Augmentative and Alternative Communication (AAC)

What is AAC?

AAC stands for augmentative and alternative communication. There will be times when children and young people and their families need augmentative and alternative communication support. AAC includes a wide range of techniques used to support or replace spoken communication. It can include low tech systems such as signing, gesture, symbols, books, and boards as well as high tech devices such as voice output communication aids. 

AAC may be used by children, young people or adults who find communication difficult because they have little or no clear speech.  As a result, others may have difficulty understanding them. 

Considering Alternative and Augmentative Communication approaches

For AAC to be considered the following criteria needs to be met –

• A need for AAC – the person will be non-verbal or have difficulties with intelligibility of speech or writing.
• A desire to use an alternative form of communication.
• Motivation to interact with others
• Opportunities to communicate
• Support within their usual environments to maintain, update, and encourage use of AAC

Support

When interacting with someone who uses AAC try to remember the following tips

• Try to find somewhere quiet to have your conversation, cut down on the distractions around such as switching off the TV
• Ask the person if there is anything they need you to do to support their communication. Ask them if they can show you how they answer ‘yes’ and ‘no’
• Allow more time for the person to respond, there may be silences, don’t be tempted to fill them. Ask one question at a time and allow them time to answer this before moving on to the next question.  Try not to ask too many closed questions – try ones that encourage the person to tell you more.
• If you don’t understand what the person has said, let them know and see if they can tell you in a different way. If you still can’t understand, say you can come back to that later, or ask if there is someone who knows the person well who can help you understand.
• Confirm with the person what you think they have told you to cut down on misunderstandings.
• The person using AAC may not pick up on your non-verbal communication such as facial expression, or gestures if they are busy looking at their AAC. You may have to explain things again if they have missed some information by not looking at your face. 
• Some people who use AAC may find it tiring and may need a break during a long conversation
• Talk to the person directly, not their supporters

What do Speech and Language therapists do?

Speech and Language Therapists can assess the person’s communication skills and can advise on the most appropriate AAC system for them.  They will link with other members of the team to support with this assessment such as the person’s family, other professionals involved, teaching staff.  They will also advise on how to develop the person’s  use of the AAC, and will be involved in training the team around the person in how to use the AAC.

Further reading and resources

Communication Matters is a national charity involved in a wide range of activities supporting those who use AAC. communicationmatters.org.uk

CALLScotland – an organisation primarily funded by the Scottish Government to provide support to children across Scotland who require access to technology I order to fulfil their potential.  callscotland.org.uk

https://www.aacscotland.org.uk/home/ – this website provides straightforward access to a range of practical AAC resources commissioned by NHS Education for Scotland (NES)

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Autism Spectrum Disorder

What is Autism? 

Autism is a neurodevelopmental condition where we see differences in:

• The ability to initiate and to sustain reciprocal social interaction and social communication 

• There being restricted, repetitive, and inflexible patterns of behaviour, interests, or activities  

• There may also be a pattern of sensory needs, whether it be hypo/hyper arousal. 

The pattern of differences/difficulties are more than would be expected for a child’s developmental level or sociocultural context. Without adaptations that take into account a person’s autistic profile challenges with both family and school life can occur.    

In addition we are now more cognisant of more subtle presentations especially in girls where the impact of difficulties may not be seen until the social demands of school life become increasingly complex such as middle and later primary or even secondary.’ 

The diagnostic criteria can be found in the International Classification of Diseases 11 and the Diagnostic Statistical Manual 5.

Identification

Children may present differently, however some of the following would be indicators for further assessment.   

• No babbling by 12 months  

• Poor unusual/eye-contact 

• Does not reliably respond to name 

• Does not try to attract adult’s attention e.g. by pointing, raising arms to be lifted 

• No gesturing (pointing, waving, bye-bye, etc) by 12 months  

• No single words by 16 months  

• No two-word spontaneous (not just echolalic) phrases by 24 months  

• Any loss of any language or social skills at any age.  

• Play is limited and often repetitive 

• Difficulty regulating emotions and expressing big feelings such as frustration 

• Echolalia (echoes verbal utterances)

Support

There are many approaches to supporting children with Autism. No two people are the same, so choosing the right ones can be a challenge. The National Autistic Society offers some advice and guidance which may be helpful.  

Some children may benefit from using alternative means of communication such as sign language or visual symbols. Others have good language skills, but they may still find it hard to understand the expectations of others within conversations, perhaps repeating what the other person has just said or talking at length about their own interests.  Communication abilities can vary depending on the environment and some children and young people will require support to ensure that their voices are heard.

It often helps to speak in a clear consistent way and to give children time to process what has been said to them. It can help to supplement verbal  information with visual information e.g. gestures, real objects, or pictures.  

