Laura,

Hope this helps.  

So?  What does this mean for you if your child has been diagnosed with apraxia?  Children have to practice SPEECH, not movements without any sound or movements with just a sound (such as “p” for /p/) to be able to learn to talk.   

Dr. Lof’s mention of working at the syllable level means that sounds aren’t practiced alone, or in isolation, as your SLP might say.  Most early interventionists and pediatric SLPs use this approach since we work on WORDS in the context of daily activities or play.  Sometimes SLPs (myself included) will cue the sound in isolation, or by itself, to be sure the child is capable of producing the sound as well as to heighten a child’s awareness of the sound. 

Your SLP might also use verbal, visual, or tactile sound cues such saying “Use your popper sound” for /p/ while pointing to her lips, or your “throaty” sound for /k/ while touching under your child’s neck.  Again, this kind of practice should be very limited (no more than a couple of repetitions) and shouldn’t be the focus of the session since we’re talking about toddlers and young preschoolers here!  Individual speech sounds should be placed in words pretty quickly so that the sounds make sense AND so that you don’t lose a child’s attention in this process.  Cognitively, most children aren’t ready for intensely focused sound production practice until after 3.  

Sound practice for children with apraxia isn’t recommended since it’s the SEQUENCING of sounds that usually causes the problems with intelligibility.  He or she may be able to say the sound alone perfectly, but then it falls apart in the word or phrase.  Practicing the individual sound over and over is often pointless since this is not the real problem.        

Let me also reiterate one more HUGE principle that I’ll emphasize yet again.  If your child is really young and his LANGUAGE skills (vocabulary size, phrase length, using words to ask for things and respond to you, etc…) are NOT age-appropriate, all of these speech or sound issues should take a back seat to helping him learn to be an effective communicator.  The time to address all of the specific sound errors is AFTER his language skills are well on their way to matching those of his same-age peers.  Focus on WORDS and COMMUNICATION.  Intelligibility will come, but it won’t matter anyway if he has nothing to say!   Laura      

One Mother’s Experience….Quality Speech Therapy or Not?

By Laurie Felty, M.S., CCC-SLP

Since the time my son, Jack, began speech therapy almost 2 years ago for apraxia of speech, he has had four different therapists with four different styles of therapy.  Some of those styles were successful and some were not.

As a speech therapist myself, with 15 years of experience, I feel that I have the qualifications to judge the level of skill and quality of services that a therapist delivers.  Not only can I speak from my own experiences as a therapist, but also from my experiences of working alongside other speech therapists and having the opportunity to observe more than one successful style of therapy.  Based on all of this, I have very specific ideas about what I expect from my son’s speech therapy sessions. 

I feel that we were very fortunate to have had Laura Mize, the creator of this website, as Jack’s first speech therapist.  Our service coordinator through our state’s early intervention program recommended her because she knew that Laura had experience with apraxia of speech.  She treated Jack until he turned 3 and was no longer eligible for early intervention.

From the moment Laura walked through our front door, she exuded warmth, friendliness and enthusiasm that immediately captured Jack’s attention and gained my respect.  She came in and briefly introduced herself, kicked her shoes off and in the sunniest, brightest voice, invited Jack to “play toys” with her.  Jack was absolutely mesmerized by her bag of toys, and she never missed a beat transitioning from one activity to another as Jack’s interest would shift, as a toddler’s interest so frequently does.  Just like that, therapy had begun and Jack had a new best friend!

Laura’s method of therapy was completely play  based.  If you’ve read any of Laura’s articles on this website, then you have a pretty good idea about her style of therapy.  Laura honestly uses every strategy and technique that she has described in her articles in her therapy sessions every day.  Jack was continually engaged in expressive speech tasks with multiple, multiple repetitions of sounds and words during the entire therapy session.  Of course, Jack thought he was just playing because Laura made it so fun.

Another key factor that made Laura’s approach to therapy a success was that she worked directly with us, as parents, to deliver therapy services.  There was a continuous exchange of information, and Laura welcomed us to not only observe, but to actually be a part of Jack’s therapy.  I feel that this is especially important because parents are with their children 7 days a week to carryover strategies and techniques learned from the therapist, who is, at most, with the child only 1 to 2  hours a week. Doesn’t it make sense that parents need to be involved in their child’s therapy sessions in some way?  

Now, I will not go so far as to say that the unsuccessful styles of the speech therapists that treated my son were “wrong,” but they were definitely not “right” for my son, and they did not meet my expectations as a mother or as a speech therapist.

For example, the second therapist that treated my son was at a pediatric rehabilitation center, through our private insurance, that only provided 20 therapy sessions per year.  With only so many visits allowed, it was important that each one be the most productive possible.  

This therapist took the first 30 minutes of a 1 hour session to “establish rapport” with Jack by allowing him to play on indoor playground equipment while she followed him around occasionally commenting on Jack’s movements.  Jack did not say and wasn’t asked to say one single sound or word during this entire time.   

Once in the therapy room, which was filled with toys, she chose to look at books with Jack.  Again, not requiring or asking Jack to say anything.  Jack, of course, wanted to play with all the toys.  However, the therapist made him sit there and look at books until she decided it was enough because she said she was working on increasing his attention to task.  It is important to know that Jack has an expressive speech disorder with age-appropriate receptive language and attention skills. 

Only after I asked her if she had any therapy strategies for working with apraxia of speech did she ask Jack to imitate some vowel sounds.  This was in the last 5 minutes of the 1 hour session.  Needless to say, that was the one and only time Jack saw that therapist.  I also called and complained to her supervisor.

Our next therapist was slightly better.  She did engage Jack in play therapy but only while seated at a table.  With apraxia of speech, it is important to elicit as many repetitions of sounds/words as possible to improve motor planning.  Although this therapist encouraged Jack to talk, the speech tasks were very non-specific with no multiple repetitions.

Also, one of his “speech goals” was to attend therapy sessions with no parent present.  What?   He wasn’t even 3 years old yet. How could that be a “speech goal” and what did it have to do with apraxia of speech?   Where was the partnership between parent and therapist?  Plus, after our last experience, that was never going to happen. 

We stayed with this therapist only for a few sessions until Jack transitioned to the public school system for speech therapy.  I was prepared for a disappointment, yet again.  However, I was pleasantly surprised by our new therapist’s style of therapy.  It was play based with lots of expressive speech tasks and repetitions of target sounds and words. Jack often brings his own toys to therapy, and his therapist uses them in his sessions.  She also welcomes parents to observe therapy.  Once again, Jack is making progress and enjoys speech therapy.

