Speech Therapy & Hypernasality Question + How to Advocate

[greenmonkey1]

Does anyone have experience with speech therapy for hypernasality?  My son (3.5 years old) is receiving speech services and the two error categories the SLP identified were "stopping" and "backing".  The SLP with whom DS is working is not the same SLP who completed the initial speech evaluation.

I am feeling out of sorts with the SLP who is doing DS' therapy.  First three weeks the SLP had neither read the initial evaluation (she had just read the report summary) nor spoken to the evaluating SLP about the evaluation.  At our first meeting the SLP indicated how DS spoke was not what she expected based on the report.  I get the feeling the treating SLP either disagrees with the evaluating SLP's evaluation or she is unfamiliar with how to treat DS' specific errors.  DS is hypernasal on some "s" sounds - the air goes through his nose (i.e. snake). Twice she has mentioned going back to the ENT and I get the feeling she is hinting that DS' issues are structural and not able to be addressed through speech therapy.  This is in contrast to the evaluating SLP who seemed very confident DS' errors could be rectified fairly easily, possibly by the end of the school year.

I am at a bit of a loss as to what to do.  On one hand I am not an SLP and I need to trust the system.  On the other hand I would expect by week three there to be some sort of therapy plan.  The last two weeks the SLP has sent home homework, but told me DS can already do it all it is just to give him something to work on.  I suppose I knew DS' speech delay would not be gone overnight, but I would like to see there is a path forward and right now I am struggling to see that path.

Is anyone aware of resources for exercises I can do at home that address hypernasality?  Also, any recommendations  (books, websites, etc) for how to advocate without alienating the therapist?

[auntie]

Is your son receiving speech services on an IEP under IDEA?

If so, "Emotions to Advocacy" is my favorite book for working collaboratively with the other members of the CSE/CST.


Assuming IEP, the treatment plan and benchmarks toward goals established by the team after evaluation should be in the document you signed as a team member. It's hard as a new-to-this parent to know in advance what the best goals are to drive effective interventions. It's also possible that the SLPs do see this differently. It's hard to say which one is correct; sometimes the older SLP with more experience has an edge, sometimes the newly minted one has more up to date training. Plus, sometimes SLPs have more narrow expertise than others. Not all will be equally versed in areas like feeing therapy, social skills, PROMPT for apraxia. It's also possible the SLP is starting slowly to establish a relationship with your son where he feels competent before starting the more challenging stuff.

Maybe you could call her and ask her about her plan forward.

[greenmonkey1]

auntie Thank you, I will look for the book you recommended. Currently DS is receiving speech services under an RTI plan so there are no specific goals/benchmarks as there would be in an IEP. If I recall the document just generically said the plan was to eliminate the speech errors. The team will reconvene at the end of the school year to see whether RTI continues to be the most appropriate way to service DS moving forward.

I think I am probably being anxious and need to relax. Thank you for your thoughts.

[auntie]

Wow, it's pretty rare to get a real SLP under RTI.

What's the plan if he doesn't get beyond his speech issues? Has he had an actual IEP eval? Would they do done then? What happens over the summer?

If this is a subtle artic issue, not a huge deal but if kids and other adults have trouble understanding him, you probably want ESY.

[waverly]

If he is getting speech through EI or the school district you are probably stuck with a particular therapist, where you might be able to switch if you were doing private practice. I find some doctors rub me the wrong way with one of my pet peeves not being a plan forward. I really just had to keep asking at each meeting and kind of devise a plan myself as I went along. They would give me guidance but it wasn't as concrete as I would like. For example ENT would refer to audiology and audiology would refer to ENT repeat 6 times. Or ENT wouldn't say when the follow up is. I eventually switched from that ENT but it was private practice.

As far as my experience with OT and PT they for the most part had a plan, but part of it I had to keep asking. Its probably easier with those topics though because it is a bit more generalized than speech.

I will say my son doesn't have the nose issue, but he got his tonsils out and it changed his voice to be extremely high pitched and nasally. In talking to my friend that her son also had his tonsils it was the same thing. It only corrected itself when his voice changed. So there could be something to the structural idea. No one to know for sure but go back to the ENT, but yeah if you have been bouncing back for a while tell them that and say hey I've been to so and so and they keep sending me back to you, so ....? And sometimes you just go to the ENT to prove them right or wrong and move forward.

