When speech difficulties overlap: Helping children with phonological delay and childhood apraxia of speech

ByLondon Speech and Feeding
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One of the questions parents often ask is:

‘What kind of speech difficulty does my child have?’

It’s a very understandable question. We often hear different terms such as phonological delay, articulation difficulties, or Childhood Apraxia of Speech (CAS), and it can be confusing.

The reality is that many children don’t fit neatly into one single category.

In fact, quite often I see children whose speech profile includes a mixture of difficulties. They might have some phonological patterns (where they substitute one sound for another) alongside challenges with motor speech planning, where coordinating the movements needed for speech is harder.

When this happens, therapy needs to be flexible, responsive, and tailored to the child sitting in front of us.

Example

Recently I filmed a short clip from one of my therapy sessions which shows exactly how this works in practice.

The child I was working with has difficulties with several speech sounds. Part of the challenge relates to a phonological pattern called fronting.

Fronting is when sounds that should be made further back in the mouth (like /K/ or /G/) are produced further forward instead.

At the same time, this child also shows signs of motor speech planning difficulty, which means the brain has to work harder to organise and sequence the movements of the tongue, lips and jaw for speech.

This type of profile can sometimes overlap with characteristics seen in Childhood Apraxia of Speech (CAS).

When difficulties overlap like this, therapy cannot rely on a single approach. Instead, it needs to draw on multiple evidence-based strategies.

That is exactly what you see happening in the clip. We started out generalising the /K/ sound which until recently had been replaced by a /T/ sound. Whilst looking at a sound loaded picture of /K/ sounds we somehow got talking about a ‘dent’ (I don’t recall how we got there!) but the ‘dent’ was a ‘det’ and I decided to tackle this there and then because there are other great words that end in ‘nt’ like : ‘count’ ‘giant’ ‘point’ or ‘paint’.

Using visual cues to support motor planning

Speech is incredibly complex. For children with motor speech difficulties, the challenge is not only knowing what sound they want to say, but also how to move their mouth to produce it.

This is where visual cues can be incredibly helpful.

In the clip, you can see me using a whiteboard with pictures and simple visual prompts. These help to:

  • Focus attention on the target sound
  • Understand where the sound occurs in the word
  • Remember the sequence of sounds needed

Visual supports can act almost like a map for the mouth, guiding children as they practise new speech movements.

For children with motor planning difficulties, this type of cueing can make a huge difference.

Why repetition of a single word (massed practice) is so important

Another key feature you will notice in the clip is lots of repetition.

This is very deliberate.

When we are supporting children with motor speech challenges, the brain needs repeated opportunities to practise the correct movement patterns. Just like learning a musical instrument or a new sport, repetition helps the brain build stronger and more efficient pathways.

In therapy we call this massed practice.

Rather than saying a word only once or twice, we practise it many times in a structured way, helping the child stabilise the new speech pattern.

But repetition alone is not enough. The child also needs to understand why the sound matters.

Showing children that sounds change meaning

This is where another powerful therapy approach comes in: minimal pairs.

Minimal pairs are word pairs that differ by only one sound. For example:

  • debt
  • dent

In the clip, I use these two words to help the child realise that the /N/ sound makes a meaningful difference.

Without the /N/, the word becomes something else entirely.

This approach helps children recognise that speech sounds are not random: they carry meaning. If a sound is missing or substituted, the message may change.

Helping children notice these differences can be a very motivating moment in therapy. Suddenly the sound is no longer just an abstract exercise; it becomes part of real communication.

Blending approaches for the best outcomes

In this short therapy moment, I am combining:

• Visual cueing

• Motor speech practice

• High repetition (massed practice)

• Minimal pair contrasts

• Listening and awareness of sound differences

Each element supports a different part of the speech system.

Some strategies help with motor planning, others support phonological awareness, and others build accuracy and consistency.

Together they create a therapy session that is both structured and responsive.

Every child’s speech journey is unique

One of the most important things I want to convey is that speech development is not always straightforward.

Two children may both struggle with speech sounds, yet the underlying reasons may be very different.

This is why careful assessment is essential, and why therapy needs to stay flexible as we learn more about how a child’s speech system works.

Sometimes a child needs more motor-based work.

Sometimes the focus shifts towards phonological contrasts.

Often, as in this example, the most effective therapy uses both.