I hope, through these examples, that parents will be able to recognize if their child is receiving quality services.  A few of the things that I’ve learned from this experience are:  Not all speech therapists are qualified to treat all disorders of speech and language; there is a huge difference between play and play therapy; and it is absolutely the parent’s responsibility to monitor, be a part of, and demand the best possible services for their child. 

Apraxia/Verbal Dyspraxia 

Apraxia is a neurological speech disorder that affects a child’s ability to plan, execute, and sequence the movements of the mouth necessary for intelligible speech.  Apraxia can also be referred to as developmental verbal apraxia, childhood apraxia of speech, or verbal dyspraxia.  Most SLPs use the terms interchangeably.  Characteristics of apraxia include:

• Limited babbling is present in infancy.  These are quiet babies.  
• Few or no words when other babies are talking by age 2
• Poor ability to imitate sounds and words
• Child substitutes and/or omits vowel and consonant sounds in words.  Errors with vowel sounds are not common with other speech disorders.
• His word attempts are “off-target” and may not be understood even by parents. 
• He may use a sound such as “da” for everything. 
• Often his errors are inconsistent, or he may be able to say a word once and then never again.  The child understands much more than he can say.   
• There is sometimes (but not always) a family history of communication difficulty.  (i.e.  “All the boys in our family talk late,”  or “My husband’s grandfather  still has trouble pronouncing some hard words.”)  

Phonological Disorders

A phonological disorder is difficulty with the “rules” or “patterns” for combining sounds intelligibly in speech in English.  For example, phonological processes patterns include prevocalic consonant deletion (leaving off consonant sounds that precede a vowel such as “at” for hat), syllable reduction (producing only one syllable in a multisyllabic word such as “bay” for baby), or reduplication (simplifying a multisyllabic word to a duplicated pattern such as saying “bubu” for bubble or even “dog dog” for doggie).  

There are many patterns for analyzing a child’s speech according to a phonological processes model.  All of these processes are common in typically developing children as well.  It becomes a problem when most children are maturing in their patterns of production, and a child is not.  For example, final consonant deletion (leaving off ending consonant sounds in words) typically disappears between 2 1/2 to 3 years of age.  If a child is not including final consonants by this age, it would be considered “disordered” or “atypical” since most of his same-age peers are now using a more mature pattern.  

A child with only a phonological disorder exhibits typically developing language, meaning that his vocabulary and utterance length are the same as his peers, but he continues to exhibit patterns that are consistent with a younger child’s speech errors.   

Important Diagnostic Differences

1.  Vowel Sounds- Indicators for me always include a child’s vowel sounds.  Both children with apraxia and phonological disorders make errors with consonant sounds.  Children with apraxia also substitute, or in some cases omit, vowel sounds too.  For the most part, children with a phonological disorder use consistently accurate vowel sounds.  (Remember that vowels are A, E, I, O, U, and sometimes Y. Consonants are the other remaining letters of the alphabet.)

2.  Consistency in Errors - Children with phonological disorders are generally consistent with their errors.  This means that if they mess up a word, they usually mess it up all or most of the time, and usually in the same manner (until they start learning new pattern in therapy, and then they will likely revert between their “old” way of saying a word and their “new” way.)  

Children with apraxia are very inconsistent.  This means that they may say a word correctly once, and say it incorrectly a minute later.  Words  may be so “off-target” that the intended word is unrecognizable.  For minimally verbal apraxic children, they may say the word once, and then you may not hear it again for a long time.

Children with a phonological disorder exhibit patterns with errors.  For example, a child may omit final consonant sounds all of the time.  A child with apraxia may include a final consonant sound in one word, but not be able to produce the same final consonant sound in the same word or the same sound in another word. 

 3.  Language Skills- Children with apraxia almost always have delayed expressive language skills (especially before therapy starts.)  They do not have the same vocabulary size and utterance length as children their age.  

Children with a phonological disorder may have expressive language skills within or closer to the normal range.  They use lots of words and try to combine them into phrases like their same-age peers, but you may not be able to understand very much.  (This is different than jargon, or “baby talk.”  Children with a phonological disorder are saying real words, but they substitute or leave off so many consonant sounds that you don’t know what they are saying.)         

4.  Other Characteristics while Speaking- Children with apraxia often look like they are “groping” for words.  Things parents say to describe this include:

• “He sometimes opens his mouth to talk, but then it looks like he forgot what he was going to say.” 
• “She doesn’t know what to do with her tongue when she talks.”
• “I see him watching my mouth closely, and he tries to move his mouth in funny ways to copy mine, but he can’t.”

Children with phonological disorders do not have these issues.  For the most part, they can and do try to repeat what you’ve said to them without the hesitations.   

5.  Verbal Imitative Abilities-  Children with apraxia have major difficulties imitating or repeating what you’ve said (especially before therapy begins).  Children with a phonological disorder can repeat you, but the word may not be accurate.  

6.  Oral Imitative Abilities- Children with apraxia have difficulties with using their mouths to talk or to imitate or perform certain movements on request , but not in other activities like eating or if the activity is “automatic.” For example:    

• “He can stick his tongue out when he’s licking a sucker, but he can’t do it when I show him.”
• “She blew out her birthday candles last week.  I don’t understand why she won’t blow for you.”     

Children with phonological disorders are more consistent with what they can and can’t do with their mouths.

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Hopefully this helped sort out some of the questions for you.  I hope it doesn’t leave you more confused!  Be sure to discuss these things with your child’s speech-language pathologist.  He or she should be able to give you good reasons why or why not he/she believes a diagnosis is or isn’t appropriate for your child. 

There are many things that you can do at home to work on the prerequisite skills necessary for spontaneous phrase production.

1.  Before you begin working on two-word combinations, be sure that your toddler is saying at least 35 words on his own (meaning without imitating you) in daily routines.  (This point is so important I’m repeating it in case you didn’t process it the first time.)

In my experience, many late talking children, especially those with apraxia, or motor planning issues, have single word vocabularies well in excess of 50 words before they can begin to consistently imitate two-word phrases, much less say novel ones on their own. 

If your child’s vocabulary is not this size, continue to work on adding new single words.