I had to listen to a lecture by the PT about her differing opinion from the doctor. I didn't say anything because at the end of the day the treatment is the same no matter the diagnosis. Not saying that is the case for you, just that some therapists fixate on things and information from the doctor can be helpful in understanding the big picture.

I would be annoyed too that she hasn't read the eval.

[greenmonkey1]

Mar 5, 2018 16:56:34 GMT -5 auntie said:

Wow, it's pretty rare to get a real SLP under RTI.

What's the plan if he doesn't get beyond his speech issues? Has he had an actual IEP eval? Would they do done then? What happens over the summer?

If this is a subtle artic issue, not a huge deal but if kids and other adults have trouble understanding him, you probably want ESY.

One of the reasons we moved to the district in which we live was the services available on both ends of the spectrum.  We are very lucky.

DS had a full IEP eval and he did not qualify because the team could not prove adverse impact.  Basically he has an articulation issue, but he is understandable enough and he uses good coping skills to make himself understood (repeats himself, chooses a different word, describes what he is trying to say).  So cheers that he has good coping skills, but I know they will not carry him forever.  The plan is to reevalute at the end of the school year as to what to do moving forward (qualify him for an IEP, keep servicing under RTI, other option of which I am not aware).  

I highly doubt he will qualify for ESY.  Not sure if the issue is subtle or not - I need to ask the SLP.  The first SLP made it sound like his speech errors could be corrected by summer so I presume subtle.  I definitely do not get that feeling from the treating SLP. 

I need to get DH to call insurance to see how to get authorized for private speech and potentially use that over the summer.  Before I looked into that I wanted to get some speech appts under our belt.  Given that it is now March I probably should just look into private speech just in case as I presume that fills up.

Thankfully DS has a full two years before kindergarten because he will miss the cut-off and thus start at age 6.  So we have two years to work through speech before DS gets into regular school.

I also need to just email or call the SLP and get on the same page.  Maybe she is just trying to start a relationship.  Honestly though, we only have so many meetings before the school year lets out for summer so let's get some therapy done.  DS (by her words) is completely participatory in their sessions.  I am the type of person who needs to know - I might not totally understand the mechanics, but I like to have an understanding of what is going on so that I can properly support and so that I have a realistic understanding of the process/timeline/expected progress/etc.

[greenmonkey1]

Mar 5, 2018 19:46:47 GMT -5 waverly said:

If he is getting speech through EI or the school district you are probably stuck with a particular therapist, where you might be able to switch if you were doing private practice. I find some doctors rub me the wrong way with one of my pet peeves not being a plan forward. I really just had to keep asking at each meeting and kind of devise a plan myself as I went along. They would give me guidance but it wasn't as concrete as I would like. For example ENT would refer to audiology and audiology would refer to ENT repeat 6 times. Or ENT wouldn't say when the follow up is. I eventually switched from that ENT but it was private practice.

As far as my experience with OT and PT they for the most part had a plan, but part of it I had to keep asking. Its probably easier with those topics though because it is a bit more generalized than speech.

I will say my son doesn't have the nose issue, but he got his tonsils out and it changed his voice to be extremely high pitched and nasally. In talking to my friend that her son also had his tonsils it was the same thing. It only corrected itself when his voice changed. So there could be something to the structural idea. No one to know for sure but go back to the ENT, but yeah if you have been bouncing back for a while tell them that and say hey I've been to so and so and they keep sending me back to you, so ....? And sometimes you just go to the ENT to prove them right or wrong and move forward.

I had to listen to a lecture by the PT about her differing opinion from the doctor. I didn't say anything because at the end of the day the treatment is the same no matter the diagnosis. Not saying that is the case for you, just that some therapists fixate on things and information from the doctor can be helpful in understanding the big picture.

I would be annoyed too that she hasn't read the eval.

Thanks.  DS has had two full audiology work-ups and been cleared by an ENT.  So the SLP telling me I might need to take DS back to the ENT just made me think "why?".  The ENT has already sent me to speech.  I imagine it is possible there could be a structural issue, but let's start with the path of least resistance and go from there.  My opinion is that if speech therapy literally does nothing then we can reconsider the medical side again, but let's at least give therapy a try.

[waverly]

What does the therapist say if you push back and on her? Something like we've already seen the ENT and there were no problems. Or the ENT didn't see what you are mentioning.

Anyway she should still be doing her therapy job regardless of the ENT. Sometimes it starts out rough and then you get on the same page after these things are worked out.

