GETTING HELP

Who to See, Where to Go, and What
Your Therapy Options Are

FOR SOME CHILDREN, listening and talking comes easily. But other kids need help hitting the important milestones. It can be hard to know just what difficulties your child is having, but in the end, you know your child best.

Navigating the different channels to get that help is a lot like parenting in general: It takes equal doses of knowledge, patience, love, and grit. Getting help can be a complicated process, as there are many factors involved. Making sure your child not only gets that help, but gets the right kind of help, can really be the equivalent of a parenting endurance test. But if you have a concern about any aspect of your child’s development—hearing, speech, language, feeding, motor skills, cognition, or social skills—then you need to contact a specialist in that area.

In this chapter, we will tell you who to see for the therapy your child needs, where to go to get that treatment, and what kinds of speech language therapy your child may receive. We will also give you some basic information on the laws that regulate the provision of therapies for young children and Dr. Michelle’s tried-and-true tips on seeking help—everything from what to talk about in an evaluation to what to expect from speech and language therapy sessions.

If your child does need help, know that you are not alone. In 2013, the most common reason that preschool children ages 3 to 5 got state and federally funded extra help was for speech and language delays, according to a 2015 U.S. Department of Education report to Congress on the implementation of the Individuals with Disabilities Education Act.

GETTING STARTED ON GETTING HELP

The initial step in getting help for your child is a called an assessment or evaluation, which refers to the process of gathering information from you, your child, and possibly your child’s teachers about his communication abilities and difficulties.

During the evaluation, a speech language therapist will speak with you to learn about your child’s medical, developmental, and family history. If your child attends daycare, preschool, or elementary school, the therapist may also observe him in his interactions with peers and teachers. Your child’s speech, language, and communication skills will also be evaluated through both informal activities, such as playing, as well as formal tests. The tests may require skills such as naming pictures, pointing to pictures, answering questions, saying words and sentences, and telling stories. The results of the tests will be indicated by a score that represents how the child is performing in those areas as compared to typically developing peers of the same age. The therapist will determine if it is appropriate for your child to receive therapy based on a combination of the scores on these tests, as well as the evaluator’s impressions and, possibly, your concerns. Usually, your child’s score is the salient factor.

The speech language therapist will interpret the information that is gathered during the assessment to make a decision about the presence or absence of a communication disorder, and if one exists, she will provide a diagnosis, or a description of the communication disorder. Speech language therapists can diagnose a range of communication disorders, including articulation disorder, a fluency disorder (typically, stuttering), expressive and/or receptive language disorder, and a pragmatic language disorder. An appropriate diagnosis is important because it is usually required to get health insurance coverage for the condition or to qualify for special education services in schools.

If a diagnosis is established, the speech language therapist will then recommend speech language therapy (which can also be referred to as intervention), which entails focused lessons on improving communication. She will also provide a prognosis, or a prediction of how well the child will improve with therapy. The diagnosis and the characteristics of the child and the family will determine the type of therapy that is most appropriate for each child. We’ll tell you more about some different types of speech and language therapy later in this chapter.

Getting help is so important for your child’s development. We know that there is variation in how children’s talking skills unfold, but kids who have delays—whether those are small delays or big delays—can only be aided by extra help. Pursuing speech language therapy for a child who shows delays is important because oral language builds the foundation for academic success in elementary school. A speech language therapist will also work with your child and your family to improve communication, which should decrease frustration for everyone and can aid your child in social settings, too. But speech language therapy is not always a cure, and in many cases it may last months or even years; talking and listening take a lot of practice for some kids. Developmental skills build on each other, so it’s important to begin therapy as soon as a delay is detected.

Assessment and intervention come in all different shapes and sizes. They can be free, expensive, or somewhere in between. Evaluation and therapy can take place in the home, at school, or at the office of a professional. In the sections that follow, we’ll explain everything you need to know about who you will visit to get help and how to get different services for your child.

Dr. Michelle has evaluated hundreds of kids and coached lots of parents through the process of having their child evaluated. Here are some of her tips about how to prepare for a speech and language evaluation:

•Be prepared to explain how your child’s communication difficulties affect his everyday life, including at home and at school and when communicating with family, friends, peers, and teachers.

•Be ready to give specific examples of these communication difficulties. Try doing a short video recording at home or school or on the playground to show the evaluator an example of your child’s communication issues, or write down specific instances of issues your child faces. The speech language therapist who evaluates your child may rely heavily on a parent, caregiver, and teacher report and might observe and interact with your child for only an hour or two.

•Try to be present for all of the evaluation if you can. This will allow you to observe your child and report to the evaluator if the concerning behaviors were displayed during the evaluation. Keep in mind that for school-age kids, the evaluation may take place in the school setting and you may not be present for it, although you will likely be interviewed about your child’s birth and developmental history as well as speech and language milestones and current communication.

