Concerns

Stammering

Stammering is a neurological condition that impacts the fluency of speech.

Stammering or dysfluency is what we call speech that doesn’t flow smoothly. Many young children go through a period of dysfluency, usually when they start to use more words. This is usually a normal developmental phase.

We don’t know what causes stammering, but we have an idea that it is something to do with the connections in the brain associated with speech production. Parents/carers do not cause stammering.

Many children will stop stammering at a young age, others will continue into school and adulthood.

How to spot it?

• Child repeats the start of words e.g.’ m-m-m-m-mummy’
• Child repeats whole words e.g. ‘I want want want a biscuit’
• Child makes sounds longer e.g. ‘ffffffffffffffive’
• Child seems to get stuck on their words or on certain sounds
• Child blinks or pulls ‘struggle’ faces when trying to talk

What to do?

We would recommend that you refer children who present with a stammer to Speech and Language Therapy, to access the appropriate information and strategies. The earlier you get information and support for your child the better.

In the meantime:

• Give time for your child to talk
• Don’t interrupt
• Reduce demands on speech e.g. ask less questions
• Use a good model of talking – be slow and clear
• Avoid saying ‘stop, slow down, start again, have another go’

Referral form for Speech and Language Therapy and for more information:

• https://referrals.cslt.org.uk/referral-for-pediatric-speech-and-language-therapy-service.php

For more information go to:

• https://www.nhs.uk/conditions/stammering/
• https://stamma.org/

Listening and Attention

Listening and Attention are skills that start to develop before children learn to talk. They are important foundation skills for later talking.

Attention refers to a child’s ability to focus on a specific task, activity, or person for an extended period of time.

Listening refers to a child’s ability to concentrate on what they are hearing while ignoring any other distracting input, like background noise.

Children learn to listen in gradual steps. Being able to listen and attend to others will support a child’s understanding of words and then later instructions.

Good listening skills can also help with how clearly a child will talk. Good attention will help with learning appropriate social skills as they get older.

How to spot it?

• Child prefers activities that are action based rather than sitting still and listening
• Child doesn’t respond when I say their name or appears not to hear when people speak to them
• Child needs lots of help to sit and pay attention, even for a short period of time
• Child finds it difficult to concentrate on an activity chosen by an adult
• Child may ‘flit’ from one activity to another without staying involved for longer periods of time
• Child doesn’t follow instructions

What to do?

To help attention and listening, when talking to  children:

• Be at their level so they can see your face
• Make eye contact
• Say their name before giving an instruction
• Point out sounds in the environment to encourage good listening habits and awareness
• Have some quiet times in the environment where  children can learn to listen just to voices without lots of competing background noise
• See ‘Information and Resources’ section for further ideas
• See ‘Ages and Stages’ section for more information about what to expect and when with the development of listening and attention

Social Communication

Social communication is often referred to as social skills or social interaction. Children may have social communication difficulties because they have diagnosis such as autism or as a result of other speech and/or language difficulties.

Social communication is the way children use language within social situations.

How to spot it?

• Child is often in their own world; watches activities from outside and makes limited or no attempt to join in.
• Child often has difficulties with pretend play and relationships.
• Child mainly communicates on their own terms in order to get their wants/needs met.
• Older children have issues with making and keeping friendships.
• Older child take things very literally and need to be told social rules lots of times in order to know how to relate to people.
• Older child talks persistently about a topic of their own fascination without noticing if the listener is interested or not.
• Older child has difficulties understanding what others may be thinking or feeling and interpreting social situations.

What to do?

• Children from six months to six years can be assessed with the Wellcomm Toolkit to see if there are other underlying language issues. The Big Book of Ideas has activities and ideas to support aspects of social communication development.
• If parents or professionals are concerned that a child has persistent and significant difficulties in this area, they may be referred for specialist assessment to learn more about the child’s development and social communication needs:https://bridgewater.nhs.uk/halton/woodview-specialist-childrens-services/ 
• See ‘Information and Resources’ section for ideas and activities to support communication development
• See ‘Ages and Stages’ section for more information about what to expect and when with social communication development

Hearing Impairment

Hearing is the process by which we perceive, process and make sense of sounds in the environment, via our ears.

Hearing impairment occurs when there's a problem with, or damage to, one or more parts of the ear or to the sound processing system in the brain.

How to spot it?

