How does a parent know if their child has low muscle tone of the oral mechanism?

The muscles of the oral mechanism include the muscles of the lip, tongue, and jaw.  Very often when these muscles are weak your child will present with an open mouth position with the tongue placed anteriorly. They might experience severe drooling and have difficulty eating, drinking and maintain a closed seal around the straw,  Weakness of the lips, tongue and jaw will most certainly impact your child’s ability to produce the precise articulation (movements of the tongue, lips and jaw) and will likely result in your child’s ability to produce understandable speech.   Additionally, low tone may result in difficulty chewing, swallowing and can result in an inability to stick the tongue out, or move it from side to side.  Drooling can also be caused by weakness in the muscles of the mouth.  Strengthening these muscles can be very important in improving both feeding deficits and speech intelligibility.

During mealtime, weakness of the muscles of the lip, tongue, or jaw can have a negative impact on the ability to maneuver the food laterally and posteriorly in the mouth as well as efficiently removing the food from the spoon or fork, and swallowing.   A heightened gag reflex and frequent choking may be caused by weak oral motor muscles, which make feeding your child quite challenging.

Are there any quick fixes?

When a child presents with oral motor weakness, I recommend a structured oral motor program designed to strengthen the lips, jaw, and tongue.  Parents are asked to participate in these routines several times a day before feeding and to increase the difficulty as the child’s strength, awareness and range of motion increases.  The following are some activities and tools that I recommend to increase your child’s strength and abilities to feed and produce intelligible speech.

Chew Tube: (textured and not textured)

1. Place laterally along teeth.  Allow your child to bite on each side.
2. Place centrally on your child’s lips/mouth and allow him/her to round his/her lips while creating as tight of seal as possible for as long as s/he can maintain it.
3. Place laterally in-between cheek and teeth so child can feel the ridges/bumps on chew toy.
4. Swipe his tongue so he can feel the texture and receive sensation orally.

 Jiggler:

1. Start on child’s hands and move to his shoulders so as to prepare him/her for the activity.
2. Using slight pressure, move the jiggler from ear to corners of the mouth several times or as long as s/he will tolerate it.
3. Allow your child to bite on the jiggler so s/he can receive sensory input orally.

Probe and /or Z-vibe:

1. Place laterally and posteriorly towards molars.
2. Apply slight pressure and encourage your child to bite down on each side.
3. Place laterally in-between cheek and teeth so your child can feel the ridges/bumps and vibrations on probe.
4. Swipe his tongue so he can feel the texture and receive sensation orally.
5. Put slight pressure against your child’s tongue and encourage him/her to push back with their tongue.

Straws and Sippy Cups:

1. Using a straw will help stabilize your child’s jaw and keep it from shifting; build his/her strength and musculature
2. Encourage your child to suck through the straw while holding his/her chin stable with your thumb and forefinger.
3. Discourage him/her from biting on the straw while drinking.  Very often a child will attempt to bite on the drinking straw to stabilize their jaw and keep their head from moving.

Horns and Whistles:

1. Allow your child to explore the tools/toys orally.
2. Place in between lips.
3. Discourage your child from biting on the tools/toys.
4. Encourage lip rounding around the horn for as for as s/he can maintain the position while blowing.
5. Model blowing for your child.

Oral Motor Games and Activities:

1. Fish faces – Use tactile prompts to bring your child’s cheeks together
2. Massage – With firm touch using one or two fingers, massage from their ears to the     corner of his mouth in a circular motion (along his teeth)
3. Lip smacking
4. Blowing kisses and raspberries
5. Bubble blowing and popping on your child’s cheeks
6. Tongue clicking
7. Place something sweet around your child’s lips so he can attempt to use his tongue to lick it off.

As with any concern you may have about your child’s development, please contact you pediatrician and or a qualified speech language pathologist.

Diane Freedman

How do speech and language develop?

The first 3 years of life, when the brain is developing and maturing, is the most intensive period for acquiring speech and language skills. These skills develop best in a world that is rich with sounds, sights, and consistent exposure to the speech and language of others.