[greenmonkey1]

waverly The SLP did not give me a response when I indicated DS had already seen the ENT. I think you're right in that we need to get going. Unfortunately school closed last week for a winter storm and is closed this week for some undetermined reason. I am not very positive we'll get much done before the close of school for the summer, but then there is always next year.

[waverly]

Yeah we only have about 9 weeks of school left ourselves. DS progressed rapidly with speech, but his was hearing loss related so once he got his hearing aids there was a difference in two months. I think probably it takes a lot longer for other issues. His PT for example has been 7 months. He is still in speech but all they are doing is the letter V all year. 🙄 I think they just don't want to release him yet until he is a certain age so they can make sure he is still proceeding developmentally wise with his letters.

[greenmonkey1]

Thanks, waverly. Sorry for the really long delay in responding, I got wrapped up in my own school work. I hope everything keeps going forward for your DS.

The SLP gave me another hard press to see an ENT last session. Said she could research a therapy technique, but that is not what they do (meaning the anatomical piece, not speech). But all I could think was, "isn't speech what you do?". I understand she isn't a doctor, but if you think xyz anatomical issue is the issue then use the speech techniques that address said issue. Everything I researched about the anatomical issue she mentioned indicates one should start with therapy before looking for a medical solution.

I think making DS2 an ENT appointment might just be something I need to do to keep moving forward. At least if the issue is anatomical then we can get it addressed and if it isn't I can give said report to the SLP and we can find another way to address DS2's delay. I just hate feeling like there is no forward path right now.

[waverly]

greenmonkey1- yes I agree. I also had seen upthread you were mentioning a private speech therapist. It might be good to get a second opinion if you aren't making any progress with this one.

Sometimes therapists give off the impression that they don't want to work on a case or maybe they don't have the skills to address that particular issue. The speech therapist might also be balking because there is no IEP. I don't know why this would matter, but just trying to think of ideas of why she is balking at treatment. We have several therapists at our school so maybe you might have a chance at working with a different one.

[agedsubaru]

What assessment tool did the SLP use to evaluate?

SLPs vary in expertise and programs in the private world. If the school didn't do a CELF and your insurance covers an eval, get a private SLP to do a CELF5. This could give you a better idea of what you need. All dependent on what your insurance covers.

[greenmonkey1]

Mar 27, 2018 13:11:06 GMT -5 agedsubaru said:

What assessment tool did the SLP use to evaluate?

SLPs vary in expertise and programs in the private world. If the school didn't do a CELF and your insurance covers an eval, get a private SLP to do a CELF5. This could give you a better idea of what you need. All dependent on what your insurance covers.

Good question.  I will need to pull his records to see what assessment tool was used. 

We will have a meeting at the end of the school year to plan for next year.  I am planning to get a copy of the full assessment report, not just the summary I received as part of the overarching evaluation.  At that meeting I hope to have a conversation about the disconnect between me and the treating SLP regarding treatment moving forward. 

I scheduled an appointment with an ENT to put the whole ENT conversation to rest one way or the other.  Thanks for the recommendation regarding the CELF5, I will look into that as well.  

[slpmel]

I'm an SLP, and my son also has speech services with a mixed phological disorder/Apraxia. As part of his apraxia, he has intermittent hypernasality that wasn't fully diagnosed until 5.5. I've heard it, brought it up to other SLPs and they didn't catch it. It wasn't until we saw a Ph.D SLP that caught it as soon as she heard him. He has a bifid uvula. We skipped a regular ENT, and went right to the velopharyngeal insufficiency clinic at Boston Children's hospital where he was assessed by an SLP that specializes in resonance disorders.

If the air is escaping through his nose, it's something I'd want to be evaluated by someone who knows what they are doing-the VPI clinic included a specialized SLP, a special ENT, and a plastic surgeon. Ultimately, my son's structural components are fine-so we will work on his apraxia to help coordinate his palate as he speaks.

Let me know if you have any questions.

[agedsubaru]

Apr 6, 2018 15:47:02 GMT -5 slpmel said:

I'm an SLP, and my son also has speech services with a mixed phological disorder/Apraxia. As part of his apraxia, he has intermittent hypernasality that wasn't fully diagnosed until 5.5. I've heard it, brought it up to other SLPs and they didn't catch it. It wasn't until we saw a Ph.D SLP that caught it as soon as she heard him. He has a bifid uvula. We skipped a regular ENT, and went right to the velopharyngeal insufficiency clinic at Boston Children's hospital where he was assessed by an SLP that specializes in resonance disorders.

