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What Is Speech Therapy?

If your child needs speech therapy, you're not alone. Here's everything you need to know about speech therapy for kids and toddlers.

How Does Speech Therapy Work?

What does speech therapy treat, signs a child may need speech therapy.

• What is Early Intervention Speech Therapy?
• Speech Therapy for Toddlers

Speech Therapy for Elementary-Aged Kids

What about private speech therapy, what age is best to start speech therapy, how parents can refer their child for speech therapy, does insurance cover speech therapy, how long will my child be in speech therapy, how effective is speech therapy.

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If your child is currently in speech therapy or you're wondering if they might be a candidate for it, you're not alone. According to the American Speech-Language Hearing Association (ASHA), almost 8% of children in the United States have a communication or swallowing disorder. It doesn't mean you've done anything wrong, but it can be tough for families. The good news is speech therapy can make a difference.

So, what is speech therapy and how can it help? Here’s everything you need to know. 

Speech therapy is the treatment of communication, voice, and feeding/swallowing disorders by a trained professional.

Speech-language pathologists (SLPs) have a master's degree in speech-language pathology and specialize in evaluating, diagnosing, treating, and preventing these disorders. SLPs hold a license to practice in their state. 

You may also come across ASHA-certified SLPs. They have taken an additional step to pass a national exam and complete an ASHA-accredited supervised clinical fellowship.

There are various reasons a child may need speech therapy. Common ones include:  

1. Speech sound disorders. This means a child has difficulty with the production of speech sounds and how we combine them into words.

2. Language disorders. A child will have difficulty understanding and/or using language to communicate. Language disorders may impact vocabulary development, grammar, as well as the ability to tell a story, follow directions, answer questions, and more.

3. Social communication disorder/pragmatic language disorder . In this case, a child will have difficulty using language to socialize. This may include difficulty understanding social cues, taking turns during conversation, initiating or maintaining a conversation, and understanding personal space. A social communication disorder often leads to difficulty forming friendships. Children with these language barriers may have a concurrent diagnosis of autism spectrum disorder .

4. Cognitive - communication disorder . This includes difficulty with memory, reasoning, problem solving, and organization, impacting the ability to communicate.

5. Voice disorder . Children will have differences in voice quality (e.g., being too hoarse or too nasal).

6. Fluency disorder/stuttering . Kids will have difficulty maintaining a smooth flow of speech. A fluency disorder may include repetitions of sounds within words, prolongations of parts of words, and/or pauses in speech.

7. Feeding/swallowing disorder . This presents as a difficulty with sucking, chewing, and/or swallowing food or liquid.

Children may need speech therapy when they have not acquired speech/language milestones by an expected age. While milestones can vary from child to child, parents should refer their child for an evaluation if they have any concerns. Evaluation, which may include both standardized and non-standardized testing as well as observation, can help diagnose a speech/language disorder.

Some signs that may indicate a need for speech therapy include:

• A child isn't babbling by 6-7 months
• The child is having difficulty with feeding and/or swallowing
• A child beyond the age of 1 has no words
• A child beyond the age of 2 is not combining words into phrases
• The child's speech is difficult to understand
• The child is omitting syllables or sounds in words
• Speech errors are noticed during conversation
• The child has difficulty following directions or understanding spoken language
• The child has difficulty answering questions
• The child has a smaller vocabulary than what is expected for their age
• The child is stuttering
• The child's voice quality has changed or is noticeably hoarse or nasal
• The child has difficulty communicating with others socially
• The child has hearing loss
• The child has a cleft lip or palate

What is Early Intervention Speech Therapy? 

Early intervention refers to state-funded evaluations and interventions—including speech therapy—for children, ages birth to 3, and their families. In some states, early intervention continues until the age of 5. While professionals may refer a child to early intervention, parents can also refer their child on their own.

Speech Therapy for Toddlers 

Speech therapy for toddlers usually resembles play where toys are used to elicit target skills, says Dominica Lumb, M.S., CCC-SLP, who has over 30 years of experience conducting speech therapy with children in various settings. 

Children are given choices during play to encourage the need to communicate. While working on language skills, toddlers are encouraged to request objects, ask questions, answer questions, and use appropriate vocabulary.

Parents may be included in therapy sessions at this age. They may be taught to model speech sounds or how to label objects and actions during everyday routines to enhance vocabulary development.

Speech therapy can also work differently depending on a child’s needs. For example, one may require a mode of communication that differs from speaking. That’s referred to as augmentative and alternative communication (AAC) and may include picture boards or computers/iPads for communicating through text or voice synthesizer. This can begin in early intervention and beyond.

Speech therapy at this stage is typically more structured. Games are often used for motivation, but goals are targeted through practice and repetition. Children practice new skills throughout a continuum until they're able to use these skills naturally in all environments.

After early intervention, children may continue receiving services in elementary school through an individualized education plan (IEP). The IEP is written by all specialists who will be working with the child. It states the child's goals and documents any accommodations the child may need to meet them.

Therapy at this age may follow a “pull-out” model where a child receives support in a separate classroom or a “push-in” model where an SLP provides services within the regular classroom. This model can change throughout the duration of therapy. For example, a child working on the correct production of a sound will typically begin with pull-out therapy and, when ready, will be observed in their classroom to assess for carryover of this skill.

SLPs in the school setting also consult with teachers to provide the support children need to communicate effectively in the classroom.

While children must qualify for speech therapy through early intervention and in public schools, private practices can provide services beyond these standards.

Speech therapy in the private practice setting typically occurs one-on-one with the child receiving the SLP's undivided attention. But group therapy may occur when beneficial to the child.

"Therapy in the private practice setting is very child and family focused," explains Shanna Klump, M.S., CCC-SLP, CEO of Kid Connections Therapy in Severna Park, Maryland. "The family's goals for their child are often at the forefront of the work we do. In addition, parents and other family members often participate in the sessions to learn strategies that can be implemented at home to encourage generalization of skills."

Parents should refer their child for a speech/language evaluation when they first notice their child is falling behind in any area of speech/language or is no longer meeting speech/language milestones . It is never too late or too early to start therapy but, in general, earlier intervention leads to a better outcome. If you're unsure if your child requires speech therapy, a referral to an SLP is always recommended.

A parent can contact their local early intervention office to learn about speech therapy options. The Centers for Disease Control and Prevention (CDC) provides early intervention contacts by state. Parents can also reach out to their child's health care provider to determine where their local early intervention office is located.

A school-aged child can be referred for a speech/language evaluation by reaching out to the child's teacher or the school's SLP.

An evaluation by a private SLP is an option at any age, but evaluations through early intervention or a public school district are provided at no cost. ASHA ProFind connects parents to SLPs who have indicated they are accepting referrals.

While public school therapy is free, private outpatient speech/language therapy is often covered by health plans, but with limitations.

According to Klump, insurance coverage for speech therapy varies by state, insurance plan, and diagnosis. She explains that while some states require habilitative service coverage for children, others do not.

Often, private practices, including Klump's Kid Connections, complete a benefits verification before initiating speech evaluation or therapy. In her experience, therapy sessions without insurance coverage may cost between $100-150, depending on location.

As each health plan has its own coverage, it is important to reach out to your insurance company to determine your out-of-pocket costs.

Insurance and Speech Therapy Coverage

If you're looking to see what insurance covers, Shanna Klump, M.S., CCC-SLP, CEO of Kid Connections Therapy, suggests parents obtain the following information from their insurance carrier:

• Visit limit. This may be a hard or soft limit which refers to whether an extension of services could be granted if deemed medically necessary
• Whether the visit limit is combined with other services. For example, occupational therapy and physical therapy are sometimes grouped with speech therapy in the number of sessions covered
• Whether there are exclusions to coverage for different diagnoses
• If a deductible must be met
• The co-pay amount per session

Speech therapy can take anywhere from months to years. Each child makes progress at their own rate and has individualized goals based on their communication needs. Just as children develop and meet milestones individually, the time it takes them to master new skills will vary.

Speech therapy has been found to be effective for children. One study of more than 700 children with speech or language disorders up to 16 years old, found an average of six hours of speech therapy over six months significantly improved communication performance. Speech therapy was shown to be much more effective than no treatment over the same period.

Children of all ages typically find speech therapy engaging, fun, and rewarding. They're able to see their progress and use their newly learned skills proudly. Speech therapy is an effective way to enhance a child's ability to communicate and through these communication skills, a child will have better access to the world.

Is speech and language therapy effective for children with primary speech and language impairment? Report of a randomized control trial . International Journal of Language & Communication Disorders . 2011

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Speech Therapy for Toddlers

What is speech therapy.

• Language Development
• Signs of Delay
• Speech Therapy Activities
• A Parent's Role

Frequently Asked Questions

Speech therapy is a treatment led by a speech and language pathologist (SLP) or speech therapist. It helps a person communicate and speak more clearly. Toddlers may develop language or speech impairments due to illness, hearing problems, or brain disorders.

This article covers speech and language milestones, causes of speech disorders, diagnosis, what happens in speech therapy, and how parents can help their toddlers. 

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Speech therapy is a treatment that helps a person speak or communicate more effectively. It is performed by specially trained speech and language pathologists (SLPs) or speech therapists. They help their patients better understand others, pronounce words clearly, or put words together. 

There are different types of speech therapy and their use will depend on the age of the child and what they are experiencing. For example, therapy practices vary for children with apraxia (difficulty pronouncing different syllables), stuttering, aphasia (difficulty speaking due to damage to the brain), and difficulty swallowing, and for late talkers.

Language Development (Newborn to Toddler)

While delay does not always mean there’s a problem, it’s important to recognize when a toddler misses a developmental milestone. The following are general guidelines of speech and language development for babies and toddlers:

Newborns communicate through crying. Their cries may sound the same at first but start to vary as they grow. They also cry to express emotions, and parents begin to understand what different cries mean.

High-Pitched Crying

A high-pitched cry not resolved by comforting or eating may mean that an infant is experiencing discomfort or pain.

