I have received many questions about therapy techniques for toddlers with apraxia. Before I give you ideas that are specific to treating children with apraxia, I want to first outline what I believe to be the best treatment approach for all children who are experiencing difficulties learning language. These strategies can also be used at home by parents, who I believe are a child’s first and best teachers.
Before I talk about my treatment philosophies, let me send out a disclaimer for all of you who are working with SLPs or other early interventionists who may be taking a different approach with your child. There may be very valid reasons she (or he) has chosen to use other specific strategies with your child. There may be reasons that the approach I take may not be the best for your child or your family, (although I can’t think of any). Ask your therapist to have a frank discussion with you about her (or his) decision-making process in choosing techniques. Most therapists welcome this kind of discussion and are happy to talk about it with you, over and over if necessary to make you feel comfortable and empowered as an important member of the team for your child.
For children who are non-verbal or minimally verbal (less than 10 words), I believe that establishing communication and improving both receptive and expressive language skills are the primary focus for treatment. Specific speech sound practice and/or oral motor exercises need to be worked into playas a very FUN part of therapy, and are absolutely necessary for kids with apraxia.? However, I do not feel that this should be the main focus for children who are non-verbal, even when they are non-verbal because of apraxia, and especially for those who are non-communicative.
By non-communicative, I mean children who lack interaction skills. These kids do not come to you to get the things they need. They do not point or use other gestures to make you understand what they want. He or she does not initiate social games with you. Many of them appear self-absorbed. They focus on their specific likes to the exclusion of more meaningful interaction. If this is your child, it is absolutely essential that you target social interaction and being “connected” to others FIRST, or at least WHILE, you are working on expressive language. Don’t kid yourself. If your child isn’t social, talking is not his main problem. Start with ideas on this site from the “Social Games” article, “Teaching Your Toddler to Listen and Obey”, and “Help! My Child Won’t Imitate Words” before, or at least WHILE, you use the strategies listed here.
If your child is social, but is not yet using gestures consistently to indicate wants and needs, and/or is not initiating interaction with you, this should also be a focus. Children who are social responders, but not social initiators, can be taught to do this. I might use another adult or older sibling to help model these kinds of things. For example, an older sibling can initiate jumping off the couch into my arms by climbing onto the couch and holding out his hands for me to begin the routine. Or I might take the child’s hand and place it on Mommy’s to help pull Mommy over to the counter to get a drink. I might sit behind the child and help him lean into take Mommy’s hands to initiate Peek-A-Boo or Row Row Your Boat.
I model pointing constantly with a child who can’t do this yet. Point to pictures in books, choices in play, clothing items, body parts, everything. I make it a big gesture. I work on pointing by making sure kids reach for things. If he’s not reaching, I hold toys he wants just in front of him to make him lean in. Sometimes I ask Mom to help him reach with hand-over-hand assistance. In play with toys and in books I also have kids pat, tickle, feed, and any other action I can think of to have them touch specific items. If this doesn’t work, I rely on a couple of oldie but goodie OT tricks. Have her practice touching a dot on a cup with her index finger with hand-over-hand assistance. When she perfects this and can do it on her own, pull the cup back just as she is about to touch it. Or practice stuffing a scarf through a hole with your finger. If this doesn’t work, talk to an OT!
Don’t get me wrong. A toddler with apraxia can still have issues with social communication, interacting, and even gesturing. However, in this kind of case, in my opinion, apraxia is not the main reason he’s not talking or communicating. More importantly, if he’s not following directions or doing other kinds of things to indicate that he understands language, direct lots of your efforts to improving language comprehension. For those of you who can’t help yourself, work on the other issues in at least the same amount of time that you spend working on saying words. See the article, “Teach Your Toddler to Listen and Obey” for ideas on improving receptive language.
The thing I do with all kids I see for therapy, and especially those with apraxia is absolutely, in the most fun way possible, REQUIRE them interact and respond. Children do not get to veg out in their own worlds, or direct all the play. (If this sounds like your child, please carefully read the next paragraph.) I do not follow children around simply narrating what they do “hoping” that they may imitate what I say. This kind of language stimulation approach is generally not successful for children with apraxia. If it were, these children would already be talking, because most good parents talk to their children in this way already. If you are using this approach, or (gasp) you have a therapist using this approach, please read on for what I believe is a better way to do things.
For children with limited social interaction skills or lower functioning cognitive skills, this “requiring a response” may not be achievable for a long time. For those kids we work on interacting during social games and participating with very basic cause/effect toys or foundational cognitive skills like object permanence. I also use Floortime techniques for at least part of the session to be sure we’re working on engaging at whatever level they can achieve. For more information on this technique, read anything by Dr. Stanley Greenspan. This approach is at the core of anything he’s written.
