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May 26, 2011 | Laura | Comments 10
Comment by Dee on 25 January 2012:
I have a little guy who turned two in December and I have a few questions. Do you see poor vocal quality as part of apraxia? My little guy barely talks above a whisper. I suspect apraxia. He has been diagnosed with low tone and he has upper respiratory issues nasal congestion and some chest congestion (drainage down the back of his throat). He also sticks his tongue out of his mouth 90% of the time. His mouth is small so it seems like he just doesn’t have enough room in his mouth. Any suggestions for how I can teach him to keep his tongue tucked in?
Comment by Laura on 25 January 2012:
Hi Dee. I haven’t seen your little friend of course, but this sounds more like dysarthria to me, especially since he’s been diagnosed with low muscle tone. Difficulty with phonation/voicing, resonance/nasality (in addition to the obvious medical issues with congestion), and with keeping his tongue in his mouth all can be attributed due to low muscle tone.
Mouth breathing is also very, very common with kids with chronic congestion since they literally CAN’T breathe with their mouths closed, and tongues with low muscle tone are going to be droopy. You won’t be able to completely alleviate his open mouth posture if he can’t breathe through his nose, so talk with mom to see what the plan is for resolving the congestion. This is a medical issue and of course you can’t treat that, but at this point, your little guy has little choice but to breathe the only way he can! I wouldn’t work on cues to keep his mouth closed until you know it won’t kill him
Let’s talk about what you can do….is his tongue movement sluggish? Can he purposefully imitate any kinds of tongue movements? I’m not a huge proponent of oral motor exercises for toddlers, but in this case, you’ll want to help him increase awareness and learn that he can purposefully control his tongue movements. Have him try to imitate new movements in the context of play. Since he’s already protruding, have him lick like a kitty cat or puppy when you’re playing with farm animals. You might try clicking your tongue like a galloping horse, etc… You could also target some purposeful closed mouth stuff to be sure his lips aren’t affected as well (although you’d expect they would be.) Blowing raspberries with his lips and even with his tongue slightly protruded will be helpful for making him more aware of his little mouth structures and help him learn they are under his purposeful control.
Tongue retraction for him is huge, so to target this in speech, try words with pharyngeal consonants /k/ and /g/. Even if his sounds are gross approximations at this point, you’ll be helping him learn the movement patterns he needs for speech AND purposefully learning to hold his tongue in a better place at rest. If he can’t do these sounds in words yet, target pharyngeal and glottal “raspberry” sounds - more like a pirate sound or a growl - which hopefully will be lots of fun for a two year old little boy. Straw drinking will also help with retraction and improve his awareness - especially with colder, thicker liquids like milkshakes. Now that’s fun therapy!
I also do work on using louder “bigger” voices with toddlers with voicing issues. I always do this in a fun way with games. “Yelling” so he makes you cover your ears or that he’s so loud he scares you is funny. You could also try the second verse of Row Row Your Boat so that he’s “screaming” at the end. This is surprisingly hard for little ones with phonation issues. It’s also a very developmentally-appropriate way to contrast a louder/bigger voice for a toddler who may not understand it any other way.
You may also try horns and whistles too to help him learn to purposefully control and direct his airflow for more consistent voicing. A kazoo is great because he has to use voice to activate it. However, some 2 year olds don’t/can’t get this kind of play yet. This should be a part of his homework too when you think that he’s had enough practice with you to be successful without your cues and encouragement. Tell mom to keep it light and fun with her so you don’t make any aspect of this negative for him.
That’s not to say that he can’t have dysarthria AND apraxia, but from what you’ve said, it sounds more like a muscle tone issue to me. Is he getting PT and OT too? Hopefully they are working to increase strength and improve movement as well as targeting overall tone - although many experts say that we can’t truly normalize muscle tone.
However, don’t lose sight that you should still focus on language, language, language with this little guy so that he has something to say! It won’t matter how he sounds if he doesn’t have any words.
This was a great, great question. Thanks so much for asking! I had a fun time tonight brainstorming treatment ideas and you’ll have to update me to let me know how they work. Laura
Comment by Dee on 26 January 2012:
Laura,
Thanks for all the brainstorming! I love your suggestions and plan to incorporate many of them over the next few weeks. This little guy is hard to read. He has little affect, loses interest easily, gives up when he thinks things are too difficult. I try to keep things light and fun, but realize that I need to keep working on this so I can keep him engaged, etc.
He has had genetic testing but with no abnormal results, however, looking at his facial features, small hands and feet, his speech-language delays, delayed fine motor and gross motor balance issues you know that something is going on. I realize that my plan of action needs to focus on where he is at and help move him forward.