Some children can imitate phrases before they are truly using 50 words on their own.  In many cases, they are learning the phrase “holistically” or as one unit.  In other words, the entire phrase is just one long word to them.  Children with difficulty processing and understanding language often learn phrases in this way.      

The only way to know if your child’s vocabulary is at this level is to keep a list of all of the words he says on his own (not imitated) over 2 or 3 days.  I routinely ask the parents of children on my caseload to do this.  Most parents have good luck keeping a running list on the refrigerator or in the den.  Sometimes parents are surprised at the results.  Some parents underestimate their child’s vocabulary and are excited when they realize just how much he/she is saying.  Some are disappointed when they realize their child might be using a core set of words over and over.  If you’re not sure how your child is doing, I definitely recommend this exercise.       

2.  Your child needs to have a variety of words in his vocabulary from different grammatical categories before he can sensibly combine words into phrases. 

When analyzing the early vocabularies of toddlers, most of the words they use are nouns/names for people and objects.  This is the case in typical language development too.  But if you’ll think about it, a child needs more words than nouns, or names for things.  It’s hard to make a sensible phrase using two nouns.  (Other than those for agent + object such as “Daddy shoe.”) 

Children also need:

• Social words (such as bye-bye, hi)
• Requesting words (such as please, more, again)
• Verbs/action words (such as go, eat, sleep, drink, jump, open, push)
• Early pronouns (such as me, mine, my, I, you)
• Prepositions/location words (such as in, out, off, on, up, down, here, there)
• Negation (such as no and then later contractions including don’t, can’t)
• Adjectives & adverbs/descriptive words (such as big, hot, fast, yucky)

Be sure you are introducing and teaching words from these different categories so that your child has broad vocabulary base in order to make phrases.    

3.  Your child needs to be able to sequence two syllables together. 

If your child routinely reduces multisyllabic words to one syllable, such as “ma” for Mama, “bu” for bubble, “Mo” for Elmo, he needs more practice with sequencing syllables first before trying to learn phrases. 

Work on this by practicing words with reduplicated or repetitive patterns since this is the easiest and earliest form noted in typically developing language.  For example, all the “early” words - Mama, Dada, bye-bye, baba (for bottle), and night-night.  Try to target words with sounds he already tries to say. 

Don’t forget animal sounds since these are more fun to practice such as moo-moo, baa-baa, neigh-neigh, quack-quack, woof-woof, etc…

Use clapping or patting the floor to help him “feel” both parts of the word.  You can model this and wait for him to imitate, or use hand-over-hand assistance to make him do this.  This technique is very helpful for children with motor planning problems (apraxia).  The motor movements actually help them produce the word.  (That’s why signing is so effective too!)

4.  Your child needs to be able to say several different types of syllable structures.        

This is going to be a little technical to explain, so hang in there with me.  Toddlers with typically developing speech and language skills usually learn to say words with various patterns and syllable structures.  For example, a toddler who can say Mama, up, no, hot, and open is using 5 different kinds of consonant (C) and vowel (V) combinations.

“Mama” is CVCV.

“Up” is VC.

“No” is CV.

“Hot” is CVC.

“Open” is VCVC if he says “open” or VCV if he says “opu” (a typical way babies say “open.)

If your child can only use one or two syllable types, he is not going to be able to say lots of different phrases.  Even if he tries, you may not be able to understand him because it will be “off-target.”

Analyze the kinds of syllable structures your child says by carefully listening to how he says the words.  (A word of caution here - new talkers do not need to be constantly corrected for their first word attempts.  Do not take this as a license to overcorrect.  This should be a process of analysis, not an opportunity to prematurely begin work on articulation!)

Note if most of his words are the same patterns.  This is common for children who are late talkers and especially those with apraxia, phonological disorders, dysarthria, or whatever else you want to call it.      

If most words are the same pattern, you’re going to have to work on introducing new syllable structures.  This requires some thought and careful planning.  If you’re not naturally good at it, call in a speech-language pathologist to give you some assistance.  (Another word of caution - Your child may not be able to do this without special coaching, and you may not be able to teach him.  Don’t despair if you can’t get him to pronounce a new pattern.  I had to go to college for 6 years to learn how to do it!)

For children who did not babble or produce jargon (saying short syllable strings with inflection similar to adult speech), this step may be unrealistic for a while, since difficulties with verbal sequencing is likely the reason he is talking late.  Some therapists try to teach kids to babble or jargon by modeling this for them.  I must confess that I am horrible at this! 

Instead, I sing to them using very familiar songs.  Singing is the best way to practice sequencing because we get help from the melodic (The technical term is “prosodic”) qualities of speech.  Remember all the advice about using a “sing-song” kind of voice from the What Works article?    It’s the same idea.  I encourage kids to sing by “bouncing” or dancing during singing.  Sometimes I just hum the song to get them going.  Or you could use a single syllable he can say and repeat it to the tune of a familiar song.  There’s more about the benefits of singing later in this article.                  

5.  Your child needs to hear a variety of two-word phrases before he is able to imitate them.   

What can you do to work on this at home?  Frequently model short two-word phrases during the day.  Try to vary your categories too.  (See #2 above if you’ve forgotten this already!)  Don’t get stuck always modeling, “Noun + Verb.”  “Mommy sees.”  “Blocks fall.”  “(Name) eats.”     

Vary the way you model phrases. 

• Verb + Noun - “Read book,” or “Eat cookie.”
• Pronoun + Verb - “I run.”
• Pronoun + Noun - “My shoe,” or “You(r) turn.”
• Adjective + Noun - “Yucky milk.”
• Noun + Preposition - “Arm in.”

Expand his single words to phrases and repeat these to him. 

• When he says, “Car” to ask for a car, model, “Want car.”
• When he sees a car and is labeling “car,” model, “There’s car.”
• When he’s making the car move, model, “Go car.”
• When you are playing cars with him, take it from him and teasingly model, “My car.”

Remember that lots of the language directed to a late-talking toddler should be at or just above his expressive language level.  For new talkers, you should be using mostly single words and short, two-word phrase utterances when you’re talking directly to them in play and in daily routines.     

6.  Your child should be able to imitate two-word phrases before he can consistently produce them on his own.

(Okay - here’s another disclaimer.  Sometimes kids with apraxia can say phrases on their own initially better than they can imitate them due to the difficulty with imitating anything, especially a challenging sound sequence, which usually includes phrases.) 

