A Little About Me and This Blog

I have been a licensed Speech-Language Pathologist (SLP) since 1987. I am a member of the American Speech and Hearing Association. I have worked in the states of New York, Hawaii and Florida. I am currently in New York State. I have worked in settings that include public schools, special education preschools, hospitals, adult day treatment programs, home health rehabilitation, early intervention and preschool homebased therapy. I have provided evaluation and therapy to people ranging in age from 6 months to 100 years. I have worked with a wide range of conditions and treatments including fluency, aphasia, apraxia, voice disorders, dysphagia, cleft palate, hearing impairment, articulation delay, language delay, augmentative/alternative communication, autism, and many others through the years.
The purpose of this Blog is to share information and answer questions that you may have. I will strive to provide the correct information to the best of my professional knowledge. I may not share the same professional opinion as other licensed speech pathologists and I encourage second opinions if you want to be as informed as possible.

Sunday, January 31, 2010

Vocal Abuse in Children

     Many children abuse their voices.  A few children will actually develop serious problems as a result. Children are known to yell, scream, cry, make loud motor sounds, make character noises, growl like animals and make other harsh sounds.  Some children are exposed to smoke.  Some children do not correctly use the muscles in their necks when speaking and may tense their neck muscles. This may be a result of inadequate breath support and supply. Vocal abuse is also seen in older children such as cheerleaders, yelling spectators at a sports event or just in a family that shouts a lot. We have all experienced a bit of laryngitis after cheering a sports event, screaming or singing loudly at a concert or a day of overusing our voice.  This one time abuse does not generally have a long term effect.
     Vocal abuse, also known as vocal misuse can lead to serious problems which can include vocal fold inflamation, chronic laryngitis, vocal nodules, vocal polyps, and contact ulcers.  Children may start to exhibit a hoarse or raspy vocal quality which is a sign that something more serious is happening.
    Vocal nodules are among the most common problem that develops.  Kenny Rogers and Rachel Ray have both been diagnosed with vocal nodules.  Their chronically raspy voice is a symptom of this problem.  Vocal nodules are non-cancerous calluses that form on the soft tissue of the vocal folds, also known as vocal cords.  The voice takes on a raspy quality because the vocal folds can not easily close due to the mass on them.  It also takes more effort to get the vocal folds to touch which adds to the problem.
     A diagnosis of vocal nodules is made by an ear, nose, throat doctor, also known as an otolaryngologist. Although surgery can remove nodules, it is not usually the first plan of attack.  With surgery, the nodules can be removed, but if the behaviors are not changed, the nodules can return. Voice therapy with a Speech Pathologist is usually recommended as a first step.  This therapy will include a vocal abuse reduction plan.  The child must learn new voice behaviors that include new breathing patterns, good vocal hygiene and easy onset of speech.
     Most conditions that result from vocal abuse are reversible.  Without treatment, however, children can become adults with vocal nodules. Since it is easier for children to change speaking patterns early, it is best to address it when the problem first starts. 
     It is recommended that you try to keep your child's vocal abuse behaviors as controlled as possible.  This is often accomplished best through modeling.  It is an interesting phenomenon that if you talk very softly to children, they tend to speak more softly as well. The opposite is also true.  In a household that is loud and the family members must shout to be heard or just tend to be loud in general, the children will follow that lead.  Young children will use their voice in a variety of ways during play and that should not be discouraged completely.  They need to make environmental noises to develop speech and language skills. They just need adult reminders and direction to help them keep it under control. 
     I am opposed to the terms "inside voice" and "outside voice" because the children shouldn't be allowed to abuse their voices just because they are outside.  I prefer that they learn one phrase that reminds them to use their soft voice.  This way, they can be reminded to change their vocal behavior with the same reminder phrase no matter where they are at the time.  It is also more clear to them after you teach them the difference between soft and hard voice.