Small steps lead to big progress

Every session helps us understand a little more about how a child’s speech system works and what support will help them move forward.

And when the pieces start to come together, when a child realises that one tiny sound can change a whole word, that is when the real progress begins.

If you are concerned about your child’s speech sounds, clarity of speech, or possible motor speech difficulties, early support can make a significant difference. A detailed assessment can help identify the nature of the difficulty and guide a therapy approach tailored to your child’s individual needs.

Feel free to contact me on www.londonspeechandfeeding.co.uk

Sonja McGeachie

Highly Specialist Speech and Language Therapist

Owner of The London Speech and Feeding Practice.

Health Professions Council registered
Royal College of Speech & Language Therapists Member
Member of ASLTIP

Find a speech and language therapist for your child in London. Are you concerned about your child’s speech, feeding or communication skills and don’t know where to turn? Please contact me and we can discuss how I can help you or visit my services page.

Reference

McNeill, B. C., Gillon, G. T., & Dodd, B. (2009). Effectiveness of an integrated phonological awareness approach for children with childhood apraxia of speech (CAS). Child Language Teaching and Therapy, 25(3), 341-366.

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    When this happens, parents naturally wonder whether it is something their child will grow out of, or whether some extra support might help.

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    If a child is frequently difficult to understand at school age, it can sometimes indicate that a speech sound difficulty has persisted beyond the stage when it would normally resolve on its own.

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    • leaving sounds out of words

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    Other children may have difficulty producing certain individual sounds clearly. This might include sounds such as:

    • /S/
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    A child might understand exactly what they want to say but find it hard to produce the sound accurately with their tongue, lips or airflow.

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    For some children, the difficulty lies in the planning and coordination of the movements needed for speech.

    Speech requires very precise timing between the tongue, lips, jaw and breath. If the brain finds it difficult to organise these movements consistently, speech can sound unclear or inconsistent.

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    Speech clarity becomes particularly important once children start school.

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    • Talking with friends
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    • Developing confidence in communication

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    • Practise accurate speech movements
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    • Build consistency through structured practice

    Different children benefit from different therapy approaches. Some need support with phonological patterns, while others benefit from more motor-based practice that strengthens speech coordination.

    Often therapy combines several strategies to support the child’s individual speech profile.

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    Speech development is not the same for every child. Some children master speech sounds quickly, while others need a little more guidance along the way.

    The important thing is that support is available when children need it.

    With the right strategies and practice, many children make excellent progress and develop speech that is clearer, more confident and easier for others to understand. If you are concerned about your child’s speech clarity or ongoing speech sound errors, a speech and language assessment can help identify the underlying difficulty and guide the most appropriate support.

    Feel free to contact me on my contact page.

    Sonja McGeachie

    Highly Specialist Speech and Language Therapist

    Owner of The London Speech and Feeding Practice.

    Health Professions Council registered
    Royal College of Speech & Language Therapists Member
    Member of ASLTIP

    Find a speech and language therapist for your child in London. Are you concerned about your child’s speech, feeding or communication skills and don’t know where to turn? Please contact me and we can discuss how I can help you or visit my services page.

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    Pretend Play using Speech and AAC in my clinic room

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    Using AAC to support speech practice

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    If you’d like support or advice, please contact me and I can help guide the next steps.

    Sonja McGeachie

    Highly Specialist Speech and Language Therapist

    Owner of The London Speech and Feeding Practice.

      Health Professions Council registered
      Royal College of Speech & Language Therapists Member
      Member of ASLTIP

      Find a speech and language therapist for your child in London. Are you concerned about your child’s speech, feeding or communication skills and don’t know where to turn? Please contact me and we can discuss how I can help you or visit my services page.

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      Why auditory memory matters (especially for little ones!)

      ByLondon Speech and Feeding
      Why auditory memory matters (especially for little ones!)

      Have you ever stopped to think about how we learn to speak, understand, and communicate effectively? It’s a complex dance of various cognitive skills, and one often overlooked but absolutely crucial player in this orchestra is auditory memory. It’s not just about remembering sounds. It’s about remembering sequences of sounds, which is fundamental to language development.

      What exactly is auditory memory?

