Friday, April 15, 2011

Apraxia Therapy: Two-Word Combinations

Making the jump between one-word utterances and two-word utterances is huge, especially for a child with Childhood Apraxia of Speech. I wanted to describe in more detail the many things you can do to try to facilitate the transition to using two-word utterances.


First I want to talk about scaffolding. This is just a fancy way of saying that you’re only going to try to facilitate something a little harder than what your child can do on their own. If they can’t imitate at all, you’re not going to ask them to suddenly repeat a five word sentence. Start where they are and try to help them do something just a little harder. When they can do that, then do something just a little harder, etc. For the purpose of this discussion I’m going to talk about a child who can imitate single words and is willing to do so, but is having trouble imitating a two-word utterance. The first thing you want to do is make sure you’re modeling two-word utterances. Try to simplify your own speech to the two-word level and use lots of two-word phrases yourself. Also, whenever your child uses a word, repeat it back increasing it to a two-word utterance. For example, if your child says “dog,” you say, “Yes! Big dog!” This is called expansion. You are expanding their one word sentence into a two-word sentence.


Children with Childhood Apraxia of Speech have trouble with motor planning. Research has shown that therapy is more successful when it is multisensory. Try to stimulate them as many ways as possible. One way to do this is to use a tapping technique. Use your hand to tap out two syllables as you say them. So, “big dog” should be said simultaneously with two taps of your hand on your knee (or claps, or snaps). If your child will tolerate it, tap gently on their knee, or hand, or arm. Or help them to clap the syllables themselves. Any time you're trying to get them to imitate two words instead of one (or a two syllable words that they are producing as a one syllable word) be sure to tap it. It can make a huge difference. It really seems to help them cue in on the fact that there are two distinct parts that they need to produce. Also try using a singsong voice. So say, “biiiiiiig dog”.

Use signs and gestures.

This might sound counterintuitive, but encourage signs and gestures. Typically developing children combine single words with a gesture before they start using two-word phrases. So, if they want to tell you “daddy’s shoe” they might say “dada” while pointing to his shoe. One of Ava’s first two “word” combinations was saying the word “more” out loud while making the sign for milk. It’s a stepping stone to saying two-word phrases and it can be very effective. As another example, spread your hands wide as a gesture for big while saying the word “ball”. If you do see them combine a word with a sign or gesture to make a two-"word" utterance, repeat both words back to them yourself. Say, "Yes! That is a big ball!" Praise their successful communication of a two part message.

Slow it down. Be direct.

So, you’re scaffolding, modeling, expanding, and combining gestures with signs and still don’t feel like you’re making progress. Make sure you slow it down. We often don’t realize how quickly we’re speaking. Deliberately slow your speech down. It gives them extra processing time. Also try being more direct. You can tell them, “Say, biiiiiiiig dog!” It sounds simple, but sometimes it can help. Be careful with that though. If your child gets defensive, don’t push.

Break it down.

You can also put a long pause in between the two words when you are asking them to imitate a two-word phrase. Again, it gives them extra processing time. It also shows them that it is ok if it takes them a long time to get that second word out. Children with Childhood Apraxia of Speech often need extra processing time particularly when they are trying something new. When Ava was trying a new two-word phrase that was hard for her, there was a huge pause between the first and second word. You could see her working at getting that second word out. I think it helps if you model that pause to begin with. Only put the pause in if necessary though, and phase it out as soon as possible. If you need to, you can break it down even further and have them imitate the first word and then the second word seperately before asking them to imitate them together.

Carrier phrases.

Use carrier phrases. A carrier phrase is a short predictable phrase used repeatedly where only one part of the phrase changes. Let me give some examples. I deliberately taught Ava the word mine. In a household with two young children that seems like a tactical error, but I wanted her to then use the phrase, “my ______” . Once you teach the carrier phrase, it can then be completed with so many other words. “My shoe. My hat. My milk. My cup." etc. This one works particularly well because you can make it into a game and get lots of repetitions. So, she says, “My shoe.” You playfully return, “No, Mama’s shoe!” She indignantly returns, “My shoe!” You continue back and forth as many times as you can. As another example, Ava’s very first two-word combination was “Papa house.” Then she used house as the consistent part of the carrier phrase. She said, “Mama house, my house, papa house, dada house," etc. Go out of your way to find carrier phrases that are fun to use in your house and use them frequently. Some other ideas might include:

  • Baby. "Baby up. Baby down. Baby sleep. Baby bad. Baby good. Baby eat." etc
  • Car. (Or train, or truck.) "Car go. Car stop. Car beep. Car crash. Car fast. Car slow.: etc.
  • More. "More milk. More water. More banana. More play. More tv. More cookie." etc.

Practice, practice, practice.

Don’t limit these activities to a 15 minute speech practice time per day. Do them all the time. Incorporate them into different activities. Do this when you’re reading books, giving them a bath, during snacks and meals, during play with toys and during an art activity. The more variety the better. Do these things in as many settings as possible – at home, in the car, at school, in a restaurant, at the mall, at the grandparents’ house. If possible, teach the other adults around you to use these techniques. Mom, dad, grandparents, and siblings can all be encouraging speech development. In fact, even though I was working on this all the time myself, it didn’t pop in until she spent the night at her grandparents’ house doing all these things in a completely different setting with different people.


Two-word utterances - Apraxia Therapy techniques

I've put the techniques I consider to be particularly powerful in bold print.

  • scaffolding
  • modeling
  • expansion
  • tapping
  • singsong
  • combining words with gestures
  • slow it down
  • be more direct
  • use carrier words and phrases
  • use techniques in different activities and settings and with different people

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