ངག་སྐྱོན་དང་སྐད་ཡིག་འཁྲུག་སྐྱོན་གྱི་གོ་རྟོགས་ལག་དེབ། by Sherig Books

དགེ་རྒན་དང་ཕ་མ་ལ་དམིགས་པའི་སྟབས་བདེ་ལམ་སྟོན།

A Simple Guide for Parents and Teachers

ངག་སྐྱོན་དང་སྐད་ཡིག་འཁྲུག་སྐྱོན་གྱི་ ངག་ ངག་ ོན་དང་སྐད་ཡི ོན ་དང་སྐད་ཡིག ག་འཁྲུག་ ་འཁྲུག་ ོན ོན་་ ི་ི་ གོ་་ ོག གོ གོ་རྟོགས། ོགས། ས།

Understanding Speech and Language Disorders

ཤེས་རིག་ལས་ཁུངས་ནས་དཔར་འ ེམས་ཞུས།

UNDERSTANDING SPEECH AND LANGUAGE DISORDERS A HANDBOOK FOR PARENTS AND TEACHERS Written by: Ms. Tenzin Kalden Designed and Edited by: Ms. Tenzin Kalden Printed at: Sarah Printing and Publication 2026

Acknowledgement Financial support from Danish International Development Assistance (DANIDA)

Published by: Department of Education Central Tibetan Administration Dharamshala,Distt. Kangra Himachal Pradesh 176215 Email: education@tibet.net

Note to the Public This book aims to spread awareness to the general public on speech-language disorders Many medical terminologies have been simplified into everyday language for better understanding. This book should not be used as a diagnostic tool for children. If a Speech-Language delay or any other developmental disorder is suspected, kindly refer to a professional for support. Some of the techniques mentioned below may or may not work for every child. Relying on them 100% without seeking medical and paramedical support is not recommended.

About the Author Tenzin Kalden is a licensed Audiologist and Speech-Language Pathologist registered with the Rehabilitation Council of India (RCI). She holds a Bachelor of Audiology and Speech-Language Pathology (BASLP) degree from Bangalore University. She has worked as a Speech-Language Pathologist in clinical settings and has also contributed to educational and counselling services through volunteer work with the Department of Education, Central Tibetan Administration (CTA). Through her professional practice and community outreach, she is committed to promoting awareness of communication disorders and advocating for timely assessment and intervention.

Table of Contents S.no.

Content

Page number

01 Communication disorders: Language v/s Speech

02 Types of Language Disorders

10-19

03 Causes and Risk Factors of Child Language Disorders

20-21

04 Developmental milestones

22-28

05 Whom should I consult? A multi-disciplinary approach

29-30

06 When should I consult?

31-32

07 Management of Child Language Disorders

33-42

08 What is Augmentative and Alternative Communication (AAC)? 43-53 09 Understanding and Supporting Sensory Needs in Children

54-59

10 Speech Sound Disorders, their causes and management

60-68

69-72

Fluency Disorders, their causes and management

12 Voice Disorders, their causes and management

73-76

13 Myths v/s Facts

77-83

14 Unique Disability Identity card (UDID)/ Swavlamban Card

84-87

Communication Disorders Communication disorders generally fall into two main categories: Language Disorders

Language disorders cause persistent difficulties in understanding or using spoken, written, or sign language. It affects vocabulary, grammar, and sentence structure, causing communication skills to be significantly below age-level expectations. Language disorders may occur in conditions such as: Autism spectrum disorder Down syndrome ADHD Cerebral palsy Intellectural Disability Hearing loss Delayed Language Development or Specific Language Impairment Selective mutism Dementia Traumatic Brain Injury Stroke

Speech Disorders

Speech refers to how we produce sounds and words. People with speech disorders may have good language skills, meaning they have good vocabulary, grammar, and sentence structure, but their speech may be unclear, disrupted, or difficult to understand. Speech disorders include: Voice disorder Speech sound disorders (unclear speech) Fluency disorder: Stuttering

We will now discuss each of these in brief detail.

Autism Spectrum Disorder Autism Spectrum Disorder is a neurodevelopmental condition that affects a child’s social communication, interaction, and behaviour. It is called a spectrum because autism presents differently in every individual. Some autistic children may speak fluently, while others may be nonverbal. Each child has their own unique strengths and support needs. Common Signs and Symptoms: Communication Difficulties: Difficulty understanding or using spoken language. Difficulty understanding sarcasm, jokes, or figurative language. Difficulty starting conversations, asking questions, or taking turns in conversations. Pronoun reversal (e.g., saying “you want chocolate” instead of “I want chocolate”) Some children may learn to read at an early age (hyperlexia) Restricted and Repetitive Behaviours Repetitive movements such as hand flapping, rocking, or spinning. Vocal stimming: repeating the same sounds, words, phrases, or songs Visual stimming: unusual finger movements near the eyes or prolonged visual focus on moving objects (i.e., looking at spinning wheels)

Lining up toys or objects. Echolalia – repeating words/phrases/songs that were just heard or heard earlier (even days, weeks or months earlier). Wanting to watch or listen to the same part of a movie or song repeatedly Strong preference for fixed routines. Difficulty switching from one activity to another Self-injurious behaviours: head banging, pinching, etc Sensory differences Becoming upset by certain sounds, smells, lights, or textures. Strong preferences for specific foods Reduced sensitivity to pain (high pain threshold) Seeking deep pressure or proprioceptive input through activities such as jumping, running, tight squeezes, or trampoline play Mouthing objects (putting non-food items in the mouth) Social Interaction Difficulties Poor eye contact. Difficulty joining in play with others or sharing toys. Difficulty making friends. Difficulty understanding others’ emotions or social cues Difficulty engaging in imaginative or pretend play (though some autistic children may enjoy and excel at pretend play) Regression of previously acquired skills, for example, a child may say a few words, but then stop as they grow older. Note: An autistic child doesn't need to present all of these characteristics. Some children may show only a few of them.

Attention-Deficit /Hyperactivity Disorder (ADHD) A neurodevelopmental disorder characterised by persistent patterns of inattention, hyperactivity, and impulsivity that interfere with daily functioning, such as in school, work, or relationships. Common Signs and Symptoms: Inattention: has trouble concentrating or focusing on a task or lesson Gets easily distracted Has problems planning, organising, and finishing tasks on time Unable to sit still and is restless and fidgety May bounce from one activity to the next Often tries to do more than one thing at once Impulsivity: May act before thinking Has problems waiting their turn, such as when playing a game Important Note ADHD and ASD can sometimes occur together. Many children with Autism may also have ADHD.

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Down Syndrome Down syndrome is a genetic condition caused by an extra copy of chromosome 21 (Trisomy 21) Common Signs and Symptoms: Distinct facial features such as upward-slanting eyes and a flat facial profile Small head and short neck Protruding tongue (tongue thrust) Short stature (short height) Small hands, often with a single crease across the palm Low muscle tone Delays in motor milestones such as sitting, crawling, and walking Delays in speech and language development Unclear speech Weak oral muscles, which may affect feeding, chewing, and blowing, and can also lead to drooling Mild-to-moderate Intellectual Disability Associated Medical Conditions: - Hearing loss - Vision problems - Congenital heart defects Down syndrome can be detected through prenatal screening tests, such as ultrasound and blood tests.

Hearing Loss Hearing is essential for speech and language development. Children learn to talk by listening to the sounds and speech around them. If a child cannot hear clearly, speech and language development may be delayed. Hearing loss may be present at birth or develop later in childhood. Early hearing screening is therefore very important, as it helps identify hearing difficulties as early as possible and allows timely intervention. Many hospitals conduct newborn hearing screening shortly after birth. If your baby has not undergone a hearing screening, it is important to ask your healthcare provider about it. Signs of possible hearing difficulty in a child: Not responding to name Not startled by loud sounds Delayed language development Unclear speech Frequently asking “What?” or “Uh?” Difficulty following instructions Increasing the volume of the television or mobile devices excessively Treatment depends on the cause and severity of hearing loss and may include: Hearing aids Cochlear implants Medical or surgical treatment for medically treatable causes (e.g., eardrum perforation or middle ear infections, etc)

Hearing Aids Hearing aids are broadly categorized based on their style (how they are worn on or in the ear). Different styles are suitable for different types and degrees of hearing loss. An Audiologist will help determine the most appropriate hearing aid for your hearing needs, lifestyle, and preferences. Some commonly used hearing aid manufacturers include Widex, ReSound, Signia (formerly Siemens), Phonak, and others.