There appear to be critical periods for speech and language development in infants and young children when the brain is best able to absorb language. If these critical periods are allowed to pass without exposure to language, it will be more difficult to learn.

What are the milestones for speech and language development?

The first signs of communication occur when an infant learns that a cry will bring food, comfort, and companionship. Newborns also begin to recognize important sounds in their environment, such as the voice of their mother or primary caretaker. As they grow, babies begin to sort out the speech sounds that compose the words of their language. By 6 months of age, most babies recognize the basic sounds of their native language.

Children vary in their development of speech and language skills. However, they follow a natural progression or timetable for mastering the skills of language. A checklist of milestones for the normal development of speech and language skills in children from birth to 5 years of age is included below. These milestones help doctors and other health professionals determine if a child is on track or if he or she may need extra help. Sometimes a delay may be caused by hearing loss, while other times it may be due to a speech or language disorder.

What is the difference between a speech disorder and a language disorder?

Children who have trouble understanding what others say (receptive language) or difficulty sharing their thoughts (expressive language) may have a language disorder. Specific language impairment (SLI) is a language disorder that delays the mastery of language skills. Some children with SLI may not begin to talk until their third or fourth year. Children who have trouble producing speech sounds correctly or who hesitate or stutter when talking may have a speech disorder. Apraxia of speech is a speech disorder that makes it difficult to put sounds and syllables together in the correct order to form words.

What should I do if my child’s speech or language appears to be delayed?

Talk to your child’s doctor if you have any concerns. Your doctor may refer you to a speech-language pathologist, who is a health professional trained to evaluate and treat people with speech or language disorders. The speech-language pathologist will talk to you about your child’s communication and general development. He or she will also use special spoken tests to evaluate your child. A hearing test is often included in the evaluation because a hearing problem can affect speech and language development. Depending on the result of the evaluation, the speech-language pathologist may suggest activities you can do at home to stimulate your child’s development. They might also recommend group or individual therapy or suggest further evaluation by an audiologist (a health care professional trained to identify and measure hearing loss), or a developmental psychologist (a health care professional with special expertise in the psychological development of infants and children).

What research is being conducted on developmental speech and language problems?

The National Institute on Deafness and Other Communication Disorders (NIDCD) sponsors a broad range of research to better understand the development of speech and language disorders, improve diagnostic capabilities, and fine-tune more effective treatments. An ongoing area of study is the search for better ways to diagnose and differentiate among the various types of speech delay. A large study following approximately 4,000 children is gathering data as the children grow to establish reliable signs and symptoms for specific speech disorders, which can then be used to develop accurate diagnostic tests. Additional genetic studies are looking for matches between different genetic variations and specific speech deficits.

Researchers sponsored by the NIDCD have discovered one genetic variant, in particular, that is linked to specific language impairment (SLI), a disorder that delays children’s use of words and slows their mastery of language skills throughout their school years. The finding is the first to tie the presence of a distinct genetic mutation to any kind of inherited language impairment. Further research is exploring the role this genetic variant may also play in dyslexia, autism, and speech-sound disorders.

A long-term study looking at how deafness impacts the brain is exploring how the brain “rewires” itself to accommodate deafness. So far, the research has shown that adults who are deaf react faster and more accurately than hearing adults when they observe objects in motion. This ongoing research continues to explore the concept of “brain plasticity”—the ways in which the brain is influenced by health conditions or life experiences—and how it can be used to develop learning strategies that encourage healthy language and speech development in early childhood.

A recent workshop convened by the NIDCD drew together a group of experts to explore issues related to a subgroup of children with autism spectrum disorders who do not have functional verbal language by the age of 5. Because these children are so different from one another, with no set of defining characteristics or patterns of cognitive strengths or weaknesses, development of standard assessment tests or effective treatments has been difficult. The workshop featured a series of presentations to familiarize participants with the challenges facing these children and helped them to identify a number of research gaps and opportunities that could be addressed in future research studies.

What are voice, speech, and language?

Voice, speech, and language are the tools we use to communicate with each other.

