Children’s Speech and Language Therapy

Some infants and children can have difficulty with eating, drinking and swallowing. Some of these difficulties are very typical e.g. gagging and retching and we expect to see these as children get used to more practise with different textures. Heath Visitors are the best people to ask for support with weaning and development with textures.

However, some infants and children have difficulty with eating, drinking and swallowing that are not linked to typical development. This is known as Dysphagia. Eating, drinking and swallowing is a complex process which involves co-ordinating and timing the different muscles of the face, mouth and tongue. When this process is not working correctly, there is the risk that some of the food or fluid could go into the lungs.

Infants may have difficulties sucking, swallowing and breathing at the same time when having either a breast or bottle feed. Children may have difficulty moving the food around in their mouths and breaking this down between their gums or teeth before swallowing. For some toddlers and children, they have good skills in breaking down the food in preparation for swallowing, but there is a difficulty during or after their swallow. Toddlers and children can also have difficulties in safely managing fluids. Please contact the Speech and Language Therapy Team to discuss making a referral to the feeding team if you are concerned.

You might see some of the following signs of difficulty if infants, toddlers or children are having difficulties with eating, drinking and swallowing:

• An infant looking overwhelmed e.g. splaying their hands, their eyes widening and arching their back during feeding

• Bottle or food refusal (however this may also be due to a difficulty with reflux)

• Eyes reddening or watering when feeding, eating or drinking.

• Coughing during or immediately after feeding, eating or drinking

• Clearing throat during or immediately following feeding, eating or drinking

A wet or gargly sounding voice during or following feeding, eating or drinking

Please contact the Speech and Language Therapy Team to discuss making a referral to the feeding team if you have any concerns.

In our service, we provide support for children’s early communication and interaction skills, where they may not be accessing verbal language yet. This may look like providing strategies for you and your family to use, which can be embedded into your everyday life, to support your child’s developing communication skills. Such as:

• Modelling language without expectation of your child responding or copying. This way, they hear some great examples of language they could use but are under no pressure to respond.

• Having a child-led approach to play. This means that you engage with your child on their level, thinking about their interests and things that they find motivating, rather than trying to get them to engage with the things you would like them to. Play looks different to every child, sometimes it could be banging a spoon on a pot or building a tower with cushions and not just sitting reading a book.

• Following your child’s lead within play also helps to build connection as your child is interested and engaged making it easier for them to take in the language that you are modelling while having fun.

• Copying their use of early language, or babbling, or noises, or facial expressions, gestures or movements. This promotes shared enjoyment and interaction and acknowledges that this is their way of communicating once again building on that connection.

• Using Makaton or signs alongside your use of spoken language, to support learning new vocabulary.

• Using visuals to aid and support language development, such as objects, photos, symbol or communication boards that you often see in schools and nurseries. Or you could tailor this more to your child and print out pictures of things that they are interested in such as Sonic or Peppa Pig, or pictures of their family members or friends to engage with.

• Use silences within play too, allow your child time to process what has been said and if they are ready, they then have time to respond with their preferred method of communication such as gestures, facial expressions or vocalisations.

Language can be split into 2 broad terms- expressive language and receptive language. Expressive language is the child’s use of spoken language, whilst receptive language is their understanding of spoken language. We do not work on literacy. We can help with spoken language but we do not work on reading and writing skills.

Children who have difficulties with their expressive language may present with grammatical immaturities, or difficulties in structuring stories. Some children may not use any language, or may only use 1-2 word sentences.

Children who have receptive language difficulties may present with difficulties in following spoken instructions, or difficulties with understanding spoken information.

Some children may have more difficulties with expressive language than receptive language, or vice versa, or they may have a difficulty with both.