•Familiarize yourself with some terminology. Knowing some general terms about speech and language development, like pragmatics, syntax, and articulation, as well as some terms about the difficulties your child may be experiencing, like apraxia, dysarthria, or auditory processing disorder, can be helpful. A good place to look? This book!

MEET THE PROFESSIONALS

A big cast of characters is available both to help you and your child find out what help she needs and to provide the needed services. Keep in mind that it’s very likely your child will need to see more than one specialist to gain a complete understanding of her underlying challenges. As you may remember from Chapter 7, many developmental difficulties co-occur with each other. This means it can often take several tries to determine the reason your child is experiencing a communication disorder, and it’s common if your child receives multiple, overlapping diagnoses such as attention deficit disorder with hyperactivity (ADHD) and expressive language disorder. What follows are some professionals whom your child may see to receive therapy and/or to help you decide if your child needs a particular type of therapy.

SPEECH-LANGUAGE PATHOLOGIST

A speech-language pathologist is a communication specialist who may also be referred to as a speech language therapist or simply a speech therapist. This individual will have a graduate degree in communication sciences and disorders. A speech-language pathologist must have a state license to practice; the majority also hold a Certificate of Clinical Competence (CCC) issued by the American Speech-Language-Hearing Association (ASHA). A speech language therapist can help your child with challenges related to speech, language, reading, listening, and social interaction skills. Many speech-language pathologists specialize in working with children with particular issues or disorders. For example, some speech language therapists specialize in hearing disorders, others in stuttering or reading difficulties.

AUDIOLOGIST

An audiologist is a hearing specialist. A professional in this field will have an advanced degree in audiology (either a master’s or doctoral degree) and hold a license in the state where they practice; the majority hold an ASHA CCC certification. You would take your child to an audiologist to evaluate a hearing disorder or deficit and provide amplification (hearing aids and other technology). Some audiologists specialize in testing babies, children, or children with special needs. Also, audiologists can evaluate balance disorders.

EAR-NOSE-THROAT PHYSICIAN

An ear-nose-throat (ENT) doctor, or otolaryngologist, is a medical doctor who specializes in the aforementioned areas of the body. Some ENTs specialize in pediatrics. ENTs can prescribe medication and perform surgeries (such as placing tubes in the ear or removing tonsils and adenoids). You should take your child to an ENT if you suspect he has a hearing disorder or hearing loss. Audiologists work with ENTs to identify and treat hearing and balance disorders.

OCCUPATIONAL THERAPIST

An occupational therapist (OT) helps people improve skills needed to function in everyday activities. For kids, this means helping them with skills needed to participate at home, in school, and during social interactions, such as how to play with and manipulate toys, how to hold a pencil to form letters correctly, and how to feed and dress themselves independently.

FEEDING SPECIALIST

A feeding specialist helps babies or toddlers with the motor skills required for eating, such as chewing and swallowing. Remember, some kids who have speech issues also experience difficulties in eating, because both have their roots in oral motor skills. Both speech language therapists and occupational therapists can be feeding specialists.

DEVELOPMENTAL PSYCHOLOGIST/EDUCATIONAL PSYCHOLOGIST

A developmental psychologist or educational psychologist can help children who are having difficulty in school related to social, emotional, or academic problems. Psychologists diagnose conditions such as autism, dyslexia, and dysgraphia, and they work with speech language therapists when providing treatment for these conditions.

SPECIALIZED TEACHER

A specialized teacher is one who can help your child with a specific learning issue, such as a learning disability or reading delay. There are different types of specialized teachers:

A special education teacher specializes in teaching kids who have learning difficulties. A special education teacher can work in classrooms where all students have special learning needs; can collaborate with a general education teacher; or can travel from class to class or school to school to work individually with children in general education settings who are having difficulty with certain aspects of learning.

A reading specialist helps children who are struggling with reading and writing skills. This specialist most frequently works with children in small groups but may also work with the classroom teacher and lead classroom literacy lessons.

A teacher of the deaf and hard of hearing works with children who are hearing impaired or those who partially or completely lack the sense of hearing. Today, most children who have hearing impairment are in general education classrooms. This specialized teacher works alongside classroom teachers to provide extra support to students with hearing loss.

An English as a second language (ESL) teacher, sometimes called a teacher of English to speakers of other languages (TESOL), helps children whose first language is not English learn to read, write, and communicate in order to be successful in social and academic settings.

PUBLIC OPTIONS FOR GETTING HELP
FOR YOUR CHILD

There are a number of routes you can take to get therapy for your child. Some are public, meaning that they are free or low-cost and available to all who qualify. Other routes are private, meaning that you will pay for therapy for your child, either out of your own pocket, through your insurance coverage, or a combination. There is no right answer about which option is best for you and your child. Some parents choose to look first at publicly funded options. Others go right into the paying options, perhaps because they already know a great speech language therapist they want to work with or they simply don’t want to tackle the bureaucracy of a public system. And some parents do both—they get free services and they supplement them with services they pay for on their own. Some start right away with paying for therapy themselves while they go through the sometimes-arduous processes of seeking free services.