Newborns pick up on rhythms of speech and their parents' voices within the first few weeks of life. Between 1 and 4 months old, they become more alert to sounds and may startle more easily or turn to look for the source of the noise. 

Around 2 to 3 months old, infants start smiling and cooing, which often sounds like "ah" or "eh." Babies begin laughing by 3 to 4 months old.  

By 5 or 6 months old, infants imitate adult sounds produced by babbling or shrieking. Babbling involves repeating sounds such as "ba," "ma," or "ga."  

7–12 Months

Seven-month-old infants hear words as distinct sounds and try to repeat them. By 9 months old, they start to understand expressions and simple commands like "no," recognize words for objects, and respond to their names.

Ten- to 12-month-olds follow simple commands such as "give mommy your cup." They also begin to say simple words such as "dada" or "bye-bye."

A Toddler's First Words

Most 1-year-olds can say a few words such as “up” or “dog” but do not put words together in a sentence.

13–18 Months

By 18 months, a toddler puts two words together and says phrases such as "push it." They often communicate in gestures that get more complex over time.

Toddlers this age start recognizing objects, body parts, pictures, or people. For example, if you ask, "Where is your nose?," they will be able to point to it.  

19–24 Months

By 24 months old, toddlers know and say 50 or more words. They start to form two- to three-word sentences. Two-year-olds can usually communicate their needs, such as “I want more milk,” and follow two-step commands.

Speech and Language Developmental Timeline

Children develop at different speeds and may not follow the typical timeline. If you are concerned about the delay, contact your pediatrician or healthcare provider as soon as possible. Early treatment can make a difference.

Signs of Speech or Language Delay in Toddlers

The following are general guidelines to help parents know if they should have their young child evaluated for speech or language problems:

• A baby who does not vocalize or respond to sound
• A 1-year-old who does not use gestures, such as pointing
• An 18-month-old who would rather use gestures than sounds
• An 18-month-old who has difficulty imitating sounds or understanding simple requests
• A 2-year-old who imitates speech but doesn’t talk spontaneously
• A 2-year-old who can say words but not communicate more than their immediate needs or follow simple directions
• A 2-year-old who has a raspy or nasal-sounding voice

Understanding the Words of a Toddler

Parents and regular caregivers usually understand about 50% of a toddler’s speech by 2 years old and 75% by 3 years old.

Speech or language delays can occur due to problems with the structures of the mouth, head injuries, chronic illnesses, or brain disorders.  

If the cause is a brain disorder, it can be difficult to coordinate their tongue, lips, and mouth to make sounds or words. 

Hearing problems can make it difficult to imitate or understand language. This is not always a problem that is apparent at birth. Chronic ear infections can cause hearing damage in one or both ears.

A speech therapist will perform tests with your toddler to check the following:

• What your child understands
• What your child can say 
• Clarity of speech
• How the structures in their mouth work together to form words and eat

The following are diagnostic tests or scales a speech therapist may perform with your toddler:

• Bayley Scales of Infant and Toddler Development (Bayley-III) : Bayley-III is used worldwide to measure all aspects of development from birth to 42 months. A speech therapist administers the language portion by watching the child follow instructions and identify people and objects. It helps them know if the child is on track or needs further evaluation. 
• Preschool Language Scales–Fifth Edition (PLS)-5 English : The PLS-5 is an interactive screening tool designed for infants and young children. Speech therapists measure all areas of language through a play-based approach. 
• Differential Ability Scales Assessment–Second Edition (DAS-II) : The DAS-II provides a scale to help speech therapists better understand how a child processes information. This allows them to develop appropriate activities for therapy.
• Goldman-Fristoe Test of Articulation 3 (GFTA-3) : The GFTA-3 involves asking a child to identify colorful drawings and measures their ability to pronounce consonants.
• The Rossetti Infant-Toddler Language Scales: This test is specifically designed for children from birth to 36 months old. It involves a parent interview, as well as observation of the child performing tasks.

What Happens During Speech Therapy?

The speech therapist will plan and perform activities to help your toddler with skills based on their specific needs. Therapy may occur in small groups or individually. 

Language building activities include using picture books, repetition, talking, and playing. If a toddler has difficulty pronouncing certain words, the therapist will teach them how to make the sound or say specific words. 

Sometimes speech therapists help toddlers with speech mechanics. This involves teaching them how to move their mouth or tongue to pronounce a word. They may also prescribe lip, tongue, or jaw exercises to continue at home.

What Concerns are Addressed During Speech Therapy?

Some of the concerns that SLPs may address during speech therapy include:  

• Speech mechanics
• Word pronunciation
• Volume or quality of speech
• Social communication skills
• Trouble swallowing

How Can Parents Help?

It helps to talk and read to your child frequently. Use correct names and speak in a slow and clear voice. When giving direction, keep things simple. Kneeling to their level can them focus on what you are saying.

If your child points at a glass of water, help them connect the gesture and language by asking, “Do you want water?” When they don’t pronounce words accurately, emphasize the correct pronunciation when responding.

Waiting for a Response

When asking a question such as “Do you want a drink?,” try waiting for a response. This helps your toddler learn to communicate back to you. 

Chronic illnesses, brain disorders, and hearing problems can cause a toddler to have delayed speech or language development. Speech therapy can help them learn to communicate more effectively. 

Parents can help by talking to their children often, speaking clearly, and emphasizing correct pronunciation. If your child is in speech therapy, it’s helpful to perform exercises prescribed by your speech therapist at home.

A Word From Verywell

Not all children follow a typical timeline for speech and language development. Sometimes they are focused on learning a new task, such as walking, and put language development on the back burner. They often catch up later. 

If your toddler is experiencing a language or speech delay, talk with your child’s healthcare provider. If there is a problem, getting help early can make a difference.

A toddler should start speech therapy any time after 3 months old if they experience developmental delays in speech or language. This may seem young, but a speech therapist can monitor the signs if there is a delay. Early intervention can make an impact. 

The estimated national average cost for the United States is $218 per session. However, many insurances and most state Medicaid programs cover speech therapy. It can be helpful to find an in-network clinic to decrease your out-of-pocket expenses. 

Nemours Kids Health. Delayed speech or language development . KidsHealth.org.

Durkin MJ. From Infancy to the Elderly: Communication throughout the Ages. Nova Science Publishers; 2011.

Meadows-Oliver M. Pediatric Nursing Made Incredibly Easy. 3rd Edition. Wolters Kluwer; 2019.

University of Michigan Health. Speech and language milestones, birth to 1 year .

Centers for Disease Control and Prevention. Important milestones: Your baby by nine months .

American Academy of Pediatrics. Language delays in toddlers: Information for parents . Healthychildren.org.

Nemours Kids Health. Communication and your 1-to-2 year old . KidsHealth.org.

NAPA Center. Speech therapy for children: What are the benefits? .

Garro, A. Early Childhood Assessment in School and Clinical Child Psychology . Springer; 2016.

Ross, K. Speech-Language Pathologists in Early Childhood . Plural Publishing; 2015.

DeVeney SL. Clinical challenges: Assessing toddler speech sound productions . Semin Speech Lang. 2019 Mar;40(2):81-93. doi: 10.1055/s-0039-1677759.

NAPA Center. 5 tips to help your toddler’s speech development by a speech therapist .

Wooster Community Hospital. At what age should speech therapy begin? .

MDsave. Speech therapy visit .

American Speech-Language-Hearing Association. Introduction to Medicaid .

By Brandi Jones, MSN-ED RN-BC Jones is a registered nurse and freelance health writer with more than two decades of healthcare experience.

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How to Support Your Child’s Speech Therapy Progress at Home 

Fifteen minutes of exercise a day could help your child tell you what they need to say! Home exercise programs (HEPs) are tailor-made for your child to improve speech and language outcomes, encourage long-term habits, and graduate from speech sooner. 

At Associates in Pediatric Therapy, we pride ourselves on being family-centered. We believe all parents are co-therapists and want to empower you and your child to carry out therapeutic skills outside of the treatment room. With daily practice, you reinforce your child’s goals in natural environments, such as at home with family members, at the park, and at the grocery store…every place can be a learning opportunity! Research shows that some children must target skills 70-100 times weekly to begin seeing progress. Parents– you can speed up progress and build that confidence by setting up time to drill speech sounds, model language in play, or practice navigating your child’s augmentative and alternative communication device (AAC).  

Not every learning environment is going to look the same. For newer skills, reducing distractions and creating routines are a must. This could be as simple as practicing in a room without a T.V. or tablet in sight, playing one-on-one with mom or dad, creating a dedicated time to practice daily, or having two to three preferred toys to practice with. For progressing skills, increase the complexity by targeting speech sounds while playing a board game…promote language acquisition in play with siblings and peers…or try encouraging social skills at the park or splash pads. The most important thing is that your child feels safe and comfortable where they are practicing.  

You may ask, “How do I create a daily practice routine?” Set clear intentions and practical durations. Five minutes of practice a day is better than none. For some, setting an alarm or timer for routine daily practice can be helpful. For others, you may find it easier to integrate your home practice into established routines such as morning or nighttime routines, bath time, car rider commutes, or meal times. It is important that you set goals that are practical for you and your family.  

Practicing should be FUNctional! Make it fun by targeting skills using motivating activities and characters. Give your kiddos some control by letting them pick a book or game. Keep the language positive – remember, this is practice. Praise them for their efforts and attempts and celebrate mastered skills! Some of my favorite specific praises are, “That was great trying!” “I like how you XX” “You made a great XX sound!” Practice with a buddy, invite friends and siblings to join in on the fun. This can help practice turn taking, model sounds in play, and encourage generalization with new conversation partners.  

HEPs are made with you and your child in mind. Follow up weekly with your therapist on things that are going well and areas of improvement.  As Mark Twain says, “Continuous improvement is better than delayed perfection.”  

