Successful Speech Therapy Strategies for Working with Toddlers with Apraxia and Other Speech-Language Difficulties
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I have received many questions about therapy techniques for toddlers (that is under age 3) 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 child can have apraxia and 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.
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.
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!
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!
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Comment by Emily on 8 April 2008:
Thank you so much for all of the information in this article. I feel like my son’s therapist has done everything you said should not be done and that I need to take a no speech break. My son has seen his therapist 7 times and this last time he hid behind me and cried. I felt terrible. I will definitely be making big changes to help my little guy.
Comment by Laura on 9 April 2008:
Emily- That’s why I launched this site. Many therapists simply don’t know how to work with toddlers. Instead of taking a break from speech, I’d recommend trying a different approach. You didn’t say how old your son is, but birth to 3 (and preschool) is a critical time for language development. Find someone who knows how to do it and can help you implement changes at home. It sounds like you’re on the right track by recognizing his signals that you need to do something differently from your current experience. Good luck! Laura
Comment by Laurie on 9 April 2008:
I am a Speech Therapist and the mother of a 3 year old child with apraxia. I decided early on that it was going to be too difficult to be both mother and therapist to my child, so I sought services through our state’s early intervention program. We were extremely lucky to have been referred to Laura for speech therapy. She worked with my son for a little over a year until he turned 3 and was no longer eligible for early intervention. During every session, Laura used most, if not all, of the therapy techniques she has outlined in her posting. Not only did my son make tremendous progress, but he LOVED speech therapy. As a therapist (and a mother), I was very skeptical that anyone could work as well with my child as I could. My standards are very high. Laura’s approach to therapy was beyond what I expected. We have since been through 3 therapists in the last 8 months. Although my son continues to make progress (sometimes not as quickly as we’d like), we are still looking for an SLP of Laura’s caliber. It can be very frustrating dealing with the day in and day out struggles of a child who has trouble communicating. I now know that from both a therapist’s and a mother’s perspective. Here are just a few suggestions that may help other parents struggling with Speech Therapy:
- Dont’ give up and don’t be afraid to change therapists. If you don’t feel your child is making progress or he hates therapy, it is time for a change. In my case, I didn’t feel that the therapist’s goals or approaches were appropriate for my son’s disorder. (Therapists that my son has seen since Laura, that is).
- Ask to observe therapy. What your child does in therapy should not be an isolated event. You are with your child the majority of the time and you need to be able to use the same strategies at home that are being used in therapy.
- Ask for specific activities that you can do at home with your child. Any of the strategies outlined by Laura would be great but make sure they coincide with the primary focus of your child’s therapy.
- Keep educating yourself. There are great resources available (such as this site) that will help you be your child’s best advocate. I’m constantly looking for new information.
- Enjoy your child. Laura actually had to remind me of this several times. Don’t be so focused on your child’s disorder or the things that he can’t say that you miss out on all the cute and fun things that he can do and say.
Thank you Laura for sharing your knowledge, ideas and expertise on this website.
Comment by Bree on 10 April 2008:
I appreciate the information that I learned from this site. I have a 34 month old with Prader-Willi Syndrome. His receptive speech is age appropriate but is behind in expressive speech. He is receiving speech therapy through early intervention but will soon be moving on to the Intermediate Unit. The problem that I am facing with his therapist is a lack of creativity and a lack of ability to control the session. It has gotten to the point where we have had a sort of fallen out over it. She does not plan any activities and she is not able to keep him focused. She needs me to constantly intervene, which I don’t mind, but find exhausting since I do not have to do this with his PT, OT, or Educational specialist. Also, it seems like every week she asks the same question, what does Nathan like to do? She has been working with hime well over 4 months now, she should know what he likes to do, especially since I am always telling her. I have complained to her supervisor about the situation and in turn she complained that I am not involved enough. My question is, how much should I be involved during the therapy session? I am there in the room with them during the session. I am listening and looking at what’s going on. I also implement what little is being taught to him during the week. Is there more that I should be doing?
Comment by Laura on 10 April 2008:
Bree - I am so sorry that you aren’t having a better experience with speech therapy. It’s quite a challenge when you see your child do well with 3 other clinicians and then struggle with the speech therapist. It sounds like changing therapists is not an option. If this is the case and you have to stay with your current SLP, I do think you need to keep intervening in the sessions, and not to make it easier for the SLP, but to make the session more fun and engaging for your child. Even if you dislike your therapist because of her flaws, try to squeeze every possible benefit from the session.
