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Clare Hollings is a Speech Pathologist with over 15 years' experience working with children. She has a strong interest in working with children under five years old. Clare has been involved in collaborative projects with preschools, early childhood education and care centres and playgroups to improve the communication skills of children in these settings and to provide support and education to early childhood workers. Clare currently works in private practise for North Shore Speech Therapy.
I have recently had interesting conversations with two different parents about reactions to their child being seen by a Speech Pathologist. The first was a mother of a toddler who had a history of ear infections which was causing some hearing loss. At 18 months old he had about four single words and was certainly not as talkative as his older brother. His mum was very concerned with his language development and had sought out Speech Pathology advice. She told me that all her friends thought that she was 'crazy' and that her child was way too young to be receiving any kind of therapy. She thought it was one of the best things that she had ever done.
The second conversation was with the mother of a four year old boy whose speech is very difficult to understand, even for those people who know him well. He has a significant speech disorder and is likely to require Speech Pathology for some time. His difficulties have caused stress for his family as they worried about how he would manage the recent transition to preschool, and the prospect of school is looming. His mum reported that people ask her why her son is seeing a Speech Pathologist, when he is only four, and tell her that he will probably grow out of it. She is amazed that people still question her decision to seek out Speech Pathology when her son's speech is often unintelligible.
These examples illustrate some of the common misconceptions about Speech Pathology and the difficulties that Speech Pathologists face in trying to provide early intervention:
- Speech Pathologist's (or Speech Therapists – it's the same thing!) don't just work with speech. We are interested in all aspects of communication including speech sounds, vocabulary, grammar and sentence structure, comprehension, social skills, feeding and literacy skills. And closely linked to all of this are a child's listening and attention skills, their play skills and their behaviour.
- Children don't usually 'grow out' of their communication problems (although there are often stories about Dad, or an uncle, or a cousin etc. etc. who did not speak until they were four and are doing fine now). Children are not being lazy when they cannot pronounce sounds properly or have difficulty constructing sentences. It is genuinely something that they cannot do.
- 18 months old, or even younger, is not too early to see a Speech Pathologist, particularly if there are other risk factors present.
- You do not need a doctor's referral to see a Speech Pathologist. Community Health Centres or Speech Pathologists in private practice welcome referrals directly from parents or carers.
- Speech Pathology is not a scary place. We work with children using a play based approach, and building on the child's own interests and preferences. Speech Pathology sessions are fun and interesting and involve parents and siblings as much as possible. It may not look like we are doing 'therapy' but there is a lot of thought and planning that has gone into making a game or toy a way of learning new skills.
- There should be no 'excuses' as to why a child is not reaching expected communication milestones (e.g. 'boys always talk later'; 'her older sister does all the talking for her'). The norms that we use apply to all children, regardless of their gender or birth order. Of course children with developmental delays or other diagnoses often have associated difficulties with communication development.
Why Early Intervention?
What does Early Intervention mean and why is it so important? Early intervention is providing support for a problem as early as we can. Research on communication difficulties over the last 20 years has conclusively shown that early intervention reduces the lifelong impact of communication difficulties. Impacts that include outcomes such as poorer school achievement, increased criminality, and reduced workforce participation. We also know that children who enter school with speech and language difficulties are much more likely to experience literacy and learning difficulties.
Children with delayed communication skills at two years old that are left untreated, are more likely to enter school with communication difficulties that will impact on their learning. From an economics perspective it is also much cheaper to provide support early – it is quicker and less support is required in the school years and beyond. So in the face of all this evidence, why do we continue to see children entering school with communication difficulties who have not been seen by a Speech Pathologist? And what can we do about it?
Your Role:
Early educators play a unique role in helping to identify communication problems and support communication development in young children. For many children, child care is the place that provides the most opportunities for them to interact, and demonstrate and develop their communication skills. There are myriad opportunities available for them to explore, discover and challenge their skills.
Children build strong and unique relationships with their carers, and parents place a large amount of trust in carers' knowledge and skills about child development. If no concerns are raised by the child care centre, then parents may assume that everything is OK, even if they have some niggling concerns of their own.
Parents are often waiting for someone to support their concerns, but might not always be confident in raising these concerns themselves– after all, many others are telling them that there is nothing to worry about. I believe it is part of the educator's role to continue to put the child's best interests first, and help parents to identify communication difficulties and to seek out support.
Too often speech therapists are told by parents "we didn't come earlier because nobody said that anything was wrong". Parents depend on your expertise and knowledge of other children to highlight when their child is falling behind.