Rachael Alter, MS, CCC-SLP

Speech Therapy for Children: When It’s Needed and What to Expect

Every child deserves the gift of communication–the ability to express their wants and needs, connect with other people, and share their thoughts and ideas with the world. Your child deserves to be heard, and speech therapists are here to help make that happen.

So today we’ll discuss how speech therapy works: when it might be needed, at what age children can start, what the sessions look like, and how long therapy can take.

Many parents and caregivers ask this common question: “How do I know if my child needs speech therapy?” There are a few ways I could answer this. But first, let me start by taking some of the pressure off. You, as a parent, never have to decide if your child needs speech therapy. A speech therapist can determine if therapy is warranted. So as a caregiver, that’s at least one decision you don’t have to make! 

One thing you can do, however, is watch for signs that your child should receive a speech and language evaluation. Let’s discuss what to look for.

If your child is not meeting speech milestones for their age, that’s a big sign that you should contact a speech therapist. To learn more about these milestones, talk with your child’s pediatrician. You can also view the milestones on the website of the American Speech-Language-Hearing Association.

Children should begin saying their first words when they’re about 1 year old. From there, they should continue in their ability to put words together and eventually speak in sentences. If your child is having a hard time with any of these skills and they’re close to, or past, the expected age timeframe, be sure to reach out to a speech therapist.

If your child is talking, but they have a hard time with their speech sounds and people don’t always understand them, this is another sign that speech therapy may be needed. By the time children are 3 years old, they should be easily understood by other people about 80% of the time. If not, the sooner they begin speech therapy, the more quickly they can make progress! 

You might also contact a speech therapist simply because you have questions, or you sense that your child is struggling to communicate. I always encourage parents and caregivers to listen to their gut in these situations. You know your child best! Speech therapists are there to answer your questions and make recommendations. And again, if your child does need speech therapy, the earlier it can start, the better.

You may be wondering when children can start receiving speech therapy. There is no minimum age! Speech and language skills begin developing in infancy. If a child is evaluated and therapy is recommended, services can begin right then. This is why it’s so important to reach out to a professional if you have concerns. Many clinical studies have shown the benefits of beginning speech and language interventions at an early age.

Speech therapy sessions typically take place at least once a week. The frequency depends on the diagnosis, treatment plan, and goals for each child.

Sessions are usually play-based. The therapist will use fun activities that are engaging for kids, and they’ll incorporate your child’s therapy goals into those activities. For younger kids, toys and books may be used. For older children, interactive games or crafts often work well. 

The speech therapist will find activities that are appealing and motivating for your child, and they’ll make sure to balance speech practice with play. Many times, children don’t even realize all the hard work they’re doing in speech–they’re too busy having fun!

Another question families often ask is, “How long does speech therapy take?” I wish I had one answer, but the length of therapy is different for each unique person. 

However, there are a few things that help determine how long therapy takes. One is the child’s age. The sooner a child begins speech therapy, the sooner they begin making progress. This also decreases the risk that they will fall further behind. 

Your child’s diagnosis also affects the length of therapy. Sometimes children with a developmental delay catch up quickly with the right support and intervention. With more involved diagnoses that involve neurological complications or congenital disorders, therapy may take longer.

As your child’s caregiver, you actually have a role to play here. The more you help your child practice, the more quickly they’ll progress! While speech therapy sessions are an essential part of your child’s improvement, so is the practice that happens at home, between sessions. Continuing to work on your child’s goals throughout the week helps reinforce what was learned in therapy, and it sets your kiddo up for more success at their next session.

Best of all, you don’t need any special training, materials, or expertise. When it comes to speech and language, the world is your classroom. You can easily help your child practice during everyday activities and the time you already spend together.

As a parent or caregiver, you’re doing the right thing in learning how to support your child’s communication needs. No matter where you are in the speech therapy journey, your speech therapist is there to walk alongside you and your child. Trust your instincts, and know that you are never alone in this process!

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Birth To Three Newborn Screening

Home » Health » Birth To Three (Idaho Infant Toddler Program)

The Idaho Infant Toddler Program

The Idaho Infant Toddler Program (ITP) is responsible for coordinating early intervention services for children between birth and three years of age in Idaho who have developmental delays or conditions that may result in a delay. The program aims to support the overall development of these children and provide assistance to their families.

ITP connects eligible children and their families with a range of services to address their specific needs. Some of the services provided through the program include:

• Family education: Providing information and resources to help families understand and support their child’s development.
• Speech therapy: Addressing communication challenges and improving language skills.
• Occupational therapy: Assisting children in developing the necessary skills for daily activities and promoting independence. Service coordination: Coordinating and ensuring the delivery of appropriate services to the child and family.
• Family training: Equipping families with skills and strategies to support their child’s development.
• Counseling: Offering emotional support and guidance to families.
• Home visits: Providing services and support in the child’s home environment.
• Health services: Addressing health-related needs and coordinating medical support.

When a child is referred to the Infant Toddler Program, an assessment is conducted to determine their eligibility for the program. If the child is eligible, an Individualized Family Service Plan (IFSP) is developed. The IFSP outlines the specific services and supports the child and their family will receive and is reviewed every six months to ensure its effectiveness. When the child reaches three years of age, the ITP assists in their transition to a developmental preschool program or other community services suitable for their ongoing needs.

The Idaho Infant Toddler Program plays a vital role in supporting the early development of children with delays or conditions that may impact their development, while also providing valuable resources and support to their families. Visit the Idaho Infant Toddler Program Here https://healthandwelfare.idaho.gov/services-programs/children-families/about-infant-toddler-program

Newborn Screening In Idaho

The State of Idaho requires that all babies born in the state undergo newborn screening. This screening involves two tests that are performed shortly after birth to identify the presence of certain disorders, including Phenylketonuria (PKU) and other conditions that can lead to intellectual disability or other serious health issues.

The screening procedure, commonly known as the “newborn screen” or the “newborn blood spot screen,” is mandated by the Idaho Legislature. It is important to note that the screening in Idaho encompasses more than just PKU. Currently, Idaho screens for over 46 different conditions. For more information you can visit the About Newborn Screening page .  To download the infographic below as a  fully-text-readable PDF file click here,  

Newborn Hearing Screening Idaho Sound Beginnings

Idaho’s newborn hearing screening program is called Idaho Sound Beginnings.

Hearing loss is the most common birth disorder in newborns. It affects how your baby perceives sound and is able to communicate with you and the world. Much can be done if hearing loss is identified early. If you need financial assistance please contact us prior to having any testing done.

Contact Idaho Sound Beginnings if you have questions about newborn hearing screening, diagnostic testing, or Early Intervention. If you need financial assistance, please contact prior to having any testing done.

Idaho Sound Beginnings provides training, technical support, and quality assurance to newborn hearing screening programs in every birthing center in the state.

ACT Early Idaho

Act Early Idaho also has several great resources on their page. There’s a great virtual developmental monitoring training available for Birth-to-three and from three-to-five years old

Birth to 5: Watch Me Thrive!

Birth to 5: Watch Me Thrive!   is a coordinated federal effort to encourage healthy child development, universal developmental and behavioral screening for children, and support for the families and providers who care for them.

Birth to 5: Watch Me Thrive!  will help families and providers:

• Celebrate milestones.  Every family looks forward to seeing a child’s first smile, first step, and first words. Regular screenings help raise awareness of a child’s development, making it easier to expect and celebrate developmental milestones.
• Promote universal screening . Just like hearing and vision screenings assure that children can hear and see clearly, developmental and behavioral screenings track a child’s progress in areas such as language, social, or motor development.
• Identify possible delays and concerns early . With regular screenings, families, teachers, and other professionals can assure that young children get the services and supports they need, as early as possible to help them thrive alongside their peers.
• Enhance developmental supports.  Combining the love and knowledge families have of their children with tools, guidance, and tips recommended by experts can make the most of the developmental support children receive.

Idaho Parents Unlimited, Inc. 4619 W Emerald St, Ste. E Boise, ID 83706

Phone: (208) 342-5884 Fax: (208) 342-1408 Email: [email protected]

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Programs and services offered by Idaho Parents Unlimited are supported in part by the U.S. Department of Education (H328M200033) and the U.S. Department of Health and Human Services, Health Resources Services Administration (HRSA) Affordable Care Act Family to Family Health Information Center (H84MC12896), opinions expressed herein do not necessarily represent the positions of either department, endorsement is not assumed.

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Gliding Minimal Pairs: What they are and how to use them in Speech Therapy

Phonology and phonological impairments can be tricky to understand! Often, children with phonological issues are mistakenly treated using an articulation-based approach, which can slow their progress. When we choose the correct approach, we should see consistent—and sometimes rapid—improvement.

There are excellent tools to help you choose the right method for your specific student. Since I specialize in the R sound, today I want to focus on the minimal pairs approach , which I use frequently with my own caseload. Keep in mind that my private practice focuses solely on R. While minimal pairs aren’t the only approach for treating speech sound disorders, they are a solid, evidence-based strategy that’s especially useful and relatively easy to grasp. Let’s dive in!

What are minimal pairs?

Minimal pairs are pairs of words that differ by only one sound (phoneme). For example:

• c at & s at
• g ear & d eer
• ro ck & ro t

Remember, in speech therapy, we focus on phonemes (sounds), not necessarily on how words are spelled.

WHAT IS MINIMAL PAIRS THERAPY?

Minimal pairs therapy is an evidence-based method for treating phonological disorders. It’s especially helpful for students who substitute one sound for another. A handy tip: if the student’s only error is the R sound, minimal pairs can be a very effective strategy.

WHAT IS GLIDING?

Gliding is a phonological process where a child substitutes a glide sound (W, Y) for a liquid sound (R, L). You’ve probably heard it before—those adorable kids who say “Mommy pwease weed to me” instead of “Mommy please read to me.”

WHAT ARE GLIDING MINIMAL PAIRS?