First, we are going to tell you about the publicly funded options to get help for your child. Then Dr. Michelle will tell you about various other private ways that you can receive therapy for your child—including some ways that may not burn a hole in your pocket.

A little background: The landscape for the way free services and interventions are provided for young children in the United States has been shaped by federal law. It’s a good thing, because Carlyn is a former legal reporter, and she enjoys telling you about how laws work.

The main U.S. law you need to know about is called the Individuals with Disabilities in Education Act, or the IDEA, which was passed in 1990 and has been updated several times. The idea (get it?) behind the IDEA is that children with disabilities (and that’s the word the law uses, although it’s not our favorite) get a free and appropriate public education. Every child in the United States—who meets the criteria—is entitled to free services.

Each state implements the IDEA on its own. Each state has its own eligibility requirements, has its own standards, and provides its own services. So, while there is a federal mandate to provide free services to kids in need, there’s a lot of variation in how different services are actually given out. There is also a lot of variation by state as to who qualifies for different services—what specialists refer to as eligibility. In addition, some states have their own laws and regulations that cover additional services, which means that your options for your child might be different from your cousin’s in another state.

Have the politicians who have passed these laws and the regulators and educators who have implemented them gotten everything completely right? No. (If they did, we probably wouldn’t need to write this chapter!) But this is the system we have now, and in many areas and for many children and their families it works.

In the sections that follow, Dr. Michelle discusses the different systems available to obtain free (or, in some cases, mostly free) services. Please keep in mind that there’s a lot of variation in the provision of these services depending on where you live and whether you have an infant or a school-age child.

EARLY INTERVENTION SERVICES (BIRTH TO AGE 3)

According to the IDEA, every state must have a program to provide therapies to kids with developmental delays from birth to three years. These programs are usually called Early Intervention (EI) or simply Birth to 3. In many states, these services are free; in some states, they are publicly funded, but you may be asked to pay for a portion of certain services on a sliding-scale basis.

If your baby was born with a hearing loss, the doctors at the hospital may refer you to your local EI program so that she can start receiving services right away. Or, let’s say your little one is 16 months old and you notice she’s not saying any words yet (refer to Chapter 3, for Dr. Michelle’s guidelines on when kids acquire their first words), then you might want to start your search for a speech and language evaluation by calling your state, city, or county’s Early Intervention program to seek help. (Because every place has a different program, you’re probably going to have to do an online search for the phone number.)

Your child’s pediatrician or teacher could also refer your child to the state’s Early Intervention program. Under part of the IDEA called Child Find, states are required to refer kids who they think might need extra help to get evaluated for services. You need to give consent for your child to be evaluated or receive services.

Your child will receive an evaluation to determine if he’s eligible for services. Specialists in early childhood development will look at all aspects of your child’s development during the evaluation, rather than just the aspects that you, a teacher, or a medical professional may be concerned about. Then, they’ll determine whether your child qualifies for Early Intervention services. The threshold for whether your child qualifies for these services depends on what state you reside in. (Go to the Resources section at the end of this chapter for more information about how to look up your state’s criteria.) Most states use a formula to determine eligibility. For example, some states grant services if a child is deemed to be 25 percent delayed from a typically developing child; others will grant services if a child is determined to be 50 percent delayed.

If your child qualifies for services, you’ll receive an Individual Family Service Plan, or IFSP, which is a legal document that spells out the services your child is entitled to (tailored to meet her needs and the needs of her family) and a set of goals for your child. The goal of the IFSP is to have parents involved in therapy for their children.

Birth to 3 programs cover lots of different services for children who have speech and language delays or hearing loss. Remember Marlowe, the young child who was born with hearing loss whom we introduced in Chapter 1? Her hearing aids were covered by her local EI program. Other kids can receive several hours of free or low-cost speech therapy a week. Sometimes, kids get multiple kinds of services, like speech therapy, physical therapy, and occupational therapy, too.

PRESCHOOL SERVICES (AGES 3 TO 5)

Now, let’s say your child is three years old and you or your child’s daycare teacher is worried about how she’s putting words together to communicate. Or she has already received services through Early Intervention and you want her to keep getting them. Preschool Special Education is the name for federally mandated services for children ages 3 to 5 who need some extra help. Sometimes, services for kids this age are referred to as Section 619 services, named after the section of the IDEA law that establishes them. Different states and cities may also have their own names for the committees and offices that evaluate preschool kids and help families get services.

Your child is entitled to free special services at this age—provided she meets your state’s criteria—even if she does not attend a preschool. If she’s home with a parent, grandparent, or other full-time caregiver, she can get these services. If she goes to a private daycare or preschool, including religious and parochial schools, she can get them, too. Just as with Early Intervention, a teacher or medical professional can also recommend your child get evaluated for services.

If your child qualifies for services, he will receive what’s known as an Individualized Education Program, or IEP. You will hear this term so often over the next year (or longer) that you’ll be surprised when other parents don’t know it! An IEP is a legal document that spells out what diagnosis your child has received and what services she will get. Your child’s IEP will state your child’s current level of functioning and include goals for her to achieve.

