Language & Feeding

Today outside of the therapy clinic where I work, I was speaking with an occupational therapist about oral motor exercises. Yes, there is a lot of debate around oral motor exercises and there are definitely reasons for controversy about some approaches. However, I think it’s wise to look at the evidence-based hierarchy, which includes clinical-expertise and expert opinion, and take these into account when we look at our therapy approaches. This way we do not throw the baby out with the bathwater. Nancy, the OT, and I were chatting about how she often sees improvement in speech when she begins intervention for feeding. And she has said that parents report seeing the same at home. In fact, I can very clearly remember a session Nancy and I had together many years ago where we were co-treating a little guy at a pediatric clinic.  I was pulling out every trick I had up my sleeve to try to get some vocalization out of this little one: singing, using exclamatory phrases while knocking over blocks, animal sounds, you name it. And then Nancy approaches him to begin her feeding therapy. She uses vibration on his mouth with something very similar to a Z-Vibe. And this little guy started humming. He hummed and then turned those hums into very slight babbles of /meh meh meh/. When Nancy removed the Z-Vibe, there was still an occasional hum coming from him. Although it took me many years to really start considering the oral-motor component, when I studied feeding therapy, I went back down the oral-motor rabbit hole. I came across an interesting article that shows that children with a prior history of feeding-swallowing difficulties have a higher incidence of language learning disabilities. I wanted to share this article.

The relationship between language impairment and feeding difficulties

The article looked at the relationship between difficulties with feeding and swallowing (poor latching as infants, food transition difficulties, food selectivity, salivary control difficulties). The children in the study were not diagnosed with a feeding or swallowing disorder. This was a retrospective analysis where 48% of the children with a language impairment but not an overall gross or fine motor impairment showed prior histories of feeding-swallowing concerns. Children with language impairment were three times more likely to have a history of feeding-swallowing concerns than the general population.  Although language impairment and feeding-swallowing difficulties have often been considered unrelated behaviors, there is new interest in whether there is some type of cross over between the two systems. As the authors wrote, “Neurological disease or damage in the adult often results in cross-system impairments in language and feeding and common neurological structures underlying these seemingly diverse behaviors have been implicated.”

Possible Explanations for the Relationship

The authors point to a few explanations about why feeding and speech impairments may be related to language impairment. 1. The difficulties with feeding-swallowing may negatively impact language learning opportunities by possibly decreasing language stimulation and interaction at mealtimes. 2. The oral motor difficulties in chewing and sucking might influence later neurodevelopmental outcomes and as the authors write,    “[studies] found that term infants with reduced sucking efficiency at 2 weeks postnatal age had minor to severe neurodevelopmental disabilities at 18 months, as measured by global neuromotor, language, and cognitive assessments. They suggested that sucking proficiency may actually provide insights into the “integrity of the nervous system” of developing infants.”

The purpose of this study is to identify children sooner who may be at risk for language impairment. I think it also brings some interesting questions to the table about the cross-over between what have typically been thought of as two distinct systems (the system of oral motor movements for feeding and swallowing with those for speech and language).

Also, I realize that Nancy’s observations alone do not provide a strong evidence base for oral motor and speech sound production, although she is a keen observer. However, there are many experts who, although not researchers, have gathered evidence to support the relationship between oral-motor differences and speech and language production. Diane Bahr, for example, has excellent materials and research that she very generously shares with all who ask.




How our Sensorimotor System May Affect Speech Perception

Hello fellow SLPs

Ok this post goes a little deep but it’s pretty interesting and worth the read (in my humble opinion), especially for those of  you working with children with speech sound disorders.

It’s pretty well accepted that when we don’t perceive sounds accurately, we have little chance of producing them accurately. You’ve seen this firsthand when you try to imitate something in a language you don’t speak and a native speaker shakes his head as you stumble through his language. In your mind, your pronunciation was fairly good. But, unless you were exposed to Italian as a baby, it’s obvious as soon as you say bongiorno that you are not a native speaker. (By the way, for any of you who have seen Inglourious Bastards, do you not crack up as Brad Pitt’s character tries to pass for a native Italian speaker?!) Our brains weren’t primed as infants to hear the phones in non-native languages and so we have little chance of imitating them with native-like speech. We also know that for babies with hearing loss, their vowel shapes and babbling are not the same as their normally hearing peers. So, when we don’t perceive phones, we don’t produce them accurately. This is a given.   What may come as news to many SLP’s though is how articulation of sounds may affect perception of sounds, according to a recent study.

