Does your child have a “raspy” voice?


Recently, I have had quite a few kids on my caseload who have a “horse” or “raspy” voice. When I bring this up to parents, many of them respond “oh she’s always just had a raspy voice!”. But did you know that this “raspy” vocal quality is often a sign of vocal abuse? Vocal strain and nodules are caused by stress to the larynx. This stress is generally referred to as “vocal abuse” or misuse, and can eventually lead to the development of vocal nodules.

Usually children develop nodules or strain due to the interaction of two or more of the following done in excess:

  • Talking and singing excessively without quiet “recovery time”
  • crying, laughing, and loud prolonged outburst of emotion
  • throat clearing
  • forcefully using their voice
  • Excessive coughing or loud forceful sneezing
  • Shouting
  • restricted fluid intake

Vocal nodules and strain are diagnosed by an Ear, Nose and Throat provider (ENT). Once the child has an ENT examination, speech therapy for the voice is usually recommended. The goal of voice therapy is to teach a healthy, non-abusive voice production patterns so the vocal cords can heal, allowing a return to a normal voice.

A typical vocal hygiene program will consist of:

  • isolating medical conditions (like GERD) that aggravate vocal problems, then undergoing treatment
  • modifying behaviors that cause distress to the vocal cords, like yelling
  • learning how to take deep breaths and relax the muscles in the throat
  • taking time to speak slowly and clearly
  • staying properly hydrated throughout the day
  • avoiding caffeinated beverages, like soda, which dry out the vocal cords

If your child presents with a hoarse, breathy or rough voice, consult with a speech pathologist and learn more about the benefits of voice therapy!


Information for Families: Vocal Nodules in Children

Melanie Yovino, MA. CF-SLP



How to use sign language to foster your child’s Speech and Language development


Did you know that sign language can be beneficial to not only individuals with hearing impairments, but also to babies who are first learning to communicate?  In fact, babies actually develop the ability to point and gesture before they even use words to express their wants and needs! Many parents may be skeptical to introduce sign language to their babies out of fear that it may actually delay the development of spoken language. However, research as shown that sign language often provides a bridge to support a child’s spoken language development.

So what exactly are some of these benefits to using sign language?

  • Sign language can reduce frustration by providing children a way to express their wants and needs. Research has shown that having an alternate way to communicate often decreases behavior issues, such as screaming and crying, because the child can more effectively communicate their wants and needs
  • Sign Language can improve language, vocabulary and reading skills.  When a child hears a word paired with a visual sign, the child is actually receiving two repetitions of the word through two different modalities. These repetitions can actually strengthen a child’s ability to recall and and enhance the development of oral language for reading comprehension. “The benefit of using this system is the representation of information through seeing, hearing, and movement. The more pathways created in the brain, the stronger the memory.”
  • Sign language can also help children to expand the length of their utterances. Studies have shown that when children are exposed to sign language, they have a better understanding of the grammatical structure of English, and use language in a more productive manner. If a child is only using one word utterances to communicate wants and needs, such as milk, parents can model that word and pair it with a sign, for example “more milk.

Now that you know about some of the benefits to using sign language with your child, your probably wondering, how do I choose which words to introduce first? When choosing words to target, you need to keep in mind what is going to be the most functional and beneficial for your child, in order to help them effecitvely communicate in a wide variety of situations. Some common early signs include:

  • More
  • eat
  • drink
  • play
  • stop
  • finished/ all done
  • help
  • my/mine

Remember that all children are different and some may require more assistance than others, such as hand-over-hand assistance, in order to use sign language to communicate.  If you are considering introducing sign language to your child, consult with a speech language pathologist for tips on how to appropriately teach and chose sign language targets that are individualized to meet the needs of your specific child


Vroom, J. (2004) Encouraging Spoken Language through Signs. Super Duper Publications.




Melanie Yovino M.A CF-SLP 




Can Speech and Language Therapy Help Improve Literacy Skills?

decoding-x-language-comp-reading-comp Did you know that a child’s speech and language development can actually have a significant impact on their development of literacy skills? Many people may not know that literacy skills, such as reading and writing, are actually language based skills.  Research has shown that there is a strong relationship between language impairment in early childhood and reading and spelling difficulties in school age children. Since there is a significant relationship between spoken and written language, and SLP’s are the experts when it comes to language development, it makes sense that speech and language therapy can actually impact literacy skills, such as reading and writing! So how exactly can a Speech Language pathologist help improve these skills?