Gliding minimal pairs are word pairs where one word has a glide and the other has a liquid sound. Some examples include:

• r ake & w ake
• y ack & l ack
• r ip & l ip

In minimal pairs therapy, it’s crucial to choose pairs where both words are real and have distinct meanings. This helps children recognize the communication breakdown that happens when they confuse the two sounds.

HOW DO YOU IMPLEMENT THE MINIMAL PAIRS APPROACH?

Here’s a simplified step-by-step guide to get you started:

Step 1: Introduce Show the child a minimal pair, using pictures for both words. Explain that the words sound almost the same but differ by just one sound—and that small difference changes the meaning completely.

Step 2: Discriminate Say each word aloud and have the child point to the picture of the word they heard. This step helps them recognize the difference between the two sounds.

Step 3: Produce Now it’s the child’s turn to say the words. This can get tricky with R if the child isn’t stimulable yet. Your goal is to help them produce a clear R sound so they can start practicing correctly.

A key element of minimal pairs therapy is the feedback you provide. When the child is correct, give plenty of positive reinforcement. When they make a mistake, use pragmatic cues—such as showing confusion with your facial expression or pretending there’s been a communication breakdown. This helps mimic a real-life situation where a listener might not understand them. Afterward, guide them to correct their error and repair the communication.

That’s all for today! I hope this post gives you a good starting point for using minimal pairs therapy with students who are gliding their R sounds. If you’re looking for a no-prep activity, check out my gliding minimal pairs Boom deck . And don’t forget to explore my VIP freebie library (sign-up required) if you need more R sound materials. Happy therapy planning!

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Hi! I'm Lindsey!

I’m a pediatric SLP who specializes in the R sound. Fun fact- I actually used to dread the R but after dedicating a lot (like…  a lot a lot ) of time to researching and troubleshooting… I now love it! So much, in fact, that I currently spend my days treating “R kids” via my private practice and creating R resources and continuing education for SLPs via Speechy Things. I’m so glad you found me! Let’s “Rock the R” together!

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Coventry Children's Speech and Language Therapy Service

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Where speech and language therapists and assistants thrive - make a difference with Coventry Children’s Speech and Language Therapy Service

Working in Coventry Children’s Speech and Language Therapy Service means joining a large, but incredibly supportive team, where you will be encouraged to grow your skills, explore your clinical interests, and above all; make a difference for children with communication and eating and drinking needs, and their families. 

With a team of over 50 people, the size of the service means there are lots of clinical areas for speech and language therapists and assistants to explore, including speech, language, voice, stammering, alternative and augmentative communication, dysphagia and more. 

Whether you want to have a varied caseload with different client groups or to specialise in one or more areas, we will support you to do just that.  

Hear from our therapists and assistants.

Why join us?

As a community service, we offer flexibility and autonomy for our therapists and assistants. As Coventry is a compact city, you’ll spend less time travelling and more time with the children and families you are supporting.

We have a bright and airy office space at our head office, Wayside House, and modern clinic rooms in the City of Coventry Health Centre.

A snapshot of what you can expect in our team:

•         Array of clinical areas for you to explore or specialise in
•         Hybrid and flexible working opportunities
•         Joining a supportive and friendly team
•         Excellent development opportunities, including formal and informal training, clinical supervision, CPD days and more
•         Multidisciplinary working with other services
•         Training and upskilling other professionals
•         Excellent career progression
•         Work in an innovative and award-winning service
•         12-month preceptorship for newly qualified practitioners

Meet our clinical service manager, Julie.

How my experience with the Coventry Children’s SLT Service ignited a new passion - with Sarah, Speech and Language Therapy Assistant

  "I was a parent to children who use the service. During the lockdown in 2020, I felt I had no job satisfaction, and I wanted a career change. I thought about what in my life means a lot to me, and I knew that I love the work I do with my own children on their speech and language because my older boy had a stammer and my youngest had speech and language delay. It inspired me to change careers.

It's been a long journey, but I am hoping to go back to university and become a speech and language therapist. My job now gives me so much job satisfaction, it’s so rewarding, and I genuinely want to make a difference in people’s lives. I feel like I have been on that journey as a parent as well, so I feel like I add value to the team.

I predominately go into schools, and I have a flexible diary so I can manage my own time. I go into schools all around Coventry and work with wonderful children, including in special schools which means I will need to work in a different way and adapt the interventions we do.

I was always told that this is the team I should work for, and I had spoken to my children’s therapist about the fact I wanted a career change, and she said, ‘you have to come and work for my team’. I have worked for other teams, but my end goal was always to work within children’s speech and language therapy. I have to say, she was right. It is such a supportive team, and I feel really privileged that I am a part of it. They support you, from the other speech and language therapy assistants, right up to your leads and the service manager, I feel like they’re always there and they are always available.

One thing I would say about this role is you do get flexibility. For example, on a day when it was my youngest son's sports day, I was able to go out of a training day to attend, because that was important to me. For me, because I have been a parent, and had that lived experience of two children with additional speech and communication needs I can see it from a parental point of view, and the worry and the sleepless nights that can give you. I hope I can help people on that journey because every child is unique and ultimately, we all want to make a difference and have the best possible outcome for that child.”

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Do you want to join our innovative service? See our new opportunities on our vacancy page , or email [email protected] to express your interest in working with us.  

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Speech and Language Therapy Clinical Team Lead

• Reference: SCC/TP/288093/1940
• Positions: 1
• Salary: £48,105 - £51,587 per annum
• Category: Speech and Language Therapy
• Contract type: Permanent
• Working hours: 36 hours per week across 42 weeks per year
• Posted on: 26 September 2024
• Closing date: 13 October 2024
• Directorate: Children, Families & Lifelong Learning
• Location: Woodhatch Place, Reigate, RH2 8EF

Description

• Flexible working options around school core hours
• Up to 5 days of carer's leave per year
• Paternity, adoption and dependants leave
• 2 paid volunteering days plus 1 team volunteering day per year
• Paid fees for RCSLT membership and HCPC
• Mobile and agile working solutions (laptop, iPhone, online resources and assessments)
• A team of students, therapists and assistants led by a Therapies Manager who is an SLT
• Ongoing CPD opportunities including termly Study Days and for specialist teams access to external training and supervision
• A structured supervision model including regular 1:1 supervision and peer supervision
• A generous local government pension scheme to provide you with a secure and guaranteed future income
• Access to a range of health and wellbeing tools to support your mental and emotional well-being, including our free confidential Employee Assistance Programme, a range of mental health apps and support for staff in crisis
• Lifestyle benefits: access to a huge range of discounted vouchers and memberships covering gym, retail, cinema and holidays. We offer many great benefits for staff depending on what is important to you.
• You will have a management role in the South East Team which includes working alongside the other Team Leads to support and develop an enthusiastic and friendly team who work in mainstream and specialist schools
• Through a joint up approach with colleagues across Surrey, you will ensure the wider team is informed of current research and evidence base in the area of ASD, and that clinical practice is of high quality
• Provide clinical supervision and line management to members of the Team and support with second opinions, observation, training and shadowing opportunities for colleagues
• Support student placements
• Work with management on the operational and strategic development of services to our schools across Surrey
• Provide advice at educational panels
• A BSc (Hons) degree or equivalent in Speech and Language Therapy
• Registered membership of the Health and Care Professions Council and Royal College of Speech and Language Therapists with permission to work in the UK
• At least 5 years post graduate experience, and specific experience of working within schools with an ASD caseload
• A working knowledge of the English education system including the National Curriculum and SEND code of practice.
• Experience of line managing and supporting others including newly qualified therapists, assistants, students and work experience placements
• Experience of working within an effective multidisciplinary team
• Experience of training and positively influencing practice in large staff teams
• Continuing commitment to learning and development of self and others with regard to evidence base and research
• The candidate has evidenced the minimum criteria for the role through their application
• The candidate has chosen to share that they have a disability on the application form

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• Volume 14, Issue 9
• Clinical efficacy and therapeutic mechanism of active ‘five-tone’ speech therapy compared with conventional speech-language therapy for treatment of post-stroke aphasia: protocol for a randomised controlled trial
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• http://orcid.org/0000-0003-4282-4318 Mengxue Wang ,
• Jinglei Ni ,
• Bingbing Lin ,
• Fujian University of Traditional Chinese Medicine , Fuzhou , China
• Correspondence to Dr Jia Huang; jasmine1874{at}163.com

Introduction Aphasia is a common dysfunction among patients with stroke that can severely affect daily life. Listening to the ‘five-tone’ melodies of traditional Chinese medicine can improve some of the language functions of patients with post-stroke aphasia; however, passive listening may limit its clinical efficacy. In this study, we transform the passive listening five-tone melodic therapy of traditional Chinese medicine into an active five-tone speech therapy. This randomised controlled trial aims to investigate the clinical efficacy of active five-tone speech therapy in the treatment of post-stroke aphasia, such as language function, daily communication ability and communication efficiency, as well as investigate the therapeutic mechanism of this innovative therapy by electroencephalogram and MRI.

Methods and analysis The study is a multicentric, randomised, parallel-assignment, single-blind treatment study. 70 participants will be recruited from the Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine and the Third People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine and randomly assigned to two groups, the five-tone speech therapy group and the control group, at a 1:1 ratio. The control group will receive 20 sessions of conventional speech-language therapy, while the five-tone speech therapy group will receive 20 sessions of five-tone speech therapy in addition to conventional speech-language therapy. The primary outcome measure for this study will be the score on Western Aphasia Battery. Secondary outcomes include communicative abilities in daily living, percentage of correct information units and correct information units per minute, as well as resting-state electroencephalogram, event-related potentials and MRI data. All outcomes will be evaluated at 0 weeks (before intervention) and at 4 weeks (after 20 intervention sessions).

Ethics and dissemination Ethical approval of this study was granted by the ethics committees of the Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine (2023KY-009-01) and the Third People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine (2023-kl-010). Recruitment commenced on 24 April 2023. Informed consent will be obtained from all participants of the trial (or from their legal guardians, where applicable). The outcomes of the trial will be disseminated through peer-reviewed publications.