Once a hearing aid has been selected, the Audiologist will program it according to your hearing test results. During the fitting process, it is important to provide feedback regarding sound quality and comfort. Let your Audiologist know if sounds seem too loud, too soft, unnatural, echoey, or uncomfortable so that the settings can be adjusted accordingly. Consistent Hearing Aid Use: One of the most important factors in successful hearing aid use is wearing them consistently every day. Aim to gradually increase wear time until the hearing aids can be worn comfortably throughout most waking hours. When you first begin wearing hearing aids, many everyday sounds may seem unusually loud or distracting.

Sounds such as traffic, fans, footsteps, running water, or rustling paper may feel overwhelming at first. This is a normal part of the adjustment process. These sounds often seem louder because your brain may not have heard them clearly for a long time due to hearing loss. With regular hearing aid use, the brain gradually relearns how to process these sounds, and most people become more comfortable with them over time. Patience, consistent use, and regular follow-up appointments with your Audiologist are key to achieving the best benefit from your hearing aids. Communication Strategies for Family Members: Even with hearing aids, understanding speech can still be difficult in some situations. Therefore, family members can: Gain the person's attention before speaking. Face the person while talking. Speak clearly and at a natural pace. Reduce background noise when possible. Rephrase rather than simply repeat if a message is not understood. Ensure good lighting so facial expressions and lip movements can be seen. Hearing Aid Care and Maintenance: Keep hearing aids clean and dry. Clean earmolds and domes regularly Replace wax guards, domes, or tubing periodically when required. Remove them before bathing, swimming, or sleeping. Store them safely in their case when not in use. Consider using a hearing aid dehumidifier Change or recharge batteries regularly. Keep hearing aids away from excessive heat and moisture.

Intellectual Disability Intellectual Disability is a neurodevelopmental condition, characterised by significant limitations in intellectual functioning and adaptive behaviours—skills needed for daily life. It affects learning, communication, and self-care, varying from mild to profound. Symptoms & Identification: Delayed developmental milestones (late to talk, walk, or perform self-care). Difficulty with memory, problem-solving, and abstract thinking. Challenges in social interaction and understanding social rules. Significant, ongoing need for assistance with daily routines (adaptive functioning).

Specific Language Impairment Specific Language Impairment (SLI), often called Developmental Language Disorder (DLD), is a condition where children exhibit significant delays in speaking and understanding language despite having normal hearing, intelligence, and no obvious neurological or developmental disabilities.

Selective Mutism Selective Mutism is an anxiety disorder in which children, and sometimes adults, are unable to speak in specific social situations (such as at school) despite speaking comfortably in others (such as at home). The difficulty is not due to a lack of language ability, but rather intense anxiety that interferes with verbal communication in certain environments. It is important not to confuse Selective Mutism with simple shyness. While shy children may take time to warm up, individuals with Selective Mutism show a consistent inability to speak in particular settings, often accompanied by signs of anxiety such as avoiding eye contact, freezing, or appearing tense. A commonly cited fictional example is Raj Koothrappali from The Big Bang Theory, who initially struggles to speak to women due to anxiety, illustrating how the condition can be situation-specific.

Cerebral Palsy: Cerebral Palsy is a group of non-progressive neurological disorders that affect movement, muscle tone, posture, and coordination. Symptoms Spasticity (rigid/ stiff muscles) or flaccidity (soft/ floppy muscles) Weak muscles Involuntary movements (uncontrollable writhing or jerky movements of the hands, feet or face) Developmental delays Difficulty in speech (delayed language, and/or unclear speech) Feeding and oral-motor difficulties (e.g., chewing, biting, swallowing). Drooling Poor balance and coordination Symptoms vary greatly depending on the type of cerebral palsy (spastic, dyskinetic, ataxic, or mixed) and the brain region impacted. While not curable, therapies and treatments can significantly improve long-term functionality

Causes and risk factors of Child language disorders: Speech and language delays may result from a variety of factors. In many cases, there is no single cause, and delays may result from a combination of biological, medical, and environmental influences. Possible risk factors include: Genetics and family history of speech, language, or learning difficulties Consanguinity (marriage between close relatives) Exposure to alcohol, smoking, or drugs during pregnancy TORCH infections during pregnancy (Toxoplasmosis, Other infections, Rubella, Cytomegalovirus, Herpes) Poor maternal nutrition: Inadequate intake of essential nutrients such as folic acid, iron, and iodine may affect fetal brain development Advanced parental age: research has shown that parents older than 35 years are more at risk Maternal health conditions, such as diabetes, hypertension, and thyroid disorders during pregnancy, may increase developmental risks.

Premature birth and low birth weight: Babies born before 37 weeks Delayed cry after birth (suggestive of birth asphyxia or respiratory distress) Prolonged or difficult labour Cord prolapses: when the umbilical cord comes down before the baby during delivery, and the baby may press on it, which can reduce the oxygen supply to the baby. Meconium aspiration: When a baby inhales a mixture of their first stool (meconium) and amniotic fluid into their lungs before or during delivery causing respiratory distress. Seizures or epilepsy Head injury or trauma Excessive screen time Lack of language stimulation at home, reduced interaction with caregivers Associated neurological and developmental conditions, such as Autism or ADHD, etc Hearing loss, frequent ear infections, etc.

Developmental milestones Parents often wonder how to know whether their child’s development is progressing typically or if there may be signs of delay. One way to monitor development is by tracking developmental milestones — skills that most children achieve by certain ages. These milestones provide a general guide for a child’s motor, speech, and language development. Gross Motor Milestones Neck control: around 3 months Sitting with support: around 5–6 months Sitting without support: around 7–9 months Crawling: 7–10 months Walking independently: 12–18 months (with 12 months being the average) Walking up and down stairs with help: 18–24 months Running and jumping: 18–36 months Walking up and down stairs without support: 36–42 months Fine Motor Skills Birth–12 Months Reaches for and grasps objects. Transfers objects from one hand to the other. Bangs two objects together. Develops a pincer grasp (thumb and index finger).

1–2 Years Scribbles spontaneously. Stacks blocks. Uses a spoon independently. Turns pages in a book. 2–3 Years Copies simple lines. Strings large beads. Begins using scissors. Manipulates buttons and simple fasteners. 3–4 Years Copies a circle. Uses scissors with increasing control. Demonstrates improved pencil/crayon grasp. Draws simple figures. 4–5 Years Copies a square. Buttons and unbuttons clothing independently. Uses a mature tripod grasp. Write some letters and/or their own name. 5–6 Years Copies a triangle. Cuts out simple shapes accurately. Writes own name. Colours within boundaries.

Language Milestones Cooing (vowel sounds such as “ooh,” “aah,” “eee”): 2–3 months Babbling (repetitive sounds such as “ba-ba-ba” or “goo-goo”): 6–8 months First word: around 12 months By 2 years: Uses at least 50 words Begins combining two words (e.g., “Mommy go”) By 3 years: Combines 3 or more words into phrases (e.g., “I want milk”) Answers simple “who” and “where” questions By 4 years: Answers “why” questions Uses sentences averaging 4 or more words (e.g., “I want the blue car”)

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Important to Remember The timelines provided are approximate ranges, and not every child develops at the same pace. However, it is important to regularly monitor your child’s developmental progress and consult a paediatrician if you have concerns about delays.

Cognitive Skills: Birth to 12 Months: Recognises bottle or breast at feeding times Recognises mother Attends to and plays with a toy for short periods. Explores objects in many different ways (shaking, banging, throwing, dropping, finding functional side). Develops object permanence (realises objects exist even when out of sight) Ages 1 to 2: Recognises self in the mirror and in a photo Very curious about surrounding but has little understanding of common dangers. Points to objects or people in picture books and begins simple pretend play (like feeding a doll). Ages 2 to 3: Sustains attention on preferred activities for longer periods. Sorts objects by simple categories (e.g., colour, shape). Understands where familiar objects belong. Ages 3 to 4: Can recall a three-step direction, such as "Go find the ball and bring it to me" Tells which objects go together (e.g., spoon and bowl). Counts meaningfully to about 3- 5. Learns through observation and adult explanation.

Ages 4 to 5: Tells whether objects are heavier / lighter (lesser weight). Understands daily routines and sequences in the correct order. Recalls details from stories and pictures. Matches letters, numbers, and symbols. Tells what's missing when one object/picture is removed from a group of three. Ages 5 to 6: Arranges objects in the sequence of width and length. Recognises and reads some common sight words. Recites the alphabet in order. Writes or prints their first name. Counts at least 20 objects accurately. Shows increasing interest in the community and surrounding environment.