I have not had a child who is barely audible. One day it seemed like he was attempting to repeat a lot of simple words, but you could barely make out that he was actually using his voice, let alone the word he was trying to say. I didn’t think of dysarthria and will investigate that further.
His mom is great about working on signs and he will use a few when prompted to do so. He doesn’t make much eye contact or watch your face/mouth when you talk. So that is another thing we are working on.
Thanks again for your suggestions. I really appreciate all the information and ideas. Often I listen to your podcast and hear just something that is just what I needed. Your information and ideas keep me motivated to try to do my job better. Dee
Comment by Laura on 26 January 2012:
Thank you Dee!!!!!!!! Let us know how he does. Laura
Comment by sarah on 30 March 2012:
Hello, i was looaking for some advice and seem to be in the right place! My boy is 22 months old and hasnt uttered one word!
He makes, what we call, caveman grunts. Very low gruntle noises that all sound fundamentally the same but have slightly different tones.
I am partially deaf and depend on lipreading and have noticed he doesnt form his lips around the sounds he makes. I have had his ears tested and it was fine.
In all other developement he is fine, he was walking at 1O and a half months and is very loving towards us.
When we do the whole ”You say it” routine, it looks like he wants to try then nothing.
I have been referred to a speech therapist which could take months and i was wondering if aproxia could be the cause and if there are any other symptoms i could.be looking for. Thank you! ! !
Comment by Court on 12 July 2012:
Laura,
My son has been in speech therapy for a few months now. His speech therapist and I have both noticed he has a hard time trying to form the words. He tries but it’s like there is a breakdown between his brain and his mouth. She doesn’t want to diagnose him with apraxia just yet, but we believe this could be the problem. One of the things I’ve noticed with my son though is that because of his frustrations at not being able to speak he expresses his emotions in other ways. If he’s really excited he flaps his arms with an excited expression on his face. If he’s mad, upset, scared, frustrated, etc…he hits, screams, bites, pinches, anything to get his point across. How can we help him be less violent about his frustrations. I know it’s just his way of expressing himself but I’m concerned about the damage he could do to himself and others. I’m having a hard time finding any websites that deal with behavioral techniques and helping me help him with his expressing his negative emotions in a less violent way.
Comment by Laura on 12 July 2012:
Court - You really need a good OT to help you address his sensory processing issues. I know some of what he’s feeling is probably due to frustration BUT extreme reactions like that nearly always mean there’s something else going on too. Ask your SLP for a referral to the best OT in your area who treats sensory processing differences. Laura
Comment by Court on 12 July 2012:
He sees an occupational therapist once a week in addition to his speech. He was born at 34 weeks and had some delay in his fine motor skills. He just switched OT’s a few weeks ago because he didn’t like his first one. He’s made a lot of progress in things like focusing and catching up on the fine motor skills he was behind on. I will talk to her about treating sensory processing differences and what she thinks as well. Thank you so much for the insight!! I started reading about it and he seems to exhibit some of the signs of a child with hyposensitivity… I’ll print out a checklist and take it with me to his next OT session.
Comment by Angela on 13 July 2012:
Hi Laura,
My cousin’s daughter just turned 2 last week. She does not have many words as yet. I see her quite often..once a fortnight at least and I noticed that she mostly says, ‘baba’, ‘mama’, ‘no’, ’sit’, ‘milk’ and a few other single words (maybe 20-25..I am not sure of the exact number). I have not noticed her combining 2 words. Her mommy was also concerned about her lack of speech and got a hearing test done last month. The reports were normal. She understands what we say to her but that too not all the time. Also she’s very clingy and is attached to her parents in all social events. If I or someone else tries to take her or play with her, she will cry and run to her mommy or daddy. She does not play with other kids her age but can play well by herself with her dolls and other toys. Do you see any flags in here? I voiced my concerns to her mommy but she’s happy that the hearing test results were normal and is confident that her daughter would start speaking after 2. Her older daughter also did not speak until after 2 so she does not feel the need to do anything at this time. Could you please suggest if there is any way I could help this little girl when I visit her? Should I speak with her daddy?
Thanks a ton for your help!
Angela
Comment by jill on 14 September 2012:
hi my 26 months old have apraxia sometime he say something but some time he does not. he can barely speak 8 to 10 words i am worried cuz when ever he demand for something and before giveing that to his i tried to tell hime the name so he can repeat and than i can give the the thing but when i tried to teach him somthing he cries and does not baball i mean he does not even try ,at that time i just really get so mad i have 11 months old too when he get so angry sometime he push her my question is how i can just teach him not to cry but at least try the word thanks