• Child does not always respond to their name
• Child appears not to hear loud noises.
• Child ignores me and other people when we are talking to them.
• Child does not respond to voices if they can’t see someone talking to them
• Babies who start to babble and make sounds then stop

What to do?

Referral to audiology for a hearing test is made via a Health Professional or school.

For more information visit http://bridgewater.nhs.uk/haltonsthelens/childrensaudiology/

Contact on 01744 624 933 or email alwch.hsthpaediatricaudiologydepartment@nhs.net

See Support Services section of the Communication Hub for more information about services to support children with Hearing Impairment in Halton or the Local Offer

Understanding Language

Receptive language refers to a child’s ability to understand and gain meaning from spoken or written language. Receptive language is often also referred to as “comprehension skills” or “understanding skills”.

Understanding words is important for other areas of speech and language development such as saying sentences and talking clearly. Children need to understand words before they can say them.

How to spot it?

• Child doesn’t understand what is said to them.
• Child struggles to follow steps in instructions.
• I feel like I have to change what I say/do for them to understand what I say.
• Child sometimes looks blank when I ask them a question or ask them to do something.
• Child repeats back part or all of what has been said to them

What to do?

Children aged six months to six years can be assessed with the WellComm Toolkit. The Big Book of Ideas is full of activities and ideas to support understanding.

• Use visual supports e.g. use pictures and objects to  help children see what you are saying
• Make your instructions shorter and in smaller chunks, repeat key​words

Some top tips for understanding:

• Say less- keep  it simple
• Stress (emphasise your words)
• Go slow
• Show them what you mean
• See ‘Information and Resources’ section for ideas and activities to support communication development
• See ‘Ages and Stages’ section for more information on what to expect and when with the development of understanding
• Follow the Early Years/ School Age communication pathway for information about when to refer for specialist speech and language support

Expressive Language

Expressive language is our ability to use words and sentences and grammatical structures and concepts.

Expressive language difficulties will impact on a child’s ability to effectively communicate their thoughts, wants and needs. This may lead to reduced confidence to talk and frustration.

Children use more words as their vocabulary develops from interactions with adults and peers, and the experiences they have. Talking is gradual; a child’s ‘talking’ starts with making sounds, to single words, to joining words, to finally using fully formed sentences to have sustained conversations.

How to spot it?

• Young child/baby doesn’t use any sounds or babble
• Young child doesn’t say many words or put many words together.
• Child seems to use made up words.
• Child will use gestures e.g. pointing and taking my hand to show me what they want, with no real words.
• Child gets frustrated when he can’t express him/herself
• Older child puts words in the wrong order or uses very immature sentences that a younger child would use.
• Child often can’t remember words or uses the wrong word.
• Child has difficulties remembering and using new words

What to do?

• Children aged six months to six years can be assessed and supported with the WellComm Toolkit. The Big Book of Ideas is full of activities and ideas to support language following the assessment.
• Use visual supports e.g. pictures and objects so that children can show you what they want to say
• Use a good clear model of language, keep it simple, so the child can copy
• Repeat words and phrases
• Interpret what you think the child is trying to say
• See ‘Information and Resources’ section for ideas and activities to support communication development
• See ‘Ages and Stages’ section for more information on what to expect and when with the development of expressive language
• Follow the Early Years/ School Age communication pathway for information about when to refer for specialist speech and language support if you have concerns

Selective Mutism

Selective Mutism is an anxiety based communication disorder in which a child is fearful to talk in certain situations.

A child may be described as ‘chatty’ or a ‘confident talker’ by parents at home but is unable to talk, or in some cases, communicate in other places/situations and demonstrates ‘phobia-like’ behaviours, e.g a frozen expression.

Specialist speech and language support to manage Selective Mutism is always recommended.

How to spot it?

• Child will not talk at all in certain situations/places/environments but will talk well in others.
• Child talks happily to some people but not at all to others.
• Child finds it difficult to talk to new people and make friends

What to do?

It is recommended that a referral to Speech and Language Therapy is made if you have concerns that a child has Selective Mutism.

Referral form for Speech and Language Therapy and for more information:

https://referrals.cslt.org.uk/referral-for-pediatric-speech-and-language-therapy-service.php

Click here for more information about Selective Mutism:

http://www.selectivemutism.org.uk/about-selective-mutism/

English as an Additional Language (EAL)

If a child is learning English as a second or third language, we say they are learning English as an Additional Language. It might be that they have not been exposed to English from birth, or that the major language used in the home is not English.