Social Skills: Birth to 12 Months: Forms strong attachments with caregivers. Responds to caregivers with smiles Shows a preference for mother and/or regular caregiver over all others Pulls at adult facial features (hair, nose, glasses), etc. Ages 1 to 3 (Toddlers): Transition into parallel play. They begin to show empathy, and test boundaries Says "please" and "thank you" when reminded. Wants to help and please, such as by helping to put things away Ages 3 to 5 (Preschoolers): Shift to cooperative play Establishes special friends, and learn to understand other people's thoughts and feelings. Likes group activities and time with friends. Shows more independence and wants to do things alone. Playing with other children is competitive. Plays with both boys and girls but prefers the same sex. Engages in socially acceptable behaviour in public. Ages 5-8: Friendships change rapidly and become heavily peer-based. Children begin making up their own games with rules and identifying more with peers of the same gender. Chooses their own friend. Knows about giving, receiving, sharing, and playing fairly.

Emotional Skills: Birth to 12 Months: Most content when near mother/caregiver or when held/cuddled Cries to show discomfort, and smiles to show joy 1 to 2 Years: Demands parents' attention. Curious about everything. Expresses appropriate emotions, such as anger, when the toy is taken away 2 to 3 Years: Just beginning a sense of personal identity and belongings (uses words like me and mine) Takes pride in achievements (e.g., I washed my hands by myself) Tests boundaries and says "no" to adult requests. Shows sympathy 3 to 4 Years: Can identify his/her own feelings Develops a sense of humour, can laugh at self and others when small accidents happen 4-6 Years: Learns to develop attitudes concerning right and wrong. Enjoys obedience and thrives on praise Demonstrates growing confidence in a range of abilities Begins to cope constructively with various emotional states: rejection, disappointment, failure, frustration, success, excitement.

Whom Should I Consult? If your child has speech-language delays or any speech-related difficulties, you should consult a Speech-Language Pathologist (SLP). Speech-language pathologists are licensed professionals who diagnose and treat communication and swallowing disorders in both children and adults.

A Multidisciplinary Approach: Children with communication delays often benefit from support from a team of professionals. A multidisciplinary approach ensures that all areas of the child’s development are addressed holistically. Paediatrician / Primary Physician: Often the first professional to identify developmental concerns. They guide families, monitor overall development, and refer children to appropriate medical and allied health professionals. Physiotherapist: Helps improve gross motor skills, posture, balance, and muscle strength, especially in children with conditions such as Cerebral Palsy (CP) and Down syndrome.

Occupational Therapist: Supports the development of fine motor skills, sensory processing, and daily living skills. Special Educator: Provides academic support and helps children with learning difficulties develop skills needed for school readiness and classroom success. Applied Behaviour Analysis (ABA) Therapist: Focuses on improving behaviour, attention, and emotional regulation, especially in children with developmental disorders. Pediatric Neurologist: Evaluates and manages neurological conditions such as seizures, developmental regression, muscle tone abnormalities, and other brain-related concerns. Clinical Psychologist: Conducts assessments to evaluate cognitive, behavioural, and developmental functioning and may diagnose conditions such as ADHD, Autism Spectrum Disorder (ASD), and Intellectual Disability (ID). Psychiatrist: Evaluates emotional and behavioural concerns and may prescribe medication when needed.

Why Teamwork Matters? Each professional addresses different aspects of a child’s development. When these professionals work together, children receive more comprehensive support, helping them reach their full potential.

When should I consult? Early Warning Signs of Speech and Language Delay: Does not respond consistently to their name. Limited eye contact or social interaction. Limited interest in communicating with others. Difficulty understanding simple instructions. Limited vocabulary for their age. Lack of babbling, pointing, waving, or other gestures in infancy. Speech is difficult for others to understand. Not combining words into simple phrases or sentences as expected for their age. Frequent speech disruptions (e.g., stuttering) that persist or cause concern. Delayed achievement of speech and language milestones.

If you suspect your child may have a speech-language delay or any speech-related difficulty, seek an evaluation as early as possible. Do not wait for your child to “grow out of it.”

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Why Early Speech Therapy Matters? The early years of life are a critical period for speech and language development because the brain is highly adaptable and responsive to learning during this time. Therefore, the earlier therapy begins, the better the chances of improvement. Early intervention helps: Improve communication skills Support social development Improve academic readiness Reduce frustration and behavioural difficulties In some cases, such as children with Down syndrome, where the condition can be diagnosed at birth, intervention can and should begin from infancy rather than waiting until the child is older.

Management of Child Language Disorders Now, what to do if my child is talking late? (or what can I do to facilitate my child’s speech?) First, look for the child’s prelinguistic skills (Prelinguistic skills are non-verbal communication behaviours that develop before speech). These skills form the foundation for language development. Important pre-linguistic skills include:

Attention/ joint attention:

Eye contact: Does your child

Sitting tolerance: Does your

Sharing attention between a

look you in the eye and

child sit for some time and

person and an object.

maintain eye contact?

attend to an activity or to what you are saying.

Imitation: Does your child

Response to name-calling

Pointing: Can your child

copy your actions or what

(does the child respond to

point to show you something

you say?

his/her name)

or ask for something?

Activities we can do at home to build prelinguistic skills: Sing lots of rhymes with actions and encourage the child to copy the same When introducing a toy, always hold it near your face to draw the child’s attention to your mouth movements. Simple games like Peek-a-boo, playing with bubbles, rattle toys (or any other noise maker toys) are all great ways to gain the child’s attention, build eye contact and sitting tolerance Whenever the child wants something, always encourage them to point to the object. Parents are the role models for the children. What they see, they do. If you want your child to point, you have to model pointing for the child. Other activities for pointing include: “poke-a-dot” books, poking play dough, popping fidgets, bubbles, etc. Ever wondered why, in kindergarten, children are taught to string beads on a thread? These activities are very helpful for developing eye-hand coordination and for developing sustained attention in a child. Other activities like stacking toys, and for slightly older children, puzzles, Simon Says, “butterfly, which colour do you want”, and colouring are all great ways to improve attention and concentration. For even older kids, finding the route to a house, spotting the differences between two similar images, find the word puzzle are some of the games you can try.

Teaching simple gestures like bye-bye, hi, or flying kiss. You might have noticed that lots of babies can wave their hands when asked to say “hi”, even before they learn to speak. That is a gesture learned from imitation. Imitation is a skill that is very important for a child’s language development. Once the child learns the concept of motor imitation, verbal imitation will follow later on. Imitate your baby’s sounds. Copy the sounds he or she makes, and wait for them to repeat the sound back to you. For a toddler who is yet to speak their first word or has limited words, use lots of sound effects. Non-speech sounds are easier for toddlers to imitate. E.g., “achoo”, “oh- oh” when things fall, or animal sounds like “baa” for sheep, etc. Use lots of verbal routines during playtime. Like “1-2-3, GO”, “1-2-3, JUMP”, “ready- set- GO”, etc., after some time, say 1-2-3 and then wait for the child to fill in the words, “go”.

Physical Play: "Aeroplane baby" or bouncing on knees, or tickling games are also great ways to play with a child to work on prelinguistic skills. Mirror play

Once your child begins to develop basic pre-linguistic skills, you can start using Speech and Language Stimulation Techniques during everyday activities and play. Below are some simple strategies that parents and caregivers can use at home to improve a child’s communication skills. Binary choices: Instead of asking the child questions like, “What do you want?”, offer the child two clear choices, such as, “Do you want an apple or a banana?” This makes it easier for them to respond and also to learn new vocabulary as well. Verbal imitation: Encourage the child to copy sounds, words, or short phrases. Parallel talk: describe what the child is doing. This helps the child hear language connected to their actions. for eg, “You are stacking the blocks.” “Wow, you made a tall tower!” “Oh no! The tower fell.” This technique exposes the child to new vocabulary and sentence structures in a natural way. Self-talk: Self-talk is when you describe what you yourself are doing. E.g. While preparing food: “I am cutting the apple”, “Now I am putting the apple in the bowl.” Recasting: Recasting means correcting the child’s sentence by repeating it in the correct form, without directly pointing out the mistake. For eg. Child: “He goed home.” Adult: “Yes, he went home.”