Consider putting families in touch with local support groups or the National Autistic society Helpline.   

Further Reading/Useful Websites 

Autism and Neurodiversity across the lifespan. Accessible from Turas Learn 

Resources and training for the Scottish workforce about Autism and neurodivergence - Autism and neurodivergence across the lifespan | Turas | Learn

National Autistic Society  

Third Space Offers support to individuals with neurodevelopmental difference and the people in their lives. 

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Bilingulism

Bilingual and multilingual Development

Infants and young children have the capacity to learn more than one language. Many children grow up learning more than one language. Research has shown that being bilingual has many advantages such as being able to learn new words easily, being able to use information in new ways and developing solutions to problems.

Developing skills in two languages depends on the quality and amount of experience the child has using both languages. It is normal for bilingual children to mix rules from both languages or mix two languages in one sentence.

Growing up bilingual does not mean a child is more likely to have difficulties with their speech, language or communication.  If a child has a speech, language or communication need then this is likely to be evident across both languages.

Parents should be encouraged to speak the language they know best and feel most confident in so that children learn a good model of language. It is the quality of the parent-child communication that is important.

Key Messages

• Sometimes children go through a ‘silent phase’ when they start a setting that has a different language to what is spoken at home. Watch and wait to see how they settle in, and do not put pressure on them to speak. Remember to accept and praise communication in whatever language the child chooses to use

Support

• Encourage parents to always use the language (or languages) that they are confident with, to make sure they are giving the child natural and rich language models
• Use a range of words to label, describe actions, talk about how things look; feel; sound; taste, what they do, where they are etc.
• Share books in both languages. Don’t worry about reading the words, you can talk about the pictures or make up a story. If you are using your preferred language, your child might respond with another, such as the language of the setting. accept and praise communication in whatever language the child chooses to use

Further reading/resources

Talk With Me: bilingualism factsheet for professionals | GOV.WALES

Words for Life

Bilingualism Matters - Bilingualism Matters (bilingualism-matters.org)

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Cleft Lip and or Palate

Cleft lip and/or palate is the most common congenital abnormality of the craniofacial complex. Around one in 700 babies are born with a cleft around the world. Babies can be born with a cleft lip only, a cleft palate or both. Antenatal diagnosis of cleft lip can be made at time of mid – pregnancy anomaly scan. Most clefts of the palate are identified immediately after birth or during the physical examination of the newly born infant , as routine scanning does not generally detect cleft palate. A proportion of clefts are associated with syndromes. Some cleft palates may not be detected until sometime after birth as they are ‘hidden’ (known as a submucous cleft palate) and are identified when feeding difficulties emerge or later when speech is affected.  When an infant is given a diagnosis of a cleft, they are referred to their regional cleft lip and palate service for further assessment, advice, and management by the cleft team.

Key Messages:

• Children with cleft palate are at risk of:
  • Early feeding difficulties
  • Difficulties articulating certain speech sounds and speech may have a nasal quality
  • Hearing problems (associated with build-up of fluid in the middle ear, referred to as glue ear)
• Communication needs may have an adverse effect on literacy, social skills, peer relationships, self-confidence, and behaviour.
• Perceptual assessment and investigation of speech disorders associated with cleft palate may require further specialist and expert skills and investigations available within regional cleft centres.
• A multidisciplinary specialist team will support children with a cleft lip/palate from birth until adulthood and beyond as required.
• Surgery to repair cleft lip and palate typically takes place in the first year of a child’s life.

Role of the Speech and Language Therapist

Speech and Language Therapists are integral to the multidisciplinary management of children and young people with cleft palate:

• Provide information and advice to parents following the diagnosis
• Monitor speech and language development from infancy and throughout childhood
• Identify need for further surgery, speech and language therapy or less commonly prosthetic management.
• Provide information and advice to others as required, and plan treatment together where indicated.
• Speech therapy management and intervention extends from infancy to adulthood, tailored to the needs of the individual, and shared as appropriate with parents, and social and education authorities.

Resources
Cleft Lip/Palate Association (CLAPA)

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Deafness and Hearing Loss

What is hearing loss?

Deafness, or hearing loss, happens when one or more parts of the ear aren’t working effectively.  Find out more about the ear here What Is Deafness? | Main types of deafness

There are two main types of deafness:

• Sensorineural deafness, or nerve deafness as it is sometimes called, is a hearing loss in the inner ear. This usually means that the cochlea in the inner ear is not working effectively. Sensorineural deafness is permanent.
• Conductive deafness means that sound cannot pass efficiently through the outer and middle ear into the inner ear. This is often caused by blockages such as wax in the outer ear, or fluid in the middle ear (glue ear). Glue ear is a very common condition, especially in pre-school children.