Developmental Language Disorder

• Developmental Language Disorder (DLD) is probably the most common difficulty that most of us have never heard of.   Yet it is much more common than autism, and it affects about 7% of the population – on average that’s approximately 2 children in every classroom. 
• Children, young people and adults with DLD struggle with spoken language.  Imagine you arrive in a foreign country where everyone talks to you and to each other in a language you do not know very well.  You will pick out some words that you recognise, but it is really hard to follow instructions, or take part in conversation.  Communication takes place so quickly that it is very hard for you to keep up and you might just ‘tune out’ as a result. This is how it feels to have a DLD.
• People with DLD may also find it difficult to put their own thoughts into words to tell you what they are thinking or feeling.  Many of them get the words muddled up or miss out parts of the sentence.  We all find it hard to remember words at times – it’s that ‘tip of the tongue’ feeling you might get occasionally where you know you know the right word but you just can’t think what it is. Children with DLD can struggle to find words all of the time. Others get the sequence of sounds and syllables in long words muddled up – they might say ‘cer-fi-ti-cate’ instead of ‘certificate’, or ‘hop-si-tal’ instead of ‘hospital’.
• The world can be a confusing and lonely place if you have DLD.  It’s hard to make friends when you can’t keep up with every day conversation.  Moreover if you are having trouble with spoken language, it is very likely that you will also find reading and writing problematic too.
• Children and young people with DLD will not necessarily ‘grow out of it’.  For many, it is a long term condition and can have a huge impact on their learning and achievement in school.  It may lead to the child feeling frustrated, anxious and lacking in confidence.
• In Gateshead, we have a dedicated team of speech and language therapists who routinely work with children and young people with DLD to help them and their parents cope.  We see children in the most appropriate setting including their homes, in clinics and in schools.  We are trying to increase awareness and understanding of DLD so that families and teachers know how to help. We also offer therapy to boost the child’s language skills, improve their communication, promote independence and raise self-esteem. 

Key word levels:

• You may have heard one of our therapists, or another professional talk about following ‘key word level’ instructions. ‘Key words’ or ‘Information-carrying words’ refers to the number of words in an instruction that the child needs to understand to be able to follow it.
• For example, ‘put the shoe on the table’ requires your child to understand that you mean ‘shoe’ and not ‘sock’ or ‘coat’. They also need to be able to understand that you mean ‘on’ rather than ‘under’ or ‘behind’, and they need to be able to understand that you mean ‘table’ rather than ‘chair’ or ‘bed’. This instruction would therefore be an example of a 3 key word level instruction, as it contains 3 key words.
• A key word must have another option for it to be a key word. For example, ‘table’ is not a key word if you only have a table in front of you, and don’t have a ‘chair’ or a ‘bucket’, or something else they could use instead, because it doesn’t show that they understand ‘table’- it’s the only option in front of them.
• As a general rule, we expect children to be able to follow as many key word levels in their instructions as their age, e.g. a 3-year-old should be able to follow 3 key word level instructions.

Word Finding:

Word finding, also called “word retrieval”, is a person’s ability to think of the right word when they need it, during conversation. This may cause them to have pauses, use filler words like “um” and “like”, or use non-specific words like “that thing” or “that stuff”. This is similar to when it feels like a word is just on the ‘tip of your tongue’. There are lots of strategies that can be used to support children with word finding difficulties:

• Use word webs. Word webs can be used for words that are completely new, or words that your child has struggled to recall. Word webs help to solidify those words into your head, making them easier to recall later.

• Practice describing words. The way that word finding difficulties work is that the child will often be familiar with the word, and what it means, but struggle to remember the word itself. Therefore, instead of saying the word, you could describe what it means instead, for the other person/people in the conversation and they will understand what you’re trying to say.

• Give other clues such as the first letter, the number of syllables, whether it’s a short or a long word, rhyming words, similar words or synonyms etc.

• They may also benefit from being told the topics that are coming up at school, so that he can pre-learn some core vocabulary using word webs or using a mind map.

• They may also benefit from having more visual support available. Children with word finding difficulties often find it easier to recall words when they can see a picture of the object or concept.

Natural Language Acquisition or Gestalt Language Processing:

• Every child is different, and therefore the way that children learn language may differ from one to the next. However, broadly speaking, there are two main ways that children acquire language, and these are called ‘Analytical Language Development’ and ‘Natural Language Acquisition’.
• Analytical Language Development follows a bottom-up approach, where children learn single words, and then start to put those single words together to form short phrases, which then develop into full sentences.
• Natural Language Acquisition follows a top-down approach, where children may start learning language in chunks or set phrases, rather than learning single words first. These chunks of language can be called ‘scripts’ or sometimes are known as ‘gestalts’. Children who follow this pattern of language development are sometimes called ‘gestalt language processors’.

Key Points about Gestalt Language Processing:

1. Repeating Language (Echolalia)
   Children might echo back what they hear right away  (immediate echolalia) or after a delay (delayed echolalia), using these gestalts as a way to communicate. This is a natural part of their language development. It is common for these children to echo language they have heard at home, in school, on TV, or on YouTube. They typically echo language that was highly emotive, such as an exciting line from a TV show. They also often replicate the intonation (rise and fall of voice) or accent of the person or character.
2. Intonation
   Children who learn language in this way are often drawn to the rich intonation (up and down musical tones) of songs, TV shows, and YouTube, associating these gestalts with strong emotions. Songs tend to capture their attention, and they often sing a wide range of songs or mimic their melodies and intonations. These children may sing these songs throughout the day, such as during playtime. However, sometimes they may only repeat the intonation they hear. This may sound like babble or strings of sounds that can be difficult to interpret.
3. Understanding Language
   Initially, these children may assign a general feeling or meaning to the whole phrase or gestalt rather than understanding each individual word. Over time, they begin to break these chunks into smaller parts, enabling them to understand and use language more flexibly. They may repeat these gestalts (delayed echolalia), reflecting the feelings or meanings they originally connected to the experience.