      At its core, auditory memory is our ability to take in, process, store, and recall information that we hear. Think of it as your brain’s internal recording studio. When someone speaks to you, your auditory memory is busy at work, capturing the individual sounds, the order in which they appear, and the rhythm and intonation of the words. This isn’t just for long-term recall; it’s also vital for working auditory memory, which allows us to hold onto a small amount of auditory information for a short period, just long enough to make sense of it.

      For speech and language, auditory memory is essential for:

      • Understanding spoken language: To comprehend a sentence, we need to remember the beginning of the sentence by the time we hear the end.
      • Following instructions: Remembering a sequence of commands relies heavily on auditory memory.
      • Learning new words: We hear a word, remember its sound, and connect it to its meaning.
      • Developing phonological awareness: This is the ability to recognise and manipulate the sounds in spoken language, a critical precursor to reading. Auditory memory helps children distinguish between similar-sounding words (e.g., ‘cat’ vs. ‘bat’) and segment words into individual sounds.
      • Producing clear speech: To articulate words correctly, we need to recall the precise sequence of sounds that make up that word.
      • Developing conversational skills: Remembering what was just said helps us formulate appropriate responses.

      When auditory memory falls short: The impact on speech

      When auditory memory is poor, particularly in young children, the ripple effects on speech and language development can be significant. Children might struggle with:

      • Following multi-step directions: ‘Put on your shoes, get your coat, and meet me at the door’ can become an overwhelming jumble of sounds.
      • Learning new vocabulary: They might hear a new word repeatedly but struggle to retain its sound pattern, making it difficult to recognise or use later.
      • Understanding stories or conversations: Missing key details or losing the thread of a narrative because they can’t hold enough information in their working memory.
      • Developing phonological skills: Difficulty with rhyming, identifying initial sounds in words, or blending sounds together to form words, which can impact early literacy.
      • Speech production: They might mispronounce words, omit sounds, or struggle with the correct sequencing of sounds within words.
      • Social communication: Difficulty participating in group discussions, remembering names, or recalling what their peers have said.
      • Academic performance: Auditory memory challenges can impact a child’s ability to learn in a classroom setting, where much of the instruction is delivered verbally.

      It’s important to note that poor auditory memory isn’t a sign of low intelligence, but rather a specific processing challenge that can be addressed with targeted support.

      Nurturing auditory memory in under 5s: Preparing for schooling

      The good news is that auditory memory is a skill that can be strengthened and developed, especially during the crucial early years. For children under five, laying a strong foundation in auditory memory is an invaluable gift as they prepare for the demands of formal schooling. Here’s what we can do to help:

      1. Read aloud regularly: This is perhaps one of the most powerful tools. As you read, encourage your child to listen for specific words, predict what happens next, and retell parts of the story. Vary your voice, use different intonations, and pause to emphasise key words.
      2. Play auditory memory games:
        • ‘Simon says’: This classic game is fantastic for following multi-step instructions. Start with one command and gradually increase the number.
        • ‘I Spy’ with sounds: Instead of colours, describe sounds. ‘I spy with my little ear something that goes “moo”.’
        • Rhyming games: Sing rhyming songs, read rhyming books, and encourage your child to come up with words that rhyme.
        • Sound matching: Use everyday objects to make sounds (e.g., shaking keys, tapping a spoon) and have your child identify or match them.
        • ‘Memory chain’: Start a sentence and have your child add to it, remembering everything that came before: ‘I went to the market and bought an apple.’ ‘I went to the market and bought an apple and a banana.’
      3. Sing songs and nursery rhymes: Repetitive songs and nursery rhymes are excellent for developing auditory memory, rhythm, and phonological awareness. The predictable patterns help children anticipate and remember sequences of sounds and words.
      4. Give multi-step instructions (and praise!): Start with two-step instructions and gradually increase the complexity as your child’s skills improve. Always give positive reinforcement when they succeed. ‘Please pick up the red block and put it in the box.’
      5. Engage in active listening: Model good listening skills yourself. When your child is speaking, give them your full attention. Ask clarifying questions to encourage them to elaborate and organise their thoughts.
      6. Reduce background noise: A quiet environment makes it easier for young children to focus on auditory information. Minimise distractions like TV or loud music during activities that require listening.
      7. Use visual cues: While we’re focusing on auditory memory, sometimes pairing auditory information with visual cues can be helpful, especially initially. For example, when giving instructions, demonstrate the action as you say it.
      8. Be patient and consistent: Developing auditory memory takes time and consistent practice. Celebrate small victories and create a playful, supportive environment for learning.