Learning another language is considered to be a cultural, cognitive and linguistic advantage.

Having EAL does not mean a child is at a higher risk of a speech, language or communication difficulty.

How to spot it?

• Child can talk well in the language of the home but is not using English yet
• Child is learning English and seems to understand some words but is not using any English words yet.
• Child is learning more than one language but is not talking a lot at the moment (they are having a ‘silent’ period)

What to do?

• Children aged six months to six years can be assessed and supported with the WellComm Toolkit. The Big Book of Ideas is full of activities and ideas to support language development following the assessment.
• Parents/carers should talk to children in the language they feel most comfortable using, their ‘best language’
• Adults sing songs and read books in the language that they feel most comfortable using.
• You would only refer a child with EAL to Speech and Language Therapy if there was a difficulty learning the home language as well as English.
• Follow the Early Years/ School Age communication pathway for information about when to refer for specialist speech and language support if you have concerns
• See ‘Information and Resources’ section for ideas and activities to support EAL
• A Halton EAL training workshop link for practitioners is available on request – see Early Years training brochure each term for details

Unclear speech/speech sound difficulties

Talking is a complex skill. Words are made up of individual units of sounds call phonemes. For speech to be clear, we have to combine all the right sounds in all the right places. We learn to do this as babies when we start to babble.

Children need to think about the words they say and coordinate the air and muscles in the mouth to talk clearly. As children use more and more words, they are also learning how to combine sounds. As they practise talking, children will naturally make mistakes with using the right sounds. These mistakes typically fade away as they get older, but sometimes children will need extra support with their speech sounds.

A Speech Sound Disorder (SSD) describes when a child has difficulties producing speech sounds accurately, or using the right speech sounds in the right places, or combining those speech sounds in a way which leads to natural-sounding speech. Children with disordered speech production will need specialist support as it is unlikely that these difficulties will resolve with maturity.

Good listening skills really support speech development.

How to spot it?

• Child’s talking isn’t clear
• People struggle to understand what the child says
• Parents/carers understand what a child says, but others don’t

What to do?

• Children aged six months to six years can be assessed with the Wellcomm Toolkit to see if there are other underlying language issues. The Big Book of Ideas has activities and ideas to support communication. See the  back of the Big Book of Ideas for ideas to support listening and speech sound development.
• Reduce dummy use if present
• Check hearing
• Work on listening skills
• Consider referral at four years (before if severe issue)

Top Tips to support speech sounds

• Have some quiet times in the house where your child can just listen to your voice without lots of background noise
• Speak slowly and clearly yourself -  you are a great m
• Try not to ask children to keep repeating words they have said incorrectly e.g. ‘it’s not tar, say car’. If they could say it right they would! Instead repeat back what they have said with the right sounds ‘yes, it’s a car’
• See ‘Information and Resources’ section for ideas and activities to support communication development
• See ‘Ages and Stages’ section for more information on what to expect and when
• Follow the Early Years/ School Age communication pathway for information about when to refer for specialist speech and language support if you have concerns

Voice

Voice difficulties are characterised by the child having a voice that may sound different in quality, loudness or pitch, to those of their siblings and peers.

Our voice is created from our vocal chords. The vocal chords meet in the middle and move in and out to create a smooth sounding voice. Sometimes the vocal chords can be disturbed; this impacts the smooth movement and this makes our voice sound different.

Excessive shouting or screaming can cause this.

How to spot it?

• Child’s voice sounds hoarse/strained/abnormally low pitch/their voice breaks.
• Child persistently complains of a sore throat and this has changed the way that their voice sounds.

What to do?

If you feel a child’s voice has suddenly changed, parents/carers should consult their GP.  A referral to an ENT (Ear Nose and Throat) specialist may be advised.

Make sure they drink lots of water, being well hydrated really helps. Encourage use of an ‘inside voice’ if the child shouts excessively.

Feeding

Dysphagia is the term used to describe difficulties with eating, drinking, and swallowing.

Swallowing is a complex process which involves transporting food and liquids from the mouth to the stomach.

How to spot it?

• Child has difficulties chewing/swallowing food or drinks.
• Food/fluids are coming down the child’s nose.
• Child frequently chokes when eating/drinking.

