#344 I Need a Plan! A Framework for Working with Late Talking Toddlers

This week’s show outlines the framework for working with late talking toddlers.

Here’s the show:

Here’s the summary:

As speech-language pathologists and parents, when a toddler is not talking yet, we rush in to try to help them learn to say new words and pronounce them clearly. When these first attempts don’t work, we become frustrated, sometimes very frustrated, with the lack of progress. This is the point where I usually meet parents – and even therapists – at a point of frustration. They’re out there looking for a way to do things better or faster and they find this website, my videos on youtube, or my podcast.

That’s the purpose of this post, to help you find a way to help your own late talker – or, if you’re a therapist like me, a whole caseload of toddlers with language delays!

Anytime you’re working on changing something, you need a plan! I’ve been a speech-language pathologist for over 25 years now, and early in my career, I recognized the need for a consistent way of designing my own treatment plans to make sure that I addressed every aspect of helping a child learn to communicate – especially those things that may not be as easy to identify as “he’s not saying any words.”

To keep myself on track, I developed a hierarchy or a plan for how to look at a child’s communication skills in a continuum knowing that everything a child learns is building a strong foundation for what comes next. I started sharing this hierarchy when I launched my website teachmetotalk.com in 2008 and began publishing my DVDs and therapy manuals. In 2010, I began teaching this hierarchy to therapists throughout the United States.

Today I want to briefly share that hierarchy with you and then show you how to apply this method or treatment plan using a specific activity.

Remember – what you’re doing is not that important. You can use this method for ANY toy or everyday activity. The important thing is learning the 4 big areas you should be looking at and in what order to make the most impact for working with a toddler with language delays.

The four areas are:

Social & Interactive Skills

Receptive Language

Expressive Language

Speech Intelligibility

Let me briefly explain each area and tell you why it’s important for language development.

Social & interactive skills are the foundation for communicating. Every time we communicate, it involves at least 2 people. Actually, this 1 on 1 interaction is the reason language evolved in the first place. We don’t need to know how to talk to do many of the solitary things we do every day, but as soon as another person enters the picture, communication becomes necessary. The first piece of that is realizing another person is there and then learning to enjoy that interaction. Social engagement begins very early in a baby’s life – on day one! Over the first several weeks and months, a baby shows evidence that he likes being with other people and seeks out others for the purpose of interacting. Those skills continue to grow and develop over a child’s first year. However, sometimes a baby who has been pretty social begins to withdraw. He or she begins to avoid interaction and tune other people out – especially people outside her own family. Or it may be more subtle – a child used to smile and giggle and be super engaged, but then it shifts a little. He becomes more interested in toys or screens that people. He or she doesn’t learn to consistently respond to her name or pay attention as people talk to her. She doesn’t look at things when you point to them. There’s diminished eye contact so that it may difficult to get them to look at you. They look like they’re always busy with something else or not listening as you talk to them. Let’s contrast this with toddlers who have typically developing social skills. They do respond to their names. They watch you often as you talk to them. They seek out other people to help them and try to communicate with facial expressions and their own body movements, even before a child can talk. When a child is not naturally social and interactive, he’s at a real disadvantage for learning to communicate because that foundational piece is missing. If a child you’re working with or your own child doesn’t frequently connect with you and a variety of other people, then this is the area where you should begin your plan. You’ll work to help a child learn to like (or at least tolerate) interacting with others. Without this piece, communication skills will not move forward.

Receptive Language

The next big area for language development is receptive language or how a child understands the words he hears. Babies and toddlers must first learn to understand words before they use those words to talk and communicate.

The best and most practical way to judge a child’s receptive language skills are by looking at how well he follow directions during everyday routines such as “Go get your shoes,” “Bring me the cup,” or “Let’s go take a bath.” Toddlers with typically developing language skills are completing these kinds of routine requests by the time they are 15 to 18 months old.

For therapists, there should also be evidence of a child’s ability to follow commands during sessions. If mom says, “He understands everything,” but I can’t get him to do anything for me during therapy, there’s a problem! You’ll want to tease that out. Is a parent overestimating a child’s comprehension or is it about behavior? Many times, parents attribute a child’s lack of compliance to behavioral or personality issues like “He’s stubborn” or “She’s lazy,” but most of the time, that’s not the case. Even the most strong-willed toddlers with normal receptive language skills follow many different requests during everyday routines at home, especially when there’s something in it for them!