• Voice is the sound we make as air from our lungs is pushed between vocal folds in our larynx, causing them to vibrate.
• Speech is talking, which is one way to express language. It involves the precisely coordinated muscle actions of the tongue, lips, jaw, and vocal tract to produce the recognizable sounds that make up language.
• Language is a set of shared rules that allow people to express their ideas in a meaningful way. Language may be expressed verbally or by writing, signing, or making other gestures, such as eye blinking or mouth movements.

What is articulation in children?

Articulation is the ability to make sounds clearly. Children learn correct sound pronunciation by listening and imitating appropriate speech role models. Articulation develops gradually over the first 8 years of life.

When should I be concerned about my child’s articulation?

As therapists we typically are not concerned with a child’s articulation until they reach the age of 3. Under age 3 we expect children to make quite a few articulation errors and substitutions and to be frustrated when they are not understood. By age 3 a child should be using at least 200 words, using 3-5 word phrases and be understood at least 80% of the time. By age 4 a child should be 100% intelligible even if they continue to have some articulation errors. If you are concerned about your child’s articulation or intelligibility (how well you or others understand his/her speech) you should have him/her seen by a licensed speech pathologist to rule out any early concerns or delays.

What sounds do children learn to produce first and in what order?

Most children are able to produce the bilabial sounds (made with the lips) of “b, p, m, w” first since these are sounds are visible on the lips. They may also produce sounds such as “d, n, t” early on as well. These sounds are called lingu-alveolar since they are produced with the tongue behind the teeth against the alveolar ridge in the mouth. The acquisition of new sounds is a developmental sequence for young children, but by the age of 8 all children should have a mastery of all speech sounds. So keep in mind that some children will continue to work on mastery of the more difficult sounds such as “r” and “s”, as well as some blends like “sh” or “ch” until around 3rd grade. In other words, if your 2 year old is not yet using the ‘k” sound or ‘r” sound correctly yet there is no need for concern.

What interferes with articulation?

Children who have had multiple ear infections may be at risk for articulation problems since having excess fluid in their ears is like listening under water or in other words, sounds are muffled to some degree. Even after getting tubes, children may still experience articulation errors since they may continue to pronounce sounds as they heard/learned them when they were experiencing a conductive hearing loss due to the ear infections. Children who have a specific diagnosis, such as cerebral palsy or Down syndrome or who have abnormalities of the face, oral cavity or jaw would also be more prone to articulation problems.

How do you treat an articulation disorder?

Articulation treatment is provided by a licensed speech pathologist and may involve demonstrating how to produce a sound correctly, learning to recognize which sounds are correct and incorrect, and practicing sounds in different words. For young children this is all done through fun and play during natural daily routines.

Sources: ASHA, Hearing Speech & Deafness Center.

Learning to Speak and Use Language

Birth

Newborn babies make sounds that let others know that they are experiencing pleasure or pain.

0-3 months

Your baby smiles at you when you come into view. He or she repeats the same sound a lot and “coos and goos” when content. Cries “differentiate”. That means, the baby uses a different cry for different situations. For example, one cry says “I’m hungry” and another says “I have a pain”.

4-6 months

Gurgling sounds or “vocal play” occur while you are playing with your baby or when they are occupying themselves happily. Babbling really gets going in this age range, and your baby will sometimes sound as though he or she is “talking”. This “speech-like” babbling includes many sounds including the bilabial (two lip) sounds “p”, “b”, “w” and “m”. Your baby can tell you, using sounds or gestures that they want something, or want you to do something. He or she can make very “urgent” noises to spur you into action.

7-12 months

The sound of your baby’s babbling changes. This is because it now includes more consonants, as well as long and short vowels. He or she uses speech or other sounds (i.e., other than crying) in order to get your attention and hold on to it. And your baby’s first words (probably not spoken very clearly) have appeared! (“MaMa”, “Doggie”, “Night Night”, “Bye Bye”, “No”)

1-2 years

Now your baby is accumulating more words as each month passes. He or she will even ask 2-word questions like “Where ball?” “What’s that?” “More chippies?” “What that?”, and combine two words in other ways to make the Stage 1 Sentence Types (“Birdie go”, “No doggie”, “More push”). Words are becoming clearer as more initial consonants are used.

