Closed Head Injury

There are many children, unfortunately, who suffer from TBI or Traumatic Brain Injury. Falls are the most common cause of TBI. 28% of TBIs are due to falls Children and the elderly are especially vulnerable. (Roseberry-Mckibbin & Hegde, 2016) Bicycles, roller blades, pools, cars, and sports are all culprits of head injury. Many parents and teachers know how to help prevent a child from getting hurt (using helmets, seat belts, and practicing traffic safety), but what many do not know is the effect even a slight head injury can have on a child’s memory, cognition, and speech-language skills. Traumatic brain injury (TBI) can result in a concussion or coma. (Robyn A. Merkel-Piccini, 2000) The following difficulties are results from TBI:

  1. Loss of short term memory
  2. Loss of sight, or the ability to recognize objects by sight
  3. Loss of smell and taste
  4. Loss of fine motor skills (writing, holding a fork)
  5. Loss of oral motor skills (eating, blowing, producing sounds)
  6. Loss of sensation and/or the ability to execute gross motor movements (walking)
  7. Loss of emotions, constant frustration, depression, constant anger or inappropriate behaviors
  8. Dysarthria or lack of tone in the lips and tongue
  9. Aphasia, or word finding problems and/or loss of the ability to express ideas through spoken language
  10. Dysphagia or difficulty swallowing

(Robyn A. Merkel-Piccini, 2000)

Automobile accidents, including pedestrian injuries account for 20% of TBI. Motorcycle riders have a higher risk of TBI than car drivers. About 19% of TBIs are due to being struck by crashing objects. Assaults and interpersonal violence (including child and spousal abuse) account for 11% of TBIs. (Roseberry-Mckibbin & Hegde, 2016)


Recovery for Children with TBI

     While the symptoms of a brain injury in children are similar to the symptoms experienced by adults, the impact may be different. The brain of a child is continuing to develop while an adults brain is matured, and no longer growing. “The assumption used to be a child with a brain injury would recover better than an adult because there was more “plasticity” in a younger brain.”  (Brain Injury of America, 2015) However, a more recent research has shown that this is not necessarily the case. A brain injury has a much more negative impact on a child than an injury of the same severity has on an adult. (Brain Injury of America, 2015) “The cognitive impairments of children may not be immediately obvious after the injury but may become apparent as the child gets older and faces increased cognitive and social expectations for new learning and more complex, socially appropriate behavior.” (Brain Injury of America, 2015)

Children who suffer a TBI often receive rehabilitation services including physical, occupational, and speech therapy. Children may have residential or private placement before returning to school. Although it is rare, the public-school educators may encounter a child who is recovering from TBI in the classroom. If this should occur, a SLP, physical therapist, or occupational therapist in the school may be able to provide important information regarding techniques to facilitate learning. (Robyn A. Merkel-Piccini, 2000)





Gabrielle Cormace MS CF SLP


Brain Injury of America. (2015). Brain Injury in Children. Retrieved from Brain Injury Association of America:

Robyn A. Merkel-Piccini, M. C.-S. (2000). “Children and Closed Head Injury” . Super Duper Handy Handouts!

Roseberry-Mckibbin, C., & Hegde, M. N. (2016). An Advanced Review of Speech-Language Pathology (Vol. Fourth). Austin, TX: Pro-ed.


S.O.S Approach and Development

S.O.S Approach also known as, the Sequential Oral Sensory Approach to feeding was developed by Dr. Kay Toomey, as an effective way to address problematic feeding behaviors in a variety of settings and populations. Parents of children who will not eat or are “picky eaters”, are faced with a difficult challenge. SOS approach assesses the “whole child” focusing on the organ systems; sensory processing; oral-motor skills; learning, behavior; nutrition and the child’s environment. “The SOS Approach focuses on increasing a child’s comfort level by exploring and learning about the different properties of food. The program allows a child to interact with food in a playful, non-stressful way, beginning with the ability to tolerate the food in the room and in front of him/her; then moving on to touching, kissing, and eventually tasting and eating foods.” (Toomey & Associates, 2016)

Top 10 Myths at Mealtime

Myth 1: Eating is the body’s number one priority. Correct: The body’s first priority is breathing, second is postural stability is space.

Myth 2: Eating is instinctive. Correct: Eating must be positivly enforced by the body.

Myth 3: Eating is easy. Correct: Eating is the most difficult sensory task that a child can do!

Myth 4: Eating is a two-step process: sit down, eat. There are actually 32 steps to eating!

Myth 5: It is not of to play with your food. Correct: Always play with purpose, increase interactions with foods by touching, smelling and tasting.