Back to the premise of my treatment philosophy – I require the child to respond. Their attempts can be off-target. If they can’t talk, they can sign, or use any other mode (such as gestures or pictures) they can. But they absolutely, positively MUST communicate. I don’t give any kid who can initiate or respond a turn with any toy, a piece of any snack, or let them do anything else, until he at least tries to ask for it using the highest level of communication he can. I’m not mean about it. In fact, I could possibly the most fun adult many of my little clients know, but I am VERY insistent that they respond.
Like I’ve posted on other sections (What Works / What Doesn’t Work), I play for most of my therapy sessions. For most toddlers I see over 15 months old or so, play means using toys. I like to use a combination of things we sit down to do and alternate them with movement activities.
Strategies for Toddlers with Apraxia
For example, we might start the session with a favorite toy that I know a kid likes. Initially most children are generally pretty eager to attend and play when I first arrive. I try to make this as upbeat and as fun as possible. You do this with your tone of voice (very animated and bubbly) and your facial expressions. Smile!? Laugh! Act like you are having the time of your life!
For parents, this is essential. Begin your own play sessions with toys you know that he or she likes. Then move on to new things or things that are difficult. Lavish your child with affection and attention during this special play time. Let her know how crazy you are about her by how totally focused you can be during play. Don’t answer the ringing phone. Don’t constantly look over her head to watch TV. Those things can wait. Pay attention so she will!
BUT absolutely withhold or sabotage the activity by keeping the pieces of the toy until the child requests what he needs with words (if he’s verbal) or gestures/signs (if he’s not). Model what he should imitate if he’s not using spontaneous words or signs yet. Say the word or demonstrate the sign and wait.
As I’ve stated before on this site, I always give choices. Ask, “Do you want trains or cars?” Wait for him to pick one, either with a word or sign. If he can talk or sign, model the choice 3 to 5 times before giving in and playing. Take his hands and help him sign if he can’t/won’t do it on his own.
If he resists or becomes too upset, go ahead and play with what you think he wants. I think it’s too mean to hold out beyond this point. I want to keep the toddler engaged and wanting to play with me. I believe that it is counterproductive to have a toddler throw tantrum after tantrum in a session because he’s so upset. It should be the same during playtime with mom and dad too.
When kids are this upset, they don’t learn. Or the lessons he is learning are ones I don’t like. He either feels like, “This woman is so horrible to me that I don’t ever want to play with her again.” Or equally non-constructive, “This tantrum thing is working for me. All I have to do is scream and pitch a fit to get my way.”
When a toddler begins to exhibit these kinds of patterns, I do not use withholding or sabotage as my primary approaches. I still choose the activities so that I can make them fun and target language, but I do lots of modeling in an animated way with occasional withholding when he’s happy and can tolerate it. I use LOTS of praise and then immediately reward (with the toy or snack) when he’s participated in a positive way.
By praise I don’t mean a 5 minute lecture with language that’s over his head before I give him what he wants. Don’t “lose” the kid with this mistake. I do lots of smiling, laughing, tickling, and saying, “Yay!” I try to project sheer and utter delight that they have done what I wanted them to do with my facial expressions and actions as I am giving him what he wants (the real reward).
When we’ve done several sit-down play activities (or even one) and I sense that I may be losing him, I ask him if he’s finished and have him sign/say “All done,” or “Clean up,” or whatever other word or gesture he can use to indicate that he wants to move on. I always insist that kids help me clean up an activity. I am not a therapist who lets a kid drag out 7 or 8 different toys at a time. How in the world can a busy toddler stay focused on what we’re doing in that kind of clutter? Your child needs this kind of environment even during your special play times. It may be one thing to let him play as he pleases on his own, but when you are doing this together, specifically with teaching language in mind, it will help to limit his choices and clean up a bit so that he’s doing one thing at a time.
Several parents of children on my caseload save certain toys to use only when they play together with their child. They put them in bags or baskets and put them away in the closet until Mommy or Daddy can play too. The novelty alone will make your child want to interact. Think of the reaction you’ll get when you bring out the special bag! Playtime!
When my own children were toddlers, there were many kinds of activities that I never let them do alone. For example, play-doh, paint, crayons, markers, sand, etc… Get the messy theme here? If you have a child that continues to mouth toys, you may choose to introduce ones during this time that you’d never let him play with on his own while your attention is solely focused on him.
Back to my point about cleaning up – This cleaning up process does so much to help with transitions. It also prevents them from moving on to something else before you’re ready and keeps them engaged with what you’re doing. I sing the standard “Clean Up Song” from Barney so much, they ought to charge me, but it works. Have your child try to sing this with you. If a kid can say “up,” I sing, “Clean up, clean … ” and then pause for him to finish “up” once he’s learned the song.
