The relationship between ADHD, language, literacy and writing

As Speech-Language Pathologists’ we work alongside children with language deficits however, in many cases we find that these children typically have a comorbidity disorder. Research has indicated that there is a greater percentage of children with Attention Deficit Hyperactivity Disorder (ADHD) who are somewhat delayed in the onset of language compared to children without ADHD Children. Additionally, the literature has suggested that children with ADHD and have had language impairments are at high risk for writing difficulties and other literacy deficits. This compelling research has allowed SLPs to work closely with teachers, special educators and other professionals in settings that provide treatment for children with ADHD since literacy and writing are important elements of success in school. As SLPs what are the research facts we should know about this intricate relationship between ADHD, literacy and writing? What are some evidence based treatment approaches we may use to treat this population? These questions will be further explored down below.

Children who have ADHD and language impairments have:

• history of language delays or disorders that are at the root of their writing difficulties.
• demonstrate writing difficulties with literate language components such as cohesive devices, complex grammatical structures in writing.
• higher frequency of grammatical errors in writing.
• deficits in working memory and executive functions that affect writing skills
• children with ED see writing as laborious and avoid it as much as possible

Treatment approaches:

• Stop and List
• Graphic Organizers (sequential)
• Assistive technology
• Sentence Combining
• Writing lab approach
• Focusing on the process of writing

Further, it is our professional duty to collaborate with other professionals that are part of the team, advocate for self, client,  family, educate parents and other professionals on the connection between language disorders and ADHD. This will help us provide a better understanding of our role to others and help this population.

By: Jacqueline Prieto M.A., CF-SLP

Constitutional factors in stuttering: Genetic and brain differences

Research has demonstrated that there are genetic and brain differences in individuals who stutter. While there are genetic factors that may indicate higher chances of being a person who stutters there are also factors that may predict natural recovery such as:

• Being Female
• No family history of persistent stuttering
• Early onset
• Good language, articulation and intelligence skills

Considering that these are factors that may predict natural recovery, how can we as SLPS use these factors to educate parents on stuttering and guide our therapy approaches?  These are some ways that we can use this research based knowledge to educate and guide our therapy:

• If the client is female, research has demonstrated that natural recovery is more probable. Educating parents on this fact may motivate parents to practice fluency skills at home, modify environment and encourage slow easy speech on a daily basis. Thus, by educating parents on the positive outlook of this prognostic factor we may be able to promote better carry-over and generalization.
• Looking over the case history information is vital for each and every single one of our clients. However, knowing that the research suggests that there is a better correlation of recovery in individuals who do not have persistent stuttering is  crucial for individuals who stutter. If the case history does not exhibit this information, it is our job as clinicians to find this information in order to individualize therapy. By knowing this information we could offer more rigorous approaches to these clients as they can tolerate it and may even benefit from them.
• Children who have early onset stuttering tend to have a better prognosis therefore, knowing this information will help us determine types of therapy that were successful, and those that were not in the past.
• Looking at other areas such as good language, articulation and overall intelligence may us also give us a better picture of prognosis. This is due to brain’s overall plasticity and ability to use other functions to aid in the fluency skills. Therefore, using these domains to build confidence, reduce anxiety and shame in the school-population is vital.

While there is still many domains and research to unveil in the realm of disfluency, we as therapists can still use research and our knowledge base to make prognostic decisions that will best help our clients. This is important to consider when we are scheduling, identifying the frequency of therapy and deciding on therapy materials/activities that are best suited for our clients.

 

By: Jacqueline P.

Collaborating to Support Students with Feeding Difficulties

As clinical Speech-Language Pathologists (SLP) we find that many of our children also see school based Speech-Language Pathologists. However, the collaboration between the school SLP and clinical SLP may not be fully explored especially when it comes to children with feeding limitations. Since feeding difficulties manifest in different ways such as refusing foods, appropriate feeding skills, only consuming small variety of food and liquids, it is important as SLPs to consider these variables across all settings.

