

Types of hearing loss

There are different types of hearing loss, different causes of hearing loss and different severities/levels of hearing loss. Find out more about the different types of hearing loss.

How can I support a child with hearing loss?

The video ‘Supporting your deaf child from babyhood’ includes strategies for supporting communication starting from babyhood. The video is for parents/carers of young children and may also be useful for adults working with young children.

Speech and Language Therapists and Teachers of the Deaf can answer questions and offer advice about supporting communication. Wearing hearing technology (for example, hearing aids or cochlear implant processors) all waking hours helps children with hearing loss to develop spoken language. Parents can seek support with hearing technology from Audiology, a Teacher of the Deaf or a Speech and Language Therapist.

Supporting your deaf child with communication from childhood

How can I support a child with their listening?

Hearing through hearing technology is not the same as typical hearing. The sound a child hears through hearing technology is less clear and is different for every child. This means that deaf children are likely to need some extra help with developing their listening. You can support a child with their listening by:

• Supporting the child to wear their hearing technology all waking hours – speak to your Speech and Language Therapist or Teacher of the Deaf if this is proving difficult
• Reducing background noise (turn off the washing machine, tumble dryer, TV as much as you can)
• Singing action songs (or singing and signing) together – sing the same songs over and over
• Musical activities
• Using a sing-song voice when you say your child’s name
• Using particular phrases over and over within a familiar routine (for example ‘up..up..up!’, ‘ready, steady, go!’, ‘one, two, three, whee!’)

Your child’s Speech and Language Therapist or Teacher of the Deaf may recommend particular activities for your child. The video ‘Auditory training’ includes information about auditory training which your Speech and Language Therapist may recommend and guide you with.

Auditory training

Signing

If parents themselves are deaf their preferred language may be British Sign Language (BSL). BSL is a full language which does not include spoken words and which has a different structure to English.

In some families, parents may choose to learn BSL to support their child. BSL can be taught by a qualified BSL teacher. In some families, parents may learn signs to use alongside spoken language (for example, Sign Supported English) to support their child.

Speech and Language Therapists and Teachers of the Deaf can answer questions about learning signs to use alongside spoken language and/or about learning BSL.

Sensorineural hearing loss

Some children have sensorineural hearing loss (SNHL) – this usually means that the cochlea (part of the inner ear) is not working effectively. Less often this means that the auditory nerve (the route from the inner ear to the brain) is not working effectively – this type of SNHL is called auditory neuropathy spectrum disorder (ANSD). SNHL is always permanen

Conductive hearing loss

Some children have conductive hearing loss – this means that sound is unable to pass effectively through the outer and middle ear to the cochlea. Conductive hearing loss can be permanent or it can be temporary (for example, glue ear causes temporary hearing conductive hearing loss).

Mixed hearing loss

Some children have mixed hearing loss – this means that they have both SNHL and conductive hearing loss.

Severity of hearing loss

Hearing loss is measured in decibels (units of loudness).

Hearing loss can be mild (the least hearing loss), moderate, severe or profound (the greatest hearing loss). The severity of hearing loss typically varies depending on the pitch (also called frequency) of the sound. For this reason every child has a unique pattern of hearing loss which is typically different in each ear.

Audiologists measure hearing loss and show the results on audiograms (charts similar to the picture on the right). It is important to have regular hearing tests so that children can be given effective hearing technology.

Causes of hearing loss

There are many causes of hearing loss. It is not always possible to identify the cause. Audiologists and/or paediatricians may be able to investigate/identify the cause. Possible causes of hearing loss include: a genetic condition, a viral infection during pregnancy, a head injury.

Selective mutism (SM) is an anxiety-based disorder that affects a child’s ability to speak to specific people, in specific environments despite being able to talk freely in settings where they feel more comfortable e.g. at home with their family. 

For some children, they are able to use non-verbal communication to get their message across in these situations such as nodding, pointing, using their fingers to express numbers/choices etc.  For others, they may be literally ‘frozen’ in their anxiety and unable to respond in this way.

SM is NOT a choice

It is important to remember that the young person does not CHOOSE to remain silent, their anxiety prevents them from being able to speak, even if they desperately want to. It is not personal. They need your help to build their confidence and trust.

If you have concerns about your child’s talking in different environments and think they may have selective mutism, please speak to your health visitor or your child’s nursery or school to discuss whether a referral to the speech and language therapy team is appropriate.

If your child is not in education, please contact us on 0300 123 344 or email: medch.childrenscommunity@nhs.net to discuss accessing further support.

Assessment for Selective Mutism

Assessment for selective mutism will look slightly different for each child depending on the needs identified in the child’s referral. The assessment will often involve an observation of the child or young person in an educational setting and a meeting with parents and school/nursery staff to gain a picture of the child’s communication across different settings. At times, it will be appropriate to complete a direct assessment with the child however for some children this will not be appropriate. The therapist seeing the child for assessment will be able to explain the assessment process in more detail once a referral has been triaged and accepted.

