Child with speech bubble

How To Improve Speech Intelligibility

It can be frustrating for both parents and child when a child’s language is difficult to understand! During preschool and school-age years, a child’s language is expanding and he is using more words to request, exclaim, and to label. Parents will often guess at what their child is saying, and unfamiliar adults may rely on parents to decipher their child’s speech. Many times children will throw tantrums or give up when trying to communicate. See below for some helpful tips to improve your child’s intelligibility and your understanding!

Rate: An increased rate of speech leads to more words blending together and doesn’t always give the listener enough processing time to take in all of the information. If your child has an increased rate of speech, encourage him to slow down and try again. Multisyllabic words may get simplified (e.g., “tephone” for “telephone”), leading to further difficulty for the listener. Modeling your own slow rate will allow your child to match your speech.

Volume: Using appropriate volume depending on a situation may help to improve intelligibility. Oftentimes children’s voices will be too loud or too soft, making them difficult to understand. Contrast different volumes with your own voice (no voice, whisper voice, inside voice, outside voice), and allow your child to pick the appropriate volume based on a situation.

Speech sound substitutions and errors: Sound substitutions, omissions and errors frequently impact a child’s intelligibility. There are set milestones for speech sound acquisition, however substituting one sound for another (e.g., saying “wing” for “ring” or “fumb” for “thumb”) can leave parents guessing at what their child is saying. In these cases, parents can model accurate sound production (based on age), and overcorrect, or emphasize target sounds.

If a child continues to struggle with speech intelligibility and either child or parent is getting frustrated, a licensed speech-language pathologist can help!


 

boy learning to walk

Gait Development In Children

A majority of my clientele are babies just learning to walk, toddlers who are delayed in their walking, or preschoolers who are showing an abnormal gait pattern. Years ago, when I worked in the rehabilitation and hospital settings, most of my patients were trying to regain their ambulatory abilities after an injury. Needless to say, walking is an important part of growth and locomotion. It is a complex task that requires musculoskeletal and neurological system maturation and cohesion.

Development of Gait:

The components of typical adult walking include 1) stability in stance, 2) sufficient foot clearance, 3) appropriate positioning of foot for initial contact of the next step, 4) adequate step length, and 5) energy conservation. Depending on the age or type of injury, a person’s walking ability might be impaired in any of these factors. Physical therapists work to address each component to encourage efficient and safe walking.

At age 1, children are just learning to walk and are still working on their standing stability. When they first start walking, their arms are held up high in protective guard, and they walk really fast so as not to lose their balance.  They rely on a wide base of support to maintain their stability. They often put their feet down flat on the ground and they do not spend as much time on each leg when clearing their feet for the next step.

About 6 months later, children will often start walking with a more natural gait, with arms down in a reciprocal swing, and with heels hitting the ground first.  Because of the structure of toddlers’ bones and joints, they still stand with a wider base of support than adults do, but are in the process of narrowing their stance.

In preparation for running efficiency and coordination, children who are two years old will have better ability to stand on one leg while clearing the other foot, and they are better at lifting their legs up and forward during walking. Base of support will continue to narrow during this stage.

By three years of age, children have gained the strength, upright posture, and limb coordination to walk similarly to adults. They might still stand and walk with different joint motions than adults, but this is more due to structural differences than anything else.  As their muscles and bones mature, children’s ambulatory abilities will improve as the forces of gravity and daily activity slowly elongate and strengthen the structures needed to perform adult walking. Of course someone who is seven years old cannot walk with the same speed and step length that an adult can, but they come pretty close.

The orthopedic and neurological changes that occur in a baby to enable him or her to walk are complicated.  It takes years and lots of practice for a mature walking pattern to develop in a child. Parents often ask whether or not their child is walking “normally.” That analysis depends on the child’s age, medical history, and family history. Studies have shown that adult gait is present in children by 7-8 years of age. A child can come into physical therapy with a variety of deviations (from flat feet, in-toeing, to toe-walking, to frequent falling). It is only through careful observation and assessment of their gait cycles that physical therapists can help these children achieve the optimal pattern.