Saturday, January 23, 2010

Reading With Your Child

     I once went to a home where there were two preschool children.  I was there to work with the two year old who was not speaking yet.  The baby would later need services, but I was initially there to help the older boy.  It was at this home that I got a true understanding of the fact that some people are simply not aware of what should be done with children to ensure that they reach developmental milestones of speaking, language, motor skills, feeding etc.  While chatting with the parent and giving ideas of how she can use books with the child in ways other than just reading the stories, she said "We don't have any books for the kids."  I asked if that was because of how expensive they were, because I would be glad to leave some with her.  She answered, "No, we didn't get them any because they can't read yet." This was a very eye opening moment for me.  After this, I knew I would always be sure families of infants and toddlers had books and knew ways to use the books to encourage many skills to develop. The following is just a short list of things that can be learned through books before children learn to actually read the books and some of them are learned even before they are able to speak:
 1.  Visually attending to 2 dimensional pictures as opposed to 3 dimentional objects.
 2.  Isolated pointing with a finger as they touch pictures that are interesting to them or that are named.
 3.  Social time with parent as they spend time with a book.
 4.  Increasing length of attention to an activity.
 5.  Learning labels for pictures which increases receptive vocabulary.
 6.  Learning about things that they can not experience and gaining vocabulary.
 7.  Fine motor skills of opening flaps or turning pages.
 8.  Cognitive skill development as concepts are labeled. For example: "Big dog."
 9.   Develops book orientation, learning how pictures should face and left to right page turning.
10.  Increased listening skills.
11.  Ability to make noises and words that correspond with pictures.
12.  Imitates actions seen in pictures.
13.  Labels pictures or retells words heard in story.
14.  Begins to pretend to read orally.
15.  Begins to anticipate pages or parts of stories.
16.  Following directions such as "Turn the page." of "Point to ___."

     This list of benefits is based on the fact that a parent is using the books with the child.  If the books are available to the children, but not used with them, they will not get any of these same benefits, because there will be no one modeling the words or proper book use.  Babies will not naturally learn what to do with a book without the added interaction of an adult.  They will likely look at them on their own as well, but it can't be stressed enough, how important it is to make it an activity that is also together. 

     Using books with a child does not mean the same thing a reading stories to them.  All children are at different levels of understanding and with different attention spans.   The youngest children will do well with the sturdy cardboard books with bright pictures.  A few large pictures per page make it interesting for them to look at, easy for you to label for them and easy for them to know what you are referring to.  Say "Apple" as you point to the apple.  The babies will soon start imitating the pointing.  Later, you can ask questions such as "Where's the apple?" and they will point.

     As children get older, use books with one sentence per page that refers to the picture.  You can use the sentences and then add to it yourself by looking at the pictures and talking about them in more detail.  For example, if the short poem "Twinkle, twinkle, little star"  is on one page, you can read the poem, and then talk about the picture.  Say things like "I see 5 stars...1-2-3-4-5."  "Stars are up in the sky." 

     Read with your child every day.  Show excitement for reading.  Be enthusiastic and very animated with reading.  Be a great storyteller and it will keep your child's attention. Make it part of the naptime and bedtime routine.  Other times of the day are great too as long as it is a relaxed atmosphere.  Let the child choose the books, let them help hold the book and turn the pages. Let your child point to pictures and talk about things. Let you child fill in the last word of a sentence in a familiar story. There are many ways to use books, be creative. 

     Never worry about the fact that you didn't "Read" the story to them.  It is not the completion of the written words on the pages that matters.  It is the time with you and the time with books that will make the difference.

     Books are expensive, but I encourage everyone to purchase a few.  In addition, I think it is extremely important to introduce young children to the public libraries.  Depending on your area, libraries are now offering many activities for infants and toddlers.  It becomes a nice routine to go once each week to read books there and to bring new ones home.  Attend any story time activities that are offered.  This prepares children for the large group setting of a classroom to listen to stories and enjoy books/stories  told by others.

     It is also good also for your children to see you reading.  Reading the newspaper, magazines and your own books will show children that reading is fun and since they like to copy their parents, they will probably go and get one of their books when they see you reading!  Read with your older children as well.  When they begin to read chapter books on their own, take turns reading the chapters.  At night, even older children enjoy the time you will spend with them reading to them. They will always remember this time with you too.  Have fun and read every day with your child!

Wednesday, January 13, 2010

Parts of Speech Review

     When we are in school we learn the parts of speech and their definitions.  Later, most people can remember things like "A noun is a person, place or thing." or "A verb is an action."  It is all of the other parts of speech that we forget.  It is not until your fourth grader comes home with homework that it all starts to come back to you.  I thought I would do a little review of the definitions of the parts of speech and some other terms we learned in elementary grammar lessons.  In language therapy, if a child is having difficulty with grammar, we will focus on specific areas of weakness.  Some students need to be more descriptive in their writing so we work on adjectives.  Some students have difficulty with irregular plural nouns or verb tense agreement. I will not get into the complications of the language such as when words are sometimes pronouns and sometimes adjectives for example.  Anyone interested in more than the basics can feel free to research this topic. Here is a list of terms with examples. Some you may remember and some may be unfamiliar.