Myth 6: If a child is hungry enough, they will eat. They will not stave themselves. Correct: Children need skills in order to eat an appropriate diet. If a child does not have the skill, they cannot eat.

Myth 7: Children only need to eat 2-3x a day. Correct: Children should eat 5-6x a day to maintain a steady metabolic rate and in order to meet appropriate caloric intake.

Myth 8: A child who won’t eat has either a behavioral or an organic problem. Correct: Most times it is a combination of both! Often, gastrointestinal problems are an issue.

Myth 9: Certain foods are eaten only at specified times of the day and only certain foods are healthy for you. Correct: Allow children to eat foods that will work for them.

Myth 10: Mealtimes are a proper social occasion and children should “mind their manners” at all meals. Correct: It is more important to teach children skills they need first.

Always remember that a food is considered new unless it is tried ten times! Rejecting a new food is normal and exposure is key!

Facts about fetal/infant development regarding tastes

Taste begins to develop at approximately 7-weeks gestation! Below is a table of developmental taste milestones:

Child’s age

Taste Milestone

7-8 weeks gestation

Appearance of specialized taste cells

10 weeks gestation

Mature taste cells develop

11-13 weeks gestation

Taste buds begin to develop with the majority on the dorsal surface of the tongue

12 weeks gestation

Fetal swallowing begins

6 months gestation

Increase in swallowing to sweet tastes inject tin amniotic fluid and a decrease in swallowing bitter taste injected. A liking for sweet and salty and a disliking for bitter are innately organized!

The flavor of the amniotic fluid reflects the flavor of the mother’s diet. The flavor of the mother’s diet in the last trimester impacts newborns responses to similar foods after birth. The flavor of mother’s milk also reflects the mothers diet. Breastfeeding facilitates acceptance of novel flavors also; this acceptance may generalize past specific flavor exposure.


Remember, interacting with new foods that may be non-preferred by a child is a new and at times difficult task. Start by slowly integrating the child’s senses of sight, touch, smell, and taste within the SOS hierarchy. A SOS-trained Speech-Language Pathologist is able to help integrate this hierarchy and teach parents and caregivers what to do to improve their child’s eating habits at home!


Gabrielle Cormace M.S., CF-SLP



Toomey & Associates. (2016). Retrieved from SOS Approach to Feeding:

SOS: The Sequential Oral Sensory Approach to Feeding; A Review. PowerPoint from The Suffolk Center for Speech. (All information origionally presented by Kay A. Toomey PhD., Erin Ross PhD, CCC-SLP, and Bethany Kortsha, M.A., OTR and is property of the SOS Approach to Feeding.)



Water Importance and Speech

       The vocal folds need to be lubricated with a thin layer of mucus in order to vibrate efficiently. If the vocal folds are not properly lubricated, your voice may become hoarse or scratchy, or you may experience vocal fatigue or “vocal fry”. The best lubrication can be achieved by drinking plenty of water. Drinks that contain caffeine and alcohol will actually dehydrate or dry out the vocal folds. Caffeine and alcohol pull water out of your system and deplete the vocal folds of needed lubrication. Caffeinated drinks include coffee, tea, and soft drinks. Small amounts of these beverages are acceptable but must be counterbalanced by drinking more water. (Texas Voice Center, 2016) A good rule of thumb (if you have normal kidneys and heart function) is to drink at least two quarts of water daily. Dr. Van Lawrence, a world-renowned Laryngologist, often said, “Drink until you pee pale.” It is important for children and adults to drink enough water every day. (Texas Voice Center, 2016)

       The traditional honey bear straw cup, an idea recommended to SLPs for many years, and continues to be a popular method for helping kids learn to drink liquids today. For smaller hands, the 6-ounce honey bear straw cup with the flexible straw will be most beneficial. The tiny size is perfect for a toddler’s grasp and the ideal height placed on the table for a smaller child. Parents can add self-adherent wrap or a few clean wide rubber bands to the bear’s belly to provide added grip. Be sure the wrap and the rubber bands are tight enough that little fingers cannot get underneath and get caught. With such a small cup, it’s easier for kids to “drink it’s all gone” and be ready to refill it throughout the day. The cup is also “see-through” allowing kids to see how much is left before they are all done! Refilling the cup gets kids thinking about drinking water, and that’s the key. (Potock, 2016)


       Making infused water is another way to get your child and family drinking more water! Involve your child in food preparation! Adding fruits, herbs, and vegetables to create subtly flavored water is an excellent way to get kids involved in handling new foods, encouraging them to drink more water and also trying a new food. Using kid-safe knives, help kids slice cucumbers, mint, watermelon, and other foods to add to the water. Popular combinations include oranges and strawberries, cucumbers and mint, pomegranate seeds and cantaloupe. Eating more fruits and vegetables that are high-water-concentrated is another way to increase water intake! “Juicy” fruits and vegetables such as watermelon, strawberries, cucumbers, iceberg lettuce, radishes, and celery all contain water which can help in overall intake. (MacMillan, 2016) Eating these foods will aid in increasing hydration, however, drinking the daily recommended amount of water is the most effective way.