Students with behavioral feeding difficulties may fall into these two type of main eaters:

Selective: Decline most foods, however eat enough of a variety of foods to sustain a healthy weight. These children typically will eat the same foods for lunch everyday however maintain healthy nutritional development.

Resistant: Consistently avoid foods and typically have developmental delays that cause them to eat 15 foods or fewer. These children may avoid entire food groups all together and demonstrate anxiety, or tantrums when presented with a novel food item.

When children with feeding difficulties experience trouble eating, it affects them throughout their day, especially at school. Therefore, as clinicians it is our duty to find strategies to collaborate with school SLPs to help during mealtimes at school. These are some suggestions that will help the school and clinical SLP facilitate their goals across settings:

Positioning and location of student in the cafeteria:

The school SLP may observe a child when he/she is sitting in the cafeteria and look to see if they are sitting next to students who eat similar items? This may signal the school SLP that the child prefers a social setting during mealtimes and share the experience with others. The clinical SLP can then emulate this in the clinic by also eating what the child eats: preferred or non preferred.

Engage students in food related activities:

The school and clinical SLP can target articulation goals by naming foods such as go on a “picnic”. Describing food and drink properties while working on descriptive language goals can also help facilitate feeding language. Also talking about food outside of meal times may help ease the pressure while helping children explore food. These are activities that the school and clinical SLP can facilitate together in their own individual sessions while also collaborating to use similar language.

Monitor student’s progress: 

The school SLP may notice minimal progress as they interact with children on a daily basis. This is important to recognize since students may be more open to new items on their lunch tray, show less discomfort around others eating various foods or become less messy when they eat. The school SLPs data and observations on progress are important as they can relay this information to the clinical SLP. The clinical SLP can also monitor  this progress and convey this information to parents which can hopefully facilitate more carry-over at home.

Collaboration between the school SLP and clinical SLP is vital for children with feeding difficulties. By working together, the school-based SLP and clinical SLP can help move students closer to their ultimate goal of increasing their food repertoire. 

By Jacqueline P.

The Link between Conversational Turns and Language Development

We all know and understand that it is important to talk to children since this is the first way they acquire language. However, with new research we are truly now understanding just how important it really is. A study in MIT gathered 36 children between the ages of 4-6 years old for two days and recorded every word they said within those two days. The study analyzed the number of words by the child and the number of words spoken to the child as well as the exchanges between caregiver and child. The fascinating results of this study concluded that not only did more conversational turns correlate with better scores on language skills but brain scans demonstrated an increase in activity in Broca’s area (an area in the brain linked to speech production and language processing).

Therefore, the research indicates that the important thing is not to just talk to your child but to talk with your child.  While it may be easy as clinicians to tell parents to speak and bombard their children with language and exchange conversation, we also understand that it may not be easy at times given the stressful demands imposed by life on a daily basis. Therefore as clinicians we have come up with some ideas that will elicit natural conversational exchanges between you and your child. These are also some fun ways to spend time and incorporate natural conversational exchanges with the whole family.

I spy at the Grocery store:

Use your time at the grocery store to incorporate conversational language between you and your child and at the same time make it fun through an I spy game. You can start by saying I spy with my little eye something red and round! This will have your child engaged in conversation while also exposing them to descriptive vocabulary.

Scavenger hunts:

Hide a toy and give your child easy instructions to help her/him find it, like, “Look behind the red chair” or “It’s sitting on one of the kitchen counters.” If you have an older child turn the tables and ask her to hide an object and give you a set of clues.

Storytime:

Don’t just read to your child. Engage in the book by making silly voices for characters, exaggerate scenes, play out scenes in the story and ask lots of questions that promote conversational exchanges between you and your child.

Simon Says:

Give simple instructions such as, “Pick up the ball and throw it to me” and “Bend down and touch your toes.” You can also make it more challenging for an older child by adding temporal concepts such as bring the ball before you touch your toes! You can then ask the child to tell you what to do and reverse roles as such.