What do I mean by that?

In this study, researchers wanted to see how restriction of the articulators would impact a baby’s ability to perceive a speech sound.   In an infant’s brain there are pathways that support the “auditory-to-motor” mappings meaning that the brain sends cues down to the articulators when certain sounds are heard. This study proposes that there is a loop with speech perception and speech production. New sounds are processed in the brain and then produced by the articulators and that the articulators being able to produce the sound also reinforces recognition of that sound by the brain.

When a novel sound is introduced to an infant, they attend more to this sound.  This study divided babies into groups who were exposed to a speech sound that is not discriminated by adults because of neural pruning that happens usually around 9-12 months of life. But, small babies who have not yet had neural pruning do identify subtle differences in phones across languages. In one group, the researchers “restricted” the tongue by placing a baby mouthing toy in the babies’ mouths where they would typically produce the sound. The babies were then exposed to the nonnative phoneme (a sound in Hindi). In another group, the babies were not given anything to mouth so their articulators were not blocked. They were then exposed to the nonnative sound. Babies whose articulatory placement was blocked attended less to the nonnative sound (which was measured by babies trying to localize the sound).  The sound was a lingual alveolar sound, so having a chewy toy effectively blocked placement. Well, what if the babies weren’t attending because they had something in their mouths which focused their attention on mouthing rather than locating sounds? So a third group was designed to rule this out. In the third group, the babies were given a mouthing toy that was gummy and flexible and allowed their tongue to move to the alveolar ridge. And this group of babies did attend to the novel sound similar to the group with no chewy toy. So, what does this study mean about what we think is a unidirectional learning of sounds (i.e. only from the brain to the articulators rather than a feedback loop.)  

This study indicates that the ability to articulate a sound can influence how it is perceived in the auditory system.

The authors of this study hypothesize that impairments in the motor function of the articulators can also affect speech perception. If speech perception were affected, wouldn’t language also be affected as children with oral-motor differences may not be perceiving the phonemes of their own language that they are hearing.  They also state that, “This raises the question of whether speech perception is compromised in clinical populations with congenital oral–motor deficiencies or dysmorphologies. At present, these children are given speech therapy to improve their production skills, but no consideration is given to whether their perception is also affected by differences in their
productive systems (i.e. Bruderer, et al.”

I find this study interesting and there are few others that I have found like it, but I’m hoping that this area will continue to gain interest among researchers as many clinicians attest to seeing an oral-motor difference linked to a speech perception connection. My next post will be a follow up on this one as well as discussing a relationship between the sensorimotor system and language delays. Grazie!


A Follow-Up on Books

I have a follow up story to my last post about books and why they are holy. I work in a school district whose students come from low income homes. I have really made it my quest to emphasize the importance of book reading so that parents understand the many wonders that books (not I-pads) can do for children. A recent meeting that I had with a parent opened up my eyes to how important book reading is throughout our entire lives and gave me a perspective on books I’d never had before. The parent, an administrator from the school, and I were seated in a small office discussing her son’s individual education plan. When we discussed strategies to help him understand and grow his vocabulary, books came up, naturally. The mother confessed that she had trouble reading and had never gotten to a point where she could sit down, pick up a book, and get totally lost in the story. She wants her son to one day be able to do that because she sees how important reading can be in a person’s life. She told us the story of how a few years back she was visiting her brother on the island of Tonga. He had just gotten out of prison. He had spent several years in prison. They were spending some time on the beach, relaxing and not doing much. He had brought a book with him in his backpack. He opened the book and asked his sister that they read together. She began to read out loud, but after a few moments of halted sounding out of words, he took the book from her and said, “Let me read. You’re going too slow. It sounds like you’ve never read out loud before. When I was in prison, the only thing that got me through being bored and lonely was books. Do you know how much you can learn from books? Do you know what you can find out from these? ” He took the book from her and began to read out loud and she leaned next to him and listened. And she was hooked on listening to a story in a way she hadn’t been fore. She confessed that it’s still hard to read and understand at the same time. A lot of readers don’t get passed the stage of being able to sound out the words (decoding.) Because there hasn’t been consistent practice sounding out the words and starting to understand them, this reader could only decode and not comprehend. And when a person doesn’t comprehend, there’s very little motivation to keep reading. That’s why reading has to start young and start out positive. Books can get people through some of their hardest times. Books offer us knowledge, allow us to question and think critically about our world. They can be our friends and our inspiration. I love books!

Books and Bilingualism for Toddlers

Speech Therapists, ST’s, when working with your families in early intervention, one way that I have found to help parents support the home language is through the use of books. Of course, before we break out The Very Hungry Caterpillar, let’s make sure that the child is at an appropriate stage for what may be a (very) short story time.

What’s great about using books in therapy is that even if the books are not available in the child’s primary language, parents can use popular books for toddlers and modify them for the child’s primary language and the child’s receptive/expressive developmental stage.  As ST’s, you can help the parents to come up with the target language. Does the child need to work on verbs? Then make sure that many of the pages include short sentences with verbs: The caterpillar eats. The caterpillar sleeps. The caterpillars climbs up. Uh oh, he falls down! Etc.

As a reminder, here are the traits of good books for a toddler

  1. It has big, colorful pictures and isn’t too busy.
  2. It centered around, at least to some degree, the child’s interests. I find most animal books interest children, but you may need to try other books, such as books about cars, dinosaurs, or food.
  3. It tells a simple story. A review of the alphabet from A to Z is not really a story. Neither is counting from 1 to 10. Again, where’s the plot, I ask?
  4. It’s sturdy. Find board books when possible unless you’re okay with ripped pages.

When it comes to translating the language in the book, here are a few of my recommendations:

  1. I use removable print labels and place the label anywhere on the page where it won’t be obstructing the pictures.
  2. I don’t translate the books word for word. I think about the clients who will use the book and then, depending on their stage of communication, I come up with the appropriate vocabulary words and sentence length and complexity.
  3. If the child has needs in receptive language, I will try to repeat key vocabulary throughout the text so that there’s a lot of repetition to hear the word. For example, with the book, “The Very Hungry Caterpillar” I would use a very common and functional verb throughout the book such as eat. I might not even really emphasize the word hungry if I felt that word would be too challenging for the child to comprehend at that time. And then, perhaps I would focus on a few of the foods and not list out every single food that the caterpillar ate. And maybe, instead of calling him a caterpillar, I’d use an easier, more familiar word such as bug (of course, this depends on which language the parent is translating the text to). I will post pictures to give an idea of how this might look.
  4. Remember, simultaneous translation is not necessary during book reading. By simultaneous translation, I mean first saying one line in the book in English and then repeating that same line almost immediately after in the primary language. This back and forth simultaneous translation will focus the child’s attention on differentiating the languages. It will not focus the child on learning the key vocabulary. It is advised that you read through it in one language. If the child points out words in the non-Primary language, such as saying, “cookie” when you’re trying to get them to say this in Portuguese, in a positive and praiseful way, repeat back what they have said, pointing at it and in Portuguese saying, “bolacha.”  And then make sure to use that wait time to allow the child to say this word back to you in Portuguese.





Research: Bilingualism & Autism Spectrum Disorder

Although we continue to have a huge need for research in the area of multilingualism and autism spectrum disorder, we are fortunate to have an increase in studies and publications. This is a little nudge in the ribs for you research inclined SLT’s!

What does the research say about our early intervention and preschool population with an ASD diagnosis?

One study in China on children with an ASD diagnosis focused on parent reported communication development, specifically pragmatic language and  structural communication development (Reetzke, Zou, Sheng & Katsos, 2015). A group of monolingual children were compared with bilingual children. Parent ratings showed no statistically significant difference in the pragmatic or structural language abilities  in the dominant language of bilingual children when compared to their monolingual peers with ASD. In other studies on children with autism, (Petersen et al 2012) children with ASD who were bilingual were found to have a larger vocabulary than their monolingual peers when total vocabulary was taken into account.

The take away! Exposure to two languages has not resulted in a negative impact on the dominant language for clients with an ASD diagnosis. When we discuss with our families the possibility of limiting the primary language and focusing on English only, we need to consider the following  consequences:

*If the parents are not fluent in English, the child may have less exposure to a language rich environment.

*The child’s inability to understand the primary language may further limit interactions in the community and among family members which may result in social isolation which is the exact opposite of what we’re trying to target with our clients and their families. We need them to have the ability to have meaningful interaction, which won’t happen if their exposure to their primary language is limited.



Resources for your Bilingual Families

Fellow speech therapists, (I use the term or Speech therapists, ST’s,  on my website as this is a more commonly used name for our profession outside of the U.S. Because I hope to reach therapists from different reaches of the world, I will refer to my esteemed colleagues as STs.) here are some of the websites I commonly share with parents on language impairment and bilingualism. They are in no order of importance.

This is a bilingual website (English and Spanish) that focuses on reading, language maintenance, and preserving heritage and cultural traditions. This website also has great handouts on reading tips for children of all ages and it comes in ten languages: Arabic, Chinese, Haitian, Hmong, Korean, Dine (Navajo), Russian, Tagalog, Vietnamese, and Spanish.

This is a great website created by parents who are raising their children to be trilingual. There are a lot of helpful tips and hints for overcoming obstacles and dispelling myths.

This is a website created by many of our colleagues who are researchers in bilingualism and language impairment. The cite, as far as I can see, is mostly maintained by Dr. Elizabeth Peña. Definitely subscribe to this website as journal articles that don’t always appear on ASHA are occasionally offered for free for limited amounts of time.

I will continue to add to this thread and feel free to email me if you have websites that you would like to recommend.


Podcast Episode on Teach Me to Talk

Today I had the wonderful opportunity to speak on Laura Mize’s podcast, Teach Me to Talk. She is a speech therapist I very much admire and whose podcast I have listened to for years. Listening to her podcasts has given me so much information on working with our birth to three population. These last few months, I have felt especially motivated to discuss bilingualism and best practices for our children with language impairments. It is my hope that we can continue to dispel myths and support our bilingual families. Laura was a great host and asked some really good questions. Here’s a link to the podcast if you’d like to listen!

How to Support Our Bilingual Families

Provide the family with accurate information about learning two languages. 

We are finally at a time when more research is being done in the area of bilingual language development for children with developmental delays. This is no small thing as the amount of research on bilingual language development in children with disabilities has increased ten-fold to where it was a few decades ago. With the knowledge we have now, we can reassure our families that children who are capable of learning one language are almost always capable of learning two. Many parents that I have met resist teaching their child the home language because of fear that this will delay learning the second language, which in our case here in the U.S. is English. Although learning two languages may initially result in acquisition of some vocabulary in L1 and other vocabulary in L2, the expressive vocabulary size of a bilingual child’s dominant language is comparable in size to a monolingual child’s expressive vocabulary. In one study, the expressive English vocabulary of two groups of children both in the early stages of language development with Down Syndrome was compared: children who were bilingual and children who were monolingual. The bilingual children’s vocabulary in English was as large as the children who were English monolingual speakers. And we aren’t even taking into account the amount of vocabulary in the second language! (Kay-Raining Bird, et al., 2005).

Parents can and should be the best language models to their child and provide a strong foundation in the home language. If the parents’ use of L2 is limited, how are they going to provide a good language model? As a speech-language expert, you need to provide parents with both short-term goals and long-term consequences. Although parents may have a short term goal of their child saying as many words as possible, regardless of the language, they should realize that in the long-term, their child will more easily acquire L2 if their L1 is strong. I have also seen the opposite end of the spectrum, which is when parents are afraid to expose their child to L2 because they believe it will overpower L1. While this is a legitimate concern for parents as children often show preference for the majority language, there are ways parents can do their best to ensure that L1 is maintained. You can provide this handout for parents which offers ideas and suggestions for helping to support the home language. Children who learn two languages simultaneously from infancy show the best outcomes in both languages (Gutierrez-Clellen, 1999). However, this doesn’t mean that a second language can’t be learned sequentially, especially if the only option for therapy is in L2.For sequential language learners, some research has demonstrated better results if a child with language impairment waits to learn L2 until kindergarten, after they have a firm base in L1 (Pettito et, al., 2001). The logistics of doing this  are tricky, especially when therapists, siblings, and t.v. expose the child consistently to English. I have heard of some families who are almost militant about not letting one word of English be spoken in the home. Again, I understand wanting to have structure and consistency but I do think that being almost fearful of exposure to another language might create unnecessary negativity and stress around language learning.

I’ll be posting more on how to implement therapy in L2 when you don’t speak L1.

Here are handouts for other professionals to share on dual language development

Supporting Our Bilingual Families

Here are the handouts in English and in Spanish about supporting the primary language!

Ayudar a su hijo ser Bilingue

Teaching your child your native language