      By actively engaging in these strategies, we can empower our youngest learners to build robust auditory memory skills, setting them up for success not only in speech and language development but also in their overall academic journey. It’s an investment that truly pays dividends in their future communication and learning abilities.

      Any comments or if you need help and support with your child’s speech please do not hesitate to get in touch with me: simply fill out the contact form here on the website. I endeavour to reply within 48 hours.

      Sonja McGeachie

      Highly Specialist Speech and Language Therapist

      Owner of The London Speech and Feeding Practice.

      Health Professions Council registered
      Royal College of Speech & Language Therapists Member
      Member of ASLTIP

      Find a speech and language therapist for your child in London. Are you concerned about your child’s speech, feeding or communication skills and don’t know where to turn? Please contact me and we can discuss how I can help you or visit my services page.

      1
    • · ·

      A helpful addition in my toolbox for lisp correction

      ByLondon Speech and Feeding

      Meet the MUPPY – a vestibular orthodontic plate

      I have become very well versed in Lisp Correction because so many children come to me with this problem! And I absolutely love lisp correction and Articulation Therapy! Please take a look at my blog on tips and tricks for correcting a lisp.

      The MUPPY

      Over the years I have created my unique style of remediating an Interdental Lisp and as part of my treatment I sometimes use an Orthodontic Tool, called the ‘MUPPY’, which I purchase directly from Germany. I first discovered it some years ago when working with a child with Down Syndrome. Back then I was searching for additional support with my student’s jaw grading and mouth closure difficulties and that’s when I first came across this little tool as recommended by one of my colleagues, a specialist orthodontist in Germany.

      I was a bit sceptical at first but I have used it now many times for three years on a variety of clients with varying degrees of lisps. I find it really helps together and in addition to all my other techniques which are language and motor based.

      How do I use it?

      The MUPPY is a custom-made mouth plate that gently repositions the tongue, encouraging correct tongue placement for clearer speech. It sits comfortably between the lips and teeth; a thin wire sits right behind the teeth, inside the oral cavity.

      The plate I like to use for lisp correction has a pearl in the middle. As soon as it is in situ the tongue starts fishing for the pearl and thereby keeps on moving up towards the correct place on the hard palate, just behind the front teeth. This is the place where the tongue tip needs to be for all the alveolar sounds our students find so hard to make.

      How does this help reduce a lisp?

      A lisp results mainly from incorrect tongue placement during sound production – though at times atypical dentition also contributes to the problem. Specifically, an interdental lisp occurs when the tongue protrudes between the teeth during the production of sounds like /S/ and /Z/. The tongue is often described by parents as ‘thrusting forward’ but I find that is rarely the case. Most often the tongue simply protrudes forward, which is different to tongue thrusting, a more forceful and involuntary movement. Most often I see a habitual tongue protrusion not only for /S/ and /Z/ but also for /T/, /D/, /L/ and /N/. Often /SH/ and ZH/ are also affected.

      To visualise this:

      1. A correct /S/ sound looks like this: The tongue tip is raised and touches the alveolar ridge (the bony, slightly uneven ridge behind the upper teeth). The sides of the tongue touch the upper molars.
      2. Interdental lisp: The tongue tip protrudes between the front teeth, creating a /TH/ sound.
      3. Lateral lisp: Here the mechanics of the tongue are different. But using the MUPPY can help here too. To visualise a lateral lisp, the sides of the tongue are not raised high enough, allowing air to escape over the sides. This results in a ‘slushy’ or ‘wet’ sound.

      Understanding the specific type of lisp is crucial for targeted therapy and successful correction.

      The Vestibular Plate (Muppy) HELPS to guide the tongue towards the right place from where we shape the NEW SOUND.

      Methods

      Most important to my articulation work re lisping are the motor- and language-based techniques I use, as broadly described below:

      • A thorough oral examination, tongue movements, lip closure, dentition, jaw grading, breath coordination, cheek tonicity, palatal form
      • Discussion on awareness and motivation of child to work on their speech
      • Contrasting sounds at the beginning and end of words: sing vs thing / sink vs think / mess vs mesh etc to raise awareness that it matters what sounds we use in speech and that just one sound can change the meaning of a word completely
      • Mirror work, pulling faces, moving our tongue voluntarily
      • Exploring the oral cavity and thinking about all the parts of the tongue and the palate
      • Finding the alveolar ridge and placing the tongue there at rest
      • Then working towards a good baseline of the other alveolar sounds: /T/ /D/ /L/ /N/ and from there we work towards our NEW /S/ SOUND.