Trial registration number ChiCTR2300069257.

• Magnetic resonance imaging
• Electroencephalography
• rehabilitation medicine

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2023-082282

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STRENGTHS AND LIMITATIONS OF THIS STUDY

The active ‘five-tone’ speech therapy used in the intervention group as an innovative music therapy may help improve the recovery of language processing and communication.

Based on the results of Syndrome Element Differentiation in traditional Chinese medicine, we will select the corresponding five-tone melody that is likely conducive to providing precise and specific treatment for different patients with post-stroke aphasia.

This study uses comprehensive outcome measures, including different dimensions of language function, such as spontaneous speech, listening comprehension, repetition and naming, as well as daily communication abilities, communication efficiency, changes in electrophysiological brain activity and the therapeutic mechanism of this therapy based on changes in brain structure and function.

Evaluators measuring the outcomes will be blinded to the allocation.

Evaluation will be conducted only at the end of the intervention, which means there is lack of assessment of five-tone speech therapy after-effects.

Introduction

Aphasia is a common dysfunction of stroke, and studies have shown that 21%–38% of patients with ischaemic stroke may develop aphasia. 1–3 Research has found that the prevalence of aphasia in the chronic phase after the onset of different types of stroke is 25%–50%, while the prevalence in the acute phase is 15%–42%. Post-stroke aphasia (PSA) leads to a variety of negative outcomes, such as severely hampering patients’ daily communication and social participation, as well as imposing a significant financial burden on patients’ families and the community. 4 5

Currently, common clinical treatments for PSA include speech-language therapy (SLT), music therapy (MT), scalp acupuncture and transcranial magnetic stimulation. The production, comprehension and expression of speech depend on the functional separation and integration of different brain regions and are the products of complex multinetwork synergistic processing; thus, no treatment that it is efficacious for all dimensions of speech-language functions has been found. 6 Eight clinical practice guidelines for PSA rehabilitation from 2010 to 2016 have provided different treatment recommendations for PSA, six of which recommend SLT. 7

The Expert Consensus on Clinical Management of Post-Stroke Aphasia in 2022 recommends adding MT to SLT. 8 MT consists of melodic intonation therapy; neuromusic therapy; singing, intonation, prosody, breathing, rhythm and improvisation; and the ‘five-tone’ therapy of traditional Chinese medicine. Among these, the five-tone therapy as a traditional Chinese medicine MT has been receiving more attention in recent years for patients with PSA.

According to traditional Chinese medicine, abnormalities in the functions of the five viscera lead to visceral yin and yang imbalance, and malfunction of the meridians is the fundamental pathogenesis of PSA. 9 10 The five tones of traditional Chinese medicine are ‘jue-tone’, ‘zhi-tone’, ‘gong-tone’, ‘shang-tone’ and ‘yu-tone’, which are equivalent to mi, sol, do, re and la, respectively, in the key of C major. 11 12 Su Wen 13 first made the point that the five tones correspond to the five viscera. This means that the five-tone melody can regulate the functional activities of the corresponding internal viscera through the acoustic resonance principle of ‘responding to the same sound and seeking the same qi’. 14 Therefore, five-tone speech therapy, which is centred on the five-tone melody of traditional Chinese medicine, may improve the language function of Chinese patients with PSA.

A clinical study revealed that passive listening to ‘zhi-tone’ music can increase the mean velocity of the left middle cerebral artery and promote the repair of nerve damage to improve language function, such as listening comprehension, repetition and reading, in patients with postacute or subacute stroke Broca’s aphasia of the ‘qi zhi xue yu’ type. 15–18 In addition, MT can be categorised as passive and active. Passive MT refers to the patient’s passive acceptance of the healing effects of music, such as listening to music. On the other hand, active MT, also known as ‘participatory music therapy’, refers to the patient’s direct participation in musical exercises, such as choral singing and playing musical instruments. Active MT was found to improve the scale scores in aphasia quotient, repetition, naming, and spontaneous speech and listening comprehension in patients with chronic non-fluent aphasia. 19 20 Active MT has been found to better facilitate cognitive functioning than passive MT. This may be due to the greater cognitive demands of active MT in terms of memory, language processing and motor planning. These findings suggest that the passive listening approach currently used in five-tone therapy may limit its clinical efficacy.

Therefore, we innovate an active five-tone speech therapy that adopts the principle of ‘treatment according to differentiation’ to select the five-tone melodies of traditional Chinese medicine and allows patients to carry out active training. To investigate the clinical efficacy of active five-tone speech therapy, such as language function, daily communication ability and communication efficiency, in the treatment of PSA and to investigate the therapeutic mechanism of this innovative therapy, we designed this randomised, parallel-assignment, single-blind treatment study. Participants will be recruited and randomly assigned to two groups, the five-tone speech therapy group and the control group, at a 1:1 ratio. We hypothesise that participants with PSA training with active five-tone speech therapy will show higher improvements in the outcomes of language functions and others compared with participants with PSA training with conventional SLT only. In addition, we will use electroencephalogram (EEG), which offers high temporal resolution, to analyse the neurophysiological activity of the brain. Furthermore, we will use functional MRI (fMRI), which provides high spatial resolution and captures blood flow signals across the entire brain, to analyse the functional changes in the brain.

Methods and analysis

Study design and procedures.

This study is a randomised, single-blind clinical trial with two parallel groups. A total of 70 patients with PSA will be recruited from the Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine and the Third People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine and randomised into two parallel groups at a 1:1 ratio, namely the five-tone speech therapy group and the control group. Participants will receive 20 sessions, with the first group receiving only conventional SLT (control group) and the other group receiving five-tone speech therapy in addition to conventional SLT (five-tone speech therapy group).

All participants will complete the following scale evaluation: Western Aphasia Battery (WAB), communicative abilities in daily living (CADL), percentage of correct information units (CIU%), correct information units per minute (CIU/min), EEG and MRI. The study design and participant flow chart are shown in figure 1 . The trial’s schedule of enrolment, intervention and assessments is shown in table 1 .

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Study design and participant flow chart. SLT, speech-language therapy.

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Trial’s schedule of enrolment, intervention and assessments

Participants and recruitment

Participants who meet the inclusion and exclusion criteria will be recruited from the Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine and the Third People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine. The study will be advertised through the internet and posters in communities and hospitals. In addition, recruitment and screening will be conducted by both researchers and clinicians, and the researchers will provide written information and verbal explanations to participants and their families. The researcher in charge of the evaluation will assist the physician in diagnosing the severity of aphasia. Participants are enrolled by the researcher according to the inclusion and exclusion criteria listed in Box 1 . All participants and their family members are required to review the information and to sign consent forms (Appendix) before participating in the study. Participants will be able to withdraw from the study at any time for any reason without consequences.

Inclusion and exclusion criteria

Inclusion criteria.

The first-onset stroke in the left hemisphere that meets the diagnostic requirements of Chinese and Western medicine and is confirmed by cranial CT or MRI examination;

Aphasia diagnosed by Western Aphasia Battery (WAB) with the Boston Diagnostic Aphasia Examination (BDAE) classification of 1 to 5;

At least 2 weeks post-onset of stroke;

Right-handed;

18~80 years old;

Stable vital signs, awake consciousness, no obvious audio-visual impairment;

Participants and their families fully understand the study content, can cooperate with the rehabilitation assessment and treatment of this trial, and agree to participate in the study and sign the informed consent form.

Exclusion criteria

Participants diagnosed with aphasia not caused by stroke;

Speech impairment due to organic lesions of the vocal organs, or severe cognitive dysfunction, or unconsciousness, or a history of psychiatric illness that makes it impossible to cooperate with the speech function examination and complete the relevant interventions;

People with severe auditory or visual dysfunction;

Serious post-stroke complications (e.g., lower extremity deep vein thrombosis, severe respiratory infection, upper gastrointestinal bleeding, etc.);

Other serious diseases (e.g. severe cardiopulmonary insufficiency, epilepsy, stage III or IV malignancy, etc.);

People suffering from a serious mental illness (e.g., depression, anxiety, schizophrenia, etc.);

Contraindications to nuclear magnetic resonance (NMR) (e.g., metal dentures, metal implants, etc.)

The statistical analysts, who are not involved in the study, will use SPSS V.25.0 software to generate the randomisation sequence list and the list to a dedicated staff member. After the baseline assessments, eligible participants will be randomly assigned to the treatment group or the control group at a 1:1 ratio. Group allocation will be obtained at the beginning of the first intervention session. The researcher in charge of all intervention sessions will open an opaque envelope that includes the assigned allocation.

Because of the nature of the intervention, this study will be blinded to the outcome evaluators and statistical analysts only. At the end of the trial, after the data have been entered into the database according to their random number, the first unblinding will be performed so that the custodian of the randomisation sequence list can give the grouping code of the participants to the statistical analysts. Once data analysis has been completed, a second unblinding will be performed in which the group represented by the grouping code will be announced by the custodian of the randomisation sequence list.

Consent process

Researchers will ensure that participants and their guardians understand the purpose and procedure of the study, as well as the minimal risks and potential benefits associated with it. In addition, the participants and their guardians will be informed of their rights as research subjects, such as withdrawing at any point during the study without consequences. This study requires obtaining written informed consent from all participants. In cases where participants are not competent to provide consent due to lack of civil capacity, written informed consent must be obtained from their legal guardians.

Sample size

No large randomised controlled trials have been carried out on the clinical efficacy of active five-tone speech therapy in PSA. Based on previous studies of SLT for PSA, we used the WAB as the effect indicator 21 and calculated the effect value of 0.8736745 for the two groups by substitution using G-Power V.3.1.9.2 software. We then calculated the appropriate trial sample size with 90% power and α of 0.05. The results showed that a clinically significant difference could be detected by a sample size of at least 29 in each group. Allowing for a predicted 20% dropout rate, we plan to enrol 70 participants in this study (35 in each group).

