Nancy Lotowycz, Christy Duke, Joanne Walter, Jamie Williams, Penny Harkey

1. When to Refer for Speech, Occupational, and Physical Therapies: A Developmental Milestone Guide for Parents and Educators Nancy Lotowycz, Christy Duke, Joanne Walter, Jamie Williams, Penny Harkey

2. Coastal Therapy & Learning Center • Speech-Language Pathology • Auditory Processing Skills • Reading Therapy • Fast Forward • BrainWare Safari • Social Skill Training • Occupational Therapy • Self Help Skills • Handwriting Without Tears • Motor Planning • Sensory Integration • Physical Therapy • Interactive Metronome • Motor Planning and Coordination

3. Coastal Therapy & Learning Center • Office and Off-Site Therapy Sessions • Screenings: Speech, Language, Hearing, Occupational and Physical Therapies • Consultations • Teacher In-services • Summer Camps

4. Coastal Therapy & Learning Center Providers for Insurances: • Aetna • CoreSource • Medicaid • MMSI • Ped I Care • TriCare, Prime and Standard • United, pending * We file all out of network claims.

5. Speech Language Pathology

6. Speech Language Pathology Speech-Language Pathologists evaluate and treat children with disorders in speech and language. Areas of Speech and Language Speech (Articulation) Phonological Awareness/Pre-literacy Skills Receptive Language Expressive Language Pragmatic Language

7. Speech (Articulation) Sounds typically developed by 3 years: / p, b, m, n, d, t / 4 years: the above sounds plus / h, y, w, v, f, k, g / Production of 3-4 words to make choices and express needs/wants Intelligibility is key! Children should be 100% intelligible at 4 years Why can’t you understand the student? - Does he sound garbled? Complete unintelligibility is a red-flag - Does he not produce specific sounds correctly? Errors in sounds such as / s, z, r, l, ch, sh, th / are considered normal, or developmental, because these sounds are not mastered until after 5 years

8. Phonological Awareness The ability to detect rhyme and alliteration (words that sound the same) Rhyme: cat rhymes with hat Alliteration: cat, cup, cap all start with the /k/ sound To break words into smaller units Syllables: Cookie: coo / kie To synthesize phonemes into words c / a / t sounds out “cat” Sound/symbol association: understand that words are made up of sounds that can be represented by written syllables or letters .

9. Phonological Awareness Follows a general pattern of development: Awareness of word-level units (words, syllables) Awareness of sub-syllabic units (onset, rimes) Onset: m Rime: ap Individual sounds in words (phonemes) m / a / p Rhyming map rhymes with cap However, children need not achieve mastery in their awareness of larger units (e.g., words) before displaying awareness of smaller units (e.g., phonemes) There is overlap in the development of children’s awareness of different discrete units

10. Phonological Awareness

11. Phonological Awareness Why are Phonological Awareness skills important? The assessment of phonological awareness during preschool and kindergarten provides criticalinsight into the skills that children use to learn to read. It has been demonstrated that phonological awareness, when compared to many other predictors, is the most stable and robust indicator of later reading abilities and spelling. Because children with speech and/or language disorders also often have difficulties with literacy development, assistance that could lessen later literacy problems is a crucial basic component of preschool language intervention. Phonological awareness training is one type of early intervention that is recommended. Teachers will be the first to notice if skills in this area are behind!

12. Receptive Language 3-4 years: Labels/points to body parts Receptive Vocabulary = 1200+ words colors, animals, shapes, etc. Understand comparatives big, bigger, biggest Comprehends ordinal numbers first in line, second…, third… Understands tenses past, present, future Understands spatial concepts and prepositions behind, next to, over, under

13. Receptive Language 4-5 years: Follows 3-step unrelated directions “Take off your coat, sit down at your desk, and take out a piece of paper.” Answers wh- questions who, what, when, where, how, and some why Understands complex questions “What would you do if it were raining?” Attends to short stories and can answer simple questions about them Understands broad categories “An apple, carrot, and pizza are all ____.” Determines what does not belong from a set of pictures and/or objects Knows common opposites in-out, big-little, up-down Knows simple time concepts day, night, morning, afternoon

14. Expressive Language 3 year olds: Sentences should have 3-4 words Talks about activities that happened at school or friends’ houses “I ate snack and played.” Use of: possessives mommy’s purse negatives can’t, don’t regular past tense –ed walked

15. Expressive Language 4-5 year olds: Produces grammatically complete sentences with few errors and many details “My seat on the carpet is the big, red star.” Use of: articles a, an, the varying verb tenses present, past, future correct form of “to be” “she is my mommy”vs. “she my mommy” regular and irregular third person singular “she does have a cat” vs. “she do have a cat”