Strategies:

Responding to your child

• Respond to what your child has said positively, even if it is not completely clear. Nod, smile, make affirming sounds like “uh huh!”
• Repeat back the phrase, word, song, or sound that your child has used. Match and exaggerate their intonation as much as possible.

Being a detective

• Keep track of the gestalts (phrases) your child uses by writing them down exactly as they say them.
• It is useful to take note of the context the child used the gestalt
• This is useful in finding out the meaning behind the gestalt (phrase) and were it may have come from e.g. an episode of Peppa Pig.

Making Comments

• Try to reduce your questions
• Change your questions into comments, for example, you can turn “what’s that?” or “what have you got there?” into “you’ve got a car!”.
• You can comment on what your child is looking at e.g. “it’s a blue car!” or doing “I’m jumping”

Using music and intonation

• Give opportunities for your child to finish the last word, line or verse of familiar songs
• When commenting, try to make your voice sound exciting with exaggerated intonation.
• Sing songs related to the activity you are doing with your child. For example, sing “Clean Up, Clean Up” during tidying up or “This is the Way We Wash Our Hands” during handwashing.

Augmentative and Alternative Communication (AAC) refers to a broad range of strategies, tools, and systems designed to support individuals who face challenges with speech or verbal communication. The goal of AAC is to enable effective communication in as many situations as possible, ensuring individuals can express their needs, thoughts, and emotions.

Paper-based

Paper AAC systems do not rely on batteries or electronic components. Instead, they use manual tools and strategies that are simple but highly effective. Despite their simplicity, paper based AAC systems can meet a child’s communication needs exceptionally well. Even for those who use powered AAC, paper alternatives are essential backups in case the powered system malfunctions.

Examples include:

• Choice Boards: Flexible visual tools that show different options, like pictures, symbols, or words. They help children communicate their preferences, make choices, and express themselves by pointing to, touching, or handing over their chosen option.
• Communication Boards: A visual board featuring pictures, symbols, or words that children can use to communicate by pointing to the relevant image. These boards are designed specifically for the child and can be created for various activities at home or school.
• Communication Books: Multi-page books filled with pictures, symbols, or words arranged into categories, such as food, toys, or places. These books are personalised to suit the child’s individual needs.

People

This type of AAC does not need anything extra to communicate. Examples include:

• Facial expressions (nonverbal communication)
• Eye movement: Showing interest by looking at something (nonverbal communication)
• Body movement or gesture: Such as pointing, nodding, pushing an object away (nonverbal communication)
• Makaton Signing: Makaton is a type of AAC that combines hand signs, gestures, and spoken words to help children communicate. It doesn’t require any special equipment, making it simple and easy to use anywhere.

Powered

Powered AAC are often electronic, requiring power or batteries to function. Examples include:

• VOCA (Voice Output Communication Aids): These devices produce speech when a user selects words, symbols, or letters on the screen or input device.
• Eye Gaze Systems: These tools allow users to control a communication device with their eye movements, making them particularly valuable for individuals with limited physical mobility.

Before accessing powered AAC, individuals typically undergo assessments conducted by your local SLTs. In cases where more specialised support is needed, SLTs may refer individuals to services like the Regional Communication Aid Service (RCAS).

The RCAS provides:

Specialist advice and training for individuals, their families, and professionals working with them to ensure effective use of AAC systems.

• Comprehensive assessments to determine the most suitable communication aid for the individual.
• Long-term loans of communication devices, including ongoing technical support and repair services.
• Specialist advice and training for individuals, their families, and professionals working with them to ensure effective use of AAC systems.

Some children have unclear speech which can make it hard for them to communicate at home, at nursery/school or with their friends. Children may:

• Find it difficult to make certain sounds. For example, when they try to say ‘k’, a ‘t’ sound may come out, or when they say a ‘s’, it may sound lispy/hissy.
• Substitute/swap sounds in their talking. For example, some children may use a ‘t’ instead of an ‘s’, saying  “tun” instead of ‘sun’ or they may swap ‘g’ with ‘d’, saying “gag” instead of ‘dad’.
• Delete sounds instead of using them. For example, they may not say the consonants at the start or at the ends of their words. They may say “-at” or “ca-“ for ‘cat’.