2-3 years

Your two or three year old’s vocabulary is exploding! He or she seems to have a word for almost everything. Utterances are usually one, two or three words long and family members can usually understand them. Your toddler may ask for, or draw your attention to something by naming it (“Elephant”) or one of its attributes (“Big!”) or by commenting (“Wow!”).

3-4 years

Sentences are becoming longer as your child can combine four or more words. He or she talks about things that have happened away from home, and is interested in talking about pre-school, friends, outings and interesting experiences. Speech is usually fluent and clear and “other people” can understand what your child is saying most of the time. In fact, sometimes “other people” hear things you wish they had not!

Overheard on a London bus on April 6, 2011 (the variety of English was RP):

Little Sister (3): It’s not fair mummy, my nose won’t blow.
Big Brother (4): Why won’t Fissy’s nose blow, mummy? My nose is a snot factory.

Stuttering and hoarseness

If stuttering (as opposed to normal non-fluency) occurs, see a speech-language pathologist. Stuttering is not a normal part of learning to talk, and neither is persistent hoarseness.

4-5 years

Your child speaks clearly and fluently in an easy-to-listen-to voice. He or she can construct long and detailed sentences (“We went to the zoo but we had to come home early because Sally wasn’t feeling well”; “I want to have a horse of my own like Evan, and Daddy says when he wins the lottery he’ll buy me one.”). He or she can tell a long, involved imaginative story sticking to the topic, and using “adult-like” grammar. Most sounds are pronounced correctly, though he or she may be lisping as a four year old, or, at five, still have difficulty with “r”, “v” and “th”. Your child can communicate easily with familiar adults and with other children. Your child may tell fantastic, dramatic, inventive, “tall stories” (sometimes even scaring themselves!) and engage strangers in conversation when you are out together.

Learning to Listen, and to Understand Language

Birth

Language learning starts at birth. Even new babies are aware of the sounds in the environment.

They listen to the speech of those close to them, and startle or cry if there is an unexpected noise. Loud noises wake them, and they become “still” in response to new sounds.

0-3 months

Astoundingly, between 0-3 months babies learn to turn to you when you speak, and smile when they hear your voice. In fact, they seem to recognise your familiar voice, and will quieten at the sound of it if they are crying. Tiny babies under three months will also stop their activity and attend closely to the sound of an unfamiliar voice. They will often respond to comforting tones whether the voice is familiar or not.

4-6 months

Then, sometime between 4 to 6 months babies respond to the word “no”. They are also responsive to changes in your tone of voice, and to sounds other than speech. For example, they can be fascinated by toys and other objects that make sounds, enjoy music and rhythm, and look in an interested or apprehensive way for the source of all sorts of new sounds such as the toaster, birdsong, the clip-clop of horses’ hooves or the whirr of machines.

7-12 months

The 7 to 12 months timeframe is exciting and fun as the baby now obviously listens when spoken to, turns and looks at your face when called by name, and discovers the fun of games like: “round and round the garden”, “peep-oh”, “I see” and “pat-a-cake” (These simple games and finger plays have regional names and variants).

It is in this period that you realise that he or she recognises the names of familiar objects (“Daddy”, “car”, “eyes”, “phone”, “key”) and begins to respond to requests (“Give it to Granny”) and questions (“More juice?”).

 1-2 years

Now your child points to pictures in a book when you name them, and can point to a few body parts when asked (nose, eyes, tummy). He or she can also follow simple commands (“Push the bus!”, “Don’t touch; it’s hot!”) and understand simple questions (“Where’s the bunny?”, “Who likes Miffy?”, “What’s in your purse?”).Your toddler now likes listening to simple stories and enjoys it when you sing songs or say rhymes. This is a stage in which he or she will want the same story, rhyme or game repeated many times.

2-3 years

By now your toddler will understand two stage commands (“Get your socks and put them in the basket”) and understand contrasting concepts or meanings like hot / cold, stop / go, in / on and nice / yuccy. He or she notices sounds like the telephone or doorbell ringing and may point or become excited, get you to answer, or attempt to answer themselves.