16. Pragmatic Language The Use of Language in Social Situations Says “hello” and “good-bye” to teachers and friends when entering and leaving class Maintains appropriate eye contact during conversation Demonstrates ability to take turns with friends and teachers during play and conversation Demonstrates ability to create imaginary roles and understands object function Asks for help when unclear of expected action Initiates new conversation appropriately with teachers and peers Able to provide a first-hand account of past events and retell stories/movies A red flag may be a child who responds “I don’t know” when asked to recount a past event. Expresses empathy “I’m sorry.” “Are you ok?” When something new or unusual happens, the child asks appropriately about it Mrs. Jones is absent today. Student asks, “Where is Mrs. Jones?” Able to reason Teacher says, “Why do we have to wear our raincoats outside today?” Students says, “Because it’s raining.” Able to predict Teacher says, “What happens if we don’t wear our raincoat outside today?” Student says, “We’ll get wet.”

17. Speech and/or Language Referrals • Delays in • Speech (Articulation) • Phonological Awareness • Expressive, Receptive, and/or Pragmatic Language • If you’ve tried facilitation strategies with students who are having difficulties, and you think they are still falling behind other students, consult with a speech-language pathologist.

18. 0-6 Months Repeats same sounds Frequently coos, gurgles and makes pleasure sounds Uses different cry to express different needs Smiles when spoken to Recognizes voices Localizes sound by turning head Listens to speech Uses phonemes /b/, /p/, and /m/ in babbling Uses sounds or gestures to indicate wants 7-12 Months Understands no and hot Responds to simple requests Understands and responds to own name Listens to and imitates some sounds Recognizes words for common items Babbles using long and short groups of sounds Uses song-like intonation pattern when babbling Uses large variety of sounds in babbling Imitates some adult speech sounds and intonation patterns Uses speech sounds rather than only crying to get attention Listens when spoken to Uses sound approximations Begins to change babbling to jargon Uses speech intentionally for the first time Uses nouns almost exclusively Has expressive vocabulary of 1 to 3 words Understands simple commands Speech and Language Milestones

19. 13-18 Months Uses adult-like intonation patterns Uses echolalia and jargon Uses jargon to fill gaps in fluency Omits some initial consonants and almost all final consonants Produces mostly unintelligible speech Follows simple commands Receptively identifies 1 to 3 body parts Has expressive vocabulary of 3 to 20 or more words Combines gestures and vocalization Makes requests for more of desired items 19-24 Months Uses words more frequently than jargon Has expressive vocabulary of 50-100 words Has receptive vocabulary of 300 words Starts to combine nouns and verbs Begins to use pronouns Maintains unstable voice control Uses appropriate intonation for questions Is approximately 25-50% intelligible to strangers Answers "What's that?" questions Enjoys listening to stories Knows 5 body parts Accurately names a few familiar objects Speech and Language Milestones

20. 2-3 Years Speech is 50-75% intelligible Understands "one" and "all" Verbalizes toilet needs Requests items by name Points to picture in book when named Identifies several body parts Follows simple commands and answers simple questions Enjoys listening to short stories, songs and rhymes Asks 1-2 word questions Uses 3-4 word phrases Uses some prepositions, articles, present progressive verbs, regular plurals, contractions, and irregular past tense forms Uses words that are general in context Continues use of echolalia when difficulties in speech are encountered Has receptive vocabulary of 500-900 words Has expressive vocabulary of 50-250 words Exhibits multiple grammatical errors Understands most things said to him or her Frequently exhibits repetitions  Speaks with loud voice Increases range of pitch Uses vowels correctly Consistently uses initial consonants Frequently omits medial consonants Frequently omits or substitutes final consonants Uses auxiliary "is" including contracted form Speech and Language Milestones

21. 3-4 Years Understands object functions Understands difference in meanings Follows 2 and 3 step commands Asks and answers simple questions Frequently asks questions Produces simple verbal analogies Uses language to express emotion Uses 4 to 5 words in sentences Repeats 6-13  syllable sentences accurately Identifies objects by name Manipulates adults and peers Continues to use echolalia Uses up to  6 words in sentences Uses nouns and verbs Is conscious of past and future May repeat self often Increases speech rate Whispers Masters 50% consonants and blends Speech is 80% intelligible Sentence grammar improves Tells two events in chronological order Engages in long conversations Uses contractions Speech and Language Milestones