Children develop their speech sounds at different rates, but most children have learnt and can use all speech sounds by the time they are 7 years of age. As a general rule, by 4 years of age, children’s speech should be intelligible to unfamiliar adults, even if they do have some persisting speech errors. To support children who have unclear speech, you can:

1. Talk about sounds in your everyday environment with your child e.g. You could say. “The sun is shining today. Sun starts with a ‘s’. ssssun”
2. Correctly repeat back any words to the child so that they hear the correct pronunciation.
3. Play games with sounds e.g. I spy
4. Read rhyming books or listen to rhyming songs.
5. Clap along to the syllables for things that they find exciting or motivating, e.g. ‘it’s Mario! Let’s clap along to Mario- Ma-ri-o! 3 claps!’

Glue Ear

Glue ear is where the middle part of the ear canal fills up with fluid. This can cause temporary hearing loss. Glue ear is very common with 1 in 5 pre-school children experiencing glue ear at any one time and 8 out of 10 children will experience glue ear before the age of 10. It usually clears up within 3 months, but see a GP about any hearing concerns.

Deafness

When deafness is the primary factor impaction on a child’s speech, language or communication difficulties they will be discussed with the Deaf Children and Young People’s Speech and Language Therapist (DCYP-SALT). The DCYP-SALT works as an integrated part of the Low Incidence Needs Team (LINT) supporting Deaf children and young people within Gateshead.

In conjunction with LINT staff, we target functional communication skills, speech and spoken language development as well as sign language development from birth to school leaving age depending on an individual’s specific needs. This may be direct intervention, programmes of work or tailored advice which is embedded into daily routines.

Speech and language therapists also work with children and young people who stammer.  Around 8% of children will start to stammer at some point. Stammering usually starts between the ages of 2 and 5 years, however it can start later, sometimes even in adulthood.

Stammering (also known as stuttering) and is a difference in the way some people speak, for example there may be single sound repetition, for example, “M-m-m-m-my name is D-D-D-D-Dan”. There could also be part or whole word repetitions, “Be, be, be, because”, “Can, I, can I, can I go to the park?”  Some people may also ‘strrrrreeeetch’ words or block in which words get stuck and won’t come out.

Sometimes stammering is also accompanied by other behaviours, such as tension in the face, mouth or body, blinking a lot or closing their eyes or looking away. Some children may feel out of breath and hesitate or pause before speaking. Sometimes children develop body movements such as jerking their head or neck, or tapping their feet or fingers in an attempt to help get their words out. Filler words such as ‘like, ‘um’, or ‘er’ may be used to help move into a sentence or a word they are struggling to say.

Some children may develop ways to reduce their stammer that are not obvious to others but are effortful for them, such as planning ahead and changing their words to ones they find easier to say or using a technique to help manage their stammer. Everyone’s stammer is unique and everyone stammers differently. How often a person stammers can vary, dependent on the environment or situation. Lots of people find they stammer more when they are tired, experiencing any heightened emotion or in a time pressured situation.

For most children, stammering will be temporary and may stop naturally. However some will continue stammering into adulthood. Usually, the longer someone has been stammering, the more likely it is to continue. Currently we don’t know which children will continue to stammer and who will stop.

There are several ways in which a speech therapist can support a child or young person who stammers to help reduce the struggle to speak, this may be indirectly through parents, nursery or school, or through direct therapy approaches based on individual need.

Should you have any concerns about your child stammering please contact the department and complete a referral.

For further information and advice please see:

Home – Action for Stammering Children

STAMMA home page

Michael Palin Centre for Stammering – The Michael Palin Centre for Stammering

Some children are naturally quiet and present a similar personality at home and in school. However, for some quiet children they may have a specific anxiety around speaking in certain situations. They may have plenty to say but are unable to speak freely. This is often not apparent until the child goes to playgroup or nursery. It is now understood that a child’s mutism is not a choice. This is not normal shyness or obstinacy; it is a psychological condition where children have developed a ‘phobia’ of talking to anyone outside of their comfort zone. Their panic reaction can lead to them ‘freezing’ and being unable to talk or doing all that they can to avoid the need to talk.

In the first instance, you will be offered a parent only appointment. This will help us to learn more about your child’s areas of strength and need and their patterns of talking. We will identify some helpful strategies for home and for nursery/school.

