Language Explosion = Speech Intelligibility Issues

As I mentioned, almost in passing, Ava was discharged from speech therapy at the end of the school year. I was fine with that. She had achieved all of her goals working on specific age-appropriate sound targets. We finally got the /k/ and /g/ sounds even at the conversational level and the only sounds she makes errors with at the word level aren't eligible for therapy until she's much older. Besides, we were beginning homeschooling, and as a SLP myself, I'd rather do therapy here at home from here on out.

I've taken a more laid back approach with Ava at home. Once she started making progress and her intelligibility was no longer an issue, I decided to let structured therapy happen with her therapists and let her time at home with Mama just be Mama time. And it has been fine. She's doing so well. Most people can understand her most of the time. You would no longer pick her out from a crowd of her peers and notice her speech. All of these things are wonderful and amazing and facts I wish I could have known about two or three years ago. It would have saved me so much worry.

However... She's 4. She has so much to say. Her language skills are perfectly normal and so her sentence length and grammatical complexity are shooting up. She want to tell stories and participate in active conversations and is competing with an extremely verbal older brother. And we're starting to have trouble understanding her again. It certainly isn't all the time, but several times a week she'll say something and we won't have any idea what a couple of key words are. We'll ask her to repeat herself, and that doesn't help. I'm finding myself asking questions like, "Can you tell me something else about it?", or "What does it do?" in order to try to figure out what she's trying to tell me.

Some of that is specific sound errors. She has a consistent /v/ for voiced /th/ and /f/ for voiceless /th/ substitution. /w/ and /r/ are weak. But some of it is the mild apraxia rearing it's head as utterance length and complexity increases. Soon it will be time to incorporate some structured speech therapy into our homeschooling routine. If it weren't affecting her intelligibility, I would wait. But it is. So, soon...

Silence

We found some old home videos tucked away in a folder we had lost track of. Ava was about 4-5 months old when the videos were taken. What struck me as I watched was how smiley she was. I remember very few smiles, and yet while watching these videos, she responded with a huge toothless grin every time I smiled at her. Her eyes would light up and there was this huge smile. And yet she was wrapped in a huge bubble of silence.

I listen to babies coo and babble all the time. I play with those sounds in waiting rooms, babbling back and forth with any infant who will play the game with me. Ava was silent. It's a little creepy - all the talking around her and this completely silent little baby. She didn't seem unhappy, she was just silent. She was silent in the bouncer, on the playmat, and in the arms of loved ones. We have some videos of me trying to make her laugh - tossing her gently in the air or creeping tickle fingers up her leg towards her neck. The vast majority of the time I was unsuccessful. The once or twice she managed to giggle, it looked and sounded effortful. And yet, somehow, even as a speech pathologist I managed to miss how exactly abnormal it all was. I was a sleep-deprived mother of a 4 and 19 month old. My professional experience was with preschoolers and school-aged children. At the time, I wasn't getting out much and didn't realize how much noise babies should be making.

There was a video where... well, I have no idea exactly what I was trying to capture in the video, but Ava was laying on her back on the floor. She couldn't roll over yet and looked a lot like a turtle stuck on her back. She was obviously frustrated. She was lifting her head and shoulders and waving her arms and staring straight at me. And there were no sounds. None at all. No grunting, no fussing, no crying even. Just silence in the presence of frustration and physical effort. And why exactly did it take me 18 more months to start assessment?

Has anyone had similar experiences with their apraxic children? If you go back and watch videos when they were babies are they silent? I know that "abnormal history of babbling" is a red flag for apraxia, but this complete silence... Anyone?

And then she was 4

Ava is now four years old. She is such an independent spirit. She prefers to do things for herself and to make her own choices. Ava likes to choose her own clothes and I let her (assuming they are clean and seasonally appropriate). If she chooses to wear the same favorite dress to school every day of the week - so be it. If the dress, leggings, socks, and shoes are all different colors and patterns- so be it. Making your own choices is awesome and she shouldn't miss out just because she's little and her fashion sense is still developing.

And yet, for all her independence, somehow that doesn't stop her from wanting to be close to people at the same time. Ava is not a loner. She wants to be near her loved ones and engaged in conversation. She doesn't hear the siren call of the computer or a game on a phone the way the rest of the family does. Ava would just as soon walk away from the electronics and engage someone in conversation, a snuggle, a tickle, or a game of chase. If I'm sitting in my rocking chair reading a book, she will snuggle in at my side just for company. If her Daddy is cooking in the kitchen she will drag a chair over to the counter and ask to help. I love that about her even while the introvert in me often wishes for a pry bar and 5 minutes of space upon occasion.