Depending on her needs, your child can get lots of different kinds of services. She may get a free preschool education at a specialized school, like a local school for kids with communication difficulties. She might get transportation to the school paid for. She may receive a few hours of speech therapy at a speech therapist’s office each week. Or she may have an extra teacher in the classroom to help her out.

The IDEA lists 13 categories of disabilities—remember, that’s the term the law uses—that can qualify children ages 3 through 21 for services. (Some states also use an extra, optional category, called developmental delays, for kids ages 3 to 9.) Many of the difficulties, delays, and disorders that we’ve discussed in this book fall under several of these IDEA categories, including:

Speech or language impairment

Deafness

Hearing impairment

Autism

Specific learning disability

SCHOOL-AGE SERVICES (AGE 5 AND OLDER)

Your child is ready for kindergarten and he still has difficulty pronouncing lots of common speech sounds, or he’s stuck in a reading rut in first grade, or he’s in second grade and his teacher thinks he might have learning and attention deficits. Now what?

Welcome to the special education process. Your child can receive free special education services if he attends a public or private school or if he is homeschooled. The IDEA says he is entitled to receive a free and appropriate public education in the least restrictive environment. But there’s a catch: The law doesn’t always make it easy—and neither do schools—to get those services.

To qualify, your child must, according to the IDEA, have a recognized disability (again, that’s the word the law uses) and this disability must adversely affect his academic performance. So not every kid who faces challenges is going to meet this threshold. In Dr. Michelle’s opinion, these standards often mean that kids who need help do not qualify for it until they are too far behind.

Your child will receive an evaluation to see if he qualifies for an IEP. If your child attends public school, the IEP process will typically happen at his school. Social workers and administrators at the school should help guide you through the evaluation process. If your child goes to a private or parochial school or is homeschooled, her evaluation will take place through your local school district; you may have to bring her to an office or public school to receive the evaluation.

If your child qualifies for services, his IEP will specify the services he is entitled to. It will set out specific, measurable goals. The word individualized in IEP is there for a reason: Every parent and child’s IEP experience is going to be different, depending on the challenges your child has, his age, and his school environment. For many families, the IEP process is fraught with bureaucracy; for others, it is relatively easy and painless. There are lots of rules that govern the IEP process, everything from the duration of time it should take to get an evaluation to when your child’s IEP should be renewed. These rules, while important for maintaining the integrity of the process, can also make it hard for parents to get help for their child. The IDEA contains important safeguards for parents who are unhappy with the process. It allows them to ask for independent evaluations, request a hearing to address their grievances, or set up a dispute-resolution process. Consult the Resources section at the end of this chapter for some of Dr. Michelle’s favorite websites to help you familiarize yourself with the relevant laws and terminology and to find a description of the safeguards available to parents.

Nearly 6 million students ages 6 to 17 across the United States received services under the IDEA in 2013, according to a U.S. Department of Education report to Congress published in 2015. The most common reason was for having a specific learning disability; the second most common reason was for speech and language impairment. For kids with communication challenges, special education can take many forms. Remember that speech and language difficulties can intersect, and that speech and language issues can often co-occur with behavioral and academic issues that can make learning difficult. Here are some common forms of intervention, also called service delivery models, that your elementary school–age child may receive for a broad array of communication issues:

Related services refer to when a child receives educational instruction from a general education (or regular) classroom, but receives additional help, such as speech therapy, occupational therapy, physical therapy, or reading instruction. Speech therapy provided as a related service could take place either in a small group or in a one-on-one setting. It can also take place at school, in the classroom, or at a separate location.

An inclusion classroom, also sometimes called an integrated classroom, refers to a classroom that has a mixture of kids—some with IEPs who may have speech, language, or learning disabilities and who require specialized instruction to succeed in the classroom, as well as some kids who are typically developing. In such situations, two teachers—a general education teacher and a special education teacher—work together to help all the children in the classroom learn the material.

A self-contained classroom is composed solely of kids who have special learning needs. For these kids, a general education classroom or integrated classroom does not meet their educational needs. Self-contained classrooms may be taught by speech and language therapists (who also hold a teaching certification) or special education teachers.

Some schools or districts go beyond federal standards and provide services to a wide range of kids; count yourself lucky if that’s the case for you. In addition, school-age children with communication difficulties can sometimes get extra help under a federal law called the Rehabilitation Act of 1973, which calls for accommodations for children with disabilities. Often called 504 plans, after the section of the law that governs them, these accommodations can include extra classroom teachers for children with special learning challenges. See the Resources section for a guide to finding out more about 504 plans.

PRIVATE OPTIONS FOR GETTING HELP
FOR YOUR CHILD

As we’ve explained, not every child is eligible for all those free or low-cost public speech language therapy (or other therapy) services. If you go through the evaluation process by way of your local school and your child doesn’t qualify, but still shows delays in speech or language skills that you think are affecting his communication, social, or academic skills, Dr. Michelle strongly suggests you pursue speech language therapy using another route. Or, your family may want to start with alternative options to begin with, knowing some of the roadblocks often involved in gaining free services.