Teach phrase patterns so he has a model of what words to combine.  Use predictable patterns for extra practice since motor planning will be easier if one word is changed. 

The ones I start with first are:

More + (Noun he says frequently)         (Noun he says frequently) + please

More  + please                                      Bye-bye + (Name/noun he says frequently)

If your child has used sign language, it may be helpful to model the sign as you are saying the word. 

Even if your child has “dropped” signs in lieu of words, you may want to pull them out again as a strategy to help him “motor plan” for phrases.

Another way I use signs at this level is for me to sign the word, but not say it, as a cue to help the child know what to say.  If he can’t do it with this no verbal cue, I mouth or even whisper the word.  Sometimes kids can even say a phrase in unison with me, but not repeat it.  If your child is interrupting you while you are modeling, he’s indicating that this technique will work for him, especially if he’s doesn’t “finish” the phrase without you.          

One mistake many people (including therapists) make when practicing phrases is to break up the phrase into single words.  For example, they have the child repeat, “more,” then “milk.”  This is okay for one time or perhaps two, but please resist the urge to split up phrases every time you practice!  This defeats your purpose!  Model the phrase with the words together.  You already know he can say single words.  You’re working on phrases!

If a child keeps repeating the first or second word as the phrase, such as “ball ball” for cheese ball, he is having difficulty with motor planning.  Keep using these strategies.  He needs them!   

Another thing I do is to model the phrase using a sing-song tone of voice.  Again, this helps with motor planning/programming because of the rhythm and prosodic (melodic) qualities.  Your kid won’t sound like this forever, but doing this now may give him a shot at being able to produce phrases sooner.

When he’s imitating those well, move on to other patterns including: 

            Hi + Name/Noun                       Night-night + Name/Noun  

                                                                  (For you purists out there, “good night” is usually too hard!)

When he’s doing these well, I listen for words he says frequently to model and prompt as phrases.     

If he says, “go” and “choo-choo,” I model the phrase both ways to see what’s easier for him to imitate, “Go choo-choo,” or “Choo-choo go.”  I always keep these kinds of “probes” in context too.  Don’t sit down with your word list while he’s having a snack and try to see what he can imitate.  Keep it real!   

7.   Some kids need an “in-between” step when making the leap from single words to two-word phrases. 

Some kids need that extra practice with sequencing before they are able to try phrases.  I like to use the same word for this kind of practice.  Use words in a repetitive pattern like “up, up, up.”  Location words/prepositions and verbs/action words usually lend themselves better to this kind of practice.  Try, “Walk, walk, walk,” as you’re walking or making an animal walk in play.  Try, “Down, down, down” when you’re going doing the stairs.    

Another way I practice is to label pictures in a book or toys placed in a line on the floor sequentially.  (This is a great way to work in a language focus for kids who line up all their toys!)  Start with all of the same kinds of objects.  For example, if he’s lined up all his trains, point to each one and say, “Choo-choo, choo-choo, choo-choo.” 

Instead of counting objects or pictures of like items, I practice labeling them.  For example, in a counting book with a picture of a group of dogs, I point to each one and say, “Dog, dog, dog.”   

I also practice with different pictures or objects in play when a child’s sequencing is better.  Try to stick with words she can already say.  For example, when playing with dolls, place a few items in a row and label, “Baby, milk, sock.”  Pause between words, but not for too long or you’ll defeat the purpose of practicing to improve sequencing.   

8.  Take advantage of “automatic” speech.  

When something is familiar to us, it becomes “automatic.”  When you’ve heard something over and over again, your brain “recognizes” and “predicts” the next part.  Use this with your child.   

One way to practice this is with books with repetitive themes.  Look for ones with a tag line that’s repeated over and over.  Again, make sure this makes sense to your toddler.

Another way to practice this is by singing familiar songs.  When your child has heard a song many times, his brain begins to expect what comes next.  You can use this to get new words by singing a line from the song and pausing for him to complete the next word.  Toddlers usually do this best when you leave the blank at the end of the phrase.  For example, sing, “Row, row, row your” and wait for your child to sing, “Boat.”  This works best when it’s an age-appropriate word.  The next line in this song illustrates my point.  “Gently down the _______.”  I don’t know a two-year old with typically developing language skills who says, “Stream” in everyday conversation.  Be sure you’re using common sense in choosing which words you expect him to say.           

When you’re singing, be sure to slow down the rate so he has time to catch up.  This is the main reason you should sing, and not rely on CDs.  You can control the speed!  Some children’s CDs and toys sing so fast that I can’t even keep up.

Don’t forget to try other familiar sequential phrases such as, “Ready,” and pause for him to say,

“Set - Go.” Or “1″ and wait for him to say, “2 - 3.”  Make up your own cute phrases at home during daily routines and say them over and over so your toddler expects what’s coming next.  We had lots of these in our house (and still do!)       

9.  Try wholistic phrases if your toddler is really struggling.

As a rule, I don’t model lots of these unless I don’t think I can get phrases any other way.  Sometimes children with apraxia can imitate or “pop out” a holistic phrase and then it becomes part of their core vocabulary.  Good ones to try are:

I did it             I got it             There it is        Here you go      See ya              Where (did it) go?

Right there      Right here        That one         This one           No way!                        Oh man!

Gimme 5          

I also try funny, novel sequences such as, “Oooh - Yuck,” “Uh-oh Spaghettios,” or “Oopsy daisy” to help move sequencing along if I’m not having any luck with more traditional combinations.  

10.  Listen for any “pop out” phrases and try to elicit them again in similar situations. 

Pay attention to any “accidental” phrase he might use and try to get your little guy to say it again.  You may have to set up the same situation later to see if lightning will strike twice.  Remember that repetition is what increases the strength of your child’s brain’s motor pathways or connections for speech.  Do all you can to help your child be able to say the phrase again, without lots of obvious pressure.  Sometimes the more you push, the harder it is for him!  Set up the situation and wait (and hope and pray!)    

Hope these ideas help at home!  If you need clarification, please feel free to leave a question or comment!  I love to hear from you!  Laura 

EDIT TO ADD -

11.  Try carrier phrases.

Use simple phrases with the same words at the beginning so that your toddler only has to “plan” to change one word at a time.  For example,

There’s a ___________.

That’s a ____________.

I see a _____________.