Intervention

Participants in the five-tone speech therapy group and the control group will all receive the same conventional SLT. The five-tone speech therapy group will additionally receive the five-tone speech therapy, with the five-tone melody selected following the principle of treatment according to differentiation of traditional Chinese medicine. The duration of the SLT is 30 min/day for 20 sessions. The duration of the five-tone therapy speech therapy is 30 min/day for 20 sessions.

Control group

The control group will receive SLT. Conventional SLT according to the Code of Practice for Commonly Used Rehabilitation Therapeutic Techniques (2012 Edition) written by the Chinese Society of Rehabilitation Medicine, such as listening, speaking, reading and writing therapy training, is performed by exceptional speech therapists who have been professionally trained. The duration of the SLT is 30 min/day for 20 sessions.

Five-tone speech therapy group

The five-tone speech therapy group will receive SLT, same as the control group, and will additionally receive five-tone speech therapy (details in the next paragraph). The five-tone speech therapy is an active MT method that combines the five-tone melody of traditional Chinese medicine with the active training model of melodic intonation therapy. According to the results of the five viscera identification, we will select the corresponding five-tone melody, respectively. The training is divided into three stages. In the first two stages, phrases in common usage with fewer words are used, while in the last stage longer and more complex phrases are involved. Within each stage, there are three common steps of demonstration, unison singing and the gradual withdrawal of the therapist, as well as steps of different difficulty gradients unique to each stage, such as immediate chant retelling and immediate chant answer in the first stage, delayed chant retelling and delayed chant answer in the second stage, and delayed natural intonation retelling and delayed natural intonation answer in the third stage. The duration of the five-tone speech therapy is 30 min/day for 20 sessions.

The selection of the five-tone melody follows the principle of treatment according to differentiation of traditional Chinese medicine. The principle of treatment according to differentiation in Chinese medicine refers to the selection of appropriate treatment principles and methods according to the different symptoms of each patient. In this study, we select different five-tone melodies of the traditional Chinese medicine for the five-tone speech therapy according to the different diagnoses of each patient’s five viscera. Specific actions are as follows: We will collect information about participants’ symptoms and use the weighted threshold method according to the syndrome differentiation criterion in Professor Zhu Wenfeng’s Syndrome Element Differentiation 22 to determine the five viscera elements. Then, according to the direct correspondence between the five viscera and the five tones (the five viscera of the liver, heart, spleen, lungs and kidneys correspond to the five tones of jue-tone, zhi-tone, gong-tone, shang-tone and yu-tone), the five-tone melody is selected for the participants. Each five-tone melody library consists of 15 audio clips that have been modified and adjusted by the researchers and 4–15 five-tone songs. All of the above training phases of five-tone speech therapy will use the melodies in the corresponding audio.

Study endpoints

Table 3 provides an overview of the measurement instruments used in the study.

Measurement instruments

Primary outcome

The main observation is the difference in WAB 8 21 23 scale scores between the two groups after 20 sessions of treatment to assess patients’ language abilities.

Secondary outcomes

Secondary outcome measures are the CADL 24 scores for patients’ functional communication abilities and the CIU% and CIU/min 25 26 scores for patients’ communication efficiency, as well as the Boston Diagnostic Aphasia Examination for evaluation of aphasia severity in patients with PSA.

EEG data acquisition

The 64-channel EEG recording and analysis system (Neuroscan, USA) and Synamps EEG amplifier will be used to collect EEG signals. The electrode channel arrangement is shown in figure 2 .

64-channel EEG electrode channel arrangement.

Resting-state EEG data acquisition

EEG data in the resting state will be collected for 5 min while the participants are awake and quiet. Participants will undergo EEG at different times on the same day as the scale evaluation.

Event-related potential data acquisition

The tasks used to activate event-related potentials (ERP) include the verbal fluency task and the picture naming task. We will collect ERP data during these tasks and 3 min resting-state electroencephalogram (rsEEG) data before and after the tasks to analyse the effects of the five-tone speech therapy on the neurophysiological activity of the brain during the verbal tasks.

Verbal fluency task: The verbal fluency task will be edited using Eprime software, requiring participants to name the nouns of a category as many as possible in 30 s, for example, name the nouns in the categories of fruits, animals and so on. There are a total of 10 categories in this task, and the order of presentation will be randomised. ERP data will be recorded during the task.

Picture naming task: The picture naming task will be edited using Eprime software. Before the task, we will make sure that participants are familiar with all pictures and their names. At the beginning of each trial, a 500 ms fixation cross is presented in the centre of the screen. The participants will be required to fixate on a displayed central cross and minimise eye blinks and body movements. A picture will then be displayed in the centre of the screen for 2 s, after which the participants will be asked to name the picture as quickly as possible when the ‘?’ is shown in the centre. If the participant does not respond within 2 s, the picture will automatically disappear. A total of 144 black-and-white pictures will be presented in a randomised order. ERP data will be recorded during the task.

MRI data acquisition

The scanning equipment is a Siemens 3T Prisma MRI scanner and a standard head coil as the transmit and receive coils. Before scanning, all participants will be told about the scan requirements and will be asked to lie down and relax without falling asleep or thinking. All participants will be asked to wear earplugs and to keep their heads still. The sequence and parameters of nuclear magnetic resonance scanning are as follows:

Structural image parameters: the scanning sequence adopts the magnetisation prepared rapid gradient echo T1-weighted and sagittal scanning, with repetition time=2000 ms, echo time=1.73 ms, field of view=240 mm×240 mm, flip angle=15°, number of layers=160, layer thickness=1 mm and imaging matrix=256×256.

fMRI scanning parameters: the scanning sequence adopts the gradient echo planar imaging and axial scanning, with repetition time=2000 ms, echo time=30 ms, field of view=220 mm×220 mm, flip angle=90°, number of layers=37, layer thickness=3.5 mm, imaging matrix=64×64 and time points=250.

MRI scans will be performed on the subjects by specialised MRI technicians before and after the intervention. To ensure the quality of the images, after the scanning is completed, two experienced radiologists will check the quality of the acquired images and eliminate those with image defects, artefacts and other problems to ensure the accuracy of the subsequent preprocessing work.

Data management and confidentiality

Every participant enrolled in this study will be required to complete a raw data form and a clinical case report form, after which an electronic database will be created. The computer files will be encrypted and password-protected, while data files, discs and reports will be physically secured in a locked area with only authorised personnel having access. The data collected during the study will not be included in the participants’ clinical profiles. Data processing will use the method of ‘data anonymity’, omitting information that can reveal the participants' personal identity. The researchers involved in this trial will have access to the final trial data set. The data sets analysed during this study are available from the corresponding author at the end of the trial on reasonable request.

Statistical analysis

Clinical outcome indicators of efficacy in this study, that is, language scales data, will be analysed using intention-to-treat. Missing values will be interpolated using the last observation carried forward method of single interpolation, that is, dropout subjects’ postintervention data will be interpolated using their baseline data. rsEEG spectral analysis data as well as MRI data will be analysed per protocol.

Statistical analysis of all the data will be conducted by an independent researcher who will not participate in the experiment. We will use SPSS V.28.0 statistical software for data analysis. All statistical tests will be conducted bilaterally, and p<0.05 will indicate statistical significance. Continuous data will be expressed as mean±SD or median (IQR), whereas categorical data will be represented as percentages. For comparisons between the two groups at baseline and postintervention, an unpaired t-test or Mann-Whitney U test will be used based on whether the continuous data conformed to a normal distribution. For comparisons within the group before and after the intervention, a paired t-test or Wilcoxon test will be used based on whether the continuous data conformed to a normal distribution. χ 2 test will be used for categorical data. In addition, we will use mixed linear regression analysis for between-group intervention effects, time effects and the interaction effects of intervention and time.

EEG data analysis

EEG data will be preprocessed by MATLAB V.R2023a software. The preprocessing consists of filtering, interpolating and re-referencing, while ECG, ophthalmic and myoelectric artefacts will be removed by independent component analysis.

rsEEG data analysis

The preprocessed rsEEG data will be extracted as epochs of 2 s each. Then, the relative power of channels in different frequency bands will be extracted and calculated using the HERMES toolbox in MATLAB V.R2023a software to analyse the changes in brain functional network characteristics before and after the intervention, such as the magnitude squared coherence (COH), phase locking value (PLV), phase lag index (PLI) and weighted phase lag index (wPLI). Changes in the difference in the relative power values of each channel in different frequency bands such as δ, θ, α and β between the two groups before and after the intervention will be explored by rsEEG spectral analysis.

ERP data analysis

In this study, we will collect and analyse the latency, wave amplitude and evoked potential topography of the P300 and N400 components of ERP, which are related to language function. In the ERP data, each stimulus point is considered as 0 ms. After preprocessing, epochs with −200 to 1000 ms will be superimposed averaged and corrected with −200 to 0 ms as the baseline period using EEGLAB V.14.1.1 in MATLAB V.R2023a software. The selected time windows for obtaining peak and mean amplitude data after stimulus onset will be 220–360 ms for the P300 component and 350–550 ms for the N400 component. Finally, the waveforms of each electrode channel and the whole-brain topography of the P300 and N400 components will be plotted.

MRI data analysis

We aim to use fMRI to study five-tone speech therapy-induced brain reorganisation without making any specific assumptions about the target region. Regional homogeneity (ReHo) is believed to be capable of reflecting the degree of synchronisation of local brain neurons and their abnormalities, 27 and it can be used to study changes in local spontaneous brain activity before and after the intervention. We will further perform seed-based functional connectivity (FC) to measure their functional connection with other brain regions. We aim to explore vital brain reorganisations in aphasia, whether focusing on ipsilateral networks or the transcerebral hemispheric network.