To receive services in settings outside of your local school district, your child must go through an evaluation process, just as for publicly available interventions, but you will likely have to pay for this evaluation. Depending on your health insurance, you may be able to get reimbursed for the cost. But the threshold for qualifying for these services can be different when compared with the public sphere. Private practitioners who aren’t bound to strict government or school district standards are likely to happily provide services to kids who face challenges because they recognize that many kids will benefit from extra help.

Let’s outline three options you might want to consider for your child, along with some of their pros and cons.

PRIVATE PRACTITIONERS

Private practitioners are specialists who work out of an office or make home visits. Some may accept medical insurance or they can provide you with an invoice that has ICD-10 codes (universal codes for medical billing), which can be submitted to your insurer to get reimbursement. See the Resources section of this chapter to find a therapist in your area.

Among the upsides of working with a private practitioner:

Your child will receive high-quality, individualized therapy in a 1:1 setting in your home or in a location that is convenient for you.

You or a caregiver can be more involved and communicative with the therapist than in a school setting because you or another caregiver will usually be present for therapy sessions, or you’ll be around to meet with the therapist before or after the session.

Private practitioners typically work year-round, so your child’s therapy does not stop during school breaks.

Among the downsides:

You may be paying a lot of money if your health insurance does not cover these services.

You have to take your child to therapy, and travel time can add up.

Scheduling the best appointment slot can be challenging if your child has other commitments, like sports or music lessons.

HOSPITAL (OUTPATIENT) CLINICS

Some hospitals have outpatient clinics that specialize in speech, language, and hearing evaluations and treatment. These clinics typically accept many types of medical insurance.

Among the upsides of hospital clinics are:

You will likely receive high-quality, individualized therapy for your child that is affordable.

You can be involved in your child’s treatment because you can be at the clinic with him when therapy takes place.

Some hospitals may have access to extra resources, like sound-treated rooms or ear-nose-throat doctors (ENTs) on staff.

Among the downsides:

You will have to bring your child to another location for this therapy, and the time that you are able to schedule his sessions may not be ideal (such as after school hours).

If your child is struggling in school, it may be hard for a therapist from an outside clinic to communicate with his teachers about specific difficulties and strategies to use in the classroom.

COLLEGE AND UNIVERSITY CLINICS

Colleges and universities that have undergraduate and graduate programs in Speech-Language Pathology usually have speech, language, and hearing clinics on or close to campus. Under the supervision of licensed and certified therapists, graduate students work with children experiencing difficulties. Payment for services is affordable and often on a sliding scale. Some may also accept medical insurance.

Among the upsides of college and university clinics:

You can likely get very affordable services for your child.

The individual helping your child is likely steeped in some of the latest research in the field.

Students working in clinics are often enthusiastic about their new profession and strive to help young children.

Among the downsides:

Unlike a veteran practitioner, students helping your child will not have decades of experience treating kids (although their supervisor will), and these individuals may rotate on a regular basis.

As with other private practitioners, you will have to bring your child to therapy, and travel time can add up.

Clinics often have lengthy breaks due to the academic schedule that may not overlap with your child’s school or daycare schedule.

A PARENT’S PERSPECTIVE

Joshua’s Story

When Joshua was about three years old, his mom noticed that he didn’t seem to be producing speech sounds like other children did. Through the local daycare that he attended, his mom contacted a local social worker in the town in southern Virginia where the family lived. The social worker said Joshua was too young to receive services because he had a good grasp of spoken language. But as he got older, his mom felt that his articulation wasn’t improving, so she took him to a local hospital clinic to receive speech services, which she paid for herself. “It started to hit the pocket,” she said. She then successfully petitioned her local public school system to provide speech therapy services for her son. Joshua attended a private preschool and was approved for an IEP. Even as he progressed through the early elementary school years, attending both public and private schools, Joshua still struggled to pronounce his speech sounds and received speech language therapy. One of the things his mother liked best was that some of the therapists gave him homework, assigning Joshua to practice specific words at home that were hard for him, like gorilla.

It took many years for Joshua to successfully pronounce tricky sounds like his r correctly, but his mom credits many hours of speech therapy practice with helping him. “It’s been such a noticeable difference,” she said. “He is conscious of how he speaks in conversation.”

LET’S LOOK AT METHODS OF SPEECH
LANGUAGE THERAPY

First we got you through an evaluation. Now it’s time to focus on what happens once therapy begins.

No matter how you decide to pursue help for your infant, toddler, or school-age child, Dr. Michelle urges you to be aware of some basic professional guidelines for speech language therapy. The speech language therapist should be using evidence-based practice when working with you and your child. Evidence-based practice is a general term used in many different clinical practices that asks practitioners to take a multifactor approach in evaluating and treating patients. In 2005, ASHA published guidelines for evidence-based practices urging speech language therapists to consider three important factors when working with clients:

1. Speech language therapists should use research-based evidence when making decisions about evaluation and treatment. This means that your child’s therapy should be based on academic research stating its effectiveness rather than simply on anecdotes and personal likes and dislikes.