22. 4-5 Year Olds Counts to 5 Understands concept of numbers up to 3 Continues understanding spatial concepts Recognizes 1-3 colors Has extensive receptive vocabulary Counts to 10 by rote Listens to short simple stories Answers questions about functions Uses grammatically correct sentences Has extensive expressive vocabulary Uses sentences of 4-8 words Answers complex 2 part questions Asks for word definitions Speaks at rate of approximately 185 words per minute Reduces total number of repetitions Enjoys rhymes, rhythms, and nonsense syllables Significantly reduces number of persistent sound omissions and substitutions Frequently omits medial consonants Speech is usually intelligible to strangers Talks about experiences at school, at friends' homes, etc. Accurately relays long story Speech and Language Milestones

23. Occupational Therapy

24. An Occupational Therapist: • Provides evaluation and treatment • Focuses on improving a child’s occupational performance (ADL’s, Play, Social Participation, etc.) to meet his/her specific needs and improve quality of life • Helps promote independence, mastery, and self-confidence in physical, emotional and psychosocial development • Treats many diagnoses: Autism Cerebral Palsy Traumatic Brain Injuries Developmental Delay Learning Disabilities Down Syndrome Low Vision ADD/ADHD Coordination Disorders Sensory Disorders Delayed Fine Motor Skills Neurological Disorders

25. What Areas do Occupational Therapists Treat? ADL’s: Treatment may be provided to develop skills that a child needs to function on daily basis. Depending on his or her age, various ADL’s include sleeping, feeding, playing, potty training, social interaction, dressing, and academics. Fine Motor, Strength, & Dexterity: Having good strength and dexterity are essential components in development, growth, and handwriting. These skills enhance a child's ability to achieve age-appropriate milestones including: buttoning, cutting with scissors, manipulating zippers, tying shoes, and game participation.

26. What Areas do Occupational Therapists Treat? Visual Motor & Perception: Vision involves seeing, muscle control, cognitive processing, and interpretation for meaningful use. Visual processing is essential for academic success, play, and self-care activities. The Senses: Sensory integration is the ability to process sound, sight, smell, and touch that enable us to appropriately react to environmental changes in stimuli. OT addresses each child’s particular sensory issues in order to integrate and normalize sensory input. OT also helps parents and children learn how to independently manage and regulate sensory disturbances.

27. Additional Treatment Areas • Bilateral Coordination / Motor Planning • Muscle Tone & Strength • Environmental Adaptations • Range of Motion • Body Awareness • Achievement of Developmental Milestones • Problem Solving / Sequencing

28. Why Early Intervention? **The first three years of life are a critical time period for brain development. Goals of Early Intervention: • “To prevent or minimize the physical, cognitive, emotional, and resource limitations of young children disadvantaged by biological or environmental risk factors” (Smith, 771) • Enhance and develop age-appropriate milestones and minimize the potential for developmental delay

29. Occupational Therapy Red Flags • Weak/stiff uncoordinated movements • Awkward grasp or clumsy use of crayons, pencils, scissors, or other tools/utensils • Excessive seeking or avoidance of movement or touch • Absence of hand preference after age 6 • Difficulty with age appropriate self-help skills such as dressing and toileting • Attention and organizational problems with school tasks • Difficulty with feeding, food aversions or eats a very limited diet • Poor balance skills • Difficulty in sports, such as catching/throwing a ball • Unable to ride bike independently by age 8 • Poor organizational skills • Difficulty regulating activity level • Frequent emotional outburst or “meltdowns” in behavior • Lack of age appropriate play skills

30. 0-6 months Removes socks 7-12 months Helps with dressing Clasps hands Finger feeds self Imitates scribble Stacks 2-3 blocks 13-18 months Pulls pants & socks off independently Drinks from cup Brings spoon to mouth Scribbles spontaneously Uses both hands in midline Sucks a straw 19-24 months Scoops food & feeds self with spoon Builds 4-6 cube tower Zips/unzips large zipper Sits on potty chair w/assistance Imitates vertical/horizontal lines Developmental Milestones

31. 2-3 years Dresses with supervision Dry during the day Undoes large buttons/snaps/shoelaces/zippers Cuts a piece of paper in half Eats and drinks independently Knows main body parts May reject many foods 3-4 years Buttons Dresses without supervision Helps with bathing Matches pictures of like objects Names colors Responds to prepositions of over/under Helps with bathing Verbalizes need to use toilet Developmental Milestones

32. 4-5 years Distinguishes between front and back Stays dry through the night Recites numbers 1-10 Brushes teeth Helps with bathing Prints any 2 letters without model Cuts a circle/square Writes parts of name 5-6 years Draws person with at least 7 parts Ties shoes Writes name Recites numbers 1-20 Shows right hand No toiletry accidents Prints simple words without model Cuts with knife and fork Developmental Milestones

33. Physical Therapy

34. Physical Therapy • Physical therapists provide examination, evaluation, and treatment to patients with impairments, functional limitations, disease, and disability. • Physical therapists specializing in pediatrics assist children in developing and enhancing mobility so they may safely participate in activities at home, in the community, in the classroom, and on the playground.