Common Noun: A word used to label a person, place, thing or idea such as ball, home, or happiness.
Proper Noun: Names a particular person, place or thing and is capitalized, such as Bob, Chicago, or  the Declaration of Independence.
Pronoun: A word that takes the place of  one or more nouns such as he, she, it, both, you.
Adjective: A word used to modify a noun or pronoun. It will often be a word that will answer the questions What kind? Which one? How many? or How much?  Examples : tall, last, many.
Article:  The most frequently used adjectives: a, an, the.
Proper Adjective: An adjective formed from a proper noun which will also be capitalized such as:  American flag.
Action Verb: A word that expresses a physical or mental action such as run, or imagine.
Linking Verb:  A word that helps to make a statement by linking the subject and predicate. The most common are the forms of the verb be: am, is , are, was, were, been, be, being, been.  Other common linking verbs are: seem, taste, become.
Helping Verb: A word that accompanies other verbs to make a verb phrase. Some examples are will, have been.  She will walk.  They have been wondering.
Adverb: A word used to modify an adjective, verb or another adverb.  Usually answers questions When? Where? How? and To what extent? Examples: It started here. He threw the ball far.
Preposition: A word that combines with a noun or a pronoun to make a phrase. Examples: in, on, under, from, off, through, against.
Conjunction:  A word that joins words or groups of words. 
      Coordinating Conjunctionand, but, or, nor, yet
      Correlative Conjunction:  Found in pairs with other words between them: either...or, neither...nor,
             not only...but also.
      Subordinating Conjunction: A word that introduces an adverb clause such as since, as, because, or 
             if .
Interjection: A word that expresses emotion and is not related to other words in the sentence grammatically.  Examples: Oh! Wow! Well, 

Tuesday, January 12, 2010

Bubble Play for Early Sound Development

   One of my most favorite activities to do with infants, toddlers and preschoolers is to play with bubbles.  The kids absolutely love bubbles and I often bring them out for the last few minutes of a session.  The older kids think it's a reward and will work well with the promise of bubbles. I love them for several reasons.  If the child is old enough, I have them practice blowing the bubbles as part of the activity.  This works on oral motor strength and coordination.  I use bubbles to encourage sign and gesture usage for "more," "please," "done," "bye," "yes," etc.  I use related words to encourage all early developing sounds such as /h,p,b,d,m,n,w/.  Some bubble play related words are: bubble, more, up, bye-bye, pop, done, please, wet, gone, blow, wow, uh-oh, high, yes, no.
   When blowing bubbles with the child...use the key words repeatedly. For example: "Look....bubble..up-up-up...bye-bye bubble....pop-pop-pop...."  "More bubble...pop-pop-pop....all gone..."  "More bubble...uh-oh...pop-pop-pop...."  "Bubble...wow!....up-up-up... uh-oh...pop!"   "Wow...high bubble....bye-bye." This is also a chance to ask questions of your child and encourage responses either verbally or with gestures.   Ask child "Do you want more?"  Encourage them to use head gesture for "Yes," sign for "More" or use words if they are able to say "more" or "more bubble."
     This bubble activity is done regularly and the children begin to respond to the repetiveness of the words modeled and the activity of blowing and popping (popping the bubbles with a pointer finger encourages fine motor skills as well). They will often imitate the repeated words like "pop-pop-pop" after a few sessions.  Soon they start to use some of the phrases spontaneously!   Parents in my sessions usually love this activity as well.  I encourage them to get bubbles and use them as often as possible when the children are learning these early sounds..  I recommend the spill proof type of bubble containers that are available now.
     I will also work on body parts and object recognition with bubbles. I will catch the bubble on the wand and pop it on a body part or toy while I label it.  "I'm going to pop this bubble on your foot."  "Pop on block."  You are then modeling speech sounds and vocabulary.
     So get those bubbles out and have fun!  The learning opportunities are endless.

Tuesday, January 5, 2010

Keep A First Words Journal

  When I first go into a home to start therapy with a toddler that is delayed in their speech I always ask the parents how many words the child currently uses.  At first, parents usually do not know exactly how many words their child has.  They may then start remembering that their child has said "mama" or "baba" or "dada."  There are situations where this is actually the number of words the child has. More often, however, the child may actually have ten to twenty words in their expressive vocabulary.  Parents can forget easily, even though at the time they think they will remember every word the child uses.