2. The family’s unique perspective, including preferences, cultural considerations, and values, are to be taken into account in the provision of the child’s services. If your child is struggling to say words, your therapist may start with the names of family members or the name of a pet. If your child lives in an urban environment, he might want to learn words that are relevant to his neighborhood, like bus or sidewalk; names of farm animals are less important.

3. The speech language therapist should use her expertise, past experiences, and knowledge in the development of an appropriate and unique therapy plan for your child.

These three guidelines have been established as the gold standard for speech language therapists when working with clients. Dr. Michelle strongly urges parents to make sure that any therapy your child receives contains these elements.

The therapist you engage will develop an individualized therapy plan to address your child’s specific strengths and weaknesses. Think of therapy as climbing a ladder: When your child is first evaluated, the therapist will determine what rung of the ladder your child is on. The therapist will then come up with a plan that will contain long-term goals—which you can think of as the top of the ladder—such as improving the child’s ability to be understood by others. The plan will also contain short-term goals—which you can think of as the rungs on the ladder—which are the incremental improvements needed to achieve the overall goal and to get to the top of the ladder.

And whatever the goals are, speech language therapy should be enjoyable, because kids learn best when they are playing and having fun. For toddlers, speech therapy may look very similar to play, but the therapist will structure the play to address both your child’s long-term and short-term goals. For older children, therapy should still be enjoyable and individualized; the therapist should try to involve your child’s particular interests, such as working on getting him talking about outer space, superheroes, or a favorite movie, to make the therapy session personalized and focused.

Speech language therapy is most effective if everyone integrally involved in your child’s life is involved and on board. Make sure to reinforce at home what your child works on during therapy sessions. Start by setting up regular communication with your child’s therapist(s). We know you’re busy, and we know the professionals helping your child are, too, but a weekly note or progress report from the therapist tucked in your child’s backpack, or a text message or email containing information about what can help you implement your child’s therapy at home, can go a long way toward helping your child improve.

Now, Dr. Michelle will have you step into her virtual office and tell you about how speech language therapy actually works.

DIRECT SERVICES

Speech language therapy can involve either direct services or indirect services. With direct services, the therapist works with your child in a one-to-one, small group, or large group setting. Direct services can involve different types of activities; some of these are structured and others are unstructured. For example, drill activities are very structured and involve saying or repeating a sound, word, or phrase many times. For kids, these types of activities may be necessary to learn how to say a speech sound a new way, to learn how to put three words together to make a sentence, or to decode simple words.

Unstructured activities, sometimes called play-based therapy, or learning while engaged in play, involve taking the child’s lead to practice communication skills. Play-based therapy takes place in a naturalistic environment—comfortable, familiar settings, such as at home while the child is participating in everyday activities like playing with toy trains. A technique that speech language therapists use during play-based therapy to increase a child’s language skills is called expansions, where the therapist rephrases a child’s utterance to be more complex. Let’s say a three-year-old is playing with a toy farm and remarks, Cow eat. The therapist may reply, The cow is eating grass, in order to model an appropriate sentence and in hopes that the child will repeat the longer sentence. For some children, in particular babies and preschool-age children, unstructured play-based therapy may be best because it teaches new skills and reinforces these skills in a naturalistic environment. Other kids may respond best to a combination of structured and unstructured methods.

Speech language therapy may also involve teaching children to use alternative and augmentative communication (AAC) strategies to communicate. AAC refers to the process of using all forms of communication—other than speech—to express ideas, including using facial expressions, pointing, and symbols or pictures. AAC strategies can be high-tech or low-tech. Children with severe speech and language disabilities, including children who are nonverbal or have very few words for their age, may use AAC to either supplement oral communication or to replace it if they are not able to use speech.

AAC can involve using manual languages such as sign language, a picture board, or high-tech communication devices that have voice output. Tools can range from very small and simple yes/no pictures to large and complex devices such as a handheld computer or tablet with specialized software. Research shows that using AAC strategies and devices can supplement as well as facilitate speech production; AAC devices can sometimes even improve the speech of children with severe delays.

INDIRECT SERVICES

Speech language therapy can also be delivered through indirect services where the therapist provides consultation and training to family members or caregivers on how to improve a child’s communication. One example of an indirect therapy approach to improve language in young children (birth to age 5) who have language delays is called It Takes Two to Talk—The Hanen Program for Parents of Children with Language Delays. This program was developed by researchers in Toronto, Canada, to educate and train parents of young children with language delays about how to interact with their children to improve their language and communication. Researchers have shown that this program, when done with the appropriate supervision of a therapist, can be effective.