I want _____________.

I like ______________.

Give me ____________.

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! 

Below is a list of the most common diagnoses associated with pediatric speech-language problems with a basic explanation for each one.  Please remember that this is a listing of specific speech-language diagnoses and not necessarily a medical or educational label.  For example, a child diagnosed with autism may exhibit characteristics of apraxia, a child with Down Syndrome may have dysarthria, a child with dyslexia may also have an auditory processing disorder, etc… 

The speech-language diagnosis may be just a part of a condition that affects a child’s overall developmental picture, or it could be the only issue a child faces.  I have often evaluated children whose parents referred them for what they thought was a speech or language delay, when in fact their children were exhibiting delays in other developmental domains as well.  This also happens with other disciplines too.  My colleagues who are physical and occupational therapists often end up referring children for communication assessments when parents initially sought their help for what they assumed was just “late walking” or “difficulty with feeding” not realizing that their child was behind in other areas too.  Many children with developmental difficulties have issues that overlap the motor, social, cognitive, adaptive, and communication domains. 

When in doubt, get an evaluation.  Be sure to ask the professional if there are other developmental concerns as well.  You’d rather know, and the sooner, the better.  All of the current research tells us that early intervention gives a child the best chance of minimizing long-term difficulties.  Waiting until your child is school age to see if he will “outgrow” a problem puts him at a serious disadvantage, especially when it comes to communication difficulties.   

Apraxia  

Apraxia is a neurological speech disorder that affects a child’s ability to plan, execute, and sequence the movements of the mouth necessary for intelligible speech.  Apraxia can also be referred to as developmental verbal apraxia, childhood apraxia of speech, or verbal dyspraxia.  Most SLPs use the terms interchangeably.  Characteristics of apraxia include:

• Limited babbling is present in infancy.  These are quiet babies.  
• Few or no words when other babies are talking by age 2
• Poor ability to imitate sounds and words
• Child substitutes and/or omits vowel and consonant sounds in words.  Errors with vowel sounds are not common with other speech disorders.
• His word attempts are “off-target” and may not be understood even by parents. 
• He may use a sound such as “da” for everything. 
• Often his errors are inconsistent, or he may be able to say a word once and then never again.  The child understands much more than he can say.   
• There is sometimes (but not always) a family history of communication difficulty.  (i.e.  “All the boys in our family talk late,”  or “My husband’s grandfather  still has trouble pronouncing some hard words.”)  

There has been controversy in the field of speech-language pathology in giving this diagnosis to children under 3.  However, the kinds of therapy useful for children with apraxia are often not introduced if the clinician does not suspect this as the root cause for a child’s communication difficulty.  If you suspect this as your child’s problem, initiate a conversation with your child’s pediatrician and begin speech therapy with a clinician who has experience treating children with apraxia.  If your therapist says that he/she does not believe that this can be diagnosed before age 3, look for a new therapist!

An excellent resource for parents and professionals working with children with apraxia is www.apraxia-kids.org. Another comprehensive resource for an explanation of apraxia is http://www.kidspeech.com/index.php?page=56.

Many children with apraxia also have difficulty with sensory integration, or how he processes information from all his senses including visual, auditory, tactile, and proprioceptive.  (For more information about sensory issues, go to  http://www.kid-power.org/sid.html .) 

Feeding issues are sometimes present because of the sensory issues a child exhibits such as poor awareness in his mouth so that he overstuffs to “feel” the food, or to the other extreme, he is so sensitive that he gags when new textures are introduced.    

For more answers to a parent’s questions about apraxia on this site look under Amy’s question in the comments section under Ask the SLP or go to this link http://teachmetotalk.com/2008/01/31/ask-the-slp/#comment-24.     

Phonological Disorders

A phonological disorder is difficulty with the “rules” or “patterns” for combining sounds intelligibly in speech in English.  For example, phonological process patterns include prevocalic consonant deletion (leaving off consonant sounds that precede a vowel such as “at” for hat), syllable reduction (producing only one syllable in a multisyllabic word such as “bay” for baby), or reduplication (simplifying a multisyllabic word to a duplicated pattern such as saying “bubu” for bubble or even “dog dog” for doggie).  

There are many patterns for analyzing a child’s speech according to a phonological processes model.  All of these processes are common in typically developing children as well.  It becomes a problem when most children are maturing in their patterns of production, and a child is not.  For example, final consonant deletion (leaving off ending consonant sounds in words) typically disappears between 2 1/2 to 3 years of age.  If a child is not including final consonants by this age, it would be considered “disordered” or “atypical” since most of his same-age peers are now using a more mature pattern.  

A child with only a phonological disorder exhibits typically developing language, meaning that his vocabulary and utterance length are the same as his peers, but he continues to exhibit patterns that are consistent with a younger child’s speech errors.  A child with phonological disorder needs speech therapy to learn new patterns.  The most popular approach for therapy for this disorder is the Hodson cycles approach.  A pattern is targeted in therapy for a certain number of sessions, then a new pattern is initiated.  Once all of the patterns are addressed, the cycle starts over.  Your child’s speech sounds begin to improve, even if it’s not “perfect” through the first few cycles.  This approach has lots of research to support it.  It’s generally used for highly unintelligible kids over 3.  For more information on this approach, ask your child’s SLP if it’s right for your child because even the veterans know and use this technique.                     

Articulation Disorders 

An articulation disorder is difficulty with the production or pronunciation of speech sounds.  This difficulty may be present with an isolated sound such as substituting /w/ for /r/, difficulty with blends such as “st,” or with distortion of sounds such as a lisp.  Sometimes clinicians speak of phonological disorders and articulation disorders interchangeably.  I use the term phonological disorder when there seems to be difficulty with attaining a “pattern” of sounds and the term articulation disorder when a child has difficulty with only a couple of sounds rather than an identifiable pattern.   If a child is still exhibiting errors with even a few sounds after most of his peers can correctly use the sound, he needs therapy to help him.  For a list of ages when children acquire certain sounds, try  http://www.talkingchild.com/speechchart.aspx.  

For a good discussion of articulation and phonological disorders go to  http://www.psllcnj.com/articulation_disorders.htm .                            