Cooking:

Use cooking a meal as an opportunity to exchange conversations with your child! You can ask them to help  you cook and talk about the different ingredients, steps in order to make the meal and finally help you set the table.

By Jacqueline P.

Expectations for Your Child’s Feeding Evaluation

If you’re a parent of a picky-eater/problem feeder, we understand your frustration when attempting to provide adequate nutrition in your child’s meals. Remember, it is normal for your child to reject foods, however exposure is key! There are various underlying factors that may inhibit a child’s willingness to eat. Some factors include: pain, discomfort, limited oral motor skills, deficient swallowing skills, sensory processing problems, learning/ behavioral and nutritional factors.

The first step is to schedule an evaluation with a speech-language pathologist to assess your child’s overall feeding and/or swallowing skills, as well as their dietary repertoire. Feeding skills include the steps it takes to get the food into the mouth, while swallowing involves chewing pattern, propulsion of food from mouth into throat, and protection of the airway. The speech-language pathologist will assess the underlying factors of your child’s feeding/swallowing difficulties, for example whether they experience a sensory aversion to different textures or difficulty with food transportation.

Here is what to expect during the feeding evaluation:

1. Full interview – The speech-language pathologist will complete a comprehensive interview to obtain pertinent information regarding your child’s medical, familial, and developmental history with specific insight to your child’s feeding/food preferences and non-preferences.
2. Oral Peripheral Exam – After the clinician has established rapport with you and your child, they will assess the musculature of the oral cavity (i.e., cheek, lip, jaw, tongue), including its strength, agility, and range of motion. They will observe their ability to complete various movements within the oral cavity as well as their ability to manipulate different food consistencies/textures. Additionally, they will examine facial symmetry, tone, and chewing pattern.
3. Food Trials –The speech-language pathologist may ask you to bring in preferred and nonpreferred food items. They will observe your child’s interactions with various consistencies, textures, and tastes of food. Additionally, it may be beneficial to bring the child’s favorite cup, utensil or plate to help promote their naturalistic feeding habits as best as possible. The speech-language pathologist will observe your child’s amount of food intake, ability to hold food within their mouth, chewing pattern, formation of chewed food prior to the swallow, timing of a swallow, as well as presence of residue left behind. Furthermore, the speech-language pathologist may assess your child’s drinking pattern including their lip seal, jaw stability, and positioning of their tongue.

The completed evacuation will be followed up with recommendations for your child. Recommendations may warrant the need for intervention as well as techniques that may accommodate your child’s individual needs to assist in the home environment. Some sample suggestions/techniques include implementing family mealtime, modeling good feeding behaviors, discussion of the sensory and visual properties of the food, over-exaggeration of correct motor movements, involving the child in all aspects of the meal prep and clean up, remain at the table until mealtime is completed, and no punishment during meals!

 

 

Ashley Feiss M.S., CF – SLP TSSLD

Swallowing Disorders in Adults

If you have ever found yourself saying, “my drink went down the wrong pipe”, it typically means it went down your trachea, which may lead to aspiration. Aspiration is the entry of food, liquids or saliva past the vocal folds potentially into the lungs; it is more frequently observed when swallowing fluids. Symptoms typically include coughing, difficulty breathing, and in some cases choking. Normally, everyone encounter’s this process every once in a while due complications coordinating the respiratory and digestive mechanisms. However, individuals with swallowing disorders experience this type of pain and discomfort on a regular basis, which places them at heightened risk for life-threatening complications, such as pneumonia, blood infections, or lung abscess.

Swallowing disorders, also known as dysphagia, may be defined as the difficulty with the transportation of liquids, solids, or both from the pharynx to the stomach. Individuals may encounter difficulty transporting hard textured foods while others have difficulty drinking liquids. Dysphagia, occurs in all age groups and may be a result of a variety of congenital abnormalities, structural damage, or medical conditions. Such conditions typically include, Cerebral Vascular Accidents (CVA), nervous system disorders (i.e., Parkinson’s Disease, Multiple Sclerosis, Cerebral Palsy, respiratory complications, esophageal complications including gastroesophageal reflux (GERD), Traumatic Brain Injury (TBI), head and neck cancer, etc. Other conditions may include intake of antihistamine medication or associated psychological behaviors.