Research has shown that reading can be broken down into two component parts, decoding and language comprehension.

  • Decoding is defined as efficient word recognition and the ability to sound out words based on phonics rules. Difficulties with decoding words typically involve deficits in the area of phonological awareness, or the ability to hear and identify the sounds that make up words.
  • Language Comprehension is defined as the ability to derive meaning from spoken words, when they are part of sentences or other discourse. Language comprehension encompasses receptive vocabulary, grammatical understanding, and discourse comprehension.

Based on this criteria for reading, children can fall into one of three general categories. Each category requires a specific type of intervention.

  • Poor Language Comprehension – Children with poor language comprehension have adequate decoding skills and weak language comprehension skills. Speech-Language pathologist can work with children with language comprehension difficulties to improve their vocabulary, increase their understanding of syntactical and morphological structures, and improve their overall discourse comprehension.
  • Poor at Decoding – Children with poor decoding skills have adequate language comprehension and weak decoding skills. Children that fall into this category also often receive a diagnosis of  dyslexia.  Speech-language pathologists can work with children with deficits in decoding to improve their phonological awareness skills. SLP’s help boost their ability to identify, recall, and retrieve these sounds and link them to written language.
  • Weaknesses in Both Areas – These children require intervention in both the areas of decoding and reading comprehension.

If you think your child fits into any of the categories mentioned above, contact a Speech-Language Pathologist and schedule a full evaluation!


Catts, H.W. & Weismer, S.E. (2006). Language Deficits in Poor Comprehenders: A Case for the Simple View of Reading. Journal of Speech, Language, and Hearing Research, 49, 278-293.  

Hoover, W.A. & Gough, P.B. (1990). The Simple View of Reading. Reading and Writing, 2,  127–160

Melanie Yovino MA CF-SLP



Stroke Warning Signs: Be Prepared!

What is a stroke?

  • Brain Disruption caused by “vascular disruptions”
  • Loss of blood or bleeding
  • “sudden and severe attack” Cerebrovascular Accident (CVA)

Incidence of Stroke

  • 3rd Leading cause of death and disability behind heart disease and cancer
  • Annual incidence 2 per every 1,000
  • 5 million survivors of stroke in any given year
  • 65 and over increases with age

Causes of Stroke

  • Vascular Disease
  • Disruption in blood circulation

Did you know? Hypertension, cigarette smoking, diabetes, frequent alcohol consumption, obesity, lack of physical activity, and a history of transient ischemic attacks (mini strokes) or CVA’s are all potential factors that may heighten an individual’s risk for stroke.

The Stroke Association uses the acronym F.A.S.T. to help people remember the sudden signs of a stroke. Warning signs are listed below:

  • Facial drooping: Is the person weak or numb on one side of the face? Ask the person to smile and see if one side of their face is drooping or uneven.
  • Arm Weakness: Is one arm or side of the body weak or numb? Ask the person to raise both arms- Does one arm drift downward?
  • Speech Difficulty:  Is the individual having difficulty speaking or understanding speech? Have the person repeat a simple phrase, such as “Hello, my name is ___.” Is the sentence imitated correctly? How is the quality of the speech? Is
    it slurred?  Other warning signs or sympstroke-warning-signs-and-symptoms-and-what-to-dotoms may include: impairment of vision, episodes of dizziness or falls, and/or severe headaches.
  • Time to call 9-1-1: If you or a loved one is displaying any of the aforementioned symptoms, call 9-1-1 and get the person to the hospital immediately. Also, try and remember the time when first symptoms appeared.

Visit the link below to learn more about strokes, how to prevent them, and moving forward after one has occurred. Remember, good health choices made today can prevent stroke later.

American Stroke Association

Amanda Weiner MS CF-SLP TSSLD

All About Fluency!

What goes into coordinating fluent speech?

  • Respiration- the process of using breath to create speech sounds.
  • Phonation- the process by which the vocal folds produce certain sounds
  • Articulation- the adjustments and movements of speech organs involved in pronouncing particular sound, taken as a whole.
  • Resonation The buzz created by the vocal folds resonates (vibrates) the air column and this in turn causes the structures above and around the larynx to vibrate/resonate as well.

