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 We started out generalising the /K/ sound which until recently had been replaced by a /T/ sound.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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    (Stiegler, 2015, Fay 1967, Blanc 2014)

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    Much research has gone into the meaning and treatment of Echolalia and the following list consists of possible functions that have been identified:

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    • Labelling
    • Drawing attention to self
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    • Requesting
    • Giving instructions
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    (Stiegler 2015, Prizant 1983)

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  • · ·

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    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.

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    Methods

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    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.

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    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

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    1
  • · ·

    The Hanen Program® – The beauty of the ‘4 S’

    ByLondon Speech and Feeding
    Image by freepik

    One of my favourite pieces of advice I give to parents is the ‘4 S’, a strategy coined by the Hanen Program® which I teach, particularly the ‘More than Words’ programme which is designed for and aimed at parents of children with Social Communication Difficulties or Autism. It is honestly one of those golden nuggets that I use myself in my practice and I highly recommend it to all my parents. There is something about terms like the ‘4 S’ that is easy to recall and therefore use.

    Introduction

    The ‘4 S’ is a strategy that helps to clarify the words we use with our children so that they can notice us, hear us and understand what we are saying.

    Research shows that we use on average 120-200 words per minute during everyday conversation. That’s a lot! And our children who are still learning to communicate are often bombarded with endless speech coming at them all day long. If we take into account that many of our students are Gestalt Language Processors, we can see that picking out relevant chunks of what we are saying is not at all easy, and this contributes to our children’s delays.

    So let’s look at the ‘4 S’

    1. The first one is SAY LESS

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    Good grammar helps to give clues about what words mean and how they are used in sentences. So, instead of ‘shoes on’ say ‘let’s put our shoes on’.

    2. The second one is STRESS

    I hear you think ‘I am stressed!‘. – NO! here it means ‘highlight’. We use our voice to highlight the important words in our sentence or phrase. For example, when you say ‘this banana is so yummy’ you can stress the word ‘yummy’ by saying it a bit louder and you can make a gesture, like rubbing your tummy as you say it.

    3. The third one is GO SLOW

    This means to speak a bit slower than you normally would and add pauses. By slowing down the pace of our speaking we give our child time to think and understand what we are saying. When we allow for pauses after we have spoken, we are inviting our child to say something in response.

    4. The last one is SHOW

    Always remember to show actions, gestures, objects, and point to pictures while speaking to help support your child’s understanding. We can show our child what words mean by pointing to things or holding up objects whilst describing or talking about them.

    At this point I would also like to recommend the use of Core Boards, and particularly Electronic AAC devices, such as LAMP Words for Life or PODD. I have written about this in other blogs but can always be persuaded to say a bit more on the matter… 😊 It is such a big help to have an AAC talker available for both the child and the adult so we can find words and pictures to help support the words we are saying.

    For example, today when reading a book like The Hungry Caterpillar (so good!) I used my LAMP AAC talker to make comments as we were looking at the pages together with my student. Example: ‘Look! He is eating more cake he is very hungry’ using my AAC talker I was able to supplement my speech and at the same time I was inviting my minimally speaking child to press a button or two and reply with ‘cake!’ which they would not have said with their mouth otherwise.

    5. It does say ‘4 S’ but really it should be ‘5’ except the fifth is not an ‘S’

    The fifth is REPEAT.

    Repeat words and phrases often throughout the day. When learning a language we all need to hear words and phrases several times and in different situations before we can understand, remember, and then eventually use them. Our children are ‘new language learners’ and so we can apply the same principles that we would when learning a new foreign language ourselves.

    Any questions or need help with supporting your little one’s language please contact me via my contact form, or you could also check out www.hanen.org for advice and lots of inspiration.

    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
  • · ·

    Your child’s communication journey

    ByLondon Speech and Feeding

    Understanding our neurodiversity-affirming, child-led approach

    Welcome to a different kind of therapy!

    Your child’s communication journey

    The start of a new year often brings fresh hope, and sometimes fresh worries, for parents supporting their child’s communication. I am always genuinely excited to begin a new journey with children and their families, and I know that, for many parents, this kind of therapy may look very different from what they were expecting.

