Yup... I said it.  Given all the buzz from that McCleod & Crowe article last year, it should be no secret that we've totally been misinterpreting those articulation norms. But, for a lot of SLPs it still begs the question... "then at what age should we be addressing particular sounds in speech therapy?"

Some of the most common questions I hear from SLPs sound something like this:

"When should I start treating kids for /r/ errors?"
... or ...
"Aren't /s/ sound errors still age appropriate for preschoolers?"

Those are the WRONG QUESTIONS.

If we base eligibility criteria and/or target selection primarily on arbitrary "cut-off" ages for acquisition of sounds, then we're missing the whole point. There are so many other variables that should be considered in addition to what particular sounds a child has at a particular age...

• Intelligibility... if a child isn't at least 75% intelligible to unfamiliar listeners by the age of 3 (and 100% by age 4), then it's time to address speech, regardless of what the charts say.
• Presence of phonological processes... all sound errors are not created equal. Maybe a child has all their "age appropriate" sounds, but they're still deleting final consonants at the age of 3.  Time to treat and remediate that phonological process! #phonologyisnotarticulation
• Underlying structural or functional deficits... if things like VPI, tongue thrust, etc. are present, making referrals or getting a jump on speech intervention can be hugely beneficial. This also highlights the importance of ALWAYS administering an oral facial exam whenever possible. It can help you uncover or rule out issues that could be contributing to speech sound errors and help you make necessary referrals to other professionals.
• Presence of multiple errors... even if all those errors are "developmentally appropriate", if there's a bunch of them and they're significantly reducing speech intelligibility, don't wait!
• Family history of speech difficulties or learning disabilities...  this is a big one!  If you know there is a history of speech/learning disorders in the family, that's definitely something to consider when recommending services.
• Difficulty learning to read and/or write... we know that children with speech sound disorders are at higher risk for having literacy related deficits, especially in the areas of  phonological awareness, decoding, and spelling.  So much more about that from Dr. Kelly Farquharson here.
• Social/emotional impact... if a child is self-conscious about their speech difficulties, if it's inhibiting participation in their school or community, or if they're avoiding speaking in certain situations, please don't wait to treat.

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I like a good bar graph as much as the next guy... but I have to remind myself its just one piece of a bigger puzzle.

Let's take the /s/ sound, for example. Here are some factors I take into consideration when I decide whether or not to recommend speech therapy:

1. How much do the child's speech errors impact intelligibility? Usually a simple frontal lisp doesn't impact intelligibility too much, but if they’re 4 years or older and strangers can’t understand them close to 100% of the time, then it’s time to treat.
2. Are they omitting, substituting, or distorting the /s/? I may consider treating earlier or later depending on whether they are reducing consonant clusters or stopping vs lisping. Again, phonology is not articulation.
3. Are there any other speech errors? If you’re already treating this child, for the love of speech sound disorders, please start treating /s/... even at 3! We already know they have trouble acquiring speech, so get a jump on it!
4. Are there red flags for a myofunctional disorder? This deserves a post in itself... But, if there’s a tongue thrust, low tongue resting position, mouth breathing, high/narrow palate (I could go on and on), by all means don’t wait! Treat the underlying myofunctional deficit or refer to an SLP who can.
5. Is it a lateral lisp? TREAT NOW. That’s not a developmental error and kids don’t “grow out” of it. I developed the Bjorem Speech Sound Cues for Lateralization for this particular speech sound disorder, which I've found to be so helpful with little ones who have such a hard time understanding correct placement.

​Now, I completely understand that many school-based SLPs are all too often bound by black-and-white eligibility guidelines put in place by administrators with little to no understanding of the nuances of SSDs.  And believe me, I can totally empathize with the concerns over gigantic caseloads in light of all these considerations (I was a school-based SLP for many years, myself). Unfortunately, I have no easy answers.  I just know that we do our kids and their families a disservice when we solely rely on speech acquisition norms as an arbitrary threshold for eligibility criteria.

With everything we’re learning about complexity theory, how we’ve been misinterpreting those speech acquisition charts, and how speech delays/disorders can impact literacy... it becomes pretty clear that there really is no “magic age” at which we should begin providing intervention for kids with errors of particular sounds. It’s much more complicated than that. 

There is so much confusion among parents and professionals about who is most qualified to give a definitive diagnosis of Childhood Apraxia of Speech (CAS).  To understand who should be diagnosing this disorder we have to understand what CAS actually is...

"CAS is a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone)..." Ad Hoc Committee on Apraxia of Speech in Children, American Speech-Language-Hearing Association, 2007

There are 2 important aspects of this definition... one usually leads to confusion about who should diagnose, and the other actually helps to clarify the confusion.

1. "neurological"... That word understandably leads many people think that a medical professional (specifically a neurologist or developmental pediatrician) would be most qualified to give a diagnosis.  But, as Cari Ebert, an SLP and nationally recognized speaker on the topic of CAS has explained, it simply means that the issues with the child's speech difficulties begin in the brain, not the mouth.  