Expansion: Expand the child’s words or phrase into a longer sentence. E.g. Child: “Car.” Adult: “Yes, a red car.” Child: “Dog run.” Adult: “Yes, the dog is running.” Child: “More juice.” Adult: “You want more juice.” This way, the child learns how to join words and how to form sentences. Use lots of gestures while talking (Gestures are a great form of communication, esp for children who are learning to talk or who have a delay. These are easier to imitate than verbal speech and also reduce frustrations in a child by providing them a means to communicate. Use declarative language instead of asking too many questions: make comments about what is happening and give the answers yourself. For eg. Example: Instead of: “What is this?, What colour is it? What is the dog doing?”, which can create communication pressure on the child. Try: “Look! The dog is running”, “A red ball”

Wait time: After speaking, pause and give the child time to respond. Children need extra time to process language. For example: You say: “Do you want juice or milk?” or ask, “What is this?”, then wait quietly for at least 5-10 sec

Create communication opportunities. For eg. Place a toy slightly out of reach so the child needs to ask for help. Give one cookie at a time, so the child has to ask for more. Keep a toy in a container that the child cannot open easily. These small situations motivate the child to initiate communication. Incorporate lots of play: Children learn best through play, not just structured learning. Instead of only using flashcards, include different types of play such as pretend play (playing kitchen set) and sensory play (sand, water, play-dough) to teach new vocabulary and phrases. And use age-appropriate toys. Reading together: reading books regularly helps children develop vocabulary, grammar, listening skills, attention, and story understanding. Repetition: Children usually need to hear a “new word” dozens of times before they can understand and use it. While some toddlers can pick it up just after a few exposures, others may need 50 plus repetitions.

Simplify your language: Use short and simple sentences when speaking to young children. Instead of: “Can you please bring the red ball from the table?”, say: “Bring the ball.”

Being silly: Children enjoy playful and exaggerated reactions, which can capture their attention and encourage interaction. For eg, act surprised when you open something, make funny sounds such as blowing raspberries and pretend to slip and say “Oh no!”. Follow the child’s lead: Pay attention to what the child is interested in, and talk about that or play with that toy. If the child is interested in animals, talk about animals, imitate animal sounds, or play with animal toys. This keeps them engaged and motivated to communicate. Keep your agenda flexible: Be willing to adapt your plans based on the child’s interests. For example, if your goal is to teach fruits but the child wants to play with colors, join the coloring activity and incorporate fruit vocabulary by coloring pictures of fruits. This helps maintain engagement while still targeting therapy goals. For older children, encourage them to narrate their day. This helps develop storytelling and conversational skills. Reduce screen time: Children below 2 years of age should not be exposed to screens, while children aged 2–5 years should have no more than 1 hour of screen time per day. The fast-paced, bright, and loud content can overstimulate a young child's brain, making it harder for them to focus on slower, real-world communication. Excessive screen time reduces opportunities for human interaction, making it harder to develop language and social skills. It may also contribute to difficulties with attention, behaviour regulation, and social engagement.

Introduce non-stimulating shows: If children do watch television, choose slow-paced, educational programs. To list a few, Trash Truck, Puffin Rock, Bluey, Daniel Tiger’s Neighbourhood, and Sarah & Duck, etc are some of the popular non-stimulating shows that are calm, have gentle narratives, muted colors and rich language.

Co-View with Your Child: Whenever possible, watch the show with your child and comment on what is happening. For example, “Look, the girl is riding a bike” to make it more interactive, instead of silently watching the show and also to monitor the type of media the child is consuming.

Choosing the Right Toys Matters: The type of toys a child plays with can influence their learning, creativity, attention, and communication development. Electronic toys that light up, make sounds, or play music can capture a child’s attention, but research suggests they may provide fewer opportunities for active engagement and interaction, as the toy often directs the play. In contrast, open-ended toys such as magnetic tiles, building blocks, LEGO, and play dough encourage imagination, problem-solving, and language development. Even simple toys like stacking rings, books, toy cars, and puzzles can be highly beneficial because they actively involve the child in learning and exploration. Most importantly, meaningful interaction with a caregiver during play is far more valuable for a child’s development than passive play with electronic toys alone.

Use a Multi-Sensory Approach: Incorporate sensory experiences that are motivating and meaningful for the child. Children often learn language more effectively when information is presented through multiple sensory channels rather than through listening alone. For example, if your goal is to teach the name of an animal: Simply showing a flashcard of a dog and saying "dog" primarily engages the visual and auditory systems. If the child washes toy animal figures in water while you label them, the activity engages the visual, auditory, and tactile systems. If the child enjoys movement, you could wear an animal mask (use a puppet) and pretend to chase the child. This incorporates visual, auditory, tactile, and vestibular/proprioceptive input. Focus on the Child's Strengths: For example, if a child is hyperlexic and has a strong interest in letters and numbers, incorporate these interests into language-learning activities. You could use magnetic alphabets to teach vocabulary, spell simple words, match letters to pictures, or build words such as: D–O–G Dog

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Always Assume Competence: Assume that the child is capable of learning, understanding, and communicating, even if they are not yet able to demonstrate these skills consistently. Avoid limiting language exposure based on what you think the child understands. Instead, provide rich language models, opportunities for participation, and age-respectful interactions. Children often understand more than they can express.

What If My Child Has Difficulty Using Spoken Language? Or what if they are minimally speaking and can only use single words occasionally with support? It is important to understand that communication means conveying and receiving information between two people, and this can happen in many different ways. Communication is not limited to spoken speech; it can occur through gestures, sign language, facial expressions, body language, writing, texting, and tab communication systems. Spoken language is only one form of communication. For some children, other methods may be easier, more effective, and better suited to their individual strengths and needs. Every child deserves the opportunity to express their wants, needs, thoughts, and feelings. By providing access to different communication options, we allow children to discover the method that works best for them and support their ability to connect meaningfully with the world around them.

What is Augmentative and Alternative Communication (AAC)? Augmentative and Alternative Communication (AAC) refers to tools and strategies used to support or replace spoken speech for individuals with limited verbal communication skills. There are many different types of AAC: No-tech and low-tech options include things like Gestures and facial expressions, Sign language, Writing, Drawing, Spelling words by pointing to letters (Spelling to Communicate, S2C), and Pointing to pictures such as PECS (Picture Exchange Communication System), communication ring, picture boards

High-tech AAC includes Speech-generating devices and communication apps used on tablets or other electronic devices. Popular AAC apps include Avaz, Proloquo2Go, TouchChat, TD Snap, and LAMP, etc.

AAC can be highly effective because many children benefit from visual supports, often finding pictures and symbols easier to process and understand than spoken language alone. For individuals who have motor difficulties in addition to communication challenges, specialised AAC systems such as eyetracking devices can allow communication through eye movements.

A common misconception is that using AAC will hinder speech development or cause a child to rely on it instead of learning to talk. This is not true. Research shows that AAC does not prevent speech development; in fact, it often supports and encourages overall communication and language development.

We must understand that it is human nature to choose the easiest and most efficient way to do things. For example, if there are two routes to a destination—one longer and more difficult, and the other shorter and faster—most people would choose the easier route. Similarly, if a child consistently chooses to communicate using an AAC app, even though it often takes more time and effort than speaking, it suggests that verbal communication may be significantly more difficult for them.

Rather than viewing AAC as a barrier to speech, it should be seen as a tool that enables successful communication while supporting the development of the child's overall language and communication skills.

Helpful Tip for Families AAC apps and devices often go on sale during April (Autism Acceptance Month) and October (AAC Awareness Month). These can be good times to explore more affordable AAC options.

Let’s dive deeper into AAC PECS (Picture Exchange Communication System): In PECS, the individual learns to approach a communication partner and exchange a picture, symbol, or photograph of a desired item to obtain it. The system is taught through six progressive phases, beginning with exchanging single pictures and gradually advancing to constructing simple sentences using sentence strips (e.g., "I want + apple") and commenting on the environment. How to create a PECS book: Take a folder similar to the one shown in the picture. Attach Velcro strips inside the folder. Print, laminate, and cut pictures or symbols into individual cards. Place Velcro on the back of each card so that they can be attached to and removed from the folder. Organise the cards into categories such as food, toys, people, actions, and places (for example, one page in the folder contains food items, and another page contains the toys, etc.) Include a sentence strip to help the individual combine symbols into simple messages. Teach the child to select and exchange pictures to communicate their wants and needs. As the child's skills develop, encourage them to combine pictures to form simple sentences (e.g., "I want + juice"). Tip: Start with highly motivating items (favorite foods, toys, or activities) to encourage the child to use the PECS book frequently.