One thing you might ask her to do for the next session is to take out his plan/report and review his goals and progress with you. Ask her EXACTLY what strategies she’ll use to accomplish each goal and then to tell you EXACTLY what activities you should do at home to work on these. When she’s given you suggestions, ask her to model HOW you should do these things at home. If she’s uncomfortable, ask her if you could play with him using the ideas she suggested with her interjecting and “coaching” to tell you how she would elicit what you’re trying to accomplish (his goals). You may be able to accomplish much more this way than if you sit back and wait on her to magically change her approach.
It sounds like she is not comfortable with your child, and this is unfortunate, even for her. Your child can probably sense this and he balks. Over the years I have had a few children that I have not been able to “make the connection” with quickly, and it always KILLS me. I too pick a mom’s brain when this happens, but usually we can come up with something together that works, and hopefully I can remember these after a few suggestions from mom.
Even if you dislike your therapist, for your child’s sake, make it work. You’ve tried complaining, and it sounds like you can’t make a change, so roll up your sleeves, dig your heels in, and do the hard work of making the session meaningful for your son. If you’ve found any ideas on the site that seem like they would work for him, feel free to print the article and share it with her. I LOVE it when moms bring ideas to the session or ask me specific questions about strategies and methods. Even if it seems like it’s not your job to “run the session,” do it anyway. You may teach HER a thing or two, and it sounds like she could use the help. I hope these suggestions are helpful, even if it means more work for you. Good luck! Laura
Comment by Jody Lynson on 18 April 2008:
My son, who is almost 3.5 yo started speech in Jan 2008. They had him just sit and repeat words back to them. One therapist played with him and he did good with her. The office felt our son needed to be in a preschool setting, as being around other kids, they said would help. So, they ended care with no transitional care. I am on a few waiting list and the schools cannot see him until the middle of May. My son has now gone 4 weeks with no care. He has done better at home by home play with me. I kind of feel the therapist violated the ASHA code.
Comment by Kacy on 2 July 2008:
My 21 month old son has about 30 words in his speaking vocabulary but he is leaving off the consonant sound at the beginning of his words, For example: milk is ilk. I don’t want this to become a habit for him and was wondering if you advised that I see a speech therapist before he is 2 years old. How do I go about finding a good speech therapist? His peditrician says he may grow out of it, but I don’t want to wait too long.
Comment by Laura on 2 July 2008:
Kacy - Leaving off initial consonant sounds is not as typical as leaving off ending sounds at this age. That being said, I probably still wouldn’t see an SLP for an assessment until after 2 1/2 because the work he’ll need is for articulation/phonology, and children really aren’t ready to work on that until they are a little older.
You do want to keep working on increasing his vocabulary so that he hits that 35-50 word milestone soon, so he can begin phrases. This is actually more important at his age than having speech sounds that are 100% accurate.
However, at home you can facilitate these initial consonant sounds by practicing the sounds he is omitting in isolation (alone). This helps him develop an awareness of the sound. Then you can try to plug them back into words. You can also practice saying syllables with a consonant vowel pattern - me me me, mo mo mo, moo moo moo, in a playful, silly way. I always do this in play, not for the sake of practicing speech. For example, take a plastic figure and have him make it walk saying, do do do, dee dee dee, dah dah dah, etc…. This helps him learn to include initial consonants with a vowel, and more importantly, sequence them in syllables to prepare for phrases.
As far as finding a speech-language pathologist, start by asking around. Ask moms with older children if they have used an SLP or know of someone who has. Word of mouth referrals are generally more reliable than any other way of finding a great therapist. You can ask your pediatrician’s office, call a children’s hospital, or even check with your insurance company to see who is listed, but again, you’d rather have an endorsement from a happy family than a name from a list.
You can also call your state’s early intervention program, but again I’d wait until he’s a little older. With 30 words at 21 months, he is likely not going to qualify for services now thru early intervention, but he may later after 2 if his phrases don’t come on in, or he’s still struggling with intelligibility.