Preprocessing and statistics of resting-state fMRI

Functional image preprocessing will be carried out using the Matrix Laboratory (MATLAB V.2018b, MathWorks, USA) with DPABI (Data Processing and Analysis for Brain Imaging; http://rfmri.org/dpabi ) software 28 and the SPM V.12 toolkit ( http://www.fil.ion.ucl.ac.uk ). For each participant, the initial 10 time points will be excluded from the analysis due to factors such as signal instability, machine noise or subject adaptation difficulties. Subsequently, head motion parameters will be calculated for all participants in this study, and those exceeding a threshold of 3 mm translation or 3° angular rotation on any axis will be excluded. Further data processing involves regressing the functional images using 24 Friston motion parameters, as well as white matter, cerebrospinal fluid and grey matter signals as covariates. Finally, T1-weighted images will be used to align with the functional images. The DARTEL (diffeomorphic anatomical registration through exponentiated lie algebra) method will be used to normalise the fMRI image space to a standard Montreal Neurological Institute template and resample to a voxel size of 3×3×3 mm 3 .

ReHo analysis

We will perform a ReHo analysis to measure regional brain activity using the DPARSF (Data Processing Assistant for Resting-State fMRI 29 ; http://www.restfmri.net ). To measure ReHo, the preprocessed data will undergo bandpass filtering (0.01–0.1 Hz) for noise reduction, which reduces the influence of high-frequency noise such as respiration and heart rate, as well as low-frequency drift. 30 Individual ReHo maps will be quantified by calculating the Kendall’s coefficient of concordance (KCC) between each voxel and its neighbouring voxel 27 and then converting the ReHo values of each voxel into z-scores. Finally, the standardised ReHo will undergo smoothing with a 4 mm full width at half maximum (FWHM) Gaussian kernel.

FC analysis

We will use the DPARSF 29 for FC calculations. Based on the preintervention and postintervention ReHo values of the two groups, brain areas with significantly different brain area activity changes between the two groups and correlation with the improvement in clinical variables will be selected as regions of interest (ROIs) for FC analysis. These images will be smoothed by convolution using an isotropic Gaussian kernel (FWHM 4 mm). Finally, bandpass filtering (0.01–0.1 Hz) and de-linear drift will be used to remove low-frequency drift signals and high-frequency noise. For each participant, the Pearson’s correlation coefficients will be computed between the average time series of each ROI and the time series of other brain voxels. To enhance normality, Fisher’s r-to-z transformation will be applied to convert the correlation coefficients into z-scores, resulting in the creation of an individual FC map for each participant.

In addition, a two-sample t-test will be performed to investigate the differences in brain regions between the two groups. Both Bonferroni and false discovery rate corrections will be used to adjust for multiple comparisons, ensuring stringent validation of our results. Pearson’s correlation analysis will be performed to examine the associations between the fMRI data and clinical variables.

Throughout the whole study, we will evaluate safety through a table of adverse events, which includes the adverse events’ time points, severity, measures taken, relatedness to treatment and time to normalisation. No adverse effect of SLT and five-tone therapy of traditional Chinese medicine has been reported.

All researchers, including the therapists practising SLT and five-tone speech therapy, as well as outcome assessors, data collectors, data managers, data entry personnel and statisticians will receive special training regarding the standard procedure and data management. All participants’ data will be completed and recorded on the original Case Report Forms (CRFs) and then entered into Excel spreadsheets by two data entry personnel independently, following which the data manager will cross-check two data sets to ensure accuracy. A data monitoring committee is not needed because the known risks of MT and SLT are minor. Participants’ trial will be suspended when a serious adverse event or a deterioration or complication that makes continuation of the trial intervention inadvisable occurs during the course of the trial, or when another stroke occurs during the course of the trial.

Furthermore, a dedicated independent data and safety monitoring committee (DSMC) will be formed to ensure rigorous oversight of the trial’s safety. This committee will comprise experts specialising in clinical medicine, statistics and ethical considerations. The DSMC will be entrusted with the duty of monitoring the entire trial process, encompassing participant recruitment, intervention safety, adverse event reporting and trial results, as well as the accuracy and completeness of data. The project manager will have authorised access to the data, and stringent measures will be taken to maintain utmost confidentiality and anonymity of all data to anyone outside the study.

The Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine and the Third People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine and their ethics committees will be responsible for making crucial protocol decisions and disseminating vital protocol modifications. Additionally, the project manager will oversee the coordination of various departments, encompassing trial registration, researcher training, obtaining informed consent from participants and data management. In the event of significant protocol modifications, the project manager will ensure timely notification to all relevant parties during the coordination meeting.

Patient and public involvement

Ethics and dissemination.

This trial protocol is in accordance with the principles of the Declaration of Helsinki. The study received ethical approval from the ethics committees of the Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine (2023KY-009-01, 24 April 2023) and the Third People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine (2023-kl-010, 21 February 2023). In addition, it has been registered with the Chinese Clinical Trial Registry (ChiCTR; ID: ChiCTR2300069257). A consent form for participation in the trial has been developed and approved by the ethics committees. Informed consent will be obtained from all participants of the trial (or their legal guardians, where applicable). The obtained results will be submitted to peer-reviewed publications.

This randomised controlled trial will explore the clinical efficacy of the active five-tone speech therapy in the treatment of PSA in terms of language function, daily communication ability and communication efficiency, as well as explore its effects on brain neurophysiological activity and changes in brain structure and function using rsEEG and MRI.

Research has shown that PSA leads to a variety of negative outcomes, such as longer average length of stay, higher in-hospital mortality rates and increased healthcare costs, and severely hampers patients’ daily communication and social participation and imposes a significant financial burden on patients’ families and the community. 4 5 However, there is currently no standardised conventional treatment for PSA, 31–33 and the optimal timing of the intervention as well as the optimal therapeutic dose remain unclear. 34 Although different guidelines and expert consensus suggest a variety of interventions, including SLT and MT, there is a lack of high-quality evidence. 7 This study was motivated by a 2022 expert consensus recommending the addition of MT to SLT. 8 Moreover, scholars have found that when patients with poststroke Broca’s aphasia of ‘qi xu xue yu’ type are humming involuntarily to music during the listening process, it is conducive to promoting the reformation of natural articulation patterns and improving spontaneous speech fluency. 35

In this study, we combine the passive listening five-tone therapy of traditional Chinese medicine with the active speech therapy training model. This innovative MT may help active MT to play a better role in promoting cognitive function, improving the recovery of memory, language processing and motor planning, as well as promoting the modernisation of traditional Chinese medicine rehabilitation therapy techniques and the popularisation of the application of speech rehabilitation therapy techniques. Last but not least, the five-tone melody in this study is selected individually under the principle of treatment according to differentiation of traditional Chinese medicine and using the weighted threshold method according to the syndrome element differentiation criterion of Professor Zhu Wenfeng’s Syndrome Element Differentiation , 22 which is conducive to the precise and specific treatment of different PSA syndromes.

The rsEEG is often used to detect changes in the relative power values of the δ, θ, α and β bands in participants. Previous studies have shown that the relative power values of high-frequency bands, such as the β band, are lower in patients with aphasia compared with healthy controls, and that the relative power value of the β band tends to correlate positively with some linguistic functions, such as informativeness, in patients with aphasia 36 ; low-frequency neural oscillations, such as those in the δ and θ bands, are thought to contribute to phonological segmentation, 37 38 and a decrease in the δ band neural oscillations is thought to impair language functions such as listening comprehension of non-native languages. 39 In addition, the left hemisphere is the linguistically dominant hemisphere, 40 while the right hemisphere is more responsible for music and emotion. 41 42 The rsEEG can also be used to analyse the effects of the five-tone speech therapy intervention on the FC of different brain regions through COH, PLV, PLI and wPLI. As a neurophysiological examination, ERP is more sensitive to changes in the neurophysiology of the brain during language processing than scale examination. P300 and N400 are two components of the ERP that are associated with cognitive function and language function. The latency and wave amplitude of P300 can reflect the recovery of poststroke cognitive impairment, and with the recovery of cognitive function the latency of P300 shortens and the wave amplitude increases. It is generally accepted that N400 is related to the extraction of semantic information in long-term memory. In patients with left temporal lobe stroke, a decrease in amplitude and delayed latency of N400 induced by semantic mismatch can be observed.

It is worth mentioning that functional and structural brain alterations will be used as outcome measures. The fMRI indirectly measures neuronal activity and connectivity based on regional blood oxygen level-dependent (BOLD) signal fluctuations. ReHo represents local connectivity and it is calculated by the KCC of the BOLD time series, which can reflect the local activity of a particular cortical region. 35 Seed-based FC measures the temporal correlation between one or more specific seed regions and other parts of the brain, thus revealing the ability of the language network to integrate linguistic information from different brain regions. Previous studies have found that patients with PSA exhibit reduced FC in several brain regions when compared with healthy controls. However, after treatment, these patients have shown improvements in language function and enhanced FC in the bilateral frontotemporal lobe. 43 Thus, ReHo and FC based on fMRI may be more sensitive to smaller treatment effects. They can be used as a tool to assess the efficacy of the five-tone speech therapy in treating aphasia. It is also possible to explore the strength of activation of local brain regions and the strength of connections with other brain regions after treatment and to clarify the brain mechanisms of the five-tone speech therapy. Therefore, this study can provide clinical evidence on the efficacy of the five-tone speech therapy in patients with PSA through a multidimensional evaluation.

The short duration of the intervention in this study will only allow us to demonstrate the short-term effects of active five-tone speech therapy on language function of patients with PSA, and it will not address the long-term efficacy or the potential for maximum improvement in language function. Moreover, this study will not involve post-treatment follow-up, and the long-term sequelae of active five-tone speech therapy are not clear.

Trial status

This trial was registered with ChiCTR on 10 March 2023 (ChiCTR2300069257). Participant recruitment started on 25 April 2023 and the study is expected to be completed by the end of 2025.

Ethics statements

Patient consent for publication.

Not required.

Acknowledgments

The authors would like to thank all the participants and their family members, as well as the staff of the Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine and the Third People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine for providing support to this study.