Communication Ring: A communication ring is a portable AAC tool that allows a child to communicate basic wants, needs, and feelings while on the go. How to create a communication ring: Select 10–15 core vocabulary words (or more, depending on the child's needs), such as yes, no, food, water, toilet, mom, hurt, go, etc. Pair each word with a clear symbol, picture, or photograph. Print, laminate, and cut the symbols into small individual cards. Punch a hole in each card and secure them together using a key ring. The child can wear the communication ring like an ID card, attach it to a bag, or clip it to their clothing for easy access. Communication rings are lightweight, portable, and particularly useful when travelling or participating in community activities.

Communication Boards: Communication boards provide a visual way for individuals to express their needs, wants, thoughts, and choices by pointing to symbols, pictures, or words. Activity- or Theme-Based Communication Boards: These boards are designed for specific settings or activities, such as mealtimes, playgrounds, medical appointments, or play areas. For example, a kitchen communication board may include vocabulary such as: give spoon water ice cream momo rice biscuit cup plate cook open fridge close Using vocabulary that is relevant to a particular environment can make communication more efficient and meaningful. Unlike a PECS book, communication boards can be permanently displayed in the environment where they are most relevant (e.g., kitchen, bedroom, bathroom, or classroom). This eliminates the need to carry them around and ensures that communication supports are readily available whenever needed.

AAC Apps: Getting Started: Select the AAC app that best suits your child's needs. Choose an appropriate grid size based on your child's visual, cognitive, and motor abilities. If your child appears overwhelmed by too many symbols, temporarily hide some symbols and gradually introduce them later. Select the preferred language (e.g., English, Hindi, etc.). Personalise the AAC system with words, people, places, and activities that are important to your child. For example, you can add foods that your child eats regularly (local dishes such as momo, thukpa, etc), upload photographs of family members, or record familiar voices for important vocabulary items. Avoid making changes to the core vocabulary or main system boards unless guided by an AAC professional. Consistent symbol placement helps children develop motor memory and learn where words are located. Think about a QWERTY keyboard—if the letters changed places every day, typing would become difficult and slow. Similarly, frequently moving AAC symbols can make it harder for a child to find and learn words efficiently. How to Teach AAC 1. Start with Highly Motivating Activities Begin with something your child really enjoys, such as a favourite snack, toy, or activity.

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Example 1: Oreo Biscuit If your child loves Oreo biscuits, press the "Oreo" symbol on the AAC device and immediately give them a piece of Oreo. Repeat this many times whenever your child reaches for the biscuit. Over time, your child will learn that pressing the symbol results in getting the Oreo. Eventually, they may begin to imitate this action and press the symbol independently. If your child has difficulty pointing to the symbol, provide gentle physical assistance to help them select the button.

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Example 2: Balloon Play If your child enjoys balloons: Press the "balloon" symbol and show the balloon. Press the action word "blow" and immediately blow up the balloon. Let the balloon fly or engage in a fun balloon activity. When your child returns wanting more, model the word "blow" again before blowing up the balloon. After repeated modelling, pause and give your child an opportunity to use their AAC device to request the action. 2.Model AAC Throughout the Day Think about how children learn spoken language. We do not teach only a few words and expect them to learn to talk. They hear language all day long. Similarly, AAC users need to see AAC being used frequently. Model words and phrases during everyday activities such as eating, playing, bathing, reading, and going outdoors.

3.Give Your Child Access to AAC at All Times Your child's AAC device should be available throughout the day, not just during therapy sessions or practice time. Communication opportunities occur everywhere, and your child should be able to express themselves whenever they want.

4.Be Patient and Wait After modelling a word or asking a question, give your child enough time to respond using their AAC device. Many AAC users need additional processing time to understand, locate symbols, and formulate their message.

5.Do Not Test the Child Many parents unintentionally turn AAC into a quiz. Avoid: "Where is 'eat'?" "Show me 'balloon'." "Press 'more'." Instead, model the words yourself during natural interactions. Remember: Children learn AAC by seeing it used, just as they learn spoken language by hearing others speak. 6.Start Small When modelling, you do not need to use full sentences. Instead of: "I want to play with the balloon." Model: Balloon, Blow or More Using 1–2 words is often enough when introducing AAC. 7.Do Not Take Away the AAC Device The AAC device is the child's voice. Avoid: Removing it as punishment. Taking it away when the child is upset. Restricting access because the child is repeatedly pressing buttons. Children learn through exploration. 8.A child Does Not Need to Master One Word Before Learning Another Children who learn spoken language hear thousands of words before saying their first words. Similarly, AAC users can be exposed to many words and concepts from the beginning. There is no need to wait for mastery of one word before introducing new vocabulary.

Understanding and Supporting Sensory Needs in Children Sensory processing refers to the ability to take in information through our senses (touch, movement, smell, taste, vision, and hearing), organise and interpret this information, and respond to it appropriately. Sensory Processing Disorder (SPD) occurs when the brain has difficulty processing and responding to sensory information effectively. As a result, an individual may react differently to sensory experiences in their environment. Although there are several types of SPD, this section focuses on Sensory Modulation Disorder (SMD).

Sensory Modulation Disorder

OverResponsiveness

UnderResponsiveness

Over-Responsiveness (Hypersensitivity): In over-responsiveness, the individual perceives sensory input as more intense or unpleasant than it actually is. As a result, they may become distressed, avoid certain sensory experiences, or react in a way that appears disproportionate to the sensory input. Under-Responsiveness (Hyposensitivity): In under-responsiveness, the individual does not register sensory information efficiently and may require stronger or more frequent sensory input before responding. Consequently, they often seek additional sensory experiences from their environment.

SENSORY SYSTEM

COMMON SIGNS OF OVERRESPONSIVENESS

COMMON SIGNS OF UNDERRESPONSIVENESS

Olfactory (Smell)

Avoids specific smells, is bothered by environmental odours, and notices smells others do not

Frequently smells objects, seeks strong odours

Prefers bland foods, limited food variety, and avoids certain textures

Prefers spicy or highly flavoured foods Chewing on clothes, pencils, toys, or other objects Seeking crunchy, chewy, or textured foods

Distressed by everyday sounds (e.g., vacuum cleaner, toilet flush, doorbell), covers ears

Makes frequent noises, prefers loud sounds, may not respond when called

Visual

Sensitive to bright lights, covers/rubs eyes, difficulty adjusting to changes in lighting, prefers predictable visual environments

Watches spinning objects, enjoys moving visual stimuli, brings objects close to eyes

Tactile (Touch)

Avoids messy play, dislikes certain clothing fabrics, distressed by physical contact, dislikes grooming activities (haircuts, brushing teeth)

Frequently touches people or objects, enjoys messy play, reduced awareness of pain or clothing discomfort

Proprioceptive (Body Awareness)

Appears clumsy, avoids physically demanding activities, dislikes hugs

Crashes into objects, seeks rough play, chews on objects, enjoys tight hugs

Vestibular (Movement/ Balance)

Avoids movement activities, hesitant on stairs/slopes, poor balance, motion sickness

Constantly moving, spins frequently, seeks movement to stay focused

Gustatory (Taste) and Oral Sensory System

Auditory (Hearing)

A Sensory Diet A sensory diet is a personalised, daily schedule of physical activities and environmental modifications designed to meet an individual's specific sensory processing needs. It provides the "just right" amount of sensory input to help someone stay calm, focused, and regulated throughout the day. Sensory diets are highly effective for individuals who struggle to process and respond to sensory information—often seen in children and adults with Autism, ADHD, or Sensory Processing Disorder (SPD).

Sensory System Propioceptive activities

Under-responsive Firm hugs Wrap and roll in a blanket Rolling a therapy ball over the body Sandwiching between pillows/cushions Deep-pressure activities Heavy work activities (carrying, pushing, pulling) Jumping on a trampoline Animal walks (bear, crab, frog, kangaroo) Wall push-ups Wheelbarrow walk Climbing stairs or monkey bars Army crawling Play-dough, therapy putty, slime

Over-responsive Introduce activities gradually and at the child's comfort level. Monitor the child's response and adjust the intensity as needed.