Auditory Processing Disorder

An auditory processing disorder is difficulty with listening to, receiving, analyzing, organizing, storing, and retrieving information. It can also be called central auditory processing disorder (CAPD).  In young children this often looks like the child cannot understand what’s been said to him, even when his hearing and language comprehension skills are within normal limits.  A child may have difficulty paying attention to what someone is saying to him or difficulty following directions in the presence of background noise or when he’s more focused on something else.  This might be the kid that won’t look away from his favorite TV program when a bomb goes off, much less when you’re calling his name. 

This is commonly included as a receptive language disorder in children under 3, with an official diagnosis of auditory processing disorder coming later in the preschool or early school-age years since there’s no tests for this condition with younger children.  Children with sensory integration differences also exhibit auditory processing disorders.  It’s very common for children with autism and other learning disabilities such as dyslexia and attention deficit disorder to exhibit these characteristics as well.  I could not find a site for information for very young children with auditory processing disorder, but this is receiving lots of attention in the field of early intervention right now, so maybe we should have a good resource soon.   

Dysarthria

Dysarthria is a neurological speech disorder that affects a child’s muscle tone.  Weakness is noted in the muscles used for speech including his lips, tongue, soft palate, and cheeks so that his speech sounds slurred.  Dysarthria is present in kids with Down Syndrome, cerebral palsy, or any other condition that causes “low tone.”  Dysarthria may also affect a child’s vocal and respiratory quality so that he sounds hoarse or breathy. 

A child may also have feeding problems due to muscle tone issues such as difficulty sucking from a bottle because his tongue isn’t strong enough, keeping foods or liquids in his mouth because his lips aren’t strong, or chewing because of overall weakness in his jaws and cheeks.  A child may also drool because she can’t close her mouth consistently. 

A child with muscle tone issues may also have difficulty with gross and fine motor skills.  Physical and occupational therapy may be necessary to help meet milestones.  Low muscle tone never truly “goes away,” and there’s a difference between strength and tone.  All of us have varying degrees of muscle tone  ranging from high to low, and kids with even very low muscle tone can learn to walk and talk.  

For more information visit  http://www.stronghealth.com/services/childrens/conditions/Dysarthria.cfm. 

You might also try  http://www.kidspeech.com/index.php?page=75.      

Dysfluency 

Dysfluency is the more professional term for stuttering.  It is the repetition of individual speech sounds usually at the beginning of words or phrases.  Many children with typically developing language “stutter” when they move from using single words and short phrases to longer sentences and/or when they are under pressure to speak and can’t encode their words quickly enough.  Typical dysfluency can occur anywhere from age 2-4.  If it lasts for more than 6 months, seek a professional evaluation.  

Many times there’s a family history of stuttering if this is going to be a chronic challenge.  Kids who repeat individual sounds at the beginnings of words with facial grimaces or tremors, tense their muscles, blink their eyes repeatedly, or tap their feet are at greater risk for true difficulty with fluency than those who repeat whole words and who don’t seem to be phased physically by this.  

The best advice for parents when your child starts to stutter is to ignore it.  Do not tell him to slow down, stop and think, or any other comment that you feel might be helpful.  Relax his environment and do not put pressure on him to “perform” verbally including asking too many questions in a row, demanding that he answer silly questions such as, “Did you hit your sister?” when you know he did, or insist that he sing his new song from preschool for grandma, grandpa, and all of your long-lost relatives at Thanksgiving.  Don’t interrupt him when he’s talking, even when he’s struggling.  This is hard!  

Our oldest son had a terrible several month bout with stuttering while I was in grad school taking the class on dysfluency.  It was horrible for me!!  My professor’s advice was simple  - ”Ignore it and it will (probably) go away.”  Another piece of advice is to make sure his teachers at preschool, sitters, or even family members are on board with the “ignore it” method so that no one calls attention to this issue.  The unnecessary pressure will make it worse, not better, so tell all of your well-meaning friends and family that you are doing this one your way.                                   

Expressive Language Disorder 

Expressive language disorder is present when a child is not meeting milestones in the area of language usually involving vocabulary, combining words into phrases, and beginning to use the early markings of grammar.  A child with only an expressive language disorder doesn’t have difficulty pronouncing the words per se, but he has difficulty learning or retrieving new words and putting sentences together.  A child may rely on non-specific words such as “that” and “there” rather than learning specific names for objects.  She may have difficulty learning verb tenses (such as the “ing” for walking and “ed” for jumped) or have difficulty learning word classes such as prepositions or pronouns. 

An expressive language disorder can and often co-exists with a speech disorder such as apraxia.  I have treated kids like this with only expressive language delays/disorders, but more often than not, late talkers exhibit a speech AND a language disorder.  Sometimes children exhibit receptive language disorders as well, so it’s not uncommon to have several speech-language diagnoses at the same time. 

An expressive language delay would be a child who is acquiring vocabulary, combing words, and learning early grammar with the same sequence as his peers, but at a slower rate.  If there are atypical characteristics present such as your child has some skills at a higher age level but is still missing many lower age-range skills, it’s called a disorder.  Delays are typically easier to overcome, and most kids with delays eventually catch up.  A disorder is generally something a child will struggle with for a while, perhaps his entire life.    

Receptive Language Disorder

A receptive language disorder is difficulty understanding language.  This is also called an auditory comprehension disorder.  Kids who have receptive language disorders don’t follow directions and not because they’re being disobedient, but because they don’t understand what’s being said.  They seem to ignore language because words don’t mean anything to them yet.  They often hate reading books unless mommy lets them flip through the pictures because it’s all about listening to words which may not make very much sense.  

When a kid gets a little better and understands a little more, signs of a receptive language disorder may be that he repeats a question rather than answering it or gives an incorrect response.  For example, if you ask a child with a receptive language disorder who has been learning his colors, “What are you drinking,” he’s likely to respond “red” because that’s the color of his cup.  Or if you ask a question such as, “Do you want milk,” she might answer ”no,” but then she still gets upset when you don’t give her the cup because she doesn’t understand that answering “no” means she doesn’t want it. 

I have seen many kids whose parents or daycare teachers label as “difficult” or a behavior problem when really there’s a major receptive language delay that no one recognizes.  Parents often overestimate what their language delayed/disordered child truly understands.  This is so sad to me because when everyone decides to work on teaching and helping him understand language BEFORE we expect him to talk and BEFORE we expect him to “obey,” then everyone benefits;  especially the kid who doesn’t understand why in the world he’s in trouble in the first place, even when his mother “told him not to do it!” 