The following are typical signs and symptoms of dysphagia:

• Inability to recognize food
• Coughing before, during, or after the swallow
• Difficulty managing food within the oral cavity
• Sudden weight loss
• Change in vocal quality (gurgly/wet)
• Pain when swallowing (odynophagia)
• Gastroesophageal Reflux (GERD)

The four phases of swallowing that encompass the transportation of food to the stomach. 

• Oral Preparatory Phase: the formation of the “bolus” or chewed up food
  • Sensory recognition of food or identification that it’s in front of them
  • Rotary chew pattern/movement and manipulation of the consistency to form a cohesive ball or “bolus”
  • Lateralization the tongue and chewing with the back molars for bolus formation

• Oral Phase: the movement of the “bolus” from the front to back of the mouth
  • Tongue pushes the bolus backwards
  • Labial closure while chewing to prevent food from lip spillage
  • Cheek tension increases to inhibit pocketing of food and increase tension for bolus formation

• Pharyngeal Phase: the transportation of the “bolus” from the top of the pharynx to the bottom of the pharynx
  • Vocal fold closure and downward movement of the epiglottis to cover entrance into larynx for airway protection
  • Velopharyngeal closure to prevent regurgitation (food to going back up nasal cavity)
  • Laryngeal excursion is the upward and forward movement of the larynx and hyoid bone while the upper esophagus is opening to help bolus move down. Additionally, it helps to protect the airway by pulling it out of the way.
  • Pharyngeal walls contract (pharyngeal constrictors) to help push the bolus through to the bottom of the pharynx

• Esophageal Phase: encompasses the passage of the “bolus” from bottom of the pharynx to the stomach
  • Peristalsis is the action of the esophageal muscles to help push the bolus down the esophagus to the stomach
  • Referral to a gastroenterologist is typically the most appropriate for patients experiencing esophageal stage dysphagia

 

Ashley F, M.S., CF-SLP TSSLD

The Late Talking Toddler

A late-talking toddler typically presents with an established foundation of language learning. This foundation includes receptive (comprehension) language, fine motor, gross motor, and play based language skills. However, they continue to demonstrate limited or no expressive (production) language skills.  Although every child’s development is unique to their “own rate” of progression when compared to their age matched peers, there are certain ranges of development that certain milestones should occur.  Some children seem to catch up on their own, while others do not. Therefore, parents and early development professionals should remain cognizant of the typical progression of speech and language development.

Critical language milestones to keep in mind for your toddler:

1. First Word – Children produce their first meaningful word for communicative intent around 12 months, around the time they begin to walk.
2. Combining Words – Most children have approximately 50 words and begin to combine 2-word phases at 24 months (i.e., mommy up, no milk, more ball).
3. Asking Questions – Children begin to use intonation to ask yes/no questions and demonstrate use of wh- questions around 12 – 26 months of age.
4. Prepositions – Children typically use about two or three prepositions (i.e., on, in, out) by 12-24 months of age.
5. Intelligibility – Children around 2-3 years of age should be approximately 50-75% intelligible by an unfamiliar listener.

Some parents may decide to wait and see if their late-talker will catch up to their peers. However, they typically struggle to determine whether their child’s language skills are typical or atypical due to the wide age variation of development. However, it is never too early to schedule and evaluation with a speech-language pathologist to determine whether your child is on the right track! The speech-language pathologist will talk to you about your concerns and determine if intervention is necessary. Intervention may be necessary if the speech-language pathologist notices risk factors that would inhibit future language learning and may suggest intervention or early intervention.