If only one is “off,” there will be a breakdown in fluency.

What is Disfluency?

  • Various surface interruptions that occur in on-going speech, whole word/part word repetitions, irregular rhythm, sound prolongation, cessation of speech
  • “Normal nonfluencies,” occur is everyone’s speech- word finding, sentence formulation, distractions, interjections (like, um, you know)

Dimensions of normal speech fluency

  • rate (appropriate timing)
  • continuity (smooth connections)
  • tension effort (appropriate force)

The Major Components of Stuttering:

Core Behavior-what a Person Who Stutters does WHEN they stutter

  1. Repetition- When a sound, syllable, or word is repeated several times: b b b-aby or ba ba ba baby
  2. Prolongation- when a sound is held for a long time or just keeps coming: baaaaaaby
  3. Complete block- when the sound and airflow are completely stopped: b—–aby

Secondary Behavior– what a Person Who Stutters does BECAUSE they stutter

  1. eye blinking
  2. foot stomping
  3. head nodding
  4. face movements
  5. avoid talking
  6. add words
  7. change what was going to be said

Feelings and attitudes about stuttering: (anxiety, nervousness, fear)

Two Approaches For Treatment

Fluency Shaping: speak more fluently, which includes factors such as: speak with a slower rate, easy onsets, airflow management, intonation and phrasing management, continuous forward moving speech

Stuttering Modification: helps the person monitor the stuttered speech more fluently (stutter more fluently)- the Moment of stuttering is changed. Some techniques include:

  • Identification: understand core/avoidance behaviors understands feelings associated with stuttering learn about stuttering
  • Desensitization: address emotions toward stuttering, relax, teach person who stutters to tolerate moment of stuttering and reduce anxiety
  • Modification: Cancellation-finish stutter, make adjustments, and re-utter word
  • Pull-outs: examine, plan, change, finish word in an easier way
  • Preparatory set: before saying the word plan change, and produce the word more easily

Treatment Goals

Acceptable Fluency

  • Noticeable stuttering of less severity.
  • Comfort in role of communicator, despite stuttering.
  • Speaker makes adjustments to maintain an acceptable level of stuttering.

Controlled Fluency

  • Must monitor and adjust speech to maintain natural or normal sounding speech.
  • Speaker must pay attention to how he is speaking.

Spontaneous Fluency

  • Characteristic of the normal speaker.
  • Effortless.
  • Speaker more concerned with what is said than how it is said.

Thanks for reading! Contact one of our seven facilities if you suspect that you or a loved one may have a fluency concern. Happy Fall!

Amanda Weiner, MS CF-SLP TSSLD

Five Levels of Attention

Did you know? Individuals with cognitive-communication disorders (e.g., TBI, aphasia, and dementia) show marked difficulty with attention, memory, and executive functions. One frequent aspect of TBI secondary impairment is disordered attention.

Five Levels of Attention: 

Focused, Sustained, Selective, Alternating, and Divided

  1. Focused Attention: The ability to respond discretely to a particular visual, auditory, or tactile stimuli. Sometimes called “orienting” to stimuli. It is the lowest level of attention or alertness.
  2. Sustained Attention: The ability to sustain a steady response during continuous attention. On average, adults have an attention span of about 15-20 minutes.
  3. Selective Attention: The ability to maintain attention in the face of distracting or competing stimuli.
  4. Alternating Attention: The capacity for mental flexibility that allows the shift of focus between tasks. People with alternating attention deficits are slow to shift their attention from one task to another. This can also affect conversations. The person will have difficulty with switching conversational topics quickly.
  5. Divided Attention: The ability to respond simultaneously to multiple tasks or to do more than one activity at a time. People with divided attention deficits might have difficulty driving and holding a conversation or cooking and listening to the news.