Reference:

Stout, JL. Gait: Development and Analysis. In: Campbell SK, eds 3. Physical Therapy for Children. Philadelphia, Pa: WB Saunders Co,2004 :161-167.

Keen M. Early development and attainment of normal mature gait. Journal of Prosthetics and Orthotics 1993; Vol 5, Num 2, p 35. Available from: http://www.oandp.org/jpo/library/1993_02_035.asp; 2014 [accessed 31 March 2014]







baby finger foods

Finger Foods for Babies

How many times have you tried to give your baby a bite of his food and he reaches for the spoon, ready to do it himself? Probably just about every time you feed him. When your baby is about 9 months old, he has begun to develop the fine motor skills needed to start feeding himself. This is often a favorite (and very messy) activity for little ones.  It’s important to remember that finger foods for babies don’t have to be bought in the baby food aisle. Many of the things we eat can be adapted for baby! This will reduce your worry about always having something for him to eat as well as expose your baby to a new foods and textures.

Allowing your baby to feed himself as much as possible will help to encourage independent, healthy eating habits. This gives your child some control over what, and how much, they eat. There will be days that he will clean his plate, and there will be days where everything ends up on the floor…but that’s okay! He is learning the process of self-regulation and learning to recognize when his tummy is full.

 Rule number 1: Always try the food first.

Here is your finger foods checklist:

  • Is it soft?
  • Is it cooked enough so that it’s mushy? Overcook those veggies!
  • Does it melt in your mouth? (Think puffs or Ritz crackers)
  • Can you gum it? (i.e. eat it without teeth)
  • Is it cut into small pieces?

Rule number 2: Give your baby a variety of foods.

It can take up to 10 times for a baby to accept a new food into their repertoire. Don’t give up if the avocado ends up on the floor the first 4 (or 7) times.

Rule number 3: let him get messy!

Food play is an important learning experience. You have similar nerve receptors on your tongue and fingers so playing with food will help your baby experience different textures and temperatures.

With those three rules in mind here is a list of great finger foods to try with your little one!

  • Bananas-To make bananas easier to pick up, try dusting them in crushed Cheerios first.
  • Mandarin orange/peach/pear cups.
  • Grapes without the skin
  • Blueberries-If they aren’t small enough, cut them in two.
  • Watermelon (seedless, of course)
  • Cooked veggies: zucchini, carrots, sweet potato, butternut squash, etc.
  • Avocados or guacamole
  • Extra soft pasta
  • Small pieces of slow cooked or ground meats like meatballs, etc.
  • Fish
  • O-shaped cereals
  • Egg yolks-Once your baby is one year, they can have egg whites too.  Try chopping up hard boiled eggs!
  • Rice cakes
  • Cheese-Start with something bland like mozzarella or cheddar.
  • Quesadillas
  • Waffles and pancakes

Remember, now that your baby is eating these foods, the biggest issue to avoid is choking. Make sure your baby is strapped into his high chair and your eyes are on him at all times when starting these finger foods. Don’t give him any foods that could get stuck in his throat: popcorn, raisins, raw veggies, fruit with hard skin, hot dogs, etc.

Have fun with it! Get creative! And, don’t think you can only give him “baby” food!  If you have questions about your baby’s feeding, contact our Speech-Language Pathologists for answers.

what is phonemic awareness

What is Phonemic Awareness?

Literacy, or the ability to read and write, is paramount to a child’s success in school. Many children struggle with these skills, and this struggle may be due to difficulty with the building blocks of reading and writing, also known as phonological awareness. Phonological awareness can be thought of as one’s ability to identify sounds and letters as they relate to our spoken (and written) language. We all remember playing rhyming games in elementary school, but many people are unaware of their importance!

Children who have an understanding of phonological awareness understand that sentences are made up of words, words are made up parts (syllables), and each syllable has distinctive sounds. One great way to practice phonological awareness is through rhyming games and alliteration. Children will enjoy saying tongue twisters like, “Sally sells sea shells by the sea shore.” and identifying how many /s/ and /sh/ words they can count!