    Parents (and children!) are often surprised to discover that our sessions are playful, joyful, and intentionally low-pressure. You won’t see demands for eye contact, sitting still, or being told to ‘do it this way’ or ‘put the red square there’. Instead, you’ll see your child being met exactly where they are.

    For families who have previously experienced more adult-led or behaviour-based approaches including Applied Behaviour Therapy, this difference can feel unfamiliar at first. Because of that, I want to take a moment to prepare you for what child-led, neurodiversity-affirming therapy looks like, so you can feel confident, comfortable, and reassured from day one.

    Why doesn’t child-led therapy look like ‘traditional’ therapy?

    Many people picture speech and language therapy as sitting at a table, using flashcards, or practising words through repetition. While those approaches can work well for some children, they are often not effective or appropriate for many neurodivergent children—including children with autistic profiles, ADHD, or demand-sensitive nervous systems.

    Our approach is grounded in a simple and powerful truth:

    Children learn best when they feel safe, motivated, and emotionally connected.

    When a child’s nervous system feels calm and secure, learning becomes possible. When a child feels pressured or controlled, communication often shuts down, even if they can speak.

    🎯 Our purpose: Communication through connection

    Our goal is not simply to help your child say more words. Our goals go deeper and are built on strong foundations:

    • Trust and regulation: We focus on building a trusting relationship where your child feels safe, understood, and emotionally regulated. A calm nervous system is the starting point for all communication.
    • Motivation: We follow your child’s intrinsic motivation, the things they naturally enjoy to make communication meaningful, joyful, and purposeful.
    • Spontaneous communication: We create opportunities for your child to communicate because they want to, not because they are asked or instructed to.

    🧸 What to expect in a session

    Our sessions are intentionally child-led and often look very much like play.

    FeatureWhat it looks likeWhy we do this
    Minimal toysWe usually offer just 3–4 carefully chosen activities (such as bubbles, blocks, or sensory play).Less is more. Fewer choices reduce overwhelm and help children focus on what genuinely interests them.
    Child choosesYour child decides what to play with and how to engage.This immediately establishes us as a safe, non-demanding partner and increases motivation.
    The therapist’s roleWe join your child’s play, observing closely and responding naturally.We model language, share attention, and reflect your child’s experiences in a way that feels natural and supportive.
    No pressure or demandsThere are no ‘must-do’ tasks. If your child wants to spin, crash, line up toys, or repeat an activity, we follow.Reducing demands lowers anxiety and supports communication, particularly for children with demand-sensitive profiles.

    Is this really effective?

    It’s completely natural to wonder, ‘Are they just playing?’ The answer is yes, and very intentionally so.

    Our sessions are guided by nearly 30 years of speech and language therapy experience, alongside clear, achievable goals tailored to each individual child. Play is a child’s natural language and their most powerful learning tool.

    Within play, we are constantly creating opportunities to:

    • Build joint attention (sharing focus and interest)
    • Model language at the right level
    • Encourage back-and-forth communication
    • Develop a deep, authentic connection

    If your child has struggled to engage or communicate in more structured or demand-heavy settings, this child-led approach is often the key to unlocking their potential.

    💛 What this might look like at home

    You may notice that when pressure is reduced:

    • Your child begins communicating more during everyday routines
    • Language emerges through play, movement, or shared enjoyment
    • Communication feels more natural and less forced

    Small moments could be a shared smile, a look, a sound, a gesture. All matter. These are the building blocks of meaningful communication.

    📚 Resources for parents

    If you’d like to explore these ideas further, you may find the following helpful:

    I look forward to meeting you and your child. Please bring any questions, uncertainties, or curiosities to our first session, there is no such thing as a silly question. This is a journey we take together. Contact me via my contact form.

    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.

    3
  • · ·

    Using AAC during play with your child

    ByLondon Speech and Feeding

    Playtime! It’s a magic time for exploration, learning, and connection.

    If your child is struggling to use words with his/her mouth, we can always use a robust Augmentative and Alternative Communication (AAC) device to help find their words. We know that using such a device does never stop or delay children to speak with their mouths. On the contrary it helps, enormously!