THINGS THAT HELP

Normalise worries about talking for your child:

• Let them know that you recognise it isn’t a choice.
• Reassure them it is OK and that you accept that they find talking difficult sometimes.
• Accept all forms of communication and respond as though they have spoken (e.g. smiles, head nod/shake, gesture, writing etc.

Confidence and self-esteem:

• Focus on what children can do rather than can’t. Foster their individual skills, talents and interests so that they have plenty to feel good about.

• Create opportunities for success and problem solving (e.g. learning a new skill, developing independence, consider activities where the focus is not on speaking – arts/sports/self-care etc.

• The BBC Bitesize website includes lots of good information about how to build resilience (bounce back ability) for children and young people.

What to say when:

Adults put pressure on your child to speak e.g. “are you going to speak to me today?” or “what have you been doing today?”

• You can say … “X will speak as soon as they feel ready”.

Your child is not able to speak in a situation.

• You can … change questions to comments “we’ve had a busy day” or rephrase to a yes/no questions that can be answered by head nod/shake.

You want to give some feedback or praise to your child.

• You can … Acknowledge the achievement in private. You might choose to describe what you are praising and add a strength word. For example, “you shared your toys/game/sweets with X that was really kind of you” or “You nodded to answer that man in the shop today, I know that can be hard to do, you are very brave”.

For more ideas and advice for children and young people who experience anxiety around speaking, please visit: http://www.selectivemutism.org.uk/

As a service, we do work with children and young people with voice differences, such as chronic hoarseness or roughness of the voice. Your child may be assessed in our service, but typically, you will be referred to a specialist voice clinic. There are 3 main clinics regionally: RVI, Sunderland Royal, James Cook.

Reducing shouting between rooms, over background noise, overlapping talking

Vocal hygiene tips:

Vocal education e.g., clapping hands analogy and straining

Hydration

Children aged 4-8 years need approximately 1 litre per day

Children/Young people aged 9-13 years need approximately 1.5 litres per day

Need to top up throughout the day rather than a lot of liquid at once

Water is best – avoid caffeinated drinks e.g. energy drinks/coke and excessive amounts of dairy drinks

Advice needs to be shared with school settings about accessing water through the day

Steam inhalation (usually for older children) can thin down mucous/hydrates voicebox directly

Voice rest – Telling a child to be quiet is generally impractical – doesn’t last/limited monitoring ‘in the moment’! Instead, child/family identify ‘quiet time’ activities

Reducing Vocal Hyperfunction – Telling a child to be quiet is generally impractical – doesn’t last/limited monitoring ‘in the moment’! Instead, child/family identify ‘quiet time’ activities

Throat Clearing Advice – Cyclical nature of harm from persistent throat clearing: Breaking the cycle by improving vocal hygiene and introducing cough suppression strategies e.g. sip swallow breath, ‘huffing

Environmental Changes – Reducing shouting between rooms, over background noise, overlapping talking

The children’s Speech and Language Therapy Service work with lots of children who use English as an additional language (EAL) across Gateshead.

Children who are EAL learners have either spoken or been surrounded by a language other than English during their early childhood years and have continued to speak this language either in their home environment, or in their community.

There are children all across the globe who speak more than one language, so children who are brought up with English as an additional language are not being required to do anything particularly unusual or difficult.

Children who are learning English as an additional language are just as able as any of their peers!

If your child is being referred to our service as an EAL learner, it is likely that you will be offered an interpreter for your appointments. Sometimes this is so that we can communicate effectively with you, but sometimes, we ask interpreters to come along to our sessions so that we can assess your child in both their first language, and in English.

It’s really important that your child has a good model of language from adults around them. If you are not fluent in English yourself, the best model that you can give is in your first language. It’s natural to want to surround your child with English given that you’re living in the UK, but we want them to hear your very best model, which may not be English.

When we WOULD see an EAL learner:

• Your child has difficulties with feeding, fluency, selective mutism, voice, hearing, or speech sounds.
• The development of your child’s first language is delayed or disordered.

When we WOULD NOT see an EAL learner:

• If your child’s first language is within normal limits for their age, then they do NOT have an underlying language delay or disorder, and therefore do not require our support.
• Your child’s first language follows normal development, but they have difficulties with using English.

The 0-19 Service is an integrated service for families, expectant mothers, children and young people that offers interventions from the pre-natal stage up to the age of 19. Harrogate and District Foundation Trust leads on the delivery of this service, with a focus on working across services and organisational boundaries to improve public health outcomes.  The universal reach of the HCP provides an invaluable opportunity from early in a child’s life to identify families that need additional support and children who are at risk of poor outcomes.