DR. MICHELLE’S TRIED-AND-TRUE
THERAPY TIPS AND STRATEGIES

Throughout this book, and especially in Chapter 7, we’ve discussed a lot of concerns that parents have when it comes to their child’s speech, language, and hearing development. No two kids are alike—so no therapy session or strategy will be, either. Here are some tips from Dr. Michelle on what to look out for when your child receives therapy for some of the most common diagnoses:

Apraxia: Expect therapy for your child several times a week, with practice focusing on using all the speech sounds correctly in syllables, words, and sentences. Push hard for intensive therapy if you are seeking school-based services. However, remember from Chapter 2 that current scientific research does not support therapies that focus on mouth movements, such as blowing a horn, puckering, and drinking from a straw, which are sometimes used during therapy sessions for kids with apraxia but are not shown to improve the ability to make certain speech sounds.

Social communication disorder: Your child will likely work hard, over a period of many years, to understand the conventions of language, including practicing communicating with peers, adults, and teachers. Therapy may be most effective if your child is paired with a peer to practice his social language skills.

Autism: If your child is diagnosed with autism spectrum disorder, he should be working not only with a psychologist, special educator, and occupational therapist, but with a speech language therapist as well. Make sure that all specialists try to reinforce what he is practicing in speech language therapy. For example, if he is working on using gestures to communicate, show the OT and psychologist these gestures so that he can use them during sessions with those professionals, too.

Dysarthria: Your child will likely work with a physical therapist, occupational therapist, and speech language therapist, because his underlying challenge is a difficulty based in motor movements. Work with your child’s speech language therapist to come up with ways for everyone involved in your child’s life to communicate effectively with him.

Language-based learning disability: Your child will likely work specifically with teachers trained to help her with a particular learning issue. Be sure that your child’s special education teachers are familiar with all of her language development history, even reaching back to the toddler years.

For a little more detail about what frequently goes on during therapy sessions, Dr. Michelle offers composite profiles of three children with some of the most commonly occurring challenges, based on some of her patients, and explains the strategies she would use to work with them.

Spencer is five and a half years old and has an articulation disorder. He doesn’t say certain speech sounds correctly, and his family, teachers, and peers are having a hard time understanding him when he says words containing the sounds s, z, sh, th, l, and r.

Dr. Michelle would approach therapy for Spencer by concentrating on improving speech production skills—the coordination of respiration, phonation, and articulation. This therapy should improve his speech intelligibility, or his ability to be understood by others.

First, it’s important for children to hear the difference between speech sounds in order to say them correctly, so Dr. Michelle frequently does something called perceptual or ear training. This involves listening for target sounds and hearing the difference between correct and incorrect productions. She would work with Spencer to help him hear the difference between the s and sh sounds. The s sound is particularly important, because the first sound in his name contains an s blend—an s plus another sound (in Spencer’s case, p).

Next, Dr. Michelle would work with Spencer to practice saying his speech sounds correctly, placing his articulators—his tongue and lips—in the correct position to say these speech sounds alone and in words and sentences. The most important aspect of treatment for speech sound disorders is practice, practice, practice. Practice does make perfect when it comes to speech sound production, and it should take place during therapy, at home, and at school. This means it’s important for Dr. Michelle to establish a communication system with Spencer’s family and teachers so that everyone is able to help him succeed.

Sarah is an eight-year-old with auditory processing disorder (APD). She has difficulty following along in the classroom, especially when it is noisy or when the teacher walks around the room. An audiologist has confirmed that Sarah has auditory processing disorder, a hearing disorder that we discussed in Chapter 7, and that she needs to work with a speech language therapist to help her follow directions and process information better.

Dr. Michelle would approach therapy for Sarah by working with her classroom teacher on strategies, techniques, and adjustments to her routines that would improve Sarah’s ability to understand auditory messages. Some activities that Dr. Michelle would use include auditory training, focusing on improving listening in situations where Sarah demonstrates deficits, such as in noisy environments. One way to do this is to have Sarah listen to quiet background noise while she’s engaged in schoolwork and practice blocking out the noise while completing her task.

Dr. Michelle may also teach Sarah compensation strategies, skills that can be used in conjunction with listening, in order to understand the message. Examples of compensation strategies include paying attention to facial expressions and gestures, and relying on context clues—that is, using known words or phrases to figure out unknown or missed words. These strategies will help Sarah to understand the message that’s been transmitted.

Dr. Michelle would also work with an audiologist to provide Sarah with an assistive listening device such as an FM unit. This device would help her at school by picking up her teachers’ words through a microphone and sending them through FM radio waves directly to headphones Sarah would be wearing. The device would help Sarah hear her teachers better because it would reduce background noise.

Sam is a three-year-old with a language disorder. He uses only five words to communicate. Sam can understand language, follow directions, and point to objects, pictures, body parts, and clothing items, but he can become very frustrated when he is not able to express himself using words.