The following are a few risk factors in future language difficulties:

1. History of being quiet as an infant
2. Limited number of early developing consonant sounds (e.g., /p, b, m, t, d, n/)
3. Limited vocabulary use
4. Lack of verbal imitation
5. Difficulty playing with others
6. A family history of communication delay, learning or academic difficulties

Research suggests there are some late-talking toddlers who seem to catch up on their own without intervention by the time they enter school. However, they continue to perform at a lower level than their peers in certain aspects of language (i.e., literacy, grammar). Seek advice from a professional and schedule an evaluation with a speech-language pathologist to address your concerns. In addition, they may offer suggestions and tips to practice language learning at home and support your child’s expressive language development.

Get Ready for Back to School with these Fun Language Activities

As we approach the end of the summer, there remains plenty of opportunities for parents to target their child’s language skills in preparation for the upcoming school year! After a summer of adventure and freedom, language-based activities can be enjoyable while enhancing your child’s overall academic, social, and emotional well-being.  Check out the following activities that can be used throughout your child’s everyday activities!

• Story Time: Shared story reading is the best way to promote overall academic by targeting communication, language form/use, and literacy skills. Shared reading is powerful interactive approach involving participation of both the parent and child. As the parent demonstrates proficient reading skills, they involve the child through active participation. This type of involvement will help improve the child’s lexical repertoire (vocabulary), print awareness, as well as the sound correspondences between written and spoken words. In addition, shared reading targets a child’s attention skills, conversational skills, and verbal reasoning. To target their critical thinking skills, ask your child to predict what will happen next or reason why something happened.
• Treasure Hunt: This activity is the simplest way to enjoy a beautiful day with your kids! Take a few household objects and make a list of descriptive words to describe each item as well as the location (behind a chair, under the statue) they will be hidden in your backyard! Give your child the list of clues and have check off each item as they find each item. Additionally, this activity can be modified to target articulation skills if the objects hidden include the targeted sound. For example, to target the /s/ sound: scissors, can of soup, sunscreen, sunflowers, necklace, sock, etc.
• Go on a picnic: This type of activity is great to target vocabulary, sequencing, descriptive words, and following directions! Have your child gather and identify all needed items to go on a picnic (basket, utensils, napkins, cups). Then, create a menu for the lunch you will want to bring on the picnic. For example, if you are bringing sandwiches, have your child identify the ingredients needed. Then, together write down sequenced steps to create the sandwich. Last, have them follow the directions to create their desired sandwich!
• Watch a Movie: What a better way to target language skills than to watch a movie on a rainy day! After watching a movie, conduct a family discussion and have your child provide a recap of the movie. Their recap may include, description of the characters (protagonist, antagonist) and their personalities, discussion of the main idea, sequencing the movie scenes, discussion of both your favorite part and your child’s favorite part (or not so favorite part) of the movie, etc.
• Re-cap the Summer: Discuss all the exciting adventures you and your child have completed over the summer. This helps prepare your child to answer those ice breaker activities typically introduced in the beginning of the school year to begin conversation and help children establish rapport with their peers. Some questions may include:
  • Something fun you did this summer
  • Name a cool/fun place you visited
  • Talk about a new hobby
  • What is something you tried for the first time?
  • What was your favorite thing to do? or Did you find something new that is your favorite thing to do?
  • What do you expect to learn this year?

 

 

Ashley F. M.S., CF-SLP TSSLD

How to communicate after a laryngectomy

The ability to speak is a complex procedure that involves several parts of the body. These include the mouth, the articulators (tongue, teeth, hard palate, soft palate, lips), the respiratory system and the brain. Sometimes, people may experience trauma that affect their ability to speak appropriately. Examples of this include a cardiovascular accident (CVA or stroke) or head and neck cancer. When the trauma is severe and speech is severely affected, SLPs and doctors may opt to remove the larynx. The larynx, commonly known as the voice box, houses the vocal folds giving us the ability to speak. Once the larynx is removed, our ability to speak is impaired. However, there are alternative approaches to speaking once the larynx is removed.

