Q: I am working with a child 2;6 who substitutes /n/ or /m/ for many other consonants.  We have worked with words she says often, and she can make the correct sounds in words with a model, but talking on her own she just sounds like she is whining.

Two-year-olds can be so variable, and what looks like something very severe can turn out to be nothing.  She simply may be jargoning, and her jargon happens to sound like whining.  Time and more treatment may be all she needs. HOWEVER–– With excessive nasality like this, she may need to be seen for VPI evaluation. Do you know if this ever has been initiated for her?

Referring for VPI evaluation can be very problematic with toddlers because you don’t want to alarm the parents unnecessarily. They probably have never heard of a VPI and to introduce it now may send them into a panic. But yet you need to know what is going on.

I probably would see her for a while (3-6 months) and do whatever I could to stimulate a wide variety of phonemes without bringing up the possible VPI issue.  I would stimulate all Cs and Vs. Don’t worry about trying to change the ones she is using wrong. Just encourage her awareness and production of all the C’s and V’s.  You could work in simple cycles––one week on P, one week on T, one week on S, and so forth.

See how she moves along. See what changes and emerges. Research has shown that toddlers have tremendous variability in phoneme productions until three years of age, so the therapy does not have to be so much about correction as it does general stimulation of phonemes. Let her mix up the phonemes and make mistakes, but just shoot for more variety. Enjoy and celebrate every new word and sound.

I also would have her playing regularly with a kazoo.  As you probably know, the kazoo only works when oral sound is produced through it.  So use it to encourage general oral sound and to reduce the amount of time she is making nasal sound.

And see how she comes along and how she changes. If she starts gaining new sounds, and they are not nasal, then you know that this is not a structural problem, and she just needs more therapy.

But if she continues to produce only nasal Cs, and if there is nasality on the Vs, and she cannot make sound through the kazoo because she cannot direct airflow only through the mouth, then I would teach the parents about the VP mechanism and express my concern in terms they can understand, and I would refer her to an ENT for evaluation.

You probably will have to refer to the primary physician. So write a great short letter explaining your concerns.  Make sure you tell the physician that the child should be moving along faster than she is, and use the phrase “to rule out any velopharyngeal structural anomalies.”