Ava and her brother are best friends. She spends time happily away from him, but when school is over or when he wakes up later than she does (always!) she is glad to see him. They play together seamlessly and effortlessly. When she is offered a treat, she asks if she can have one for Michael as well. When she's told she can have a special privilege (some extra tv or a special snack, for example) she'll call to him to make sure he doesn't miss it. If he is upset she tries to comfort him. If she cannot help him, she'll get upset too. Their play together has its own dynamic. Michael often leads the imaginary play and Ava happily follows along. She's the mouthpiece of the duo. If they want something (a real snack for their pretend picnic), Michael will send her to ask. Ava will appear at the head of the stairs bellowing a question. After being answered we hear her footsteps heading for her brother as she reports our answer.

Ava's favorite colors are pink and purple although I am beginning to see signs of her branching out a little. She loves art and is particularly content when coloring a picture with an adult happily giving instructions about which color should be used on which section next. She still loves kittens although the kittens don't have to be Hello Kitty any more. Any adorable kitten will do. She prefers to wear dresses rather than shirts and refuses to wear any pants other than leggings. She likes to turn her bed into a tent by covering the sides (she's still in a toddler bed converted from her crib) with blankets. She sleeps with stars on the ceiling and a glowing fairy on the wall and does not at all like to sleep in the dark.

Ava's showing signs of liking to perform. She'll want to show off tricks from gymnastics or the way she can use her dance streamer to make a spiral. She will definitely watch to make sure you are watching during her mini performances.

Ava is a little girl. It has been so much fun to be with her as she changes from the toddler she once was to an active, healthy, communicative preschooler. Happy fourth birthday to my big girl!

Ava Speech Update - Winter 2013

Birthdays, holidays, trips, surgeries, and reduced childcare have been conspiring to decimate my previously immaculate record of regular posting. Bear with me please, I'm working on it.

We just had Ava's second IEP meeting. She's come such a long way.

(Brief review for those who aren't caught up.

We began almost exactly two years ago with her early intervention evaluation. At that time she was barely talking at all even though she was almost two years old. Even more concerning was that she only had a few speech sounds she could make and she couldn't imitate. She was also giving up - beginning to turn to rudimentary gestures instead of even trying to talk.

Over the next several months we started using communication boards and sign language which gave her some tools to communicate and made her much happier. She began receiving services and working with me intensively at home. We all worked hard, and we saw a great deal of progress. She learned new sounds and started using words along with her signs. She made the jump to two-word utterances. Steadily we saw progress.

Six months after her initial IFSP meeting the second one was held and the team identified an additional area of need. Ava had sensory issues that were affecting basic life skills like dressing, bathing, feeding, and socializing. She began to receive occupational therapy in addition to her speech therapy. She continued to make progress in both areas.

Another six months crept by as she approached the age of three where children transition from early intervention to services provided by the schools. We needed to have her reevaluated to see if she would continue to qualify for services. Fortunately, she did and so her first IEP meeting was held. On her third birthday she joined a speech group using the cycles approach. It has served her well and over the next year we have seen so much progress.)

At this point Ava is speaking in full sentences using age-appropriate vocabulary and morphology. She is not at all hesitant to communicate and is usually intelligible. She continues to exhibit many speech errors but the only ones that are age-inappropriate at this point are /k/ and /g/. If you've been following me for a while, you'll know that we've been working on /k/ and /g/ for something like 18 months. I am happy to report that they are finally starting to come in. She can produce velar sounds now. She can do it almost all the time when imitating words in medial and final position and at least 85-90% of the time when imitating initial position. I even hear it pop in occasionally in spontaneous speech. (Okay, very occasionally, but that is huge!) So, finally we are on our way with the velars. Now it is just a matter of time.

At her IEP meeting we decided that the speech group using the cycles approach was no longer the most appropriate setting for her given that she's only working on velars. We are reducing her minutes to 30 minutes a week and she will receive those services via a traditional pull-out method. Her therapist will pull her out of her preschool room for 15 minutes twice a week to work with her on her velars.

I know there is more to work on than the velars, but I am so much more relaxed about it. The other sounds come in later anyway (/th/, /r/, etc.). She's mostly intelligible. I'm going to start homeschooling in the summer, and I think I'll sneak speech work into pre-reading phonics lessons rather than addressing it completely separately during "speech time". She's really have a phonemic awareness explosion enjoying playing with syllables, beginning and ending sounds, rhyming, and alliteration and so working on the speech covertly through a related area of strength makes more sense to me.