It is possible for children to have a combination of sensorineural and conductive deafness. This is known as mixed deafness. One example of mixed deafness is when someone has glue ear as well as permanent sensorineural deafness. It is also possible to have a permanent conductive deafness, but this is less common.
Very few deaf children have no useful hearing. Most deaf children can hear some sounds at certain frequencies and loudness, and with the use of hearing aids they are often able to hear more sounds.

Identification

Approximately 1 in every 1000 children is born with a severe or profound hearing loss. 90% of all deaf children are born to hearing parents.

Universal Neonatal Hearing Screening Programmes (UNHSP) were introduced into Scotland in April 2005. The aim of this early screening is to diagnose children with deafness at an early age and to provide hearing amplification as soon as possible.

There are several things to watch out for that may be indicative of a hearing loss.

For example:

• They do not respond to sounds, music, or voice
• They do not react to loud sounds
• They strain to hear
• They appear very watchful
• They misunderstand things you say
• They withdraw from social situations
• They ask you to repeat things
• There is a deterioration in a child's behaviour

Supporting families

Having your baby diagnosed with a hearing loss soon after birth can be a very emotionally draining experience. Health visitors can provide emotional support to parents. They can also:

• Stress to the family the importance of consistent hearing aid/cochlear implant use as underpinning a child's progress
• Support the establishment of a good listening environment in the home- encouraging some time with the TV off.
• Link with the child's speech therapist, audiologist, and teacher of the deaf.

What do Speech and Language Therapists do

There are Specialist Speech and Language Therapy Services for the Deaf/Hearing Impairment in many Health Board areas in Scotland although not all. Those areas that do not have specialist provision have access to advice through the Clinical Excellence Network (CEN). Specialist Speech and Language Therapists for the Deaf/Hearing Impairment usually have additional training in working with deaf children and sign language. The pattern of working varies from Health Board to Health Board. In some areas therapists work with families from point of diagnosis and in other areas they become involved if necessary when the child is a bit older.

A Speech and Language Therapist's role may involve:

• providing support to families of newly diagnosed in use of hearing aids/cochlear implants
• providing information of various communication methods to allow the parents to make an informed choice on communication method
• encouraging consistent use of hearing aids/cochlear implants all waking hours in order that children will have the best outcome in terms of speech, language, and communication
• giving support and advice to families to promote the best listening environment for the child
• providing families with the skills necessary to promote optimal outcomes in respect of speech and language development in their child regardless of what communication method the family choose
• liaise with other professionals to share information and provide support E.g. audiology, teachers of the deaf, health visitors

Further reading/resources

• National Deaf Children’s Society (NDCS)
• NHS Choices Making sounds checklist
• Royal College of Speech and language Therapists (RCSLT)  website
• National Deaf Children’s Society (NDCS)
• National Deaf Children's Society | For every deaf child
• Royal College of Speech and Language Therapists (RCSLT) Commissioning Specialist Services for the Deaf and Clinical Guidelines for working with deaf people

• Universal Neonatal Hearing Screening Programmes

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Developmental Language Disorder

What is developmental language disorder?

Developmental language disorder (DLD), previously known as Specific Language Impairment is a condition where children have problems understanding and/or using spoken language. Children with DLD present with spoken language difficulties without any obvious explanation and they often go unrecognised.

A child can be diagnosed with DLD if:

• Their spoken language has a negative impact on their daily interactions and learning.
• Their language difficulties have not resolved by 5 years of age.
• The problem is not associated with autistic spectrum disorder, learning difficulties, brain injury, hearing loss, Down’s Syndrome etc.

Children with DLD may present with co-existing difficulties such as attention difficulties, motor difficulties and dyslexia. Children who do not meet the criteria for developmental language disorder should be referred to as having ‘language disorder or language difficulties’.

Identification

Children with Developmental Language Disorder have difficulties learning, understanding, and using spoken language.

Look out for children who:

• Have trouble understanding instructions
• Take longer to learn new words and have a limited vocabulary
• Struggle to find the words they want to use
• Find it difficult to join in with conversations
• Use very simple sentences

It should be noted that in very young children developmental language disorder, preventable speech language and communication needs associated with risk factors, late talking and some profiles of bilingual language development may all look very similar. However all of these groups of children will benefit from early supports which focus on caregiver/child interaction and language promoting strategies/activities such as shared book reading, playing, talking and singing.