In the meantime, keep reading for ideas to help him at home! Laura
Comment by Shaffon on 6 July 2008:
*SIghing with relief*
My son will be 4 at the end of august and my husband and i have always been concerned with his speech. We were on a waiting list for the states early intervention program but lucky we got insurance and he was referred to a speech therapist. He tends to leave of the ends of words and sometimes doesn’t say the beginning of words also. For example instead of “fish” or “four” we would hear “ish” or “our”. I’m normally with him outside of him being in preschool and i usually correct him ( i don’t tell him NO u said it word) by telling him to look at momma’s mouth and say what i say. He also speaks fast and jumbles his words or uses sounds sometimes to fill in the words. The thing is i can understand him and others can to (depending on what he says) an extent but atleast he is making sentences. For example he would say I *then mumbled fast words* beach. I know he said i want to go to the beach, but what i don’t understand is if i tell him to slow down and ask him what do you say” he would say it slowly and clearly. He doesn’t do it all of the time, but as another mom said her son would just say milk, or juice. He tends to do that also, but he corrects himself if we tell him to say it properly. If we ask him a question he usually answers yes or no and sometimes its followed by No i want this or yeah i want that etc.
So i don’t know if i should really be considered or not. My son has been seeing a SLP for a month and at our last session she said she wanted to send him to see a developmental pediatrician. My mouth dropped and i began crying because it’s only been a month. When i asked her the reasons behind it she said just to rule out any other underlying problems and then asked me to read the 14 signs if autism. I got defensive immediately and decided to calm down and explain to her tha my son is in school and they have no issues with him. He’s very friendly and is smart. He knows how to work the computer, play online educational games, write his name, shapes number and alphabet. She then said if i could video tape him to more or less prove to her that he’s different at home. Is that even right to ask? I know that i’m writing a lot but i’m also 38 weeks pregnant and don’t sleep well because i’m up stressing and worrying about my son. I personally don’t think he needs to see one neither does his pediatrician, but laura what do i do from here on out. This website and all of the information you have given along with the other parents have been a sigh of relief because i felt alone.
My goodness i didnt realize i wrote so much, but i just had to let it out. What should we do? Is he making progress? I also do my own fun activities at home, in the car etc with him. Any advice would help and thank you again for reading.
Comment by Shaffon on 6 July 2008:
Oh laura she also said she notices echolalia, but its not all of the time either. He can express himself at times and other times he whines. I was told by his pediatrician he will outgrow that and he understands that another child is on the way and it actually has eased a lot. His pediatrician also said that children tend to correct themselves overtime with speech and by 5 he should be better. Is that true? Am i just over reacting and jumping the bullet or am i doing the right thing?
Comment by Laura on 6 July 2008:
Shaffon - TAKE A BREATH! I can tell that you are soooooo worried and worked up about your son. I never tell moms not to worry because I think that God gives us that inner nudge that lets us know when something isn’t quite right, and usually, we should listen to that voice. That being said, I hope you can take a deep breath while I give you my opinion on this in an effort to help you try to sort all of this out.
First of all, I can tell that you are totally freaked out by even the mention of the word autism. It is so scary to hear the possibility of this diagnosis, let alone process what it could mean for your son, and for you. This has to be an incredibly difficult thing for you to hear - not only because you love your son dearly, but also because you’re about to have a second baby. I am sure your hormones and protective instincts are all in over-drive right now! This has to be an incredibly stressful time for you, and I hope you are getting the support you need for this.
However, that being said, I would go ahead and pursue the additional appointment with the developmental pediatrician. Best case scenario is that the doctor will tell you that it’s not autism. Less than best, but still good, is that he’ll say he IS on the spectrum AND point you in the right direction as far as pursuing additional treatment options. There is not a BAD outcome for going ahead and having this assessment. Actually I think the only bad outcome would be not having it done because the possibility of autism would loom over you until you get the evaluation and have it ruled out. Then your cycle of worrying will continue on and on without resolution, and you’ll completely second guess yourself for a long time.
Waiting for a child to improve at a magic age is often a huge mistake that parents regret since you may lose valuable treatment time. However, you already have your son in therapy, so it sounds like you’re doing everything you can to help him, with or without a diagnosis. If your SLP is providing the same treatment she would for his challenges regardless of what it’s called, there is no harm in waiting. However, if in waiting you don’t give him the time, effort, and specific interventions his issues deserve, you’ll be doing him an injustice. Does that make sense to you?