If the air is escaping through his nose, it's something I'd want to be evaluated by someone who knows what they are doing-the VPI clinic included a specialized SLP, a special ENT, and a plastic surgeon. Ultimately, my son's structural components are fine-so we will work on his apraxia to help coordinate his palate as he speaks.

Let me know if you have any questions.

I am not the op but wanted to thank you for your response. It was helpful to me and I have talked to two places about scheduling something for my dd. Her PROMPT SLP thought looking into VPI is a good idea for dd. I wouldn't have heard about other than your post. Thank you. 

[greenmonkey1]

slpmel and waverly Just a quick update. We saw the pediatric ENT and while DS2 has a slight structural deformity, the ENT believes the errors are correctable with speech therapy. I have a call out to the pediatric speech therapy group to schedule private speech for the summer. Also had a follow-up with the school and what it boils down to is the SLPs there, at least the ones who service elementary, do not have experience with this type of speech error. Which is interesting because our elementary school is a magnet school for speech and language including kids with hearing impairments.

I am hopeful that DS2 can make some positive gains with intensive summer speech therapy with an SLP who is experienced in hypernasal speech. We can take the information from that therapist back to the school for speech during the academic year. DS2 will also be working with a different SLP and be transitioned to an IEP (rather than RTI) for next year, which I think is good. It's been a really interesting experience working with SPED at our school and I 100% understand why some families use advocates to navigate.

[waverly]

Thanks for the update. I was thinking of you. Our school too is a magnet for students with hearing loss. They have heating itinerant teachers, however their speech teachers have no additional training in hearing loss.

When we contacted them for EI we were told to wait until school age at that point- about 8 months. That was 8 months we could have had audiology and speech help that we had to wait for...

On the other hand they were willing to screen him at 3, but his hearing loss and speech got better so we declined. Should have kept that appointment in hindsight. But he’s doing well now.

[greenmonkey1]

waverly I am glad your son is doing well. Right now it is hard for me to be at the beginning of this process and feel like he is making no progress and not knowing how to get him what he needs. The school district really dropped the ball and we're in what is considered a good district. If they had raised the anatomical issues back when I started this (Thanksgiving), we'd have not wasted 2.5 months with an SLP who has no idea how to treat DS' errors and (I quote) "doesn't have the time to figure it out". At the end of the year meeting the school psych and SLP kept trying to reassure me about DS' needing more intense speech therapy and going on an IEP. I am really the least bit concerned about him being on an IEP and I told them that. What I am concerned about is (a) whether they have a therapist who can help my son and (b) whether they are going to manage the process in a more organized, transparent, professional and honest fashion.

DS will be starting speech with a private SLP through the local hospital system mid-June. I am hopeful DS can make some progress with her and I can take the information back to the school system for the upcoming year.

[agedsubaru]

slpmel,

Thank you for your post. We saw ENT today with a specialized SLP. We are looking at VPI along apraxia and dysarthria. I am thankful for your help. My SLP came along for the eval with the ENT. 

Your post started this path. I am grateful for the information.

May 22, 2018 13:59:36 GMT -5 agedsubaru said:

Apr 6, 2018 15:47:02 GMT -5 slpmel said:

I'm an SLP, and my son also has speech services with a mixed phological disorder/Apraxia. As part of his apraxia, he has intermittent hypernasality that wasn't fully diagnosed until 5.5. I've heard it, brought it up to other SLPs and they didn't catch it. It wasn't until we saw a Ph.D SLP that caught it as soon as she heard him. He has a bifid uvula. We skipped a regular ENT, and went right to the velopharyngeal insufficiency clinic at Boston Children's hospital where he was assessed by an SLP that specializes in resonance disorders.

If the air is escaping through his nose, it's something I'd want to be evaluated by someone who knows what they are doing-the VPI clinic included a specialized SLP, a special ENT, and a plastic surgeon. Ultimately, my son's structural components are fine-so we will work on his apraxia to help coordinate his palate as he speaks.

Let me know if you have any questions.

I am not the op but wanted to thank you for your response. It was helpful to me and I have talked to two places about scheduling something for my dd. Her PROMPT SLP thought looking into VPI is a good idea for dd. I wouldn't have heard about other than your post. Thank you.