Support:

• Keep your own spoken language simple
• Give one instruction or piece of information at a time
• Give the child time to process what you have said and give them time to answer
• Show the child what you mean rather than relying on words
• Help to support communication by using pictures and gesture
• Focus on the child’s strengths
• Do not put pressure on the child to speak
• Notice what the child is interested in and talk to them about their interests

What do Speech and Language Therapists do?

Every child is different so there is no simple approach to supporting children with Developmental Language Disorder (DLD).  The speech and language therapist will have a conversation with a family member to ascertain the impact of the difficulty and what is important to the child and the parent or carer. 

The speech and language therapist can also assess the child’s expression, comprehension, speech sounds and social communication if that is appropriate. 

If the child requires additional input, the speech and language therapist will aim to empower the parents or people close to the child to facilitate successful communication techniques/ strategies and improve the child’s communication skills.  This could involve developing the knowledge and skills of key people in the child’s life such the parents, wider family, and nursery or school staff. For example, this may include indirect coaching, modelling, and training, or more direct interventions focussing on particular aspects of the child’s communication such as developing vocabulary or sentence structure. 

Further reading/resources

• Raising awareness of Developmental Language Disorder (RADLD) or https://www.youtube.com/watch?v=MU1inVSISFo

• Raising awareness about DLD Fact sheet

• Royal College of Speech and Languag Therapists (RCSLT). Developmental Language Disorder

• DLD and Me Useful resources for parents and professionals

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Development Speech Difficulties

The term Developmental Speech Difficulties is used to describe the difficulties that some children have with their articulation and/or phonological development.  Other terms also used include speech sound disorder, speech sound delay, phonological disorder, phonological delay, speech impairment and in some cases, dyspraxia.  

What are developmental speech difficulties?

• Children with developmental speech difficulties make errors by omitting or substituting speech sounds. The patterns of these errors may be observed in typically developing younger children (delay) or may be non-developmental (disordered).
• A key characteristic of children with developmental speech difficulties is that their intelligibility (speech clarity) is often significantly less than other children of the same age.
• Most children with developmental speech difficulties have no identifiable cause for their problems. However, speech difficulties can be associated with other conditions such as cleft palate, cerebral palsy, childhood dysarthria and global developmental delay.

Key messages

• Children typically vary in their speech development. Younger children may make errors and substitutions in their speech, however these may be within the normal range, depending on their age.  Refer to the speech sound development guide to review typical speech sound development. 
• It is normal for some of what children say not to be clear.  By 4 years of age, you should be able to understand roughly half of what they say. By 5 years you should understand about 75% of what they say, and nearly all by 7 years of age. (The Informed SLP, 2021)
• A developmental speech difficulty can prevent a child from communicating effectively, causing frustration or withdrawal from social situation.

Support

• Don’t correct the child or tell them they are wrong. The child may think their speech/ sounds is the same as yours.  Do say the correct word, clearly.

• If you cannot understand what the child is saying, encourage them to show you or tell you another way. If you have understood some, repeat it back to the child to check you have got it right.

• For children with developmental speech difficulties causing unintelligibility and/or frustration/anxiety, discuss your concerns with your local speech and language therapy service.

What does a Speech and Language Therapist do?

Should further advice and support be needed, the speech and language therapist may undertake a screening assessment to determine the presence and extent of developmental speech difficulties and to decide whether or not intervention is indicated.

Further diagnostic assessment and analysis will guide the speech and language therapist’s decision about which type of intervention to select and which phonemes or speech patterns to target in therapy. 

Resources

• SpeechCare Norms for Speech and Phonological Development In Children under 7 years
• Speech and language therapy dot com
• RCSLT – Developmental Speech Difficulties

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Dummies

Does dummy use impact children’s speech and language development?

Dummies can often be viewed as a barrier to children developing effective speech and language skills.

There are various confusing and contradictory recommendations available about the risks and benefits of dummy use. As a health professional supporting families to make healthy informed choices, it is important to be aware of the range of perspectives available such as this guidance here: It is recommended not to introduce a dummy until breastfeeding has been established. The time this takes differs for each person.

In relation to speech and language development, excessive dummy use is thought to cause an increased risk of ear infections which may affect speech and language development. Excessive dummy use may also affect jaw and teeth alignment which could potentially negatively impact on speech sound development.

Risk factors for speech and language development

• Regular and long term use of dummies
• Excessive use of dummies during the day which may reduce opportunities for experimentation with sounds, babble and the early use of words
• Babbling or talking with a dummy in the infants mouth

Supporting families

• Consider weaning infants off dummies beyond 6 months when they are beginning to experiment with sounds and babble.
• Save the dummy for sleep and naptime only.
• Avoid having dummies visible or within reach of your child during the day when they are alert and interacting.
• Do not allow your child to babble or talk with the dummy in their mouth.
• A child is more likely to play with sounds when they are alert and engaged in play, so they should not have a dummy in their mouth at these times.