---

The first is esophageal speech (ES),which is when air is inhaled into the pharyngoesophageal (PE) segment and then expelled into the esophagus. This expulsion brings the PE tissue into vibration thus creating voice. Although it is not implemented frequently, it is essential for SLPs to have an understanding of ES. It can be taught in two different ways: injection and inhalation.  The injection method prepares the patient for ES by producing voiceless sounds, attempting esophageal phonation and demonstrations of ES by the SLP. In this stage, the patient gains phonatory skills with ES, such as precision and speed. In the inhalation method, air intake and esophageal phonation are improved. In order for the best results, it is best to teach the inhalation method in conjunction with the injection method.

---

The second option is the electrolarynx, which involves the use of an external instrument placed against the throat or oral structures. The electrolarynx can also be placed in the oral cavity to facilitate speaking. The electrolarynx falls under the category of an artificial larynx (AL), which is what most patients who undergo a laryngectomy prefer postoperatively. Clinicians recommend using an AL in the immediate days following surgery.

---

The third and last option is tracheoesophageal (TEP) voice restoration surgery. The surgery can either be performed during the time of the laryngectomy or after surgery. A puncture is made to the posterior wall of the trachea through the anterior wall of the esophagus. Prosthesis is inserted into the puncture and shunts air from the lungs into the esophagus. This causes the upper esophageal sphincter and surrounding tissues to vibrate, thus the sound for voice is created. The pulmonary air is essentially forced to eject through the esophagus. The patient first practices phonation with single words, then phrases. It is important to note that the patient breathing effort remains the same as it did preoperatively.

---

Overall, all 3 forms of alaryngeal speech are alternative modes to communication after a laryngectomy. AL requires an external instrument for communication while ES and TEP rely on supplementary structures to communicate (i.e. esophagus, pharynx, articulators). ES and TEP are similar since the esophagus is the main mode of communication however; TEP is the only form of alaryngeal speech that requires additional surgery, which is usually done during the time of the laryngectomy.

-Ashley E. M.A, CF-SLP

Cluttering

What is Cluttering?

Cluttering is a fluency disorder where an individual speaks at a rapid rate, and/or with an irregular speaking rate and demonstrates excessive dysfluencies such as blocks, repetitions, prolongations, etc. Other symptoms can include language or phonological (sound pattern) errors as well as attention deficits. Although there is no “cure” for cluttering, an individual can learn and implement certain techniques to improve speaking rate, language skills, and attention.

---

Symptoms

The following are some common symptoms of cluttering:
• Rapid rate (talking too fast)
• Overarticulation of words (putting additional emphasis on speech sounds)
• Inappropriate breaks in speech patterns (pauses where there shouldn’t be pauses)
• Monotone speech (little inflection—sounding like a robot)
• Excessive dysfluencies/stuttering behaviors

Additional symptoms that may or may not be present include lack of awareness of the problem, family history of fluency disorders, poor handwriting, confusing and disorganized language or conversational skills, temporary improvement when asked to “slow down” or “pay attention” to speech, misarticulations, poor intelligibility, social or vocational problems, distractibility, hyperactivity, auditory perceptual difficulties, learning disabilities, and apraxia.

---

How to treat Cluttering

A speech-language pathologist can provide treatment for cluttering. The following are some ways to treat cluttering:

• Start treatment by encouraging the person to speak slower, allowing the person to “control” the rate of speech.                                                                                                 • Use visual aids such as a speedometer for monitoring the rate of speech—Keep
speech rate below the “speed limit.”
• Begin with highly structured utterances such as “Hi, my name is ___.” Then, move
toward a more typical flow of language and conversation.
• Have the person who clutters exaggerate stressed syllables in words and articulate all syllables. The goal is to have the individual learn to self-monitor his/her speech.
• Have the person who clutters listen to a disorganized speech sample and then listen to a sample of clear speech to increase awareness of the correct production.

Ashley E. M.A., CF-SLP