      I use a variety of picture clues depending on what is most meaningful for my student:

      The child likes a train set, I use the TIRED TRAIN SOUND.

      The child knows about bike or car tyres, I use the FLAT TYRE SOUND.

      With a student who loves a balloon I might use the FLAT BALLOON SOUND.

      And we work our way from correct tongue placement to these long /SSSSSSSSS/ sounds with the help of these visual cues, but also gestural and hand cues such as Jane Passy’s Cued Articulation sound for /S/.

      I really love helping children correct their speech sound, be it an articulatory difficulty like the lisp or a phonological difficulty such as ‘fronting’ or ‘gliding’ and I also love working with motor-based speech difficulties we see in Childhood Apraxia of Speech. Feel invited to get in touch if your child needs help in these areas.

      Sonja McGeachie

      Early Intervention Speech and Language Therapist

      Feeding and Dysphagia (Swallowing) Specialist The London Speech and Feeding Practice

      The London Speech and Feeding Practice

      Find a speech and language therapist for your child in London. Are you concerned about your child’s speech, feeding or communication skills and don’t know where to turn? Please contact me and we can discuss how I can help you or visit my services page.

      1

    • A Day In The Life Of An Independent Speech And Language Therapist

      ByLondon Speech and Feeding
      A Day In The Life Of An Independent Speech And Language Therapist

      A Day In The Life Of An Independent Speech And Language Therapist

      I often get asked how many clients/children I see per working day or what my working day/life looks like. I always reply that every day is different, which is true, but there is a sort of average working day which looks a bit like this:

      I usually start preparing for my first client of the day at around 9.30 am: I clean the room, wipe down all the toys and materials (that’s if they are coming to my clinic room) and then it takes me about 30 minutes to select and sometimes make suitable materials, games and activities for the child’s therapy programme. Client arrives at 10.30 am and the fun begins. They leave around 11.30am, and the cleaning and wiping down starts again – yes it’s the pandemic but to be fair I would do this anyway. I quickly write up my notes and send home work to the client via email. Now it’s 12 noon and I start preparing for the next client at 12.30 pm. This might be online parent-child interaction coaching and so I need different materials and activities that are suitable for teletherapy. We finish around 1.30 pm and I will write up my notes before having some lunch.

      Lunch tends to not be around 30 minutes. Around 2.00 pm I start prepping again for the next client: selecting activities, going over their last session, making sure I have everything I need to start at 2.45pm – we finish at 3.45pm, I write up my notes and then have a cuppa. The next client might be more on-line coaching or a child coming to see me: room cleaned and tidy, materials and activities prepared: client arrives at 4.30 pm and we finish at 5.30 pm. I clean the toys again, write up my notes and it is 6.00 pm ready for dinner. So that was four clients between 9 am and 6pm allowing for preparation, aftercare, cleaning and coffee and lunch.

      Other days I might see three clients and do more admin like ordering toys or books or teletherapy activities, or making materials (we therapist make tons of materials, we’d put Blue Peter to shame!) Sometimes I do two home visits, one in the morning and one in the afternoon – the travelling/parking in London is so time consuming that it really reduces the number of clients I can see which is why I don’t do many of those.

      I hand pick my clients to make sure that we are a good fit, and my service is bespoke: no one client gets the same treatment as another; each client is unique, usually very well-known and always highly valued. That takes time and means that in reality each client gets about 2 hours of my time, that is the actual session plus all the preparation and aftercare.

      I love this way of working and would not ever want to return to seeing tons of clients each day, not knowing any of them really well, due to high caseload numbers, staff shortages and an overload of administration.

      My way of working affords all my lovely clients the help they need to be able to feel empowered and to then support their children to make progress; when working with children they make the best progress they can make, fulfilling their potential. My lovely reviews and testimonials tell me that my clients appreciate the extra attention.

      Find a speech and language therapist for your child in London. Are you concerned about your child’s speech, feeding or communication skills and don’t know where to turn? Please contact me and we can discuss how I can help you or visit my services page.