I wish you all the best as you sort this out! Let me know if I can help you in any other way - Laura
Comment by Shaffon on 6 July 2008:
*Breathing, but now with tears*
Thank you laura for responding so quickly!! My tears are most likely my hormones being all over the place and yes the word Autism scares me. I’ve read so much on it that i don’t know what to believe he has or not. The only symptoms he has is the repeating if u ask him a question, but what gets me is he doesn’t do it all of the time. I may ask him what do you want and he may repeat it but then i might ask and he answers me and say I want to sleep. Since being in the sessions i think he talks a lot more. He actually likes to talk on the phone now and he asks questions such as where is daddy or grandma? If u ask him where something or someone is he can respond it’s over there or i don’t know. Laura i definetly have a worrying complex but because i get so much information on autism my brain is over loaded and emotionally it’s draining. But i will speak with her on tuesday and his doctor as well and begin his journey to get evaluated by a developmental pediatrician. And if he isn’t autistic then normally how long do children have to have speech therapy? Thanks again
Comment by Holly on 6 July 2008:
Hi Shaffon I just wanted to drop a few lines as a mom who’s been where you are now. I believe, not certain, that they always test all other aspects once they are receiving help in one area. My son too was tested by a developmental specialist and an OT and a PT and anyone else you can think of
I know in my state they mandate it once a child is receiving any time of special ed I don’t know if it’s the same in yours too maybe. I know it’s very hard especially when you’re pregnant. My son was diagnosed with apraxia when I was pregnant with my second child as well. You just have remind yourself to stay strong for your child and things will work out:) I don’t remember seeing what ‘type’ of speech delay your son was diagnosed with? or maybe I just missed it. The reason I ask is because I know with apraxia where it’s a motor planning issue sometimes the child will repeat themself especially if what they are trying to say isn’t coming out right or you’re not understanding what they’re saying. I wish you the best and hang in there it’ll get easier:)
Comment by Shaffon on 6 July 2008:
Hi Holly Thanks for responding. I was told that he has an articulation and language problem. He tends to repeat what you may say sometimes, but we can have a conversation. I’m going to stay strong because i know that i have no choice. I just think the way the SLP went about talking to me got me upset because she was cold and forward. My husband and i are willing to do whatever needs to be done in order for our son to get the help he needs. He is also happy that i stayed up until 330 am(eastern time) to read and write comments. So holly what therapy is your child in? How long has it been and have you seen results?
Right now my son goes once a week for 30 mins and she shows him cards and asks him to say what he see’s and whatever sound he isn’t pronouncing clearly she corrects him and he repeats it. It’s been a month but we see changes. I still would love to know why he speaks fast and jumbles his words at times. Thanks again holly, look forward to your response.
Comment by Ashi on 12 July 2008:
hi laura, How can i order DVD for my Australia address.?
Comment by Administrator on 14 July 2008:
Ashi - I have sent you a private e-mail with questions and instructions regarding the DVD. All international orders for the DVD should be handled this way by sending an e-mail to johnny@teachmetotalk.com. Thanks so much for your interest! Laura
Comment by Luz Gonzalez on 31 July 2008:
Hi, I have a 25month toddler who was diagnosed with verbal apraxia. The therapist who initially evaluated him, move to another state, and through the early intervention program he was assigned to another one. My son can say 2 words, correctly pronnounced, and 4 approximations. I’m extremely concerned because the therapist told me (on the 3rd therapy session), that he is already two, a big boy according to her, and that he needs to begin expressing sentences such as: I wan’t juice, My name is Erick, when he can’t say these words in isolation. I also told her about the previous evalution, and she told me is too early to make a diagnose.
Comment by Luz Gonzalez on 31 July 2008:
Continuation of previous comment…
My son exhibits ALL the typical characteristics of children with apraxia: he never babbled as a baby, he said some words (juice, ball) when he was 22 months, but we have never heard them again, when repeating sounds he tends to make inconsistent errors, he deletes, ommits, substitutes sounds and has come up with his own hand gestures that represent different things, he is capable of imitating some words such as yes, but can not say it on his own, he’s understanding on the language is far greater than his expressive language. I tried to express all of this to the therapist, but she said that for the diagnosis I have to wait until he is three and again said we have to focus on sentences,because he will be far behindhis peers when he gets to preeschool. I just don’t know if I’m overeacting, after all she is the one with the Master’s Degree in speech pathology.
Comment by Amy on 1 August 2008:
Luz, I know I’m not a therapist, but my son is 26 months old, and he was diagnosed with apraxia of speech just days after his 2nd birthday. Your son sounds like mine. Please do not think you’re over-reacting….usually, our mommy- or daddy-gut is right. I know mine was. Keep advocating for what your son needs. It will pay off in the end.