Sensory System

Under-responsive

Over-responsive

Vestibular

Jumping, running, hopping Rocking, rocking on a therapy ball Scooter board activities Slides, merry-go-rounds, seesaws Hammock, swing Dancing Somersault Crossing ridges Walking on balance beams Climbing stairs Spinning

Gentle rocking Slow swinging Activities with gradual movement exposure

Tactile

Barefoot walking in sand, grass, puddles, pebbles, etc Using textured mats Playdough, slime, kinetic sand Finger painting, messy play with sand, water, and shaving foam Textured boards Deep pressure massage Finding objects inside the grains Spiky balls and textured toys

Deep-pressure activities Gradual exposure to different textures through play Tactile play progressing from preferred to nonpreferred textures

Visual input

Flashlight games (darken the room and flash the light to different pictures) Sensory bottles Brightly coloured visual activities "I Spy" games Visual scanning tasks Dots to dots, mazes, word searches

Reduce visual clutter Use softer lighting Organise materials in a predictable manner Limit exposure to bright or flashing lights

Sensory System Olfactory, Gustatory Sensation, Oral Sensory System

Auditory System

Under-responsive

Over-responsive

Explore a variety of scents (spices, scented markers, perfumes) Taste foods with different flavours (sweet, sour, spicy, tangy) Eat crunchy, chewy, or textured foods Chew sugar-free gum (if ageappropriate) Use chewy tubes or other oral sensory tools as recommended by an Occupational Therapist Drink thick liquids through a straw Blow bubbles, whistles, or pinwheels

Keep rooms well ventilated Avoid strong perfumes and air fresheners Involve the child in cooking and food preparation Present preferred and non-preferred foods together Encourage food exploration in the following order: look smell touch lips lick bite Maintain relaxed mealtimes and avoid force-feeding

Music and rhythm activities Singing songs and nursery rhymes Sound-identification games (e.g., identify animal, vehicle, or household sounds) Listening games with varying volumes Musical instruments (drums, tambourines, bells, xylophones)

Reduce background noise Use noise-reducing headphones when needed Gradually expose the child to everyday sounds Teach coping strategies for noisy environments Provide a quiet corner or calm space Prepare the child before loud noises (e.g., vacuum cleaner, blender, school bell)

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Important Note: Every child is unique and may respond differently to sensory input. Activities that are helpful for one child may not be appropriate for another. Therefore, it is recommended to consult an Occupational Therapist (OT) for a comprehensive sensory evaluation and individualised recommendations. The activities listed above are provided for educational and reference purposes only. They should not be considered a diagnostic or therapeutic program and are not intended to replace professional assessment and intervention.

Speech Disorders: Speech Sound Disorder

Fleuncy Disorder

Voice Disorder

Speech Sound Disorders (SSD): Speech Sound Disorders occur when a child has difficulty producing speech sounds correctly, making their speech difficult for others to understand. In simple terms, the child’s speech may sound unclear for their age. Children with SSD may make the following types of errors: Substitution: Replacing one sound with another (e.g., "thun" for "sun") Omission: Leaving out sounds (e.g., "at" for "cat"). Addition: Inserting extra sounds into words, e.g., “filam” for “film” Distortion: Producing a sound incorrectly or unclearly. Example: A slushy /s/ sound or lisp. What Are Phonological Processes? Many young children naturally simplify words as they are learning to speak. These patterns are called phonological processes and are considered a normal part of speech development. However, if these patterns continue beyond the expected age, speech therapy may be required.

Some common phonological processes that children use are: Fronting: Occurs when back sounds (sounds produced at the back of the mouth) such as /k/, /kh/, /g/, and /ng/ are replaced with front sounds such as /t/, /th/, /d/, and /n/ (sounds produced at the front of the mouth). ཀ ཏ (e.g., དཀར་པོ། ཏར་པོ།) ཁ ཐ (e.g., ཁང་པ། ཐང་པ།) ག ད སྒ རྡ (The examples demonstrate changes in speech sounds; the spelling differences are not the focus.) ང ན Typically resolves by around 3.5 years of age.

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Stopping: Stopping occurs when continuous sounds such as /s/, /z/, /sh/, /ch/, Tibetan “ཟ་ཞ་ཙ་ཚ” are replaced with stop sounds (abrupt sounds) like /t/ or /d/. Example: “tips” instead of chips, “doo” instead of zoo Typically resolves between 3–5 years Gliding: when /l/ and /r/ is replaced with “y” or /w/ sound, for eg, a child may say “wabbit” instead of rabbit, or “yip” instead of “lip”, etc. Typically resolves by around 6 years Final consonant deletion: dropping the last sound in a word (e.g."boo" for "book"). Typically resolves by around 3 years Cluster reduction: When a consonant cluster is simplified to one sound. Example: “poon” instead of spoon, “cap” instead of clap Typically resolves between 4–5 years

Speech Sound Development Chart

The chart above shows the typical age ranges at which most children develop different speech sounds. These age ranges are based on developmental averages, meaning children may develop certain sounds slightly earlier or later than shown in the chart. However, if a child continues to have difficulty producing certain sounds significantly beyond the expected age range, it is recommended to consult an SLP for an evaluation.

Possible Causes / Contributing Factors of Speech Sound Disorders: Hearing loss Cleft lip & palate Tongue tie (in some cases) Dental problems such as missing teeth, overbite, underbite, crossbite, etc. Oral-motor weakness or poor coordination Jaw-related difficulties such as prognathism or restricted jaw movement (trismus). History of delayed language development Difficulty learning speech sound patterns and rules Neurological/ motor disorders such as Cerebral palsy, Parkinsons’s, and stroke, etc Genetic or developmental conditions such as Down syndrome

Management of Speech Sound Disorders: Although treatment depends on the underlying cause, some common approaches include: Speech therapy Oro-motor exercises Surgical intervention for issues such as tongue-tie or cleft lip and palate Hearing aids or cochlear implants in cases of hearing loss Medication when speech difficulties are related to neurological conditions such as Parkinson’s, etc

Oro-motor exercises: Oro-motor exercises involve activities that strengthen and improve coordination of the lips, tongue, velum and jaw. Examples include: Blowing bubbles, candles, or whistles: encourage the child to round their lips while blowing. If the child is unable to round their lips independently, gently support the lips into a rounded position or begin with party blowers, which naturally promote lip rounding. Straw drinking: Encourage drinking through a straw using the lips rather than biting or holding the straw with the teeth. Thicker liquids may provide additional resistance. Tongue movements (up, down, side to side): Use the child's favourite sticky foods (e.g., yogurt, peanut butter, jam) placed at different locations around the lips to encourage tongue movements. If tongue movement is very limited, gentle tactile cues may be provided as guided by a therapist. Lip puckering Puffing cheeks: Have the child puff their cheeks with air and hold the air while gentle resistance is applied. Button pulls: Place a button attached to a string between the child's lips and gently pull while the child keeps the lips closed around the button.

Holding an ice cream stick horizontally between closed lips for 25 seconds and gradually increasing the difficulty by attaching coins to both sides of the stick (The stick should be held by the lips alone, without support from the teeth.) Oral massage Use of specialised tools such as chewy tubes or Z-Vibe for oral stimulation It is important to understand that oro-motor exercises are not appropriate for everyone and may not be beneficial for all speech difficulties. These activities should only be used when specifically recommended by a qualified Speech-Language Pathologist after proper assessment. Please do not use tools such as chewy tubes or Z-Vibe independently without professional guidance.

Speech Therapy Here are a few simple speech therapy techniques to help produce speech sounds correctly. A general sequence followed in therapy is: Sound Syllables Words Sentences

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Eliciting /k/, /g/, and /ng/: One technique is to gently hold the tongue tip down with an ice-cream stick or spoon and ask the child to say /k/.Once the sound is produced correctly, practice continues with syllables: ka, ki, ko, ke, ku, then words: cat, cup, car. Then move on to phrases and sentences.

For targeting Dentalisation, a pencil can be placed horizontally between the teeth to prevent the tongue from touching them. The child is then asked to say /t/ or /d/ so that the tongue touches the alveolar ridge instead. This helps correct tongue placement.

Targeting gliding: To teach /l/: Ask the child to lift their tongue to the roof of the mouth and say /l/. A mirror can be helpful for visual feedback, allowing the child to check whether the tongue is lifted correctly.

To teach /r/: Instruct the child to lift the tip of their tongue and curl it slightly backwards. Use a mirror to give visual feedback. Without it, a child will often believe they are producing an /r/ when they are actually rounding their lips to make a /w/. A mirror helps them see that their lips should remain still while only the tongue moves. One helpful strategy is to first practice a “lion sound” like: “arrrrr”. Then blend it with vowels: arrr + ah “rah” arrr + ee “ree” Words that end with /r/ (such as car) are often easier to get it right at first than words that begin with /r/, i.e rabbit.

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Strategies for Final Consonant Deletion: Use the backward chaining technique to highlight missing sounds. Example: If a child says “ba” instead of “bus”. Start with the final sound, “us”, Then add the beginning: “b-us”. Gradually blend them into the full word: “bus”

OVERARTICULATION: Some children may have unclear speech not because of a specific sound error, but because they use limited mouth movement. In such cases, overarticulation (exaggerating mouth movements while speaking) can help improve speech clarity. For example, encouraging the child to open their mouth wider and produce each sound more clearly can make their speech easier to understand.