Strategies for Maintaining Attention

  • Avoid areas near doors, windows, and traffic patterns
  • Provide opportunities to take breaks.
  • Use a written or picture schedule and check off progress
  • Schedule most important work for times of greatest concentration
  • Break assignments into smaller and shorter segments
  • Limit the amount of information you put into your brain
  • Repeat the information in your mind
  • Create and maintain a quiet and non-distracting environment
  • Break larger tasks into smaller ones & redirect your attention back to talook-a-squirrelsk when needed
  • Allow breaks during or between tasks to reduce fatigue from extended attending

Try the sustained/selective attention tasks below by scanning through the stimuli to find the number 2 (first link), and the word “sun” (second link).  These handouts are great resources for individuals with cognitive-communication deficits, and even may be used with our young ones with attention deficits! To make these exercises more challenging, add some background distractions (e.g., music, white noise) to increase the level of difficulty for which the individual needs to attend to. Thanks for reading!🙂



Amanda Weiner MS CF-SLP, TSSLD

Picture Exchange Communication System (PECS)

The Picture Exchange Communication System or PECS approach was developed by Andrew Bondy and Lori Frost in 1985 and is a modified applied behavior analysis program designed for early nonverbal symbolic communication training. It is not a program designed to teach speech, although the latter is encouraged indirectly and some children begin to spontaneously use speech while enrolled in the PECS program.

PECS has been successful with a variety of populations including children with autism, those who have social-communicative and/or behavioral disorders, are non-verbal, and/or for those who are visual learners. It is important that from whatever target population the child belongs to, he or she can sit and attend to a two-dimensional stimulus and be able to physically hand each picture to his or her communication partner and establish joint attention.

The procedure for PECS intervention follows in a hierarchy of phases. PECS begins by teaching the child to give a picture of a desired item to a communication partner, who immediately honors the exchange as a request. The system goes on to teach discrimination of pictures and how to put them together to form phrases and sentences. In the more advanced phases, children are taught to respond to questions and spontaneously comment.

An outline of the phases are as follows:

pecs-2Phase I: How to Communicate- Students learn how to exchange single pictures for items or activities that they really want. It is important that the communication partner finds out what the child has interest in so that he or she isn’t prompted into asking for something they don’t like. We should never make PECS aversive.

Phase II: Distance and Persistence- Still using single pictures, students learn to generalize this new skill by using it in different places, with different people and across distances. This phase is also utilized for the purpose of expanding spontaneity from the child.

Phase III: Picture Discrimination- Students learn to select from two or more pictures to ask for their favorite things. These favorite things are placed in a communication book- a three ring binder with Velcro strips where pictures are stored and easily removed for communication.

Phase IV: Sentence Structure- Students seek out their PECS board, and learn to construct simple sentences on a detachable sentence strip using an “I want” picture followed by a picture of the item being requested. Students then seek out a communicative partner, and give him or her the sentence strip. Listeners read the strip back to the child, inserting a fixed time delay between the words “I want” and the item label. Additional social praise is added if a child independently provides the label during the delay.

*Attributes and Language Expansion* At this point, students begin to learn to expand their sentences by adding adjectives, verbs, and prepositions.

Phase V: Answering a direct question- Students learn to use PECS to answer the question, “What do you want?”pecs-1

Phase VI: Commenting- Now students are taught to comment in response to questions such as, “What do you see?”, “What do you hear?” and “What is it?” They learn to make up sentences starting with “I see,” “I hear,” “I feel,” “It is a,”etc.

Support provided by the clinician is included within each description of each phase; however, additional support and prompts may include:pecs-phase-4
Question Cues
: “What do you want?”

Hand Over Hand Cues: Helping to initiate the movement of putting the pictures from the communication board onto the sentence strip or by helping rip off the pictures.

Visual Cues: Pointing to the pictures on the communication board.

PECS is supported by evidenced based practice, and has demonstrated enhanced communication skills in a variety of populations. It is important to note that a therapist should be PECS trained before implementing the approach.

Clink the link below to watch how Phase 1 of PECS is used. Thanks for reading!

PECS Phase 1


Ali, E., MacFarland, S. Z., & Umbreit, J. (2011). Effectiveness of combining tangible symbols with the picture exchange communication system to teach requesting skills to children with multiple disabilities including visual impairment. Education & Training in Autism      & Developmental Disabilities, 46(3), 425-35.

Ganz, J., Lund, E., Simpson, R. The Picture Exchange Communication System (PECS): A Promising Method for Improving Communication Skills of Learners with Autism Spectrum Disorders. Education and Training in Autism and Developmental Disabilities, 2012, 47(2), 176-186.

The Picture Exchange Communication System (PECS). (n.d.). Retrieved October 18, 2015, from

Amanda Weiner M.S. CF-SLP, TSSLD