Comment by Laura on 1 August 2008:
Luz - I read your comment this morning before I left for my busy day of “mom” stuff, and I have thought about it all day long. So here goes my lengthy response to you…….
First of all, let me say that 25 months is young, but not TOO young, to diagnose apraxia. Any SLP who believes it’s too young must not have worked with toddlers for very long OR must be very reserved in using her clinical judgment and diagnostic skills with this population.
As far as this SLP goes, I actually believe that she must not have ANY clinical judgment because to work on phrases or sentences with a child who has only 6 words is well, stupid, to put it frankly. In my opinion, she lacks not only clinical judgment, but common sense! How can you get phrases when it’s still a struggle to get words???? Even therapists who are reluctant to “diagnose” apraxia in a toddler understand that a child MUST have a base vocabulary in order to be able to combine words to phrases. That’s a pretty basic concept, even if you’re not an SLP!
Secondly, please understand that a masters degree alone does not make an SLP “good.” You seem to understand more about apraxia and language development than she does!!! Just like there are bad auto mechanics and bad hairdressers and bad salespeople, there are unfortunately bad SLPs. What would you do if you got a bad haircut or sub-par work done on your car? You wouldn’t go back to that person again. That’s the same advice I’ll give you for this SLP. Move on. Find someone else who understands apraxia and how to work with toddlers since this person clearly doesn’t.
If you want to try and educate her, recommend this website, the apraxia-kids.org website, the book The Late Talker, and the book Becoming Verbal with Childhood Apraxia. These resources are invaluable for parents and for educating therapists. On this site, she should start with the oldest article in the apraxia section and read forward. On the apraxia-kids site, she could read the professionals section, but she probably should start with the basics in the parents section since she seems pretty clueless to me!!! Another idea is buying Teach Me To Talk - The DVD and loaning it to her. It sounds like she needs the help!
If you’re not wanting to “go there” with her, and you do decide to cut your losses and find someone else as quickly as possible, at least tell your service coordinator that the reason you are firing her is that she did not recognize apraxia and was incompetent in her approach. This way she’ll at least know and hopefully begin the path of self-analysis and re-education.
I hope you’ll find the articles on this site informative and helpful for home until you can get an SLP who can help you and your son one-on-one at home. No child progesses with apraxia without high-quality speech therapy. I wish you all the best as you pursue this for your son!
Let me know if you need anything else! This site is here to help!Laura
Comment by Luz Gonzalez on 1 August 2008:
Laura,Thank You for your quick response. Unfortunately, here in kissimmee FL, we don’t have too many SLPs, and very few specialize in apraxia. I’m currently on 4 waiting lists, and still looking for other options. I’m trying to do everything I can to help my son at home, I’m currently doing activities suggested in the book: “Easy Does it for apraxia preschool”, and I will definetely buy the DVD to keep reinforcing at home his expressive language. In regards with the speech therapist we have now, we will not take him there anymore.
After you posted your comment I discussed it with my husband and he told me that the SLP was teaching him some words in English and others in Spanish, supposedly some words are easier in one language and other easier in the other and eventhough we are bilingual I specifically told her one language. This reasured me, that I must cancel the therapies with her.
Again Thank You!!! This website has been a blessing!!!!
Comment by Laura on 2 August 2008:
Luz - Good luck with everything! Let me know if I can help you in any other way! Laura
Comment by Trumom on 18 August 2008:
Found this site today. Toddler (boy) turns 3 in a month. Slow at speech and follows instructions he likes or others when I insist or he feels like. Sometimes he gives a weak or no response. Does not respond much to conversation cues and does little initiation of conversation. In recent months, started responding yes or no when asked to choose from a list of things to eat. Sometimes he will pull you to the refridgerator and say the word of the item he wants to eat. He will tell you computer or “Dot com) when he wants to use the computer, open it for food, help me, let’s go or bye. Before he was even a yr old, he would call his dad “Da” and repeat some words or even phrases. We moved from one country to the another when he was 17 months and he started saying one or two phrases when he first moved. I had another baby when he was 25 months and by then I noticed that his speech wasn’t expanding much. Mentioned it to a new pediatrician who sent me to research autism. That was 9 months ago and my world has been a spiral since then. I have gotten contradicting opinions from every doctor I have seen. Almost at 3, he has expanded his vocab, saying a few 2 and 3 word phrases - “try again, help me, good job, good boy, oh boy, Let’s see - some of which he picks up fromhis compurer games but uses in the right contect. He sometimes calls us mommy and daddy now which he didn’t do before - he will call us mommy or daddy especially if there is a stranger around. He says hi and bye to most things that interest him - animals, objects and for persons he tells some people hi when he sees them. trying not to give you my entire child’s history. however we had pushed to the back of our minds that he may need therapy, but compared to other 3 yr olds he is not interactive enough with speech or communicating - interacts and plays well with peers and his baby brother - forces you to give him eye contact sometimes(physically)when he wants parent attention or if he wants you to hear what he has to say. He counts very well in english and Spanish counts objects and tells you the number as an example “5 dogs, 3 fish etc”. He loves sing a long and stories. Used the singing voice to call him before he was 2 - that’s mostly what he would respond to then.