What to do?

Talk to a health professional about concerns with feeding and any issues with weaning.

Referral to Speech and Language Therapy may be suggested if the issue is mechanical e.g. difficulties chewing/swallowing.

If the issue is behavioural e.g. child will only eat beige food/favourite foods, then a referral to this service would not be appropriate.

Developmental Language Disorder(DLD)

Developmental Language Disorder (DLD) means that you have significant, ongoing difficulties understanding and/or using spoken language, in all the languages you use. DLD was previously known as Specific Language Impairment (SLI).

There is no known cause of DLD and that can make it hard to explain and understand.

DLD is present from childhood and the term is used when a child has language difficulties in the absence of any other medical diagnoses.

Developmental Language Disorder is diagnosed when children struggle to acquire their own language for no obvious reason. This results in children who have difficulty understanding what people say to them, and have difficulties articulating their ideas and feelings.

How to spot it?

May see difficulties in some or all of the following areas:

• Attention and listening
• Development and accurate use of speech sounds
• Social interaction
• Talking in words/sentences
• Understanding or processing information

What to do?

Children aged 6 months to six years can be assessed with the Wellcomm Toolkit to identify language issues. The Big Book of Ideas has activities and ideas to support communication development in the early years setting and at home.

Speech and Language Therapists (SLT’s) should always be involved as difficulties will not resolve without specialist support.

SLT’s teach strategies to children with DLD and those around them, which aim to reduce the impact of their difficulties and develop their language abilities to their maximum potential. Children will follow a personalised care plan with specific targets and activities to support their individual needs.

• See ‘Information and Resources’ section for ideas and activities to support communication development
• See ‘Ages and Stages’ section for more information on what to expect and when with the development of expressive language, understanding, speech sounds and social communication
• Follow the Early Years/ School Age communication pathway for information about when to refer for specialist speech and language support if you have concerns

Autism(Autistic Spectrum Condition; ASC)

Autism is a lifelong developmental disability that affects how people communicate and interact.

It is not yet known what causes autism. It can affect more than one person in the same family.

Boys are more likely to be diagnosed with autism than girls. More recent research suggests that autistic girls present differently to autistic boys and this can mean they are often undiagnosed.

How to spot it?

Every person with autism has different communication skills and difficulties. Common features are:

• Difficulties communicating and interacting with other people
• Restricted interests and repetitive behaviours
• Difficulties managing changes to routines or unexpected events
• Understanding and talking about their emotions and responding to how other people feel
• Having a conversation
• Understanding more abstract language such as ‘It’s raining cats and dogs’ or ‘I could eat a horse’
• Understanding how what they say/do might impact others
• Making and keeping friendships
• Playing with other children
• A persistent focus on small details but not seeing the bigger picture

Autistic people may also be under or over sensitive to certain textures, lights, noises, smells and so on. This might mean that they avoid or have clear preferences for certain places/activities/foods.

What to do?

• See ‘Information and Resources’ section for ideas and activities to support communication development
• See ‘Ages and Stages’ section for more information on what to expect and when with the development of expressive language, understanding, speech sounds and social communication
• Follow the Early Years/ School Age communication pathway for information about when to refer for specialist speech and language support if you have concerns
• For more information and support about Autism:https://www.autism.org.uk/

The Local Offer has information about support available in Halton:

https://localoffer.haltonchildrenstrust.co.uk/

https://localoffer.haltonchildrenstrust.co.uk/health/

Augmentative and Alternative communication (AAC)

Augmentative and Alternative communication (AAC) refers to a range of approaches and systems that either support or replace spoken language.

Individuals will use their AAC in different ways. Approaches may be low, medium or high tech e.g. pictures in a book or an electronic device

AAC is used as part of a Total Communication approach where all forms of communication are encouraged and respected enabling children to communicate in a range of ways.

Formal signing systems like ‘Makaton’ may be part of a Total Communication approach.

How to spot it?

• Children who need AAC are usually in one or all of the following categories:
• Non verbal or have limited ability to use spoken language
• Have speech that is very difficult to understand
• Have the ability to use and understand symbols or pictures

What to do?

Speech and Language Therapists (SLT’s) should typically be involved in the assessment for and implementation of an AAC system. Longer term support and use of the system may be best supported by other consistent adults and peers in the child’s daily communication environment.