   One of the first things I do is to have the parents start a "First Words Journal" in the form of a piece of paper placed on the refrigerator. I find this is the best method for ensuring that the parents use it.  They see it and are reminded of it often.  Whenever their child uses a word, they are to write it down as soon after they hear it as possible. The date should be added so it can be determined how often new words are added. If they hear the word again, they are to put a tally mark next to the word that had been written previously.  This helps to see the number of times the child uses specific words and which words may have just been a one time production.

     Parents aren't expected to keep a perfect record, but in one week an impressive log is often compiled.  Through the course of therapy, I have parents continue to keep the journal as the child uses more words.  Before long, there are often two word phrases added to the list!  This is a great way to see the child's progress and have the parents be more aware of their child's speech attempts.  Parents tend to get  more involved trying to encourage new words to be able to add them to the list.

     This is a great way to document any child's first words and phrases and becomes a keepsake for memory books.  I especially encourage parents to use this if they suspect a delay.  Be sure to date the new words the first time they are used.

Monday, January 4, 2010

A Day in the Life of a Speech Pathologist

      Today was my first day back to work following the Christmas Vacation.  I thought I'd share with you a little timeline of my day.  Every day is so different, I'll share one of my totally different sort of days another time.

     I dropped my son off at the high school at 7:15.  I arrived at the Intermediate School by 7:30 after stopping for a large coffee.  Our school building has 4th and 5th graders only.  I turned on the computer and logged on to the Online IEP site. An IEP is an Individualized Education Plan and it is the document that contains the test results, goals and other relevant information about the students.

  I spent the next hour on the computer.  I first entered the attendance for the month of December for my Medicaid eligible students into the related service log of each student's online IEP.   Next, I realized that it was January and the second quarter progress codes needed to be entered  on each goal for all 26 of my kids with IEP's. This online program takes at least half of the time off of "paperwork" like this.  I only work at this school 17 hours a week, so 26 kids is quite a few.  I also have 8 kids that receive "speech improvement" and do not have an IEP. 

I had finished entering the progress codes (NP for no progress, SP for some progress, PS for progressing satisfactorily etc...) and had enough time to check school emails like the Principal's weekly newsletter and general requests from teachers for things.  I then wrote an email to all of the teachers that had my students in their classes.  I told them that I had to get started on annual review testing because I had half of my kids with early meetings this year.  They are scheduled for February 24 &25th which is much earlier than we are used to.  A change in Committee for Special Education scheduling caused this change for us.  Onced I hit send, the 8:30 bell rang.  This bell releases kids to their classrooms and to breakfast.  I take a Breakfast Club group of speech improvement kids to work on sounds 'r' 's' and 'th' during this first half hour of the day before morning announcements and the school day technically begins.  These kids do not have an IEP, so I don't feel right seeing them during the school day.  Kids with an IEP have a documented time out of regular education slated for their therapy sessions. 

The day is broken into half hour intervals for most pathologists. From 8:30 am until 2 pm were my 10 time slots for today.  This is my longest day at the school.  Other days I am only here about 3 hours.  Here is how the rest of my day played out.