Make sure your child’s receptive language skills are addressed, or the other speech-language problems are not going to significantly improve.   A child who doesn’t understand much really shouldn’t be saying much either.  To expect more is simply wrong and well above what he’s able to realistically accomplish.  Most SLPs think of working on receptive language hand-in-hand with expressive language, and this is absolutely the right way to go.  When parents get on board with this approach, wonderful things happen.        

For more information on improving receptive language, see the post titled, “Help Your Toddler Listen and Obey.”                                                

For kids who don’t catch on and try to repeat what you’ve done, I always back up and start to imitate their movements.  Pick a time when your child is in a happy, playful mood to do this.  It might also help to be in a confined space, such as inside a playhouse or under a blanket or table, so that her attention is focused on you.  Wait until she does something, and repeat her movement. Stare back at her expectantly and wait for her to do it again.  If she doesn’t, wait for her next big movement, then try again.  When she notices and repeats the same or another movement, copy her again.  Make this a game over the next several days or weeks so she expects you to imitate her.  I also try to not to talk too much during these interactions so that the focus is on imitation, not on what I’ve said.  Too much talking takes the focus off imitating, and this is the skill you need to teach.  If I talk at all during this kind of exchange, it’s usually to say a funny novel word such as Bang, Bang, Bang or making a silly noise.

Once your child understands this game, try to take the lead by initiating movements you’ve seen her do in your last few play sessions.  If she doesn’t do this on her own, try to take her hands and gently perform the action after you’ve done it.  Some of these are performed with your mouth (blowing, fake coughing/sneezing, smacking, etc..) so they are particularly useful for helping kids move toward imitating vocally. 

Additional ideas for other movements to have your child imitate -

Touching various body parts         Jumping          Pointing             Shaking his head        Smacking lips/kissing   

Opening & closing your mouth                   Clicking your tongue                       Waving             Yawning           

Give me 5                  Touching the floor           Holding arms up

Patting your head                            Stomping Feet                            Fake Cough or Sneeze                                        Blowing

Moving on to Imitating Sounds 

When your child can imitate these movements pretty well, but still doesn’t seem to be able to make the leap to imitating words, I add silly sounds to the imitation games to accompany movements he can already imitate.  For example, when I’m clapping, I say, “Yay!”  If I shake my head, I say, “No, no, no” (in a silly, playful way), or I might add “sound effects” with popping my lips, or saying, “Do Do Do” as a I jump up and down.  One silly sound that works well is saying, “Mmmmmm” when you’re eating a yummy snack.  I add a little side-to-side shoulder action as I model this one to give them a motor movement to copy.  These silly words, often called Exclamatory Words, are often among the first words that babies try to repeat and say on their own.  Try some of the following.

Other Exclamatory Words

uh-oh, oops, whee, wow, ouch, oh, Oh man!, Oh no!, yuck, icky, yum-yum, boo, an audible inhalation or exhalation (think a surprised noise)

Fun With Noises 

Some children are able to produce animal sounds before they begin to imitate words.  I try these often during play with a farm set.  A good first one to try is panting like a dog.  I particularly do this if I know the child can imitate opening his mouth.  Don’t forget other animal sounds like a bark, meow, neigh, oink, quack, moo, baa, roar, ssss for a snake, etc…   I sometimes ask a child, “What does the ____ say?” before I do it, but most of the time, I grab the animal, hold it up by my face as if I’m pretending to be the animal, and model the sound.  Exaggerate your facial expressions too.  This nearly always generates a laugh, even if I don’t get them to try to repeat the animal sound just yet.  Model the sound in play with the animals and barn too, but holding the toy animal by your face while you emphasize the sound and darn near make a fool out of yourself works really well!  If they don’t try to imitate this, I might hold it next to their mouths and say, “You do it.  You’re the ____!”  If you need to take the pressure off of vocalizing, pretend to kiss the animal using an exaggerated smacking sound, then have them try.  This also works well with puzzle pieces using animals.  Don’t forget zoo animals either, but you may have to be more creative with their noises.  

I also try noises to accompany whatever action we’re using in play with the farm animals or even dolls.  Have them eat, drink (I do a loud slurpy noise), and everyone’s favorite, snore.  When characters walk I either say, “Walk Walk Walk” or “Up Up Up” as they climb.  You might also try to model a new consonant sound that they can’t usually produce in a word attempt.  My friend Kate who is a DI uses a little chant, ”Doo dee doo dee doo” when  characters walk, and she’s gotten several children to produce a /d/ in this context when I haven’t been able to get it in a real word.  Other sounds I use routinely in play include fake crying, sneezing, laughing, yawning, and shivering for cold or scared.          

I always play using vehicle noises.  Don’t forget about vroom, zoom, boom, crash, honk-honk, beep-beep, choo-choo (or woo woo), siren noises, etc….  Try these in the middle of play.  One of my favorites to do is to get the vehicle stuck when I model “stuuuuuuuuck” and then make lots of effortful noise while I try to pull the vehicle out.  Again try the by the face method, especially for the honk, beep, choo-choo, etc…  I also do these with puzzle pieces of vehicles if a kid is too “busy” with a toy vehicle to notice all of my vocal efforts during play.

Another good thing to try is having a child vocalize into a bucket or can since this produces an echo-like noise.  I had one little girl with Down Syndrome who would not imitate any sound or word unless we first tried it this way.  Babbling syllables is a good way to start with this.  Try to use the same sounds you know your baby can do such as mamamama, bububububu, or dadadadada.  If you can’t get a babble with consonant and vowel syllables, start with vowel sounds such as “ah,” “uh,” or “oh.”  Then I move to vowels that sound like words like “i” for “Hi” or “ay” for “Hey.”                 

If a child is pretty quiet and I don’t hear much noise at all during play, my goal is always to make him noisy, even before we begin to work on words.  One thing I try to is to imitate any noise he happens to make whether it’s accidental or on purpose.  Tickling or chasing is a good way to elicit squeals or laughter, then I make a big deal out of matching the child’s laugh or squeal with mine aiming for the same sounds, length, volume, and pitch as him.            

If you have any other cute and clever sound effects or tricks to get your toddler to imitate, I’d love to hear them!  Post a comment below.   