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Early Language and Communication Difficulties

What are early language and communication difficulties?

Early language and communication difficulties is a term used to describe any baby or young child who is not developing language and communication as expected, leading to an impact on their wellbeing and ability to join in with everyday activities. Some babies and children face social inequalities and environmental factors that impact on early language and communication development. Early language and communication development can also be influenced by a range of biomedical conditions including hearing impairment, genetic conditions or neurodevelopmental differences such as Autism or Developmental Language Disorder (DLD).

All children develop language at their own rate, and it is not always easy to predict how a child’s language and communication development may progress. The evidence tells us, that with the right support, many children with language and communication difficulties can improve. 

Identifying early language difficulties:

• An impact on play and interaction with others
• Trouble understanding instructions
• Difficulty understanding and using facial expression and gesture
• Difficulty using words and sentences to communicate

Support

Consider the home learning environment and whether the family would benefit from talking about how to get ready to chat:

• Encourage caregivers to always use the language (or languages) that they are confident with, to make sure they are giving the child natural and rich language models.
• Suggest that families help their baby or child to tune in by putting their phone away when they are interacting together. Turning off the TV and reducing distractions makes it much easier for their child to focus on whatever they are doing.
• If the baby or child naps with a dummy, encourage families to put it away when they're alert.

Regardless of the reason for the language difficulty, sharing the national ‘Chatting Together’ messages with the family can help them gain knowledge and confidence in ways they can support their child at home.

Resources

• Parent Club website is the host for the Chatting Together messages for bumps to babies, and toddlers to young children and has accompanying videos to share with families.
• The following guidance document has been produced to support practitioners to have a conversation with families about the Chatting Together messages (Link to be inserted once available).

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Eating and Drinking Difficulties

What are eating and drinking difficulties?
Eating and drinking difficulties can include a difficulty with swallowing, or with coordinating lip, tongue, and jaw movements to chew and move food around the mouth. 

Children may have eating and drinking difficulties for a variety of reasons such as:

• Premature birth
• Having Down's Syndrome, or cleft lip and/ or palate
• Diagnosed with Cerebral Palsy
• Having a heart condition or a condition that affects their breathing.
• Having gastro- oesophageal reflux
• Complex medical conditions
• Tongue tie
• Developmental delay

Not all children with these difficulties will have eating and drinking difficulties. There may also be children that do not have the difficulties on this list that experience eating and drinking difficulties.

Some children have feeding difficulties that may relate to sensory difficulties. This can happen with children with ASD (Autism Spectrum Disorder) or with children who have previously had reflux or a difficult start with feeding. 

Identification

These signs may seem more obvious at sometimes and may also change depending on the type of food your child is eating.  Children with eating and drinking difficulties may experience some of the following symptoms:

• Coughing and/ or choking during or after feeding
• Changing colour and/ or noisy breathing during or after feeding
• Refusing foods
• Difficulty chewing or difficulty moving onto more challenging textures
• Gagging
• Prolonged feeding times
• Weight loss or lack of weight gain
• Trying to swallow a single mouthful of food several times
• Difficulty coordinating sucking and swallowing
• Arching or stiffening of the body during feedings 
• Congestion in the chest after eating or drinking
• Wet or raspy sounding voice during or after eating
• Frequent respiratory infection
• Spitting up or vomiting frequently
• Food or liquids coming out of the nose during or after feeding
• Irritability or lack of alertness during feeding 

General Advice on Eating and Drinking

• Children need lots of practice to learn new chewing skills and coping with new textures
• Introduce changes to tastes and textures gradually
• Let children explore foods with their hands and mouth
• Keep the environment calm and relaxed when feeding
• Consider child’s positioning when feeding/eating
• Include the child in family mealtimes, keep the experiences positive
• Consult with child’s primary caregiver if there are any signs/symptoms of eating and drinking difficulties

What does a Speech and Language Therapist do?

Speech and language therapists have skills to assess and support children with eating and drinking difficulties (dysphagia) and they work in collaboration with other professionals, such as dieticians, paediatricians, occupational therapists, physiotherapists, health visitors and nurses.

Resources/Further Information

RCSLT / Giving Voice Factsheet: Supporting infants, children and young people with feeding and swallowing difficulties

RCSLT Dysphagia, Eating Drinking and Swallowing (EDS) needs

SLT Speak, Swallow, Communicate

SLT Eating, Drinking and Swallowing

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Screen Time

What is ‘screen time’? 

“Screen time” is an expression used to describe activities carried out in front of a screen such as watching TV, using a mobile phone, tablet, or computer, playing online electronic games. 