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MW and JN contributed equally.

Contributors JH, BL and MW designed the study. MW registered the study with the Chinese Clinical Trial Registry and obtained ethical approval. JN is the intervention implementer. MW is the data collector and statistical analyst of this study. JH is the corresponding author and supervisor of this study. BL, MW and JN drafted the manuscript. All authors read and approved the final manuscript. JH is the guarantor of the study, and accepts full responsibility for the finished work and the conduct of the study, had access to the data and controlled the decision to publish.

Funding This work was supported by the Fujian Eyas Talent Program Project and the National Natural Science Foundation of China (grant number: 82074512).

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

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Russia-Ukraine war: Putin makes 'significant' attempt to 'redraw red lines' on using nukes

Joe Biden has just confirmed he will provide Ukraine with additional long-range munitions - but he has not relented on allowing the missiles to be launched into Russia. Meanwhile, Vladimir Putin is changing Russia's nuclear doctrine in a new escalation threat.

Thursday 26 September 2024 14:43, UK

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• Biden will provide Ukraine with long-range glide bombs
• Analysis : Decision a step-up - but falls short of what Kyiv wants most
• Explained: What are glide bombs? | Zelenskyy's 'Victory Plan'
• Putin proposes new rules on Russia using nukes
• Kremlin says latest threat is a 'signal' to the West
• 'Poorly timed': US condemns statement from Moscow
• Analysis: How seriously should we take Putin's bid to redraw nuclear red lines?

We are pausing our live coverage of the war in Ukraine.

Here are the main things you need to know:

• The Kremlin has said the West should take Vladimir Putin's latest nuclear threat as a "signal" , as it warned of "unprecedented confrontation" if Ukraine's allies help attack Russia;
• It comes after the Russian president suggested new rules which would let Moscow use nukes if it came under attack by conventional weapons;
• Our Moscow correspondent Ivor Bennett said this attempt to "redraw the red lines"  was  "significant" because using conventional weapons on Russian soil is exactly what Ukraine has been doing since its surprise incursion;
• But he noted Mr Putin's previous threats  "have not been followed through on" , with the West having been able to provide missiles, tanks, and fighter jets without any retaliation.
• Joe Biden has announced a "surge" in military support for Ukraine, with a new package including long-desired glide bombs , fresh air defence kit, and more training for Ukrainian pilots;
• The announcement was welcomed as "critical" by Volodymyr Zelenskyy , who has been holding talks with Mr Biden at the White House after speaking at the United Nations in New York yesterday;
• But our security and defence editor Deborah Haynes said while the package was welcome, it fell short of what Kyiv had been hoping for;
• While it includes more long-range missiles, permission for Ukraine to fire them into Russian territory has still not been given .

That's all for now - thanks for joining us today.

For more from the war in Ukraine, watch the special report below by our correspondent Alex Rossi , who joins Ukrainian forces defending a besieged city from Russian attacks.

These are the latest photographs from the frontline in Ukraine, where daily airstrikes have become the norm since Russia invaded in February 2022.

In Kharkiv in the northeast - very close to the land border with Russia - Ukrainian servicemen have been spotted operating drones.

It's certainly not the first time you've tapped into our Ukraine live blog and been greeted with nuclear threats from the Kremlin.

But our  Moscow correspondent Ivor Bennett   says this one is "slightly different" to the ones we've had on a fairly regular basis since Russia launched its full invasion back in February 2022.

He says "it's more specific, more defined, and an attempt by Moscow to redraw the red lines".

It's all to do with Russia's nuclear doctrine - the document that defines when and how Moscow can use its nuclear arsenal.

Ivor says: "Currently, it's only if the existence of the state is under threat.

"But yesterday, Putin said he wanted to update this doctrine so in theory Russia could respond with nukes to an attack by any state using conventional weapons - things like missiles, drones, and aircraft."

Has the nuclear sabre-rattling lost its impact?

That's "significant" because it's exactly what's happening with Ukraine.

He also said the Kremlin would consider any assault by a non-nuclear power supported by a nuclear power to be a joint attack - essentially a warning aimed at Ukraine's allies.

As we've reported, Mr Putin's officials have doubled down on those threats today, saying the West should take it as a "signal".

As Ivor notes, previous threats of retaliation "have not been followed through on".

"Providing missiles, battle tanks and fighter jets to Ukraine all happened without any consequence," he says.

There have been "loads of threats of nuclear Armageddon" and perhaps now both sides sense "this kind of language has lost some of its impact".

It could well be "yet another bluff".

Antony Blinken, the US Secretary of State, has condemned Russian President Vladimir Putin's warning to the West about nuclear weapons as "irresponsible" and "poorly timed".

The Kremlin said today that changes outlined by Mr Putin to Russia's nuclear weapons documents should be considered a "signal" to the West.

Addressing this, Mr Blinken told MSNBC: "It's totally irresponsible.

"I think many in the world have spoken clearly about that when he's been rattling the nuclear sabre - including China, in the past.

"So I would just say especially to do that now, while the world's gathered… talking about the need for more disarmament, non-proliferation." 

Sanctions on Russia were introduced two years ago shortly after the start of the country’s Ukrainian invasion. The purpose? To limit the Russian war machine and starve Russian oligarchs of access to luxury items.  

Our economics and data editor Ed Conway noticed that sales of British luxury vehicles to Russia had fallen away to almost nothing, yet sales to former Soviet states such as Azerbaijan and Georgia have massively increased. The suspicion was that these cars would then somehow make it into Russia, but we did not know how. 

In this episode, Niall Paterson sits down with Ed to find out the process by which sanctioned luxury European cars find their way to Moscow.

👉 Tap here to follow the Sky News Daily podcast - 20 minutes on the biggest stories every day 👈

Sergei Lavrov and Cardinal Pietro Larolin - in effect, Pope Francis's second in command - met for talks about the war with Ukraine late on Wednesday.

A statement from the Russian ministry said the pair discussed "mutual actions in the humanitarian sphere in the context of the Ukrainian crisis" on the sidelines of the UN General Assembly.

It also said Mr Lavrov and Cardinal Parolin spoke about "reasons for the geopolitical crisis, a direct consequence of the consistent anti-Russian policies of Western countries".

Relations between the Vatican and Kyiv have been strained at times due to a number of Pope Francis's comments since the invasion took place in February 2022.

However, the pope has repeatedly called for peace and condemned attacks by Russia that have caused loss of life since the conflict began.

Additionally, a papal envoy has visited both Kyiv and Moscow as part of efforts to bring Ukrainian children allegedly deported to Russia back to their homes.

Perhaps the most notable part of the new US aid package announced for Ukraine today is the inclusion of glide bombs.

This type of weaponry has been used by Russia during the war and has been long desired by Kyiv.

What are they?

The US Air Force describes them as "an unpowered glide weapon used to destroy high-value targets".

They are 12ft long, 18 inches in diameter, and weigh 2,500 pounds.

Each bomb costs up to $245,000 - they're cheaper than the ballistic and cruise missiles Russia regularly fires at Ukraine.

As our security and defence editor Deborah Haynes says - and as their name implies - they have retractable wings that help them reach targets upwards of 70 miles away.

They can be deployed from the F-16 fighter jets Ukraine also recently received from the US.

Reports suggest the glide bombs will be equipped with cluster munitions.

How do they work?

These bombs are equipped with satellite guidance capabilities that help them navigate in all conditions - day and night, and during bad weather.

They can be guided by an operator by remote control after being launched from the aircraft, but they can also lock on to targets beforehand and be guided there automatically.

The wings are arranged in an X-like arrangement, helping them glide through the air with the required accuracy.

Their wingspan is 4ft 11 inches.

The UK has just confirmed it  has extended its sanctions regime on Russia to include five ships and two shipping fulfilment companies. 

Earlier this month, the Westminster government slapped sanctions on 10 ships in Moscow's so-called "shadow fleet".

It is alleged that Russia uses these vessels to avoid Western restrictions on Russian oil exports.

In the past year, there has been growth in the number of oil tankers transporting cargoes that are not regulated or insured by conventional Western providers

The new ships under British sanctions are: Asya Energy, Pioneer, North Sky, SCF La Perouse and Nova Energy. 

And the shipping companies are: White Fox Ship Management and Ocean Speedstar Solutions OPC.

If you're just joining us, it's been a significant few hours for the ongoing conflict between Russia and Ukraine.

• Vladimir Putin has been back at the nuclear sabre-rattling , suggesting new rules which would let Russia use them if it ever came under attack - even by conventional weapons;
• The Kremlin said the West should take it as a "signal" , and warned of "unprecedented confrontation" if it helps attack Russia;
• Experts say his threat is designed to trigger  "a new wave of panic"  across the West and ensure they don't give Ukraine permission to fire long-range missiles into Russia.
• And back to those Biden-Zelenskyy talks, it's been reported the US president isn't happy with his Ukrainian counterpart's "victory plan" ;
• According to The Wall Street Journal, US officials are concerned it doesn't include enough detail on potential diplomatic solutions .

That's all for now - stay with us for more updates and analysis from Washington, Kyiv, and Moscow throughout the day.

Moscow has returned nine children who were deported to Russia back to their relatives in Ukraine, reports have suggested today.

Maria Lvova-Belova, the Children's Rights Commissioner for Russia, said the group included eight boys, aged 12 to 17, and one 17-year-old girl.

The return was co-ordinated by Qatar.

Ms Lvova-Belova said representatives from Qatar had "participated in negotiations with the Ukrainian side".

They also "accompany children and relatives" and taken care of "transportation and other expenses". 

"The International Committee of the Red Cross, regional children's ombudsmen, representatives of relevant departments, and law enforcement agencies also participate in the work."

As of today, a total of 80 children from 62 families have been reunited with their relatives - both in Ukraine and third party countries.

Ukraine has accused Russia of deporting children during the occupation of a number of cities in Ukraine, such as Donetsk, Kharkiv and Kherson.

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