Important Note: Speech therapy techniques should always be individualised. A strategy that works for one person may not work for another, depending on the underlying cause of the speech difficulty. Although a few techniques are mentioned here as examples, speech therapy should always be guided by a qualified Speech-Language Pathologist.

Fluency Disorders Stuttering is characterised by involuntary disruptions in the flow of speech. People who stutter may experience: sound repetitions — "I w-w-w-want a drink." syllable repetitions — "Go-go-go away." stretch a sound out for a long time— "Ssssssssam is nice." get stuck before starting a word— "I want a (stuck) cookie.

Typical Disfluencies Many people occasionally show normal disfluencies, such as: Using filler words: “um”, “like” Repeating whole words — "Cookies cookies and milk." Repeating phrases — "He is–he is 4 years old." Revising sentences — "I had–I lost my tooth." These are not considered stuttering.

Secondary Behaviours Some individuals who stutter may also show behaviours such as: Eye blinking Head nodding Foot tapping Jaw jerking They may also avoid certain words or situations where they expect to stutter. These behaviours often develop as attempts to escape or avoid moments of stuttering.

Variability in Developmental Stuttering: Stuttering often varies from day to day and even from moment to moment. At times, a person may speak quite fluently, while at other times, stuttering may be more noticeable. A person may stutter more during certain situations, such as when they are: Excited Nervous Frustrated Feeling rushed Speaking in front of a group Talking to authority figures or unfamiliar people Some individuals may stutter more on specific sounds or words

Interestingly, many people who stutter experience greater fluency during activities such as singing, chanting, or speaking in rhythm.

The Choral Effect: This refers to the immediate and often dramatic improvement in fluency that occurs when a person who stutters speaks or reads in unison with another person. The Adaptation Effect: This refers to the tendency for stuttering frequency to decrease when the same passage is read aloud repeatedly over several trials. Adopting a Persona: Some individuals may stutter less when acting, speaking with an accent, using a theatrical voice, or pretending to be another character.

Causes or risk factors: Stuttering usually begins between 2 and 6 years of age. Many children go through temporary periods of disfluency lasting less than 6 months. There is no single cause of stuttering, but possible risk factors include: Family history Brain differences: small differences in the way their brains work during speech Gender — Boys are more likely to continue stuttering than girls. Age when stuttering began — Children who start stuttering at age 3½ years or later are more likely to continue stuttering When to Seek Help Consult a Speech-Language Pathologist if: Stuttering lasts longer than 6–12 months It begins after 3½ years The stuttering increases over time The child shows visible tension or struggle while speaking The child avoids talking or expresses frustration about speaking There is a family history of stuttering

Management of Stuttering For young children (2-3 yrs): Reduce environmental stress Family should speak in a slow and relaxed manner. Reduce frequent questioning Allow the child enough time to respond Avoid repeatedly correcting the child’s speech. Create calm, unhurried conversation opportunities

For School-Age Children: Pacing techniques to help the child control their speaking rate, such as finger-tapping for each word, hand-tapping, or using a metronome so that the child produces one word for each tap/beat. Example: tap – I tap – want tap – juice

Encourage the child to speak more slowly than usual Prolonging (stretching) the first sound of a word, for eg, mmmmy name is Tenzin. Taking a slow, deep breath before speaking can help the child relax and reduce physical tension Avoid teasing, mocking, or negative reactions. Listen patiently and give the child enough time to finish speaking. Avoid interrupting the child or completing sentences for them. Maintain eye contact and show interest in what the child is saying Avoid rushing the child to answer questions or speak quickly. Encourage the child to participate in conversations and praise their efforts to communicate.

Important Note The goal is not simply to “stop stuttering,” but to help the person communicate confidently and comfortably. Therapy approaches should always be individualised and guided by a qualified Speech-Language Pathologist.

Voice Disorder A voice disorder occurs when the quality, pitch, loudness, or resonance of the voice is inappropriate for a person’s age and sex, or when it interferes with effective communication. Signs and Symptoms A person with a voice disorder may present with: Rough, hoarse, strained, or breathy voice Abnormally high or low pitch Voice that is too loud or too soft Hypernasal or hyponasal resonance Loss of voice Voice breaks while speaking Shaky voice Vocal fatigue with prolonged speaking Throat discomfort while speaking Possible Causes: Vocal fold paralysis Vocal nodules, cysts, or polyps Laryngitis (inflammation or infection of the larynx) GERD (Gastroesophageal Reflux Disease) Age-related vocal fold changes Laryngeal cancer Parkinson’s Disease Stroke Voice overuse Voice misuse (yelling, screaming, excessive throat clearing/coughing, speaking at an unnatural pitch) Stress and anxiety Smoking Frequent alcohol consumption, etc.

Who is at Higher Risk? People who use their voice extensively are at greater risk of developing voice disorders, especially if they frequently speak loudly or for long periods without adequate rest. This includes: Teachers Singers Public speakers Call-centre workers Sales professionals Coaches and fitness instructors Religious leaders/monks/prayer leaders Vendors or others who frequently raise their voice

Teachers

Singers

Public speakers

Call-centre workers

Sales professionals

Coaches & fitness instructors

Religious leaders

Vendors

Management of Voice Disorder Treatment depends on the underlying cause of the voice disorder and may include: Voice therapy provided by a Speech-Language Pathologist (SLP) Medical or surgical management when required Voice rest (when recommended by a healthcare professional) to allow the vocal folds to recover Improving vocal hygiene, such as avoiding shouting, screaming, frequent throat clearing, and prolonged speaking without rest Adequate hydration to keep the vocal folds well lubricated Managing acid reflux triggers, particularly for individuals with reflux-related voice difficulties Avoiding smoking, excessive caffeine, and alcohol, as these may irritate or dry the vocal folds Taking regular voice breaks, especially for people who use their voice extensively, such as teachers, singers, and public speakers In some cases, a person may undergo a laryngectomy, a surgical procedure in which the larynx (voice box) is removed, often due to cancer. Although natural voice is lost, individuals can learn alternative methods of communication. 1. Electrolarynx An electrolarynx is a handheld device that produces vibrations when placed against the neck or cheek. These vibrations act as a sound source, which the individual shapes into speech using their lips, tongue, and jaw.

2. Tracheoesophageal (TE) Speech Here, the air from the lungs is redirected through a small passage between the windpipe and food pipe, causing tissues in the throat to vibrate and produce sound, which is then shaped into speech. SOVT (Semi-Occluded Vocal Tract) exercises: These exercises help improve vocal fold vibration, reduce strain, and promote healthier voice production. Straw phonation (phonating through a straw) Lip trills (blowing air through relaxed lips to create vibration) Tongue trills (rolling the tongue while producing voice) Humming

Yawn-Sigh Technique: The yawn-sigh approach helps reduce excessive muscle tension in the throat and promotes a relaxed, easy voice. Individuals are encouraged to simulate a yawn and then gently exhale with voice, producing a relaxed vocal quality. Why Vocal Hygiene Matters? Healthy voice habits can prevent strain and reduce the risk of longterm vocal problems. Early treatment often leads to better outcomes and helps protect the voice from further damage.

Myths v/s facts When it comes to speech and language development, there is no shortage of advice and information. Unfortunately, not all of it is accurate. Misconceptions about communication disorders and speechlanguage therapy can lead to unnecessary worry and confusion. Let’s take a closer look at some common myths and uncover the facts behind them. Myth 1: "Learning two languages causes a speechlanguage delay." The Fact: Bilingualism or multilingualism does not cause language delays. A child's brain is highly capable of acquiring multiple languages simultaneously. If a bilingual child has a true language delay, it will be present in both their native language and their second language. If they are only struggling with the second language, it is a language difference (part of the normal learning process), not a disorder. Myth 2: "Tongue-ties are the main reason for speech delays." The Fact: Ankyloglossia (tongue-tie) can sometimes impact feeding or the production of specific sounds requiring tongue elevation (like /t/, /d/, /l/, /n/, and /r/). However, it is rarely the sole cause of a comprehensive speech or language delay. Many children with tongue-ties develop perfectly typical speech.