As technology continues to develop children are accessing digital content at increasingly younger ages. This growing presence of digital media has led to an increasing interest in how use of this media influences children’s development in both positive and negative ways.  There remains a lack of good quality evidence addressing all factors with respect to this, and the approach taken is Scotland has been to avoid strong headline “bans” and “limits” and instead encourage families to reflect on how far their children are getting a balanced diet of interactive play, outdoor experiences, and physical exercise.

Key messages

• Effects of digital media are likely to vary depending on mode and content. It is important to consider both the context and content of what the child is viewing; considering what the child and who is interacting with them, not merely the length of time that the child is using a smartphone, tablet, computer, or TV. 
• Family context is also important.  For example, parents who have difficulties with literacy may find tablet based speaking stories a happy and effective way to read with their children.
• Exposure to programming aimed at adults can be harmful to children’s development particularly those under 2 years of age.
• Parental over-use of mobile devices has consistently been shown to reduce parental interaction with young children with the resultant negative impact on children’s language development
• Research suggest that adverse effects occur when high levels of screen time crowd out playing time and interaction with adults.

Supporting families

• Children need opportunities to interact with their world and the people in it. It is important that parents respond to their children’s attempts to communicate with them. It’s important to remember that screen time and digital media use may reduce parent’s responsiveness.
• It can be helpful to include some “screen free” time each day (parents and child) with no distractions or background noise to support and encourage interaction
• Encourage parents to share screen time with their child and use it as a foundation for play and interaction extending the play beyond the screen
• Encourage parents to be selective about what they allow young children to watch on screen, taking time to check the content is suitable for their stage of development.
• Encourage parents to establish boundaries for their child’s use of screens using parental controls as appropriate. 
• Encourage parents to be mindful of background noise from media (eg tv/devices) which has been shown to disrupt sustained play and reduces the quality of the parent-child interaction
• Getting out and about is important for children’s physical development and wellbeing. Parents should be encouraged to be mindful that screen time does not reduce opportunities for other play and active experiences
• Children are influenced by the screen time habits they see around them. Encourage parents to review their own screen use to consider if this could get in the way of positive interactions with their child. Encourage parents to put their phone/tablet down when their child attempts to communicate or interact with them.

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Stammering

Children often stop, start again, hesitate and repeat words when they are learning to talk. This can often happen between the ages of two and five years old.  For many children this disfluency is temporary, and it may be associated with a rapid spurt in language development.

When children stammer, they may have more interruptions or struggle when they are talking, there may be emotional reactions including frustration, embarrassment, distress, or reluctance to speak, and their parents/carers are often very concerned. ‘Stammering’ and ‘stuttering’ are synonymous.

What is Stammering?

When a child stammers you may notice: 

• repetitions of sounds or words “c-c-can can can we go”
• prolongations (stretched sounds) in a word “ssssometimes” 
• blocks - difficulty starting a word, the mouth is in position but no sound comes out

You may also notice:

• other sounds/interjections/disrupted breathing e.g. throat clearing, “um um um” 
• tension e.g. around the mouth, eyes, or neck  
• extra body movements e.g. stamping a foot, tapping a hand
• sometimes choosing not to talk and/or leaving out or changing words

Information to be aware of about stammering

• Stammering involves slight neurological differences.
• Stammering usually starts between 2-5 years of age but it can be earlier or later. 
• It can start gradually over time or very suddenly e.g. overnight.
• Stammering can be different for each person who stammers and can be very variable: day to day, even hour to hour, and can come and go. 
• It can vary in different situations and with different people. 
• More boys stammer than girls.
• There may be a history of stammering in other family members.

Key Messages

• Consider what will support people to communicate freely and comfortably whether that is with or without stammering.
• Listen to people’s messages and value what they say. These are invaluable in supporting confidence in talking, self-acceptance and self-esteem.

Parents do not cause stammering. There are lots of things that parents/carers can do to support their child to talk confidently and to know that it is okay to stammer. Responding to a child in a supportive way may reduce any pressure that they may feel when talking and support their feelings about talking.