Phonemic awareness, a subset of phonological awareness, allows children to manipulate parts of language. Similar to phonological awareness, phonemic awareness is also comprised of parts including the following:
•    Segmenting: what sounds do we hear in the word “hat?” /h/, /a/, /t/
•    Blending: if you hear the sounds /t/, /o/, /p/, what do we get when we put them together?
•    Deleting: what’s “bat” without the “t?”
•    Substituting: if we change the /h/ in “house” to an /m/, what do we get?
•    Identifying: what’s the first sound in “cat?”

Phonemic awareness is separate from letter identification as it targets individual sounds; however, parents can incorporate letter names when practicing.

Phonological awareness typically begins in preschool and continues through early elementary school to prepare children for reading. These skills serve as the foundation for a child’s ability to read and write. If you suspect your child may be struggling with phonological awareness skills, a licensed speech-language pathologist can help!

Click here to read about 7 Ways to Increase Phonological Awareness.

First Sounds and First Words | What to Expect from Your Baby

Talking. Some of us don’t like to do it and some of us do it too much. But one of the most exciting things for parents is to witness their child’s first words. Babies learn to talk throughout their first two years of life and believe it or not, there are speech and language milestones that are achieved in the first few months of life. Here is a general outline of the speech and language milestones your child should be achieving from birth to 2 years.

Speech and Language Milestones from Birth to 2 Years:

Birth to 3 months

• Variety of cries to indicate needs – hungry, in need of a diaper change, or upset
• Coos, sighs, gurgles, and makes pleasure sounds
• Recognizes voices
• Localizes to sound by turning head

4 to 6 months

• Uses /p/, /b/, and /m/ to babble
• Vocalizes excitement and displeasure
• Listens to and imitates some sounds
• Responds to changes in your voice

7-12 months

• Babbles using long and short groups of sounds
• Uses a song-like intonation pattern when babbling
• Babbling has both long and  short groups of sounds such as “bababa upup tata”
• Has 1 or two words, though they may not be clear
• Uses communicative gestures such as pointing, pulling, and waving

12-18 months

• Uses nouns almost exclusively
• Uses jargon to fill gaps in fluency
• Combines gestures and vocalization
• Says more words each month, by 18 months child has a vocabulary of approximately 20 words

18 to 24 months

• Uses many different consonant sounds at beginning of words
• Expressive vocabulary of 25-50 words
• Imitates many words
• Uses some 1-2 word questions – “What’s that?” “Mommy?”
• Puts two words together – “more cookie” “no book”
• Language explosion typically occurs around 18-24 months; vocabulary grows to 150-300 words by 24 months

Further Reading

For more on Speech and Language Milestones: Birth to Age 1, click here.
For more on Speech and Language Milestones: Ages 1-2, click here.

Gross Motor Developmental Milestones for Two Year Olds

Many pediatricians refer children to physical therapy around the 15th to 18th month of development. Most of these children are showing a slight delay in their development and pediatricians are hoping that, with the help of physical therapy, they could catch up by their 2nd birthday.  Though some of these children have been delayed since their first motor milestones at 6-9 months, some doctors choose the wait-and-see approach before recommending physical therapy.  This is an understandable approach. Late term premature babies, for example, are often able to catch up to their peers by the 2nd or 3rd year of development.

There are warning signs and red flags we all look for when we are monitoring children’s development from day one. While there are obvious milestones to be met by a child’s first birthday, every child develops differently. Many factors during the first year of life could influence a baby’s evolution into toddlerhood, from sleep patterns to eating habits, to birth history and home environment. There are, however, some major gross motor milestones a typically growing child should have met by his second birthday. Read over the following and schedule an appointment with your pediatrician or pediatric physical therapist if you still have questions.