Myth 3: "Boys just talk later than girls, so there's no need to worry." The Fact: While it is statistically true that boys tend to develop early expressive language skills slightly later than girls (often by a month or two), they are still expected to meet the same standard developmental milestones within the typical age window. For example, both boys and girls should be saying their first words around 12 months and combining two words by 24 months. Dismissing a genuine language delay simply because "he's a boy" is dangerous. It often leads to the "wait and see" approach, meaning families miss out on the critical window for early intervention when neuroplasticity is at its peak. Myth 4: "Therapy only happens in the session." The Fact: Therapy begins in the clinic or classroom, but a 30-to-60minute weekly appointment is rarely enough to build lasting neural pathways on its own. Real progress relies heavily on "carryover"—the active practice of new speech and language skills during everyday routines like mealtime, playtime, and car rides. Because embedding these goals into a child's daily life is the key to faster, lasting results, parents and teachers are essential partners in the therapeutic process. Myth 5: “Speech therapy is only for children who cannot speak.” Fact: Speech therapy helps with many areas, including speech clarity, language development, stuttering, voice disorders, social communication, feeding, and swallowing difficulties.

Myth 6: "Screen time helps children learn to talk." The Fact: For toddlers, passive screen time is actually linked to speech delays, not gains. Children learn language best through reallife interaction. Talking, playing, reading, and responding to a child’s attempts to communicate are far more effective than passive screen exposure. A screen provides input, but it cannot listen, make eye contact, or engage in the crucial back-and-forth interaction a child needs to build communication skills. Myth 7: “Speech therapy works quickly.” Fact: Progress takes time, regular practice, and consistency. Every individual develops at their own pace, and meaningful improvement often happens gradually. Myth 8: “My child will grow out of it.” Fact: Some children do catch up naturally, but others may need professional support. Waiting too long can delay intervention during important developmental years when the brain is most responsive to learning. Myth 9: "Stuttering is caused by anxiety, trauma, or bad parenting." The Fact: Stuttering is a neurodevelopmental condition related to how the brain processes speech and language. It is not caused by parents talking too fast, a sudden fright, or inherent nervousness. While stressful situations can exacerbate stuttering events, they do not cause the underlying disorder.

Myth 10: "Practising tongue twisters is the best way to fix speech sound errors." The Fact: Tongue twisters test skills a child already has; they don't teach new ones. They are great for improving the speed and coordination of sounds a child can already say correctly. If a child is still learning a sound, tongue twisters may reinforce incorrect speech patterns and cause frustration. For eg. Asking a child who says /w/ instead of /r/, to quickly say "Round the rugged rock" means they will repeatedly practice saying "Wound the wugged wok." This reinforces the incorrect neural pathway, making the /w/ habit even harder to break. Frustration and Overload: Tongue twisters demand high cognitive effort. Forcing a child to attempt them with unmastered sounds usually leads to frustration and a loss of confidence. Speech therapy works best by first teaching the sound correctly in isolation, then gradually moving to syllables, words, and sentences. Tongue twisters are best used only after the sound has been mastered.

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Myths v/s facts with ASD Myth: "Non-speaking autistic children don't understand you." The Fact: The ability to speak is entirely separate from the ability to understand. Many non-speaking autistic individuals are highly intelligent and comprehend everything. Introducing alternative forms of communication, like AAC (Augmentative and Alternative Communication) devices or picture boards, often unlocks their ability to show exactly how much they know and think. Myth: "Autistic children do not want friends or social interaction." The Fact: Many autistic children strongly desire social connections and meaningful friendships. However, they may communicate, play, or initiate interactions differently than their neurotypical peers, which can sometimes be mistakenly viewed as a lack of interest.

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Myth: "Autistic children do not make eye contact." The Fact: Eye contact varies widely among autistic individuals. While some may find it physically uncomfortable or highly distracting and avoid it, others make typical or even intense eye contact. Myth: "They need to make eye contact to show they are listening." The Fact: For many autistic individuals, forced eye contact is physically overwhelming and highly distracting. Many listen and learn better when allowed to look away or use physical movement (stimming) to regulate themselves. Myth: "If a child can speak, they cannot be autistic." The Fact: Autism is a broad spectrum that includes a vast range of communication abilities. Some autistic individuals are non-speaking and use alternative communication, while others speak fluently and may even possess an advanced, adult-like vocabulary from a very young age.

Myth: "All autistic children have an intellectual disability." The Fact: Autistic individuals have a wide range of intellectual abilities, just like the general population. While some may have cooccurring intellectual disabilities, many others possess average, above-average, or even exceptionally high intelligence. Myth: "Autistic children cannot show affection or emotions." The Fact: Autistic children experience deep emotions and form incredibly meaningful relationships with their families and friends. They might simply express their love differently—such as through sharing a special interest or spending quiet time together.

Myth: "Autism can be cured." The Fact: Autism is a lifelong neurological difference, not an illness or a disease that needs to be "cured." The goal of therapy is never to cure autism, but to provide the appropriate support to help autistic individuals communicate effectively, develop life skills, and thrive. Myth: "Repetitive behaviours should always be stopped." The Fact: Repetitive behaviours (often called "stimming," like handflapping or rocking) are vital tools that help autistic individuals selfregulate, focus, or express joy. These movements should be respected and only redirected if they are actively causing physical harm.

Myth: “Autism is caused by poor parenting.” Fact: Autism is a neurodevelopmental condition. Parenting style does not cause autism. Myth: "Autism is basically just a 'boy' condition." The Fact: While boys are diagnosed at much higher rates, experts agree this massive gap is heavily driven by diagnostic bias. Autistic girls often present differently and are heavily socially conditioned to "mask" (camouflage) their traits by perfectly mimicking their neurotypical peers. Because of this, they simply fly under the radar and are frequently missed or misdiagnosed.

Unique Disability ID (UDID) / Swavlamban Card What is a UDID Card? The Unique Disability ID (UDID), also known as the Swavlamban Card, is a government-issued identification card for Persons with Disabilities (PwDs) in India. It provides a unique identity and facilitates access to various government schemes, benefits, and services across the country. Types of UDID Cards: Permanent UDID Card Issued to persons aged 18 years and above with a permanent disability. Permanent validity; no renewal required.

Temporary UDID Card Issued to persons below 18 years of age or individuals whose disability requires periodic reassessment. Valid for the duration specified by the medical board. Requires renewal or reassessment as advised by the issuing authority. Can be upgraded to a Permanent UDID Card when eligibility criteria are met.

How to Apply for a UDID Card? Application Process: Step 1: Register Online Visit the official Swavlamban/UDID portal (https://swavlambancard.gov.in) Create a user account. Step 2: Complete the Application Form Enter personal details, disability-related information, and identification details. Step 3: Upload Required Documents Upload the necessary supporting documents. Step 4: Submit the Application Submit the completed form online. An enrollment number will be sent via SMS or email. Step 5: Medical Assessment Visit the designated district hospital or an assessment centre for disability evaluation. Step 6: Card Generation Once approved, the UDID card is generated, printed, and dispatched. Documents Required for Registration Aadhaar Card Passport-size photograph Signature or thumb impression Disability certificate (if available)

Benefits and Concessions Available with a UDID Card:

Education Benefits Access to reserved seats in educational institutions Age relaxation in eligible examinations and admissions Examination accommodations and support services Access to various educational welfare schemes

Niramaya Health Insurance Health insurance coverage for individuals with Autism Spectrum Disorder (ASD), Cerebral Palsy (CP), Intellectual Disability (ID), and Multiple Disabilities

Legal Guardianship Support Provision for legal guardianship for eligible adults with disabilities under applicable government regulations

ADIP Scheme Financial assistance for assistive devices and appliances, subject to eligibility criteria

Travel Concessions Concessions on railway and bus fares, as per prevailing government rules Escort concessions where applicable

Income Tax Benefits Tax deductions under Sections 80DD and 80U of the Income Tax Act, subject to eligibility criteria

References: American Speech-Language-Hearing Association. https://www.asha.org Bernthal, J. E., Bankson, N. W., & Flipsen, P., Jr. (2022). Articulation and phonological disorders: Speech sound disorders in children (9th ed.). Paul H. Brookes Publishing Co. Dillon, H. (2012). Hearing aids (2nd ed.). Thieme Medical Publishers. Fatima Malik; Raman Marwaha (2022). Developmental Stages of SocialEmotional Development in Children. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK534819/ Guitar, B. (2024). Stuttering: An integrated approach to its nature and treatment (6th ed.). Wolters Kluwer. Karanth, P. (2007). Communication DEALL developmental checklists. Com DEALL Trust. Pyramid Educational Consultants. (n.d.). PECS®: An evidence-based practice. https://pecsusa.com/pecs/ Unique Disability ID. https://swavlambancard.gov.in Danu, N., Krishna, N., & Balan, P. (n.d.). Understanding and tackling sensory needs in children. Communicaids.