If you have a child that hates cleaning up, you could pick up 3 or 4 pieces to his 1 piece. The point isn’t to be a tyrant or a neat freak. The point is that activities have a beginning, a middle, and an end. Children, especially those with short attention spans or transition issues such as wanting to play with a few preferred things exclusively and who freak out when an adult tries to move on, need practice with this concept.
Additional Tips for Toddlers with Apraxia
Other tips to make the clean up process work are using giant zip-lock bags for most of your toys. I use the 2.5 gallon size since almost anything can fit in there. At home try baskets or bins. If your child won’t help you, try making it more fun by “throwing” the pieces in. Practice saying, “Bye-bye” to each piece. If you’re just beginning to work on sequencing phrases, by all means, use this “Bye-bye ____” during clean up time because the child is usually so focused on this process that the phrases are easier to produce.
I always alternate sit-down play with movement activities, especially with energetic little boys (and girls) who thrive on heavy work and deep pressure. (These terms are borrowed from occupational therapy. This applies to the kid who is constantly moving or who needs to jump, crash, or in any other way “feel” his body in space to regulate. Kids who have systems like this usually display sensory integration differences.? For more on this, search this term on this site or the Kidpower site.)
My favorite movement activities for toddlers are bubbles, balloons, social games with movements (See the “Social Games” article), chase (like Get’cha, Get’cha in the “Social Games” article), and jumping off furniture or on the bed. I will “hide” and let them find me or vice versa, to be sure we can run around the house. Many children have plastic slides or swings in their homes, and I never neglect an opportunity to use those kinds of things.
For older 2′s, I might use games with movement such as bowling with plastic pins or Elefun, a game with an elephant that blows butterflies out of his trunk that we catch with nets. I routinely use puzzles and turn this into a running game or obstacle course. Put the pieces at one end of the room and the board at the other. Have the kid ask for each piece and then run, climb, crawl, etc… to place the piece in the puzzle. (This also works better for kids who can’t/won’t sit for a puzzle.) Do the same thing to retrieve the pieces and target language comprehension. Ask him to “Run and get the _______.” Run, crawl, or jump along with him to get the pieces and increase the fun. Toddlers LOVE to see their parents act in unexpected ways.
I might also use other movement activities a child’s OT or PT recommend such as swinging in a blanket or Lycra with help from Mom or bouncing on a therapy ball if Mom mentions that these help a child to regulate. However, if a child associates this with “therapy” time, I avoid it like the plague and stick to more “playful” movement activities.
During the movement tasks, I require them to talk or sign to request more turns to continue. Words I routinely use for this are “more” or “please,” or better yet what they are really doing, “Jump,” or “Go,” or “Swing.” Don’t let this turn into a “break” from talking or signing! I hear and read about therapists who use this kind of play as the reward with no therapeutic focus (aka – talking). I think that they are missing “prime time” for communicating.
Once I think we’ve moved enough or read a toddler’s signals that he is ready, I go back to a sit-down play task. For many toddlers and even preschoolers, these movement breaks are absolutely essential. I cringe when I hear of therapists who make a 2 year old “perform” with several flashcards and then “reward” them with one turn from a toy or a lick from a sucker. BORING! Or more likely – FRUSTRATING!
A Word about Books with Toddlers with Apraxia
I only use cards and even books when it’s one of a toddler’s preferred activities. Otherwise, I don’t use them at all. You will NEVER catch me with a worksheet. Therapy is not as efficient as if I used cards or books, but what good is it anyway if a kid hates it? I do not see the value in this. It takes much more creativity on my part, and I may only get 5 productions of a word or sound vs. 10 attempts in the same amount of time, but again, what good is it if the child is miserable? In my experience, miserable children do not talk. When they do, it’s usually to scream, “No.” I will never see the point. I do not get my kicks from having power struggles with toddlers. I may win the battle, but not the war.? It’s just not worth it to me.
Again, I believe that specific sound practice is necessary for children with apraxia (or phonological disorders or whatever else you want to call it), but I rarely work on sounds without having a functional target. The way I work sound practice in is by seeing what sounds they do have and then getting them in words as quickly as possible. I practice new sounds vowels or consonants alone in isolation ONLY in the context of play. For example, if a kid doesn’t have an/m/, we do “mmm” when we eat snacks, pretend to feed babies, let the toy animals eat, etc… Then I move to a word with an /m/ such as “more” or “mine.” I set up situations so that he has to imitate the word to get what he wants for the next turn/snack.
I use lots of phonemic cues when we start to pay more attention to specific sounds. For example, I call a /p/ sound a “popper sound.” When I want to teach or practice this sound, I use an activity when saying this sound makes sense, such as bubbles with “pop.” Or we might play baby dolls for a child who is starting to potty-train, and we practice words like “pee” and “poo-poo.” (I am not prepared to share the list of sound cues until I figure out whose stuff I use so I can give the person proper credit!)