Gross Motor Skills at the Beginning of Year 2:

  • Independent Walking: A typically developing child usually walks independently at 12-15 months of age. This walking is usually unsteady and slow, with frequent stumbles. But within 6 months’ time, a toddler should be able to walk with his arms down, stop, turn, and step onto different terrain easily without losing his balance. He should also be able to walk sideways and backwards, while pulling a toy. Walking alone, squatting to pick up a toy, and then continuing on his way should appear easy and natural to a 2 year old. Push-toys are often part of a 2 year old’s favorite game and he can push/pull them while walking in every direction, without falling.
  • Running/Balance: With the newfound stability on his feet and all the practice of walking over the past 6-12 months, a two year old should be able to run and walk fast on level surfaces without tumbling, while holding a toy. His movements should be smooth and coordinated, not rigid and timid. Toddlers are so skilled on their feet, in fact, that they can kick a ball and throw a ball without losing their balance.   They even can stand on a 2-inch wide line with one foot in front of the other without any assistance. Most two year olds will also attempt to balance on one foot, without holding on.
  • Jumping: Though I usually tell my clients that jumping is a complex and challenging task, a typical two year old does have the strength and balance to jump with two feet.  A typically developing 24 month old is able to jump forward 4 inches, jump up 2 inches, and jump down from a low step, all without help. Sometimes, when prompted to jump forward, a two year old might push off with one foot instead of both. Parents often ask me if this is reason to worry. I suggest they pay attention to what is happening when their child is jumping. Does he always fall after jumping? Does he seem to drag one side? Does he seem to prefer to always push off with only one leg? A hand or leg preference doesn’t come in until year 3, so an obvious disparity between two sides could justify a visit with your doctor.
  • Stairs:  A toddler who has been walking for nearly a year can now safely walk up and down stairs, with or without a rail.  He might have to go slowly or put both feet on each step, but the motivation and balance should be there. If your child is still crawling up and down stairs at 2 years or choosing to scoot down on his bottom, there may be weakness in his lower body and trunk muscles. Bring him into baby physical therapy! We’ll take a look and give him some exercises to get him going.

The Basics of a Math Disorder

Mathematics is much more than adding and subtracting.  In reality, there are several factors and components that compose a child’s mathematics achievement.  Children’s mathematics skills are found to develop in a hierarchical fashion.

Stages of mathematics development:

  • The first stage of mathematics development is observed in young children and consists of skills such as understanding of one-to-one correspondence, classification, seriation, and conservation.
  • After theses skills are developed, children are able to learn addition, subtraction, multiplication, and division.
  • Finally, after these skills are developed, advanced skills such as algebra and geometry are able to be learned.

Teachers can watch to see if these skills are developing as they should be.

Once teachers have identified a child as struggling with mathematics, one or more of the following factors would likely need to be addressed:

  • Visualspatial skills
  • Linguistic abilities
  • Working memory

Visualspatial skills are necessary for aligning numerals in columns for calculation problems, understanding the base ten system, interpreting maps, and understanding geometry.  Linguistic skills are needed when performing word problems, following procedures of how to carry out operations, understanding math terminology, and knowledge of math facts.  Working memory capabilities are used for the manipulation of numbers and operations.

From here with a plan from the teacher and/or a neuropsychologist, the student can get back on track with his or her math skills.

Click here for more information on Learning Disorders.

Tips for Buying Tricycles for Toddlers

An important part of childhood is riding around in your first set of wheels. Between 2 and 3 years of age is a good time to look into tricycles. Tricycles are important for both cognitive and physical development, helping children explore their environment in new ways and develop their confidence and independence. Tricycles are also a great way to build a child’s coordination, endurance, balance, and core strength.

Tricycles are a great transition between scooters and bicycles. Scooters, strider bikes, and seated ride-on toys (learn more about these toys here) don’t have pedals so kids just have to put their feet down on the floor to propel or stop.  Tricycles and bicycles, on the other hand, require some total body coordination to pedal and steer at the same time. Bicycles require more advanced coordination and balance than a starter tricycle.