Still worried. Have decided to engage a Speech therapist to determine if there is any help we can give him and with much anticipated fear whether we should do further development testing for conditions such as autism. His dad is quiet and most of his family members have a special skill of “zoning” out other persons when they are involved with other activities.
Sharing my experience as my toddler is my first child and I don’t have much prior experience to go by. The second child is extremely engaging active and responsive. With the exception of teething, he has reached his social and physical development milestones quite early and may even be the source of helping my toddler to speak. Welcome your comments
Comment by Laura on 18 August 2008:
Trumom - You can’t go wrong having him evaluated by an SLP. He definitely is not meeting his expressive language milestones for a child who is turning 3 soon. It’s great that he’s making so much progress without intervention, and that leads me to believe you’d see even MORE progress if you had a professional be able to help you tweak things you already do at home to help him in addition to working directly with him.
I know you’re scared to death that someone might say he has autism. It’s a very unsettling feeling. But they might NOT say that too, and you’ll never know unless you have him professionally assessed. I would rather know than not know if he were mine, but I understand your very real feelings. Even if he does turn out to fall somewhere “on the spectrum,” chances are he’s going to do okay anyway because he’s moving along and making progress now without any sort of therapy. ALL of the literature tells us that children who are diagnosed early or who receive intervention early for communication issues, with or without a diagnosis of autism, do MUCH better long term than those who don’t. So my advice is pursue speech therapy for him. It’s certainly not going to hurt, and waiting might. Laura
Comment by momtorrr on 4 September 2008:
Thanks for the informative article. My question is about my 26 month old son. He has been receiving quality speech therapy for a significant expressive language delay for the last year (using many of the strategies you suggest). His progress is slow but certainly present. He tests very well in everything else, including receptive and cognitive/social, across the board. He is using about 5-10 word approximations (very loose approximations, but still consistent attempts to communicate verbally) and quite a few signs. Our SLP is great and and has said she suspects he might be apraxic. However, our local specialist apparently does not diagnose until 3. That said, do you have regional/local recommendations for private therapists with the same philosophies as you? I don’t want to waste this valuable time for additional therapy (even though we don’t have a formal diagnosis) while we still have great EI services. Thanks for all the tips and any additional suggestions you have.
Comment by Laura on 4 September 2008:
Momtorrr - Have you asked your EI SLP or your service coordinator who else locally/regionally might diagnose him before age 3? Sometimes you can get a neurologist or even a multidisciplinary evaluation team at a regional center to make the diagnosis at 2 with a very detailed progress note from your SLP stating why she believes that’s an appropriate and accurate diagnosis for him. Our regional team and local pediatric neurologists will make this diagnosis when they have gotten enough info to “make the case.”
Unfortunately, I do not have a list of regional/local sources other than for where I live and practice, but if you want to leave a comment here on the site with your location, you may hear from another reader who could suggest someone. I get lots of e-mails from SLPs and other pediatric therapists all over the country (and world) who read this site regularly.
Until then, I would encourage you to keep following the ideas your SLP gives you since treatment, not a diagnosis, is what’s most important for him. You’ll likely need a diagnosis before he’s out of EI in order to file insurance to help cover the cost of private therapy, but you’ve still got some time.