“My son is 18 months old and understands everything we say to him, but he is not talking with words yet.  He mostly looks at us, will point to what he wants, and grunts.  Is there anything we can do at home to help him learn to say words?”  -From Claire in Wisconsin

There are lots of things you can do at home to help him talk!  How do you teach new words?  By doing what you’re doing now - modeling words in the middle of your routines and during lots of one-on-one playtime so that he can repeat you.  Imitation is the number one way kids learn new words.  Talk all day long to him about what you’re doing, but make sure that you are saying lots of single words (rather than speaking only in sentences) and then pausing to give him a chance to imitate.  This was hard for me to learn as a new therapist.  I would spend so much time talking that I didn’t give my little clients a chance to respond before I had moved on to the next thing!  Thankfully I have learned to  s-l-o-w   d-o-w-n  and  w–a–i–t  for my little friends’ brains and mouths to catch up!           

Some kids respond well to parents who say the word and then wait long enough for their toddler to imitate the word.  However, some kids need direct cues such as, “Say _(the word)______.”  Another therapist’s tip - Don’t ask your child, “Can you say ________?”  The answer to this question is “yes” or “no.”  Simply use, “Say _____” or ”Tell me.” 

What’s my number one trick for getting kids to try to talk?  I always use FOOD.  Specifically junk food and lots of it.  I also use their favorite toys or activities too, but usually after I ”hook” them with cookies, goldfish, chips, fruit snacks (I call them “candy”) and everyone’s favorite, cheese balls.  Some parents and therapists try to take the high road, look down their noses at me, and in the most condescending tone they can muster, tell me that they NEVER use food to “bribe” kids to talk.  Why not?  It works!  And let’s face it, we all perform best for things we really like.  Looking at pictures in books or pointing out objects to them with the hope that he or she will begin to repeat the word may work for some kids, but in my experience, food works with almost everybody.  (Except maybe very, very picky eaters, but even then I can usually find some junk food they like!)

The food method (as I call it) always begins with me sitting on the floor holding the bag or bowl of snacks.  Try sitting on the floor first because it’s in their line of vision.  I usually say something like, “Mmmmm.  Cookies!  Do you want one?”  If I get no response, I say, “Okay.  I’ll eat it.”  That usually gets most kids riled up.  Then I say, ”What do you want?”  Model the word (or sign) for them to imitate.  When your kid tries, even if the word is not perfect, go ahead and give him the cookie.  You can clean up the sounds later when he’s older and is not as apt to be frustrated.  (See the post on What Doesn’t Work - Unproductive Strategies for more on this!)   If he doesn’t try to say the word, withhold the snack and model the word again for a few more times.  Sometimes it takes a few “models” before a kid can process and try to say it himself.  Wait him out.  If he still won’t try to say it after this long, go ahead and give it to him.  Going beyond this number of prompts really is, for lack of a better word, MEAN!  You want to keep him motivated enough to try again!                              

I usually cue a child between 3 and 5 times with a word before moving on or before giving him what he wants.  If he’s too frustrated (throwing himself backward on the floor and screaming), forget the prompting and just give him what he wants.  No kid learns anything when he’s that MAD!  But a little bit of frustration sometimes does a child good. 

I never accept “uh uh” or grunts and points from a kid when I know they can do better.  I know he can do better when I have heard him try to approximate the word before or when he’s become a fairly consistent imitator.  If not, I might hold out with a couple of models and then still give him what he wants if he truly can’t do it.  Using signs or pictures is what I switch to if a child can’t consistently make himself attempt a word.  (Look for a post later this week on using sign language to help kids learn to talk.)

An activity that I routinely have success with is blowing bubbles.  At first I sit on the floor, and I always hold the container so that I am in control.  If a kid fights to hold it, I give him a wand, and then I use another other wand to blow.  If a kid really fights to hold the bottle, I stand up so he can’t reach it.  Avoid saying, “No” or stating any other negative form or rule during this kind of play.  Just plaster a smile on your face, keep your tone playful, and move what he wants out of his reach, so that you stay in the lead, and he has to “request.”  Ask, “Bubbles?”  Model the word (and/or sign) several times WAITING on his request.  Blow only after he says the word, or after you’ve prompted the word several times with no response.  Make a big deal out of watching and popping the bubbles.  I pop them in the air with my fingers saying, “Pop! Pop! Pop!”, but I always let some fall to the floor so that I can smack the floor with a big gesture and scream, “Pop!”  Lots of kids will imitate this gesture and word for me before they imitate anything else.

One more thing I always try is using a toy with lots of accessories or pieces so that kids have to ask me for the next thing they need.  You can sabotage the activity by having all of the pieces in a clear plastic bag so she can see it and has to ask for each item to play.  I work with two-year-olds, so most of my little friends (even the boys) love playing with baby dolls.  I gather small bottles of pretend juice and milk, sippy cups, a bowl, several different colored spoons and forks, a hairbrush and comb, baby wipes, diapers, a baby blanket or baby carrier, pretend foods, and lots of doll clothes - shirts, socks, shoes, and hats.  If a kid wants a new item, he has to ask (or try anyway).  The key is having lots of items to pick from and then offering a choice between two of the items.  For example, ask if baby needs to drink or eat.  If she picks drink, ask if baby wants milk or juice, then needs a cup or bottle, then have him choose between two different colors of cups, etc…  I try to get a kid to  make several different choices before we get to the actual activity.  If your child is too frustrated with this waiting, stick to one or two choices before the activity, but always look for ways to expand his attention span and ideas in play.  It’s not always just about talking!  Be sure to join in the play modeling play and language at or just above his level.  You may get more imitation when you’re actually playing than during the choosing.

“Ball” is an easy first word.  Ball toys are always popular with one and two-year-olds too.  I like ones that have more than one ball and are clear so kids can watch the balls go in, fall down, or pop out.  Hold all the balls and have them ask you for one ball at a time.  Make a big deal about catching the balls as they fall out saying, “Got it,” so kids know they have to ask for it if they want it again.   

All of this type of play needs to be done in an animated, fun way.  Don’t look like an ogre when you sit and hold the pieces.  Don’t lecture, “You have to tell me the word first, or I’m not going to give it to you.”  Keep it light, fun, and model the word many times PLAYFULLY  withholding what he wants until he tries.  This kind of approach typically works when a kid is interactive and ready to talk.  If your child is too focused on the object instead of knowing that he has to communicate to get it, you may need to back up and work on more social kinds of games to make a real connection first before working on requesting.

I hope these ideas help!  Laura