What to look for in a tricycle:

  1. Safety: A tricycle that is compact, light, and easy to push might not be sturdy enough to support a growing child. Look for a wide base of support and a stable steering wheel (one that does not make hard turns) so the trike isn’t easily flipped over. A decent tricycle does not break easily. Look for a trike that’s made out of sturdy materials (metal as opposed to plastic).
  2. Fit: A tricycle will most likely encourage independence and confidence if the child can actually reach the pedals. There are lots of tricycles out there with adjustable seats, handles, and pedals. Make sure you pick a tricycle that your 1.5 year old can grow into for at least a couple of years. If your child has a hard time keeping his feet on the pedals, there are also Toe Clips available at most toy retailers to help strap their feet in.
  3. Function and Fun: When purchasing a tricycle for your 2 year old, consider if having a push bar would be important. Push bars let parents steer their children around, which could be a good option when trying to navigate busy city sidewalks or if your child has a hard time coordinating the pedals at first. Most push bars are removable for the more advanced tricyclist.  Some tricycles have storage or dump buckets. These are usually big hits with children; they love to cart things around.

Tricycles provide a new level of independence for young children, and promotes emotional and physical growth. As always, children should be supervised and wear protective gear when on any mobile toy.

What Is the Difference Between Occupational and Physical Therapy for Children?

Many of the parents I meet often ask why very few occupational therapist work with infants, or why an occupational therapist (OT) is seeing their child for toe-walking as opposed to a physical therapist (PT). They often wonder why one child who has balance or coordination issues would see a physical therapist while another with similar limitations would see an occupational therapist instead. Some parents think that occupational therapists only work on fine motor skills while physical therapists only work on gross motor skills.  Physical and occupational therapists work in a variety of settings, including hospitals, neonatal intensive care units, skilled nursing homes, outpatient clinics, schools, rehabilitation centers, and doctor’s offices.  Physical therapist and occupational therapist roles differ depending on the setting they work in and the medical diagnoses they work with.

In the outpatient clinic, some of these roles may overlap.  While there are some similarities between PTs and OTs in each setting, there are a few fundamental differences between OTs and PTs in the pediatric setting.

Pediatric Physical Therapy:

In the pediatric outpatient setting, physical therapists are often musculoskeletal and movement specialists. Parents can seek out evaluations when their babies are as young as 1 month old. Physical therapists have in-depth knowledge about human musculoskeletal, neuromuscular, integumentary, and cardiovascular systems. Based on our background in stages of development and biomechanics, we help children with mobility difficulties; whether they are behind on their gross motor milestones, recovering from injury/surgery, or not keeping up with other children.

Through all kinds of hands-on or play techniques, pediatric physical therapist work with children on the following:

  • Gross motor skills
  • Strength
  • Endurance
  • Balance and coordination
  • Motor control and motor planning
  • Body awareness
  • Pain relief
  • Flexibility
  • Gait mechanics
  • Orthotics training
  • Wound care

Our focus is for children to be as mobile and as independent as possible, while training their caregivers on all aspects of a child’s physical development. This includes anything that may affect a child’s quality of movement, posture, alignment, and safety.

Pediatric Occupational Therapy

Outpatient pediatric occupational therapists are trained to improve the quality of children’s participation in their daily functional tasks.  A child’s job is to play and take part in activities at school and at home. These include important endeavors such as paying attention in class, hand writing, dressing, feeding and grooming themselves, and being able to engage in age-appropriate games. Occupational therapists are also trained to help children organize and interpret information from the environment so that they can just be kids. This may include taste aversions that limit their food intake, or texture aversions that affect their clothing tolerance, or sound aversions that affect their mood.

OTs work with children on the following skills:

  • Sensory integration
  • Cognitive endurance
  • Fine motor skills
  • Hand function
  • Visual-spatial awareness
  • Hand-eye coordination
  • Attention
  • Social skills
  • Body awareness

Occupational therapists often educate parents and teachers on the best techniques to ensure children participate in learning, self-care, and play tasks.

Why do some children need both disciplines and some only need one?

So many factors can affect a child’s ability to participate in her daily life. A child may be experiencing frequent falls or may have trouble jumping due to a number of reasons.  No matter the diagnosis or underlying medical condition, any child who is having a hard time keeping up with his peers can benefit from a comprehensive evaluation by a pediatric specialist.

How to Encourage Baby’s First Steps

As a physical therapist who works primarily with the 5 and under crowd, I have had the pleasure of witnessing many babies’ very first steps. Some of the proudest moments I’ve experienced on the job have involved children meeting their milestones for the first time.  Watching a child develop the confidence in his abilities to venture onto unfamiliar terrain on his own makes the months leading up to that moment so worthwhile.