In supporting your child, try to:

• Give your child time to speak: Your child will not feel rushed when talking and will feel listened to.
• Listen carefully and give your child your full attention when you are able to.
• Keep eye-contact and show that you are interested in what your child is saying.
• Slow down your speech rate and pause for a second before you answer your child or ask a question. Your child will have more time to understand what you have said and to plan what to say. This will be a supportive model for your child and is more effective than telling your child to slow down.
• Keep your sentences short and simple.
• Reduce the number of questions you ask your child: Questions can put a child under pressure. Simply comment on what your child is doing instead. E.g. Rather than saying “What are you playing with?” you could say: “you are playing with the red car.”
• Focus on ‘what’ they are saying rather than ‘how’ they are saying it: This shows your child that you are interested in what they are saying. Try to maintain natural eye contact and respond to what they have said as you would if they were speaking fluently.
• Talk with your child in a calm and relaxed atmosphere.
• Encourage everyone in the family to take turns to talk. This will reduce how often your child is interrupted and/or interrupts others.
• Be supportive: Do not draw attention to their talking if they are not aware that they are getting stuck. Only if your child is aware, support them as you would with any other problem and acknowledge the dysfluency in a matter-of-fact way e.g. “that word sounded a bit tricky” or “everyone gets stuck with talking sometimes.”
• Talk openly about stammering and reassure your child if he or she is particularly upset about talking e.g. “That was a hard word but well done for keeping trying”.
• Praise your child for things he or she does well. This will help to build confidence.
• Encourage regular sleep patterns. Your child may have more stammering if he or she is tired.

What does a Speech and Language Therapist do? 

Further advice and support from a Speech and Language Therapist should be considered if there is parental/carer concern and/or if stammering is having an impact for the child/young person.  

Speech and Language Therapists (SLT) can: 

• Provide support for parents, carers, children, and young people 
• Empower parents, carers, and the child
• Learn more about the child’s stammering and offer specialist assessment, monitoring and/or intervention if needed. 

Resources:  

STAMMA

STAMMA support for parent

STAMMA  Stammering in Pre-school Children – How parents can help

STAMMA What Is Stammering (Stuttering)? | STAMMA

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Selective Mutism

What is selective mutism?

Selective Mutism (SM) is an anxiety disorder where the child speaks little or not at all in some situations, while in other situations the child talks freely. This doesn’t mean they are always anxious but at times when there is an expectation for them to talk, their anxiety levels rise. The pattern is predictable and has persisted for at least a month. It is not to be confused with ‘traumatic’ or ‘reactive’ mutism which is a symptom of post-traumatic stress disorder.

Indicators towards a diagnosis of Selective Mutism:

• The child has a consistent pattern of not speaking to, or in front of, certain people.
• The child talks comfortably to at least one other person, but stops talking, whispers or becomes visibly tense when aware of anyone else approaching.
• The failure to speak has a significant impact on educational or occupational achievement or social communication.
• The child has described, in the absence of stammering, a sensation of ‘freezing’ or their voice getting stuck or not coming out.

Children with selective mutism appear to be shy in many situations but are not necessarily shy by nature. Shy children may be worried about talking whereas children with selective mutism are terrified and won’t just grow out of it. Children with selective mutism may also have other diagnosis or speech and or language impairments.

Identification

Some children are just shy, but they do not show the aversion to speaking that characterises selective mutism. Children with selective mutism are not stubborn and need support to find ways for them to participate in non-stressful ways. Children who are shy, however can become selectively mute.

Look out for children who:

• Swing from relaxed and chatty to wary and reticent
• Stiffen their body and face and their communication becomes non-existent or reduced to whispers, single words, short phrases, or gestures in certain situations.
• Talks happily to their peers or some family members but when a teacher or less familiar adult approaches they clam up or, they find it easier to talk to someone they barely know
• Become so anxious in talking situations that their muscles become tense, and it can interfere with their ability to point, handle objects, walk or run

Support

• Early identification and management of selective mutism is important
• Ensure there is no pressure on quiet or reluctant speakers to speak. Also do not ask them direct questions
• Provide gentle support that enables the child to participate at their own pace
• Ease into communicating with the child by chatting with parent/ carers first, then slowly increase your non-verbal communication with the child, and perhaps give them something to play with before talking to them without any expectation for them to reply e.g. comment on something about what they are doing
• Look to more detailed advice to offer the parent from the Speech and Language Therapy Department.

What does a Speech and Language Therapist do?

Speech and language therapists work with a wide range of communication difficulties stemming from a variety of causes including psychological causes. Given the wide range of possible contributing factors and the changing presentation of selective mutism, various professionals may be involved in assessment process. This is to ensure that the most appropriate and effective interventions and be planned.

The speech and language therapist can offer specialist advice and support and liaise with other professionals if needed to help manage selective mutism effectively. The speech and language therapist can offer advice on how best to adapt the communication environment for the family, carers and those supporting the child on a daily basis to ensure they have management strategies to try out.

Further reading/resources

• Johnson, M. and Wintgens, A. (2002) The Selective Mutism Resource Manual, Speechmark Publishers.
• Johnson, M. And Wintgens, A. (2012) Can I Tell You About Selective Mutism? Jessica Kingsley Publishers.
• Selective Mutism Information and Research Association (SMIRA)

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Voice Disorders in Children

What are voice disorders in Children?