    Can playtime still be a blast? Absolutely! In fact, incorporating AAC into play can be a powerful way to boost communication skills, build confidence, and create a truly inclusive play experience. Here’s how to make it happen, with a focus on core words and core scripts for our GLP’s (the building blocks of communication used by everyone). In this video I am using the core word ‘IN’ and ‘MORE’.

    The Magic of Core Words

    Core words are the most frequently used words in everyday communication. They might be verbs like ‘want’, ‘more’, ‘go’, or ‘stop’, or adjectives like ‘happy’, ‘sad’, and ‘hot’. These words are the foundation for building sentences and expressing needs and desires. They’re perfect for children using AAC because they’re simple to understand and use.

    Let’s Play! Here’s How

    1. Choose Your AAC System

    Many options exist! It could be a low-tech picture board with core words, such as the one you see pasted on my cabinet door in the background, or it can be a dedicated AAC app on your tablet. Here I am using the GRID app but I also love using others, such as LAMP Words for Life.

    2. Make it Fun and Functional

    No pressure! Integrate your AAC system seamlessly into your play routine. Here are some ideas:

    • Car/trains: Use core words to describe what the cars are doing: (‘down’, ‘go’, ‘stop’, ‘again’ ‘fast’ ‘slow’).
    • Dress-up: Use core words to choose clothes (‘want’, ‘hat’, ‘shoes’).
    • Tea Party: Use core words to ask for and share (‘more’, ‘juice’, ‘give’).
    • Building Blocks: Use core words to describe what you’re building (‘tall’, ‘big’, ‘house’).
    • Dolls/Stuffed Animals: Use core words to act out scenarios (‘sleep’, ‘eat’, ‘cry’).
    • Arts and Crafts: Use core words to describe colours (‘red’, ‘blue’), actions (‘draw’, ‘paint’), and feelings (‘happy’, ‘sad’).

    If your child is a Gestalt Language Processor you will want to model meaningful, fun scripts instead of single words! As above, but use phrases:

    • Car/trains: Use scripts to describe what the cars are doing: (‘it’s going down’, ‘let’s go’, ‘make it stop’, ‘want it again’, ‘that was fast’, ‘it’s so slow’).
    • Dress-up: Use scripts to choose clothes (‘I’m gonna wear this’ ‘that’s a lovely hat’, ‘let’s choose shoes’).
    • Tea Party: Use scripts to ask for and share (‘I want more’, ‘more juice’, ‘give me this’).
    • Building Blocks: Use scripts to describe what you’re building (‘a tall one’, ‘that’s so big’, ‘it’s a house’).
    • Dolls/Stuffed Animals: Use scripts to act out scenarios (‘it’s time to sleep’, ‘let’s eat’, ‘he’s crying’).
    • Arts and Crafts: Use scripts to describe colours (‘a red crayon’), actions (‘let’s draw’, ‘I’m gonna paint’), and feelings (‘I’m happy’, ‘that’s so sad’).

    3. Model, Model, Model

    This is key! As you play, constantly model using your child’s AAC system.

    • Point to the picture or word or script you’re using.
    • Speak clearly and slowly while pointing.
    • When using core words for either Analytical or Gestalt Language Processors, try using good phrases. For example, instead of just saying ‘juice’, say, ‘you want more juice?’

    4. Make it a Team Effort

    Get everyone involved! Encourage siblings, grandparents, and caregivers to use the AAC system with your child during playtime. The more consistent the approach, the faster your child will learn and feel confident using their voice.

    5. Celebrate Progress, Big and Small!

    Every step counts! Acknowledge and celebrate your child’s efforts, whether it’s reaching for their AAC system or successfully using a core word. This positive reinforcement will keep them motivated.

    Remember

    • Playtime should be fun, not stressful. Don’t force your child to use their AAC system. Let them lead the way and follow their interests.
    • Every child develops at their own pace. Celebrate your child’s unique communication journey.
    • Seek professional help when needed. Your SLT can provide tailored strategies and resources to support your child’s development.

    By incorporating AAC and core words into playtime, you’re not just fostering communication; you’re creating a space for your child to thrive, explore, and build strong connections.

    So, grab those toys, power up your AAC system, and get ready for a playtime adventure filled with fun, connection and, therefore, communication!

    Don’t hesitate to contact me!

    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.

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