9-9:30 I pushed into a reading class that I have 5 language students in.  A typical lesson in here is reading a chapter in a book and answering comprehension questions.  Today we also worked on combining sentences such as The girl is running.  The boy is running.  The girl and boy are running.  OR They are running. 
9:30-10 I typically push into a reading class with a boy with Asperger's.  Today I pulled him out for a little testing.  He has trouble with things like use of idioms, metaphors, similies etc.
10-11 I pushed into a collaborative teaching classroom during English/Language Arts time.  Mondays is the beginning of a spelling list week.  They get a list of words, write these words into sentences, practice writing them in cursive, alphabetize them and copy them onto a list to study at home.  During the rest of this time I provide lessons that directly address the goals of the students in there that are on my caseload.  There are 7 in this particular group. 
11-11:30 I pulled a student from his classroom for testing.
11:30-12 I see a small group of three kids in my therapy room.  They are working on a variety of things, but the group works well together.  One student leaves off all plural and possessive "s" markers and used the wrong tense in his spoken and written expression.  The other boy in the group needs work on social skills involving conversation rules and socially appropriate topics and skills.  The girl in this group needs to speak more loudly, provide longer and more complete answers and learn to use more descriptive words in her speaking and writing.  Today was a conversation about vacation and Christmas presents.
12-12:30 I had a break.  I spent this time going through all of my files to find information for a parent I met on twitter that has a child in need of speech therapy. I was unable to make any copies for her though since the copy machine ran out of toner with all the teachers using it this morning. Grabbed a cereal bar while I looked through files.
12:30-1 I pulled another student for some testing.
1-1:30  Yet more testing. 
1:30-2 Back on the computer to go into the IEP site again.  This time I had to sign off on two therapists' attendance.  In our district there are two therapists and two pathologists.  I am the supervisor of the two therapists and I have to sign off on all of their testing, therapy, attendance, etc. 
2-2:30 Worked with two students who have Aspergers.  Great session on idioms.  One of them has caught on a bit that they are not meaning what they sound like.   The other student is so literal, he can not yet get past it. It was fun though.
2:30 I left the school...but I was not done working yet!
2:45-3:15 I worked in a home with a 4 year old who has recently had his tongue clipped.  He needs retraining in saying many words now that he has more tongue mobility.  We are working on 't' and 'd' as well as 's'  He previously made these sounds way in the back of his mouth...uses g for d for example.
3:30-4 I worked with a 2 year old boy in his home.  He is just starting to use words and we are noticing that he leaves off all initial consonants.  We are addressing this as well as increasing vocabulary and having him be able to follow more directions. 
4:00....Headed home to make dinner. Evening activities begin.

This was my first day back after a very relaxing vacation.  I honestly do not have any brain power left to write an in depth, educational post today.  Hopefully tomorrow I will be back in the swing of things! 

Sunday, January 3, 2010

Phonological Processing Delay vs. Articulation Delay

 Many children have difficulty producing sounds correctly. This is referred to as an Articulation delay or even sometimes as a Phonological delay.  In previous posts I have discussed speech sound development and given some information about delayed speech production skills.  Today I will discuss the difference between an articulation delay and a phonological processing delay.  There is great information on the ASHA Website on this topic as well.

An Articulation or a Phonological delay is a delay in the ability to produce sounds correctly.  Children may be late to speak in general or not master sounds at the times that other children do.  These sounds are usually substitutions of an easier sound for a more difficult sound.  An example is a child saying a /f/ for a /th/ in the word "bath."

A Phonological Processing delay is a sub-group of Articulation Delays where children have difficulty with a pattern(Process) of speech sound productions.  Children all use phonological processes in their developing speech.  A child's speech becomes phonologically delayed  when they continue to use these normal processes past the typical age of use. I will  give you one example of a typical phonological process.
The one phonological process that I work with most often is called Final Consonant Deletion also called Deletion of Final Consonants.  This is very common as children learn speech. It is a normal pattern.  They will say "da" before they say "dad" they will say "kuh" before they say "cup."  As children approach age 3 to 3 1/2, they have generally stopped using this process.  They will now use final consonants on a regular basis. If children are still using these processes past the general age of elimination, they may need to address it directly in therapy. 

   Once in a while a child will use a phonological process (pattern) that is not typical. This is identified as a phonological disorder rather than just a delay. I currently have one child using Deletion of Initial Consonants.  This is not a typical pattern, it is challenging to address, but I am seeing progress.  He is able to produce all age appropriate sounds in isolation and at the end of single syllables. Our therapy has focused on encouraging initial consonant production by taking him through the sounds developmentally.  Since /m, b, p, d/ are typically early mastered sounds and since he could produce them well in the final position, we started encouraging production of these sounds before a vowel such as "ba," "be," "boo."  Once he mastered this, we added a final consonant to see if he could maintain the ability to produce it in the initial position.  He is showing progress with this method and now has some spontaneous words that begin with /m, b, and d/.

Saturday, January 2, 2010

Speech Sound Development Guidelines

     Children develop at different rates in all areas.  There is a general guideline for when children reach developmental milestones, but there is a wide range of what is considered normal development.  This is also true in the development of speech sounds in children. This may be referred to as Articulation Skills as well. The guidelines below are just that, they are only meant as a guide, not a definite rule. Different sources may place sounds at different age mastery, so you may read a source with slight variations to what I have here. The ages at which children master sounds, means that they are able to use the sound correctly in all word positions on a consistent basis.  Children are always working on some sounds and can use them correctly in some word positions.  We call those sounds emerging.