Voice Disorders are when the voice sounds different persistently or intermittently to what might be considered typical.  This may be considered a change to the individual child’s usual voice or different in comparison with their friends or siblings.

The voice can be affected in different ways:

Quality e.g. the voice may sound hoarse, husky, breathy or rough.

Pitch e.g. the pitch may be habitually too high or too low for the age, or build of the child.

Loudness e.g. the child does not control the volume of their voice.

The most common voice problems in children include laryngeal strain, vocal cord nodules and vocal cord polyps.  When the voice is misused this is referred to as ‘vocal abuse’.

Identification

Dysphonia:

This may present as total voice loss (aphonia) or partial voice loss.

• Straining of the voice, shouting, and screaming.
• There may be excessive use of whisper which should be avoided. Whispering does not protect the voice and may damage the vocal cords.
• The quality of the voice may be hoarse/husky/breathy or strained/rough.
• Voice loss may occur at different times in the day.
• Voice loss can follow shouting e.g. at a football match/concert/night out/singing
• Voice loss can occur due to emotional upset reflecting tension and poor breath support

Pitch:

• Pitch control may be difficult leading to ‘pitch breaks’ in conversation or persistent high or low pitch.
• Consideration should be given as to whether the pitch is an acceptable pitch for the child’s age and build.

Loudness:

• Volume control is important for the health of the vocal cords. It requires adequate breath support and co-ordination to be effective without damaging the vocal cords.
• Trying to raise voice and straining the vocal muscles is exhausting and is not necessary.
• When a child uses a loud voice all the time it can be damaging. There is a high risk of vocal cord damage when the cords are hit together forcefully to raise volume.
• When a child uses a whispered voice. Being too quiet is a strain on the vocal muscles and can lead to further problems e.g. vocal nodules.
• If a child is unable to raise volume, there may be difficulty co-ordinating breath support for voice production.

Support

The voice can be an indicator of how we feel.  Both physical and emotional changes in a child can have an effect on their voice production.

Be aware of common bad habits:

• Talking too long and running out of breath, talking too loudly, straining voice.
• Straining caused by shouting/screaming/emotional outbursts crying or laughing.
• Excessive voice use speaking/shouting/singing resulting in voice loss.
• Coughing which is unproductive. If the child uses an inhaler encourage them to rinse their mouth after use, and rinse and air dry a spacer.
• Imitating noises from TV programmes or creating their own e.g. grunting or voicing when breathing in.
• Inadequate fluid intake.

Be aware of the child’s home/school situation:

• Is the family a loud family?
• Sitting in front of games can be stressful and result in shouting.
• Sports activities football/ swimming/athletics if shouting involved.
• Stress or tension.
• If the child uses an inhaler encourage them to rinse their mouth after use, and rinse and air dry a spacer.

Be aware of the child’s general health which may increase risk of voice disorders:

• Asthma or allergies
• Acid Reflux
• Frequent upper respiratory infections leading to chronic cough and inadequate breath support
• Behavioural problems resulting in shouting/screaming/being constantly loud

Encourage good vocal hygiene care:

• Drinking adequate fluid such as water or diluting juice.
  • Young children should typically drink between 1-1.5 litres per day depending on their size
  • Children over 14 years should drink 1.5-2 litres per day
  • Avoid fizzy drinks and caffeine
• Avoid shouting and whispering.
• Encourage positive family support such as no smoking around the child or in rooms where the child may play
• Encourage quiet play activities

Advice and support from an Ear, Nose and Throat (ENT) specialist  may be required if there are concerns about the child’s voice. The ENT specialist may seek further advice, or the services of a Speech and Language Therapist.

Contact Speech and Language Therapy for advice if required.

What does a Speech and Language Therapist do?

Following an ENT examination, speech and language therapists assess the child taking a detailed history. Information about good vocal hygiene will be shared and, if appropriate, offer a voice therapy course for the child and their family/carers/school. Education for voice care would include talking with the school, if appropriate.

Therapy covers an explanation of normal voice production and vocal hygiene care.  Normal voice production involves relaxed breathing to support voicing and volume control, as well as relaxed laryngeal muscle movement to enable easeful phonation (vocal cord movement).

All factors which are harmful to the voice should be identified and these behaviours modified or stopped.

Vocal hygiene care teaches the child how to maintain a healthy voice though adequate hydration and avoiding irritants. The management of inhaler use to reduce side effects would also be discussed if appropriate.

References:

Children Get Vocal Nodules Too - The British Voice Association

Great Ormond Street Hospital for Children. Encouraging your child to produce a healthy voice

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