35. Physical Therapy • Pediatric physical therapists are concerned with a child’s gross motor skills, strength, balance, and coordination. • Pediatric therapists focus on a child’s ability to take part in important movement activities such as crawling and walking, running, jumping, playing games, and participating in sports and other physical interactions.

36. Physical Therapy • Therapists provide evaluation, intervention and consultation in the following areas: • Gross motor development • Muscle tone and strength • Motor planning • Posture/postural control • Pre-gait and gait training • Locomotion patterns • Neuromuscular function • Endurance • Body alignment • Environmental adaptations

37. Physical Therapy • Our physical therapists perform thorough initial evaluations and use the findings to develop comprehensive treatment programs and establish specific, objective, measurable and time-based goals. • Our physical therapists also make recommendations regarding orthotics and adaptive equipment when necessary. In addition, for children who rely on mobility aids such as wheelchairs, orthotics and other supports, our therapists show them how to navigate safely in various environments.

38. Physical Therapy • Treatment programs are always individualized to meet each patient's needs. Examples of treatment include: • Positioning and posture alignment • Range of motion and strengthening exercises • Balance activities • Developmental activities • Endurance training • Gait training • Functional mobility training

39. Physical Therapy Evaluations • How do I know if my child needs an evaluation? • An evaluation may be suggested by a physician, a teacher or other medical professionals. If you are concerned your child's skills are not where they should be, he or she might benefit from an evaluation with one of our physical therapists.

40. Physical Therapy Referrals • Referring a Patient • Primary and specialty-care physicians may refer children and young adults for physical therapy. Although school personnel and other community providers also may recommend a child received physical therapy services, a physician’s order is required to obtain therapy services.

41. Gross Motor Milestones

42. Gross Motor Milestones

43. Gross Motor Milestones

44. Other Physical Therapy Concerns • W-Sitting • Limits necessary trunk rotation • May be damaging to hips and knees • Toe-Walking • When prolonged, may indicate sensory-seeking behaviors

45. Physical Therapy & The Classroom • Low muscle tone in the trunk/core muscles can result in difficulty sitting upright • Low trunk tone can result in difficulty sitting still in class as well as difficulty attending • Decreased proximal stability results in decreased distal stability for handwriting/fine motor tasks

46. Motor Planning • Motor planning is the ability of the brain to conceive, organize, and carry out a sequence of unfamiliar actions. • More parents have probably heard the term Apraxic, the inability to conceive, organize, and carry out an unfamiliar action; or Dyspraxic, difficulty in conceiving, organizing, and carrying out an unfamiliar action.

47. Motor Planning • Children with motor planning difficulties (dyspraxia) have problems learning new skills that involve using the body. They tend to require extra practice and reinforcement when learning new motor skills, and do not usually generalize these skills to new situations with ease. (Therefore, it is important to introduce activities in a variety of environments). • Some children become so frustrated with any game or activity that challenges motor skill, they avoid these tasks whenever possible. • These children tend to be disorganized in their use of time and materials, and often have difficulty becoming independent with simple routines involving household or school responsibilities. *** Expect that teaching new skills will require considerable practice and repetition

48. Physical Therapy & Sensory Integration • The Proprioceptive System & The Vestibular System are both very important components of physical therapy treatment.

49. The Proprioceptive System Proprioception refers to the sensory input and feedback that tells us about movement and body position. Proprioceptive receptors are located within our muscles, joints, ligaments, tendons, and connective tissues. The receptors tell the brain when and how the muscles are contracting and stretching, how the joints are bending or extending or being pulled/compressed, which enables the brain to know where each part of the body is and how it is moving. It is one of the deep senses, and is often referred to as the position sense. The Vestibular System The sensory system that provides the dominant input about movement and balance. Located within the inner ear, it provides information about gravity, body movement within space, and head movement. The sensory system that responds to the positioning of the head in relation to gravity and acceleration/deceleration of movement. It integrates neck, eye, and body adjustment to movement. The vestibular system sends signals primarily to the neural structures that control our eye movements and to the muscles that keep us upright. Physical Therapy & Sensory Integration

50. Physical Therapy • Midrange Control • Ability to control the movement in between the end ranges of joint movements • Example: Stance limb when descending stairs • Example: Lowering to sit in chair • Children with low muscle tone may be able to initiate muscle activity but have difficulty sustaining it with graded mid-range control