I am sure that I do not have to talk about the importance of walking as part of typical development. What parents don’t realize are the components of human ambulation and the importance of each step.   For many new parents, I often reiterate the fact that weight-bearing through their feet is a great way for babies to learn. They learn how their bodies move, strengthen their muscles and bones, and receive the appropriate feedback from their environment to perform more and more challenging tasks, such as jumping, and running, and stairs.

Often, first time parents are unsure how to best encourage their child to take those first steps. So how do we facilitate and not hamper their exploration?

How best to help out a toddler learning to walk:

  1. Cruise is first: About a month after a baby first learns to pull to stand, he will start cruising along furniture.  At this time, he still relies on his hands a lot for standing and doesn’t yet have the full grasp of shifting his weight from foot to foot. Help him cruise along by placing toys just out of reach and he will slowly become more and more stable when all his weight is on one side. Cruising long distances increases baby’s standing stamina and strengthens those important hip and thigh muscles. Place toys on a low surface off to the side and behind him, and he will learn to let go with one hand and rotate in his trunk. Trunk rotation is an essential component of reciprocal walking later on. Click here to read more about cruising.
  2. Where to support: Contrary to popular practice, the best place to support a baby just learning to walk is actually at his trunk.  If you take an early walker (say, 9-10 months old) by both hands and try to lead him, he is most likely going to tilt his body forward and step really quickly to try to catch up with his center of gravity. This will not help him place weight throughout his whole feet. Instead, he may rise up on his toes. Weight-bearing through the heels during early walking is important. That impact from the ground helps build muscles and bones up the chain so babies’ thigh bones and hip joints can become strong and stable enough to support their growth. When assisting babies to walk, stay with them and let them lead, however slow each step may be. For more info about best ways to support a toddler learning to walk, click here.
  3. Slow them down: Children usually start to take steps on their own after they feel safe during independent standing. With each new step, babies will keep their feet wide apart so they can feel balanced.  Many parents I know like to give their babies a push-toy such as a doll stroller or shopping cart so they can speed walk around the house. While these toys may seem like a great way to get babies moving on their feet, if given to a baby in the early stages of walking, they also encourage poor postures and improper weight shifts.  If you have to use push-toys, weigh them down. When a baby takes each step slowly, he can experience the way his center of mass transfers over the entire surface of his feet. His foot muscles and his ankle joints need to experience the hard work required by each step in order to properly respond and develop the balance strategies he needs for later.
  4. No shoes or socks:  While I tell parents from early on that babies should experience their environment with only a diaper on, many parents think shoes are a necessary part of early walking.  Many pediatric therapists will tell you how important it is for babies to learn to walk barefoot. Why? Because babies rely on the feedback they feel from the ground to adjust their standing balance as needed. Standing and learning to walk on plush carpet, grassy terrain, or hardwood floor are all so different and our joints, muscles, and posture have to adjust accordingly. Taking that proprioceptive feedback away from babies just learning to walk by giving them shoes will make them unaware of the differences between surfaces.  Read here for information about the best footwear for babies.
  5. Importance of squatting: Squatting is a key play position for babies. Starting as early as 9-10 months, babies can lower themselves slowly from a standing position while holding onto furniture. So place some toys at his feet and try to get him to pick them up. That up and down motion, supported or unsupported, is great for strengthening hip and thigh muscles. Learning to safely transfer their weight during standing tasks will help them with walking skills. Eventually, around 15 months, a toddler is able to stand unsupported, pick up a toy from the floor, stand back up, and keep walking, all without any help from us. Now that is one independent baby on the move!

The typically developing baby learns to walk around 11-15 months. He might not look stable and he may fall after a few steps, but he is doing what he should. He is trying. Every child is different in how and when he chooses to take that first independent step. Our job is to provide a safe and motivating environment for him.  If your baby is not making any attempts to stand by 12 months, or has been standing for a few months and seems to drag one side and trips often, or still has not walked by 16-18 months, it is a good time to bring up your concerns with your pediatrician and contact a physical therapist for an evaluation.