3-4 years

Your three or four year old understands simple “Who?”, “What?” and “Where?” questions, and can hear you when you call from another room. This is an age where hearing difficulties may become evident. If you are in doubt about your child’s hearing, see a clinical audiologist.

4-5 years

Children in this age range enjoy stories and can answer simple questions about them. He or she hears and understands nearly everything that is said (within reason) at home or at pre-school or day care.Your child’s ability to hear properly all the time should not be in doubt. If you are in doubt about your child’s hearing, see a clinical audiologist. If you are in doubt about language comprehension, see a speech-language pathologist / speech and language therapist.

Innate and learned

Language is partly innate and partly learned, as children interact with other people and the environment.

The symbolisation of thought

Language has been called the symbolisation of thought. It is a learned code, or system of rules that enables us to communicate our ideas and to express our wants and needs. Reading, writing, gesturing and speaking are all forms of language.

Language falls into two main divisions:

• receptive language: understanding what is said, written or signed;
• expressive language: speaking, writing or signing.

Pragmatic skills

Pragmatic skills begin to develop in the early weeks of life, with tiny babies “turn taking”, and initiating communicative interchanges, and “talking” (non-verbally, of course) to their caregivers.

Language Learning

How is language learned?

Whether they speak early or late, are learning one language or more, are learning to talk along typical lines or are experiencing difficulties, the language acquisition of all children occurs gradually through interaction with people and the environment.

Your role in language learning

Maybe you are a couple raising your baby, or you might be a sole parent or caregiver. Whatever your family structure, you are the most ‘significant other’ your baby interacts with communicatively. The way you engage with him or her will determine the path that language development takes in the vital first five years.

Be natural

Enjoy this exciting period in your child’s development. Talk in a natural way about what he or she is doing, seeing and hearing. Listen to the sounds, and later the words he or she says, and respond, so that your child knows you are listening. Read stories together from an early age, and make communicating fun and interesting.

Pragmatic skills include:

• knowing that you are expected to answer when a question has been asked;
• being able to participate in a conversation by taking it in turns with the other speaker;
• the ability to notice and respond to the non-verbal aspects of language;
• awareness that you have to introduce a topic of conversation in order for the listener to fully understand;
• knowing which words or what sort of sentence-type to use when initiating a conversation or responding to something another person has said;
• the ability to maintain a topic;
• the ability to maintain appropriate eye contact, with not too much staring, and not too much looking away during a conversation;
• the ability to distinguish how to talk and behave towards different communicative partners.

A rough guide to development

• Expect first words between 12 and 18 months.There will probably be a “spurt” of language development before 2 years.
• Anticipate hearing 4 to 5 word sentences by 4 years.
• Grammar should be correct most of the time by 4 years.
• “Other people” will understand almost everything your child says by the time

Progress should be steady

Children learn at different rates. Some are fast language learners and some are slow, so it is best not to compare one child’s language development with another’s. The important thing to watch is that language development proceeds steadily, not whether it is fast or slow.

Language Milestones

Ages and Stages charts for speech and language development and speech intelligibility criteria can be worrying if they are interpreted too rigidly.  Remember that children vary quite considerably with regard to the rate at which they reach the various speech and language ‘milestones’. So there is no need to put out an SOS for a speech pathologist if your child does not do the things itemised at precisely the ages stated! When you see language ages and stages and read an age like ’12 months’ say to yourself, ‘twelve months or so’.

The first three years

By 12 months (or so!) most children have one or two words that they say with meaning and can comply with simple requests (e.g., ‘Can I have your cup?’) or commands (e.g., “Don’t touch!”) and understand little questions (e.g., ‘Where’s your tummy?’).

By 2 to 3 years of age your child should be able to follow two-part instructions (‘Get he or she is 4!. Isn’t that amazing?

Late talkers

• For some time developmental specialists have used the general rule-of-thumb that ‘late talkers’ have a spoken vocabulary of fewer than 50 words on their 2nd birthday. Recent studies suggest this estimate is on the conservative side. It is probably better for parents to err on the side of caution and seek the professional opinion of an SLP/SLT if their toddler has fewer than 50 words between 18 and 24 months.
• Late talking may signal speech and language difficulties that fall in the clinical range.
• This does not mean that the 50 words will be pronounced perfectly – two year olds are supposed to talk baby talk!