I will also let you know that my 3rd DVD, Teach Me To Talk with Apraxia and Phonological Disorders, is currently being filmed and is on schedule to be released in late October/early November (pending any problems with filming I haven’t antipated!). This DVD will build on ideas from the first DVD, Teach Me To Talk, but will be more specific to the special challenges of diagnosing and treating toddlers and young preschoolers who have been diagnosed with or are suspected to have apraxia.
Thanks so much for your comments! I’m glad you’re enjoying the site! Laura
Comment by momtorrr on 6 September 2008:
Thanks for your note. I am in Pittsburgh, PA if you hear of anyone in this area. The only reason I would want an early diagnosis (or rule-out) is that if there are special treatments/services/programs only offered to children with an apraxia diagnosis, I don’t want to miss those opportunities. I will certainly continue to follow through with our SLP and EI suggestions and I will look forward to the new DVD! Thanks for the kind reply!
Comment by Laura on 6 September 2008:
Momtorrr - Lucky for you that you live in such a big city with excellent resources! There’s an apraxia guru in Pittsburgh at Children’s Hospital. His name is David Hammer, and he led one of the best training courses about childhood apraxia that I’ve ever attended several years ago. He probably doesn’t officially diagnose apraxia until 3 since I think he prefers the term “suspected” apraxia until then, but if there’s any way you could get your child seen by him, either now, or closer to 3, I’d do it. Get on a waiting list if you have to, but in my opinion, it would be worth it. Laura
Comment by Stephanie on 15 September 2008:
Thank you so much for this information. My 28 month-old son, Connor, was evaluated by our state’s early intervention program and he was diagnosed with apraxia. However, his receptive speech is spot on. It’s his expressive speech that we need to work on. He is at a 15 month-old level in this area. We will start our therapy sessions next week, and I am really looking forward to finding out what I can do, here at home, to help him.
Comment by Laura on 15 September 2008:
Stephanie - Hope you find this info helpful! Good luck! Laura
Comment by Lori on 21 October 2008:
Laura,
I am a speech pathologist who sees outpatient pediatrics and adults in a hospital setting. I evaluated a little boy today who’s CA is 3-9. The only consonant sounds he uses are /b/ and /p/. His language is WNLs, but he only uses vowel sounds. He speaks in complete sentences, but obviously intelligbility is very poor. He appears to have a phonological processing disorder, but with such severity I don’t know where to start! I thought you may have some suggestions of a particular method or approach. Any help would be greatly appreciated! Thanks so much.
Lori
Comment by Laura on 21 October 2008:
Lori - Thanks for the great question! Your little guy sounds tough, but he’s not unlike many of the children on my caseload at any given time!
I want to direct you to another article on the site called “Working Toward Intelligible Speech…” You can find it in the articulation section. It outlines how I approach intelligibility treatment decisions in toddlers and young preschoolers.
I would still use mostly a play-based approach since he’s still really young, and I’d get really creative to be sure all the toys I offered as options included his target sounds.
I would also check for stimulability to see if final consonant sounds may be easier than initial consonant sounds for him to imitate. The conventional wisdom is to start with initial consonants, but sometimes ending sounds are more stimulable.
If he doesn’t consistently include /p/ and /b/ in all words, I’d also look at what words he produces correctly that include /b/ and /p/ and look for phonetically similar words so that he can feel some initial success. For example, if he can say, “bye-bye,” try “bubble” and “baby” since these are very similar CVCV patterns. If he can approximate “pop” with an initial /p/, I’d try other verbs like “push” and “pull.” If he’s producing initial /p/ and /b/ correctly in all words, try to get an /m/ in the initial position (or final if it’s easier for him) since it’s also a bilabial and pretty easy to facilitate with tactile and visual cues.
I do still try to elicit most consonant sounds in isolation first, then get them into functional words pretty quickly. Best practice guidelines encourage getting sounds into words rather than the traditional way of mastering a sound in isolation first. If I can get it in isolation a couple of times with some visual and tactile cues, I try to move it to a word lickety-split. If he can only do it in isolation, I use that sound LOTS in vocal play as a sound-effect so that he’s still “using” it functionally. For example, if he can only say /t/ in isolation, this is the sound my character would make as he walked or ate or did any other fun action.
Another thing is to work toward is an approximation of a word that’s more intelligible than just vowels, even if the consonant isn’t correct, but a typical substitution. For example, I’d take “pish” for “fish” since this would be an acceptable substitution in a younger child. You can check out Nancy Kaufman’s apraxia tools for help in doing this.
If you need more ideas, write me back! Laura