Training for schools and parents

Once a child has been referred to our service, an assessment has been completed and a diagnosis of selective mutism has been agreed, a package of support will be discussed and agreed with home and school. If a child is in nursery or an educational setting and difficulties with talking are impacting the child at school or nursery, then whole school training may be offered to the setting to support staff with creating an anxiety free environment for young people with selective mutism.

In addition to this training, parents and school can also access online training offered by Kent Community Healthcare. This training has been developed for children and young people living in Kent but the team have kindly agreed to families and schools in Medway having free access to this online training.

To access the training please visit the Kent Pod – please feel free to use the information and strategies in this training to support children at home or in your setting however please note, any information about support pathways will be related to Kent and not to children living and accessing education in Medway.

If you have questions about accessing support for your child with selective mutism in Medway, please speak to your health visitor or your child’s nursery or school to discuss a referral to the speech and language therapy team.

Stammering can be known by a variety of names including, stuttering, repeating, words getting stuck, bumpy talking, dysfluency.

Up to five per cent of all children go through a period of stammering between the ages of two to four years old.  This is often around the time when their vocabulary/language suddenly increases and the language demands placed on them increases either by starting school, nursery or just expanding their experiences. Approximately one per cent of children will go on to stammer into adulthood.  We can not predict which children will grow out of their stammer and which ones will continue to stammer so it is important to create a supportive communication environment for all children who stammer to support their talking.

What does Stammering look like?

Stammering can present in the all or some of the following ways:

• Repetition: Repeating initial sounds, or words, for example, ch-ch-chocolate
• Prolongation: Stretching out sounds/syllables, for example, mmmmummy
• Blocking: When a word gets stuck and nothing comes out ‘ch……ocolate’.

Sometimes you also may notice

• Body/facial movements in moments of stammering
• Tension in face/neck/body
• Avoidance of certain words/situations.

If you are concerned about your child’s talking please speak to your health visitor or your child’s nursery or school to discuss whether a referral to the speech and language therapy team is appropriate.

If your child is not in education, please contact us on 0300 123 344 or email: medch.childrenscommunity@nhs.net to discuss accessing further support.

Take a look at the advice sheets (on the right) to support your child’s talking at home, school and nursery. 

Signing for schools and pre-schools

The MCH Children’s Speech and Language Therapy team have developed this video series for our education colleagues in schools and pre-schools. Staff are encouraged to use signing alongside spoken language (sign as you say the key words) with children who are developing their talking. For more information on this please visit Introduction to signing. The videos are very short (around one minute each) and many include just one sign.

To support staff to become confident with signing, schools/pre-schools could recommend that all staff watch one episode each week and to try to use the sign(s) many times that week. You are of course welcome to use the series in any way that suits your school/pre-school.

Gestalt language processing (GLP) is a different way that some children process and develop their language. Rather than starting with single words and building up to phrases and sentences from there, gestalt language processors will usually start by storing and using whole phrases or single words that they have picked up from their surroundings (either from adults, other children or media such as songs or video clips they have heard).

GLPs are often drawn to the phrase due to the melodic intonation (what it sounds like) and any emotion they felt at the time of hearing the phrase. The child will then use this stored phrase to carry its own meaning. Sometimes this will fit with the context of the situation and sometimes a phrase will carry a different meaning for the child than the literal words used.

As children store and use more and more phrases (or scripts), they gradually start to unpick these phrases and piece them together with other language to form more flexible, independent language of their own.

Some children move through the GLP stages independently in line with their peers and do not require extra support whereas some children need additional support to help them progress through the stages to enable them to develop more flexible, spontaneous language.

How can I help?

If your child’s therapist has identified that your child may be developing language as a Gestalt Language Processor you can support your child’s language development through the following simple strategies at home, at school or at nursery:

• Spend time observing your child to see what activities they enjoy. Remember that play looks different for every child. If the child is enjoying an activity for the sake of the activity itself, this is defined as play. Whether it is playing with a toy, flicking paper, rolling around on the floor, lining up toys, pouring water, watching items fall or taking something apart and putting it back together etc.
• Give your child access to movement during play to support their overall sensory regulation.(opens in new tab)
• Engage in child led play activities and follow your child’s lead. Provide lots of opportunities and access to activities that they might like and if they show interest in these activities, engage in these alongside them. Remember it’s all about connection and having fun!
• Be curious about things your child is interested in and show interest, pleasure and excitement about activities that they enjoy. If they are not enjoying an activity, model phrases/scripts to help them express this e.g. ‘I don’t like this one’, ‘let’s do something different’
• When engaging in play activities with your child, aim to model a range of phrases/scripts for the child that link with what is happening. It is important that language is linked to lived experiences for them so they can link the language to the meaning in real life. This will help them understand, store and use these phrases again in the future if/when they need to.
• When modelling language, think about different functions of language to make sure you are providing varied models/phrases that will be motivating/useful to them in the future. Match the length of your phrases to be similar to phrases the child naturally uses:
  • Expressing wants/needs – ‘let’s eat snack’
  • Joint action routines – ‘wanna jump’
  • Surprises – ‘that’s a surprise’, ‘wow, look at that’
  • Transitions – ‘what’s next’
  • Protesting – ‘I don’t like that’, ‘stop doing that’
  • Sensory-motor experiences – ‘that’s too loud’, ‘turn it up/down’
  • Shared joy – ‘play dough is the best’
  • Help – ‘need some help’
  • Commenting – ‘that’s silly’
  • Self advocacy – ‘stop now’, ‘I need space’
• Try and avoid asking lots of questions during activities – instead comment on what you are doing e.g. instead of ‘do you want a drink?’ try modelling ‘I’m thirsty’.
• When modelling language during activities or in real life, try and do so from the child’s perspective or from a joint perspective e.g. start sentences with ‘I…’ (from the child’s perspective) or ‘We…, ‘Let’s…, ‘It’s…’ etc (from a joint perspective). If the child was to store the phrase modelled and use it in the future, we want to try and avoid them storing a phrase that starts with ‘you…’ as this will be confusing for others if they are talking about themself.
• When modelling new and novel phrases, try and use varied intonation and pitch changes as this will make it easier for the child to pick up on the phrases and store/use them in the future.
• If your child uses a set phrase or ‘script’ in their talking, acknowledge what they have said even if you are not yet completely sure of the meaning. You can do this by either repeating the phrase back to them or responding with a simple acknowledgement such as ‘yes’, ‘OK’ etc. If the phrase appears out of context, try and work out where this phrase might have come from and what the meaning might be to the child (as this may not be the literal meaning of the words used). Watch out for phrases that might come from special interests e.g. Peppa Pig, Paw Patrol, Avengers, Barbies, favourite songs or stories.
• If your child does have special interests in a particular topic, toy or TV show, try including these interests in your play using visuals, toys or even clips from their favourite video to see if they use more scripts from these interests to enable you to work out the meaning of the phrases to them.
• You can also try reading and writing preferred phrases or scripts to increase engagement in these tasks. Creating words with magnet letters, in messy play or other sensory activities can also be incorporated into play activities.
• Remember the power of silence. You don’t need to model language all of the time. Incorporating silence into play can also help your child process what’s happening and figure out what they want to say
• It’s OK to use ‘your voice’ too and to take time to stop, listen and wait to see what/how the child is engaging in an activity or what they might want to communicate before deciding how it would be helpful for you to respond.

What next?

If you think your child might be processing and learning language in this way, try keeping a record of the phrases you hear and when they use them to help you work out where these phrases might have come from and what they mean to your child.

If your child is open to the speech and language therapy service, sharing this information with your child’s therapist at future assessments and reviews will help the therapist gather additional information to support your child’s needs.(opens in new tab)

How can I learn more about Gestalt Language Processing?

You can access a free online Masterclass about GLP, by registering for free on the meaningful speech website: Meaningful Speech – Echolalia Education – Gestalt Language Processing.(opens in new tab).

Stages of language development for GLPs

There is ongoing research in the area of GLP, we are seeing more and more children that appear to fit this model of language development.

We are therefore trying to support children where they are currently at and help nurseries, schools and families to work through the Natural Language Acquisition (NLA) stages outlined below:

• Stage 1 – Whole phrases – using whole learnt phrases
  for example, “hey what are you doing” “let me do it for you” “oh no what happened”, “uh oh”, “OK”. Phrases or ‘scripts’ can be as small as a single word or as long as a whole book or song.
• Stage 2 – Mixing and matching. The child is starting to ‘shorten’ or mix and match their whole learnt phrases to either shorten them or combine two learnt phrases together or be adding a single word to a short phrase
  for example, “hey + what happened”, “let me + do it” “oh no + cat”, “oh no + dog”, “where’s + book”, “where’s + mum”
• Stage 3 – Single words and combinations of single nouns and descriptions. The child is now starting to pull out single words from their phrases and use these to link to real life objects and situations
  for example, “cat” “red circle” “green balloon” “three pineapple” “fluffy”
• Stage 4 – Combining words and beginning of early grammar. At this stage, the child is starting to combine single words together to make more unique, flexible phrases with the start of early grammatical markings
  for example, “hey you heart” “cat happen now” “I doing circle”
• Stage 5 and 6 – The child is starting to develop more complex grammar in their spoken language and develop understanding of different grammatical concepts.

Children will often be using language at a range of different stages. In assessment, the child’s therapist may take a language sample by either recording or writing down the words and phrases a child is using during child led play activities. This will then be analysed to help understand what stage the child’s language is mainly at and how people around them can support their language development. It’s helpful if you can provide additional information about things that your child says at home so that this can be considered in the assessment too. Download the GLP script record sheet in the ‘Further information and advice’ section on this page to help you record the scripts your child is using.

It is common for children to continue to use some of their stage 1 phrases or scripts in their talking, even when they are using language at a much higher level. This appears to be especially common when a child is tired or experiencing heightened emotions as it may be easier for them to retrieve stored/familiar phrases rather than generating more novel spontaneous language in these situations.