Child-like speech

This may sound strange, but expect your child’s  speech to be child-like.

This is normal…

ALL children sometimes misunderstand what is said to them, utter oddly worded sentences, and put speech sounds and syllables in the wrong spots (or omit them) when they are learning to talk.

…and this is not

STUTTERING
Stuttering is not a normal part of your teddy and put it on the chair’) and string two or three words together to talk about and ask for things.

More detailed information

You might be interested to read the section here about Brown’s Stages. It provides an account of the development of the first ‘sentences’ children say, and the grammatical rules (morphemes) they apply. There is also information on this site about the way SLPs collect and analyse small children’s language samples.

If progress seems too slow

If ‘first words’ have not emerged by 18 months make a concerted effort to spend half an hour a day just playing and interacting one-to-one with your baby. This can be difficult to organise in larger families, but it often does the trick! How to set these times up and maximise their usefulness can be discussed with an SLP/SLT, who may suggest and demonstrate various activities.

When to seek help

Even though they are concerned that their child’s speech and language development may be unusual or slower than normal, people may hesitate to seek the professional advice of a speech-language pathologist. Sometimes this is because they are advised against it by reassuring friends, family and others. But sometimes it is because they think the child is too young

Many parents are surprised when their EI speech therapist comes to their home and starts playing with their child and does not sit down at a table and practice flash cards of new words.  Parents may be concerned because their child is not talking, but what may be of more concern to an EI Speech therapist is that their child is not imitating.  The ability to imitate is one key to communication development because it involves the idea that “I see you do something and then I can do it too”, including imitating sounds and words.  For a child to be able to imitate they need to be socially connected and pay attention to the other person involved in the activity as well as having the motor and cognitive abilities to imitate the action.  Many young children that we work with are not developmentally ready to start working on single words because they have not mastered the skill of imitation and therefore we need to back up and work on the beginning levels of imitation.

Developing a Child’s Ability to Imitate

An EI speech therapist may first start by developing a child’s ability to imitate actions with familiar toys, such as shaking a rattle, pushing a car, rolling a ball or hugging a doll.  The important part of these activities is encouraging the child to copy the action that you are doing.  These activities will not only help develop play skills but they will also encourage the child to attend to what you are doing and share in that activity.  The EI speech therapist may also start encouraging the imitation of simple gestures during play and daily routines such as clapping hands, stomping feet, waving, shaking head yes/no and reaching up to be held or carried.  The ultimate goal of all of these play activities is to socially connect with the child and to teach them that “you do, then I do”.

After a child has started to imitate basic actions and gestures the therapist may start encouraging the imitation of simple sounds during play such as ‘Ah’ or ‘Oooo’, squealing, grunting, snoring, fake cough or car noises.  The speech therapist may also start encouraging the use of exclamatory words during play such as “uh-oh, eeew, whoa, mmmm or ouch”.  These types of imitation activities are bringing more attention to the child’s mouth and the purpose is to have the child imitate the same noise as the adult.  After the child appears to be able to imitate simple play sounds and exclamatory words the therapist may start to incorporate set phrases or verbal routines such as “ready, set, go!”, “1, 2, 3”, “peek-a-boo” or simple childhood songs.  Using these set phrases during multiple play activities allows for predictability and memorization of vocalizations.

Once a child has developed the ability to imitate actions, sounds and verbal routines in play then the EI speech therapist may start to encourage the child’s production of real words.  By this point the child should have a better understanding of the concept “you do it, then I do it” and may be more receptive to imitating new words modeled for them.  We all understand that children learn best through play and all of the above activities are best done during play routines where the adult is thoroughly engaged and exciting to be around.  This will make the child more excited about what is going on and will encourage them to be involved in the interaction. So the next time your child is imitating you marching around the house, playing peek-a-boo, waving good-bye or saying “uh-oh!”, remember that these are the foundational skills needed for the child to begin to speak!