Red Flags 0-2yrs:
Just like motor milestones and any other area of child development, there is certainly a range of what is considered 'normal' communication development. You have probably seen children at two, three or four years old in your service who have quite marked differences in their speech and language skills. But there are some key milestones that we would expect children to achieve by certain ages. As we study early communication development more, we are further recognising the importance of these milestones and the links that they have to later language and learning success. Red Flags that indicate a child should see a Speech Pathologist are:
- No babble or eye contact by nine months old
- No single words by 15 months
- Less than 20 words at 18 months old
- No two word combinations by two years old eg, "big ball"
- Less than 50 words at two years old
Red Flags 2-5yrs:
As children grow, and their play, problem solving and attention skills develop, so too do their communication skills. Some key milestones to look out for are:
Speech Sounds/Articulation:
- By three years old should be understood 75 per cent of the time by familiar and unfamiliar listeners
- By four years old they should be understood all the time
- By five years old, children should be saying all speech sounds correctly (except for 'th')
Words and Sentences:
- By three years old can use at least 1000 words, and be putting five word sentences together. Grammar is starting to develop, although many errors are still noticeable
- By four years old grammar and sentence structures are more complex, but children still have difficulties with irregular plurals (eg mouses) and past tense (eg runned)
- By five years old they can use longer and more complex sentences and talk about things that are outside the immediate environment
Understanding:
- Can sit and listen at group time, with less prompts required as they get older
- Can follow instructions without repetition, simplification or extra prompts
Social Skills
- Shows good eye contact, can share and take turns, and plays and interacts with other children their own age.
More Than One Language:
It can be difficult to identify communication difficulties in children who are learning more than one language and these children do not always receive timely Speech Pathology support. It is very important in to discuss the child's communication development in their home language and how their skills are developing in relation to their siblings or peers.
A communication disorder will not exist in just one language but will be present across all languages that the child is learning. Remember that a child who has no previous exposure to English and learning it as a completely new language as they come to your centre may have a normal 'silent period'. Red flags should be raised when this silent period persists for longer than six months, or it is not followed by a period of language growth in English, or by lots of repetition of new words.
Language mixing is expected in new English language learners, and also in children and adults who are established bilingual or multilingual language users. It is a perfectly normal behaviour and should not be considered as a sign of poor language learning. Parents, grandparents and the important people in the child's life should all be encouraged to speak the language that they are most comfortable with. Good models in a home language and better than poor models in English. If a child has strong skills in any language, then they form a good foundation for them to learn any new language, including English.
Stuttering:
A brief word about stuttering. Many children will go through a period of 'normal dysfluency' before four years old, particularly as they are going through a burst in their language skills. Stuttering may present in different ways:
- Word or phrase repetitions eg I I I I went with Mummy OR I went with.. I went with Mummy
- Prolongations (stretching out a sound) e.g. I weeeeeeent with Mummmmmmy
- Blocks (the word appears 'stuck') e.g. I went with ___________Mummy
When a period of dysfluency persists for longer than six months, or it is causing the child distress or upset, or there is a family history of stuttering, then it is strongly advised that a child see a Speech Pathologist. As a general rule, any child who is still stuttering once they are three and a half years old should see a Speech Pathologist. Therapy is definitely more successful for children in the preschool years.
What to do if you are worried:
If you have any concerns about a child's communication skill development, then the next step is to talk to the parents and discuss your concerns. You may also want to discuss this with other staff members who know the child well. Try and be prepared with specific examples from what you have observed within the centre, and relate these to the norms and red flags described above, or other norm information that you have.
Ask the parents if they have had any concerns or noticed any differences with how their child communicates compared to their siblings or peers. Reiterate the benefits of getting a specialist opinion on the child's communication development from a Speech Pathologist, and the benefits of seeking therapy early i.e. the impacts will be long term, and will also help to prevent later difficulties. We can make bigger changes the earlier we can provide support.
Speech Pathologists:
So where do you find a Speech Pathologist? Your local Community Health centre is a good place to start, and Speech Pathologists are an integral part of the Child and Family Health team. Many services prioritise support for children who are three years old or younger, which is also a good reason to refer as early as possible. Private Speech Pathologists usually have their own websites, so if you type in "Speech Pathologist" plus your local area you will be directed to a number of sites. Speech Pathology Australia is the national body for Speech Pathologists in Australia, and their website provides a list of all Speech Pathologists who are members of the professional association and who are eligible to practise.
Ask around – staff or other parents may have come into contact with a Speech Pathologist that they would be happy to recommend to you. Many of these services, including North Shore Speech Therapy, would be happy to answer any questions and discuss concerns that you have. You don't need to mention the child's name or identifying details, but it can be helpful to talk through your concerns and get guidance on whether a referral would be recommended.
Training at your centre:
Speech Pathologists often also provide training and workshops on request to early childhood education staff, as well as to parents to help increase their knowledge about the importance of communication and ideas how to facilitate communication development in their children. Alternatively register for one of the workshops that myself and other North Shore Speech Therapy colleagues are delivering on behalf of Childcare NSW throughout 2014.
If you have any questions or specific concerns, you can get in touch with Clare on info@speechtherapy.com.au.
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