     The earliest sounds that are generally mastered by children are /m,p,b,h,w,n/. Most children have these sounds mastered by the time they turn 3.  While they are reaching mastery on these sounds, they are working on perfecting the following sounds: /k,g,d,t,v,f, y/.  These sounds have generally been mastered by age 4.  By age 6, children should now be able to use /ing, l, j, sh, ch, zh/.  The sounds that are generally the latest to be mastered are/r, s, z, th/.  Children at age 7 and 8 could still be working toward mastering these sounds. 

     Children generally use substitutions for sounds that they have not yet mastered.  You will likely hear a three year old use many words, but not use the sounds of these words correctly.  They may say "I wub ew" instead of "I love you." because they may still be working on mastery of /l, v, y/ sounds.  We know what they are trying to say, but there are sound errors. Parents can usually fill in the blanks of their child's speech.  They often do not even consciously notice the errors. 

     You may have a child that is making some later sounds, but not yet some early ones.  This is possible.  In this case,  be sure to model these early sounds and do things that exaggerate the sounds they are missing.  It is fine for parents to notice that a child is not making the /d/ sound, for example, and try to boost the development of this sound by doing activities that incorporate it.  When you are rolling a ball down a slide say "down, down, down"  Have child imitate.  It is fine to have them look at you and tell them to listen to how you say it.  Exaggerate the "d" while they see how you make it. 

     In an earlier post I told how learning speech sounds involves some trial and error.  If a child is of an age that should be mastering a particular sound and he is not, it is fine to point out this sound and focus on it in play and activities. They will not know they are using sounds incorrectly if it is not addressed either directly or indirectly through modeling.  I will do a later post on some activities to work on  single sounds.  If you feel that your child's overall speech sound development is delayed, contact your pediatrician who can refer you to a  Speech Pathologist for an evaluation and therapy.  If they do qualify for therapy, parents will still need to be involved in modifying the child's sound by doing activities and modeling suggested by the therapist.

Feel free to ask me questions if you are a little unsure about your child's current sound development. 

Friday, January 1, 2010

The Difference Between Speech and Language

     The difference between "speech" and "language" has been a confusing point for many people. I have been called a Speech Therapist, Speech Teacher, Teacher, or Speech-Language Pathologist depending on who is saying it.  Some people think I teach others how to give speeches, some think I teach kids how to speak and some think I am an English or reading teacher.  One of the biggest confusions in public schools is when kids "go to speech" but we work completely on language goals. Some kids, as well as teachers and other adults, are confused by this contradiction. To alleviate this confusion just a bit, I will provide some definitions and explanation to help differentiate. This is just the quick explanation.

SPEECH (ARTICULATION):  In the context of my profession, speech is the physical process by which we verbalize language.  It is a method of communication that uses voice and coordinated movements of the speech articulators (tongue, lips, jaw, teeth etc.).  When I am addressing "speech" in therapy, I am working on the person's ability to have adequate strength and coordination of the speech musculature through oral-motor exercises.  I am working on teaching them correct articulation or placement of articulators for production of specific consonant and vowel sounds.  For example, when a child produces an "f" instead of a "th" sound I first make them aware that they need to place their tongue between their top and bottom teeth, and blow gently rather than gently biting their bottom lip with their top teeth for making an "f."  Once they learn the correct placement, we practice the sound alone, then we practice it at the syllable level, we practice it in all positions of short words, we progress to multi-syllable words, then phrases, sentences, and finally conversation.  It is a lengthy process to correct an error sound because there is conscious effort needed on the person's part.  Eventually, with practice, there is muscle memory and a change from voluntary concentration on the sound to an involuntary carry over of correct production to all contexts. It can be compared to anyone attempting to change a habit.

 LANGUAGE: The understanding and use of our language is the focus of language therapy.  A few of the things I might address are concepts, grammar, use of language in social settings (pragmatics),  morphology (plural markers, possessive markers, irregular verb tense...), word finding, vocabulary, synonyms, homonyms, and written expression.  This is not a complete list, but it gives you an idea of the category.
When children are evaluated for their language abilities, there are assessments done in receptive and expressive language areas separately.  Children generally have better receptive skills than expressive skills since they can understand things before they can express the same things. Testing for specific areas of weakness helps to guide the development of goals for each child.
     Receptive Language:  The general definition of receptive language is the processing and understanding of language.
    Expressive Language: Expressive language is the use of the language. This can be in any form such as oral or written.