Parents and caregivers should always model good hydrating habits! Remember drinking enough water everyday is the best way to keep your body, and your vocal folds healthy. Kids learn best through modeling, grab your water and enjoy!


Gabrielle Cormace M.S., CF-SLP


MacMillan, A. (2016). 15 Foods That Will Help You Stay Hydrated. Retrieved from,,20709014,00.html/view-all

Potock, M. (2016, October 13). The ASHA Leader Blog. Retrieved from American Speech-Language-Hearing Association:

Texas Voice Center. (2016). Advice For Care Of The Voice. Retrieved from Texas Voice Center:

Childhood Apraxia of Speech (CAS)

Childhood apraxia of speech (CAS) is a motor-speech disorder. Children who are diagnosed with CAS demonstrate difficulties saying sounds, syllables, and words. This is not because of muscle weakness or paralysis. The problem occurs within the brain. The brain has trouble planning to move the body parts (e.g., lips, jaw, tongue) needed for speech. The child knows what he or she wants to say, but his/her brain has difficulty coordinating the muscle movements necessary to say the words. (American Speech-Language-Hearing Association, 2016) CAS is a disorder of speech coordination, not strength. (Donald A. Robin, 2003)


There are three main characteristics of Childhood Apraxia of Speech (CAS) that must be demonstrated in order to contribute to a diagnosis. These characteristics include the following:

  1. Variability in productions. Inconsistent errors in repeated productions may also be known as “token-to-token inconsistency”. This is a variability of the child’s productions of speech sounds produced across multiple attempts. For example, a child may produce “banana” as “bana” and “nana” within the same session. (Fish, 2016)
  2. Vowel errors and inappropriate spacing.” A child with CAS will often demonstrate pausing or noticeable gaps between sounds or syllables. When coarticulatory transitions are disrupted the child may also demonstrate productions that negatively impact speech intelligibility (e.g., voicing errors, resonance differences, difficulties producing increasingly complex phoneme sequences). (Fish, 2016)
  3. Suprasegmental differences. The most noticeable is the use of excessive equal stress. Children who use excessive equal stress have a robotic quality to their speech. Prosody can impact both speech intelligibility and the listener’s impression of the speech. Children with CAS may also demonstrate difficulties with intonation, rhythm, juncture, and tone of voice. (Fish, 2016)

Through evaluation an SLP will be able to differentiate a diagnosis of CAS from a severe speech sound disorder.

Some errors that may be observed with a child who is diagnosed or suspected to have Childhood Apraxia of Speech (CAS) include the following:

  • Substitutions (one sound is substituted for another)
  • Additions (a sound is added such as “spulash” for “splash”)
  • Distortions (sounds are produced but are not quite accurate such as too much air during the production of “s”)
  • Omissions (sounds are left out such as “pe” for “pen”).

Children with CAS most often demonstrate inconsistent distortions and substitutions. (Donald A. Robin, 2003)

Speech therapy for a child with CAS should be consistent, frequent, and repetitive. Children with CAS need frequent one-on-one therapy and a lot of repetitive practice with sounds, sequences, and movement patterns in order to incorporate them into their speech and make them automatic. Many therapists recommend the use of sign language, PECS (picture communication systems), and other augmentative or alternative communications. This combination of therapies (sign and vocal word attempt) enhances the chance that the listener will be able to understand the speaker. Visual cues can be very helpful. Telling the child “Look at my lips” and pointing to your lips when saying the /b/ or /m/ sound can help facilitate the correct placement. Practicing while looking in the mirror is another way for the child to receive helpful visual cues regarding speech production.



Gabrielle Cormace M.S., CF-SLP


American Speech-Language-Hearing Association. (2016). Childhood Apraxia of Speech. Retrieved from

Donald A. Robin, P. C.-S.-N. (2003). Understanding Apraxia. Retrieved from

Fish, M. (2016). Here’s How to Treat Childhood Apraxia of Speech (2nd ed.). San Diego, CA: Plural Publishing.

Super Duper Handy Handouts! #160: Understanding Childhood Apraxia by Becky Spivey, M.Ed. #50: Developmental Apraxia of speech and Developmental Verbal Dyspraxia: The Mystery of the Minimally and/or Non-Verbal Child