In summary, things are good. Progress over the past two years has been phenomenal and I anticipate that she will continue to improve. As I look back and remember how devastated and worried I was two years ago I wish I could travel back in time and provide a glimpse of the future. We are fine. Ava is fine. It has been a lot of work, and a huge commitment. However, even the work has often been fun. Ava enjoys her speech therapy and the friends she makes there. She’s been doing it so long, it is just a part of her life – no different than preschool or gymnastics. It is just an activity for her. I’d say the turning point is when the speech improves just enough that you can understand her most of the time. When everyone is frustrated and in tears because you just can’t understand what they are trying to say on a daily or hourly basis, things are awful. After that, it is so much easier.

Non-Hallmark Milestones Pt. 2

Speaking of non-hallmark milestones, we had another one. Doesn't everyone look forward to the first time their young child almost gets run over by a minivan?

We were leaving speech. I've taught the children to wait until I open the minivan doors (via a button on my key fob) and then walk on the line to their door. This keeps them safe because I don't open their doors until I'm sure the way is clear. Walking the line keeps them close to the car just in case.

Ava completely abandoned both of my safety checks. The children were racing along the sidewalk to see who could get to the van first. The cars were parked perpendicular to the sidewalk. Ava just ran right into the empty parking spot on her side of the van. She didn't walk the line. She didn't wait for me to open the door. And, of course, there was a minivan pulling in to that empty (except for the body of my small child) parking spot.

I screamed, but I would have absolutely been too late. Thankfully, the woman driving the minivan was paying attention. She had stopped to let us across the crosswalk and was apparently watching the children race along the sidewalk to our van. She stopped as soon as Ava ran into the parking spot.

Once my heartbeat slowed and I managed to unwrap my arms from around her body, I had a talk with Ava about object lessons and how they applied to this particular situation. We very clearly reviewed our safety procedures and talked about how they are even more important when the spots next to our car are empty.

I'm ready for a hiatus from the non-hallmark milestones. Really. I am.


Somehow, this story reminds me of another non-hallmark milestone: remember that time my almost-5 year old tried to find out how many marbles could fit in his mouth?

Speech Therapy At Home: A Minimalist Approach

I've experimented with several approaches to home therapy. We've done 30 minutes sessions five times a week in addition to the therapy services Ava was receiving elsewhere. That was intense and a schedule that was hard to maintain even when the children were only in daycare two mornings a week.

We tried doing a 15-20 minute therapy session nightly after dinner. That was working well at least 3 days a week until summertime hit and our schedule was less regular. Then sessions dropped to once a week and then we got distracted all together.

When fall approached, Ava was switching from daycare two mornings a week to preschool five mornings a week. She was also starting her speech group again twice a week for 45 minutes after the summer break. I decided to postpone home sessions until we settled into our school-year schedule.

Things are finally calming down. Ava has transitioned well to preschool. She's doing fine in her speech group twice a week. Her speech group is wonderful. They have a group for preschool-aged speech-only children. The therapists use a cycles approach working on each sound for a week or two before moving on to another sound. After moving through all the targeted sounds they begin the cycle again. Ava has a somewhat unique spectrum of speech sounds she has vs. has not acquired though. She has (with the exception of /sk/) pretty much mastered the /s/-blends. /s/-blends are typically a sound most preschool children need to address, so the group spends quite a few consecutive sessions on /s/-blends Ava already knows. Therefore, I am feeling the need to supplement at home again.

I don't want to overwhelm her though. Already her schedule is at least three times as busy as it has ever been. So I'm taking a minimalist approach to home therapy right now. I've taken a card deck upstairs to her bedroom. Usually we do final /k/, but right now her speech group is working on /sk/ so I'm switching to /sk/ this week (extensive /s/-blend sets are currently available in the Testy Shop).

I keep the deck on her bedside table and we practice the deck before nap and again before bed. It takes no more than 5-7 minutes to do a speed drill consisting of at least 50 productions. I can tell she's fatiguing near the end of the 59 card final /k/ deck (coming soon in the Testy Shop) because she's at 90% accuracy for the first 20 and down to more like 30% accuracy by the final 20).

I like this approach. It meets the two essential criteria for getting it done in our house.

• It is quick.
• It is built into our routines (before bed and nap) in a hard to forget way.
• As a bonus, it is heavily focused on child productions which is essential for progress with motor-speech problems.

Pneumonia is Contagious? Imagine that.

As you may remember, Michael walked around for a couple of weeks with a cough. He never ran a fever or had a runny nose, so I figured