Receptive language is heavily dependent upon a child’s cognition – or how he thinks, learns, plans, and remembers. Toddlers with cognitive delays will always have at least some difficulty learning language. You’ll know to expect those challenges and adapt your teaching strategies to meet a child’s needs in this area. Your goal here will be teaching a child to understand new words and new concepts, not say those words just yet.

If a child does not understand language well enough to consistently follow directions, you’ve found your first preliminary goal! Teach a child to understand more words first and to follow simple commands. Here’s why and it’s pretty obvious when you think about it…

Remember… toddlers must first understand words before they can use words to communicate.

It’s highly unproductive to spend time trying to teach a toddler to say new words when he doesn’t understand those words. Any child who is 18 months old and can’t follow simple directions during familiar daily routines will very likely be diagnosed with mild to moderate receptive language delays. Children who are 2 and aren’t following simple directions in everyday routines are at risk for significant receptive language delays. You’ll have to address this area first before you teach them to say more words.

Expressive Language

The 3rd area for language development is expressive language or how a child uses words – or even gestures or pictures – to communicate his own needs and his own ideas with others. Parents and therapists think about expressive language as the “talking” piece.

Before kids can talk, they need to be able to vocalize or use their little voices purposefully. Sometimes toddlers with speech disorders aren’t able to control their vocalizations. Everything is still very reflexive – like crying or even noises with sneezing or coughing. This has to become volitional – where a child understands that he can use his voice and imitate the sound you’ve made.

When babies first begin to babble and vocalize, the sounds are pretty random. Late talkers will continue to do that too. They may even jabber and use lots of jargon. The problem is that they haven’t learned to link meaning with those sounds yet. They don’t understand the direct imitation piece – meaning you say a word and then they say a word.

Verbal imitation is a big part of learning how to talk. It’s often a piece that’s missing too. But we can’t begin teaching a child to imitate with words – it comes at a much earlier developmental level. We first teach a child to imitate using actions with objects and with body movements. In typically developing toddlers, this process evolves over several months in the last half of the first year. It can take much longer in toddlers with developmental delays.

If a child you’re working with isn’t using very many words (but is socially engaged and does follow directions), then look at his or her verbal imitation skills. That could be your starting point. If that’s not practical or it seems like more of a stretch for a child, consider introducing strategies like sign language or picture systems or if this is likely to be a long-term issue, another kind of AAC device – a speech generating device or an app that speaks for the child when he selects the correct picture message.

Speech Intelligibility

The last big area is speech intelligibility or how well you can understand a child as he talks. Of course being understood is a big part of communicating! Speech-language pathologists think about this area as articulation – or getting the right sounds in the right places. Remember too that ALL toddlers can be difficult to understand when you’re an unfamiliar listener. Even parents may struggle to understand everything a child tries to say. The norms are pretty generous in this area. Parents may understand only about half of what a 24 month old says and closer to 75% by 2 ½ and then 90% by age 3.

A child’s speech may be hard to understand for several reasons. Sometimes they’re just using jargon or jabbering which means there are only a few true words included. Those kids understand that they should talk – they just don’t have the vocabulary yet to say what they want to say. This could be an expressive problem, but it’s usually an indicator of a receptive language problem after the second birthday.

Kids may have specific sound errors which prevent them from being understood. It may go beyond just not being able to pronounce a certain sound yet. There are often error patterns – a child speaks only using vowels or he may be able to include a few consonant sounds at the beginning or some words and never the ending sounds. Or he may shorten words and omit entire syllables. Or there may be no pattern in his errors at all. His speech sound errors are inconsistent – he may say a word fine one time and then never again or every time he tries to say a word, it sounds a little different. There are several diagnoses associated with poor speech  intelligibility. But we wouldn’t address this as the main focus for a child with delayed language until the other areas are firmly established.

Each of these 4 areas is an important part of language development.

When we don’t address a toddler’s area of weakness, it could be the reason why progress in learning to talk is much slower – even when a child is already in therapy.

So let’s take this hierarchy and then look at how we can address each of these areas with a single toy or activity. Although the toy does not matter, for the sake of keeping this interesting, I want to show you how to use this treatment model with a super exciting activity for toddlers – water play – during next week’s podcast!

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