I work in oral motor practice, or for children with apraxia, oral sequencing practice, into play activities. I exaggerate facial expressions constantly in play and encourage children to imitate me. I do this with WORDS ONLY. If something is exciting or huge, I exaggerate, “Wooooow!” We’re beginning that word with a relatively closed mouth and opening up to a huge vowel sound. I use lots of “oooh’s” and “aaaah’s” when we’re playing. I do animal sounds, and my favorite is the monkey so we can practice “oo oo ee ee,” which really is practice sequencing vowels and alternating mouth movements. When we’re playing with play food, I lick my lips and say, “Yummy!” When we’re playing with farm animals, I ask my little friends if they can wag their tongues like the doggie’s tail. You get the drift. Put everything into play.
As I stated before, as soon as I hear a new sound in isolation or alone, I try to get it in a word as quickly as possible. When a child is good at imitating a word, I set up situations for him to use the word spontaneously, or on his own. We keep it at the single word level until he’s ready for phrases. (By ready for phrases I mean 50+ word vocabulary that he says spontaneously.)
One thing I emphasize with all children I see, and especially those with apraxia, is to set up play when I have to get multiple repetitions of the same word. Repetition is how children establish the motor planning necessary for and make the brain connections that result in intelligible and consistent speech. Don’t settle for one production of a word. I always play the “my turn/your turn” routines with toys, so that kids expect me to get even a favorite toy back, and they have to request. If you have to, steal the toy (playfully) and make them ask for it again (and again)! I never let a kid get something and then silently play for even 30 seconds before I’m prompting that word again, or another one. Join in. Make it communicative, and more importantly, keep it fun!
For vocabulary selection, I try to teach words that toddlers can use and ones that represent things they love. For more ideas on this, see the section on “Early Sign Vocabulary” and “First 100 Words.” Generally, I teach more nouns/names for people, toys, foods, and other objects first. I always begin using verbs/actions during play soon after, and I especially want to focus on these when a child’s vocabulary is near the 50 word level, so that he or she can have some words to combine with their nouns to make phrases. I work on prepositions/location words at that same time too.
Many therapists make the mistake of teaching parents the wrong way to “expand” a child’s from single words to phrases by emphasizing word classes out of sequence from the way typically developing children learn phrases. I sigh when I sit in meetings and hear SLPs suggest that parents expand their children’s vocabularies by offering “blue car” or “big truck” when their children say “car” or “truck.” This is not how typically developing children expand to phrases. For specific ideas for phrase practice (and ones that work!), please look for a new article on this topic in the next few days.
I do NOT target intelligibility or articulation as the primary focus of therapy until expressive (and certainly receptive) language is close to an age-appropriate level. For most of the children I see for early intervention, this doesn’t happen before they are discharged to school-based or private services at age 3. I focus on what they are saying (what they mean) and why they say it (their intent – for more information on this see the article titled, “Teaching Your Toddler Words to Change His World.”)
I don’t focus on how they say words, with specific sounds, unless they are really, really, really unintelligible and no one, including mom, dad, regular babysitter, or me, can understand them. Nothing is more humiliating to a new talker than a parent who overcorrects first word attempts. I can see this in their little faces. They look at me as if to say, “Why bother? My mom never thinks it’s good enough.”
What you can do is restate the word they intended to say correctly. But please, I am begging you here, don’t say, “No. You said it wrong. It’s ____. Watch my mouth. ______.” Please, for the sake of your little one’s self-esteem, avoid the temptation to overcorrect. This places too much pressure on your child. When I suspect this is happening too much at home, and especially for a child with apraxia, I put the parents on a strict “NO SPEECH” vacation. They are not allowed to prompt, cue, question, or correct anything their toddler says. They are only allowed to model and shower their children with praise. Most of the time a couple of week break is all everyone needs to restore balance and order again.
This article is terribly long, but I hope you’ve hung in there to read it all. I believe that this approach works for all children with expressive language delays, but especially children with apraxia, because you are making speech practice functional by teaching words he can use, integrating specific sound practice or oral motor work into play activities to make it age-appropriate, targeting vocabulary and utterance length in a logical and sequential order, and helping his sensory and alerting systems stay regulated and focused with regular movement activities so that he can pay attention and learn.
Whew! That’s a lot of information! If you have questions or need me to expand or give more ideas, please don’t hesitate to leave a comment below. This site is for you. Laura
++++Additional Comment – I forgot to add the value of using the “sing-song” voice I wrote about in the What Works article. This really works, and your kid won’t talk like this forever, I promise!
Get my DVD specifically for parents of toddlers who are suspected to have apraxia. More info here!