Dr. Michelle would approach therapy for Sam by working with him and his family to improve his expressive communication skills. Because Sam is young, he is likely to respond to play-based therapy, which means he would learn to say new words and use these new words while engaged in play activities. So, while playing with Sam with a play kitchen, Dr. Michelle would say new words that are important to him—words related to the play kitchen set that are also in Sam’s home, like spoon, bowl, milk, pour, and apple.

To get Sam to say new words, Dr. Michelle would use various techniques such as modeling, in which a therapist says and repeats new words, as well as imitating, in which a therapist, typically through play, asks the child to say the new word. Dr. Michelle might also ask Sam questions that will elicit the new word from him, such as, Do you want milk or an apple? She might also manipulate Sam’s play environment to encourage him to use a new word, saying, Sam, you can stir the food now, making sure the spoon is visible but just out of Sam’s reach. This would encourage him to say, Spoon!

Once Sam has acquired more words, Dr. Michelle would use other strategies, such as expansions (mentioned earlier), in which the speech language therapist repeats what the child says and adds more words. So, if Sam said milk during playtime, the therapist would say Sam pours milk to encourage Sam to repeat those words. Dr. Michelle would also teach Sam’s caregivers strategies to use to help him to improve his communication while he’s working on acquiring new words, such as using gestures or signs for words that he was not yet able to say.

COMMON QUESTIONS,

EXPERT ANSWERS

Dr. Michelle hears lots of questions from the parents of her patients, as well as parents at school pickup or on the playground, about the process for getting help. Here are some of the most common questions and her straightforward answers to help you find the best therapy situation for you and your child.

QUESTION: How do I tell my child that he needs speech language therapy?

ANSWER: Be open about what’s going on, in an age-appropriate way. Toddlers or preschoolers may not realize they have speech or language difficulties. So, for a young child, it’s okay to tell him that he is going to see Ms. X, and that he will play and talk with her. You can couch it as play, because that’s just what it should be for a toddler or preschooler. Older children are likely to be more aware of their speech or language difficulties, so for a school-age child it’s okay to tell him that he is going to work with a special teacher who will help him listen, speak, and talk to others. Remind him that everybody has something he needs to work on—even Mom and Dad and other grown-ups.

QUESTION: The speech language therapist doesn’t like me to be in the room during her sessions with my child. Is this good or bad?

ANSWER: It can be good. Your presence may be distracting for both your child and the therapist, and your child may work best knowing you are not watching. But parents, caregivers, and teachers should be included in all aspects of speech language intervention. Be sure to work with your child’s therapist to establish a communication system so that you know what activities you can do at home to reinforce activities in the therapy room.

QUESTION: My child’s school said a speech language therapist isn’t available to help my child, but an occupational therapist will work with him. Is this okay?

ANSWER: No. If your child has a speech or language disorder or delay, then only a speech language therapist is the best professional to help your child. Other professionals can be great at what they do, but your child’s therapy needs to be handled by the right expert. Remember that IFSPs and IEPs are legal documents, and if your local system isn’t providing services to meet your child’s needs, you can pursue remedies to get the help your child needs.

QUESTION: My child doesn’t like going to speech language therapy. What should I do?

ANSWER: Not every professional is the perfect match for your child, and vice versa. If your child is not happy to go to therapy (after a few weeks of getting acclimated), he likely won’t improve. Try to work with your therapist to find strategies that work better for your child, and then consider shopping around for someone new. Don’t be afraid to break up with your speech language therapist if you feel she is not a good match for your child.

RESOURCES

It can be very tricky, but extremely essential, of course, to navigate all the different aspects of getting the best help possible for your child. Here are some of the websites Dr. Michelle recommends to get the best information about where to find help, as well as how to get up-to-date information on the special education process.

The University of North Carolina National Early Childhood Technical Assistance Center has a grant from the federal government to gather data and inform parents about the IDEA and the special education process: http://ectacenter.org/.

To find out about your state’s standards for eligibility for Early Intervention services, and to find state-specific websites for Early Intervention resources, check out this document from the National Early Childhood Technical Assistance Center: http://www.nectac.org/~pdfs/topics/earlyid/partc_elig_table.pdf.

The National Center for Learning Disabilities has a great primer on the IDEA: http://www.ncld.org/action-center/learn-the-law.

Understood.org, a site devoted to helping educate parents about the special education process, has informative, accessible descriptions of different interventions, services, and special education law. In particular, we recommend these resources:

•An information sheet on preschool services: https://www.understood.org/en/learning-attention-issues/treatments-approaches/early-intervention/how-section-619-can-help-your-preschooler.

•An explanation of 504 plans and how they work: https://www.understood.org/en/school-learning/special-services/504-plan/understanding-504-plans.

•A detailed account of the procedural safeguards available to parents under the IDEA, including an explanation of a dispute-resolution process: https://www.understood.org/en/school-learning/your-childs-rights/basics-about-childs-rights/important-safeguards-for-you-and-your-child.

A qualified speech and language specialist can be found by going to the American Speech-Language-Hearing Association website at www.asha.org and clicking on Find a Professional.