This word also leads people to believe there are usually medical tests (e.g., MRI) that can reveal the cause of CAS.  Though CAS can occur with other neurologic impairments (childhood stroke, infection, trauma, etc.) that do yield positive findings on imaging studies (i.e., MRI), this is usually not the case as CAS is very often idiopathic (unknown cause).  "Imaging and other studies have not been able to find evidence of brain damage or differences in the brain structure of children with Apraxia of Speech." ​Apraxia of Speech. National Institute on Deafness and Other Communication Disorders (NIDCD). Accessed 1/4/2016.

2. 'speech sound disorder"... this phrase provides the clarification we need!  CAS is at it's core a SPEECH disorder.  And who is the most qualified professional to diagnose speech disorders?... speech language pathologists (SLPs)! In fact, the word "pathologist" by definition refers to the SLPs ability to actually diagnose speech and/or language disorders. Although consulting neurologists, developmental pediatricians, psychologists, etc. can be helpful and sometimes necessary, these professionals do not have the education, training or expertise to differentially diagnose CAS from other speech/language disorders or delays.

Does this mean that all SLPs are qualified to diagnose CAS?  NO and here's why...
CAS is a very rare condition. It occurs in 1-2 children per 1,000 (Shriberg et al., 1997) and is found in only between 3-5% of children with speech disorders (Delaney & Kent, 2004).  That means that most SLPs won't see very many children with CAS across their entire careers so we can't expect all SLPs to have expertise in diagnosing a disorder they rarely come across.

So, is it really all that crucial to find an SLP with expertise in CAS to make sure you have an accurate diagnosis?  Yes! A particular diagnosis informs the type of therapy a child receives.  It is imperative that the speech therapy approach is matched to the nature of the child’s speech disorder and misdiagnosis can prevent children from receiving the help that they really need to progress.  

I often hear from parents living in countries outside the U.S. that MDs are the ones that provide the "official" diagnosis or that insurance companies require that the diagnosis come from an MD.  But, please remember if an MD gives your child a CAS diagnosis without the input of an SLP who has conducted a thorough motor speech assessment, you may not have an accurate diagnosis.  And a thorough motor speech assessment can only be conducted with children who are verbal.  So, although we can "suspect" that a non-verbal child may have CAS and treat accordingly, a definitive diagnosis should never be made in this instance.

So how do you know if your child has an accurate diagnosis?  Here are some questions to ask the professional who diagnosed your child....

1.  "What are some characteristics of CAS you see in my child?"  3 Key characteristics of CAS as defined by Apraxia Kids include:
   • Inconsistent errors with consonants and vowels on repeated productions. 
   • Difficulty moving from sound to sound or syllable to syllable, resulting in lengthened pauses between sounds and/or syllables.
   • Inappropriate stress on syllables or words
2. "How did you determine that my child has CAS and not another speech or language disorder/delay (like dysarthria, phonological disorder or language delay)?"  

These questions should help you determine if the professional that is diagnosing your child has the expertise required for an accurate diagnosis.

Lastly, here are 2 ways to make sure you're getting the best information and services for your child:

1. Find an SLP experienced with CAS. Visit the Apraxia Kids SLP Directory to find one near you.
2. Make sure you're accessing quality and up to date information from reputable online sources like the American Speech-Language-Hearing Association (ASHA) and Apraxia-Kids.  

​(For more information about CAS, click here.)

Now speaking to my SLP colleagues.... if you have a child with a lateral lisp I'm assuming you've done a thorough oral motor/mechanism exam to determine if the child has any structural or functional issues.  If not... do it! There are often myofunctional issues with these kids and those should be addressed (that's a post for another day).

​Let's talk about speech therapy for a lateral lisp....

The first thing we have to do is elicit the correct production of the target sound, whether /s/, /sh/, or /ch/ (I always start by targeting voiceless phonemes). Essentially, these kids have to learn to anchor the lateral borders of their tongue to the interior margins of their molars to prevent air from escaping laterally. There are so many wonderful techniques to cue correct tongue placement, such as the butterfly technique, using straws, and fantastic resources from Pam Marshalla. 

​For /s/, I probably don't do anything much different from the above techniques, but I call it the "long /t/ sound".  It looks like this...

1. Have the child produce quick-fire repetitions of the /t/ sound ("t-t-t-t-t-t-t-t-t-t-t-t"), which anchors those lateral borders of the tongue against their teeth.  
2. Once step 1 is consistent, I ask the child to simply "hold out" the /t/ sound which causes them to inadvertently produce the /s/ sound ("t-t-t-t-t-t-tsssss").
3. Then I go directly to words ending in /t/ and have them produce the "long /t/ sound" at the end of the word... so /cat/ becomes /cats/,  /bat/ becomes /bats/, and /hat/ becomes /hats/.... then we add /s/ to initial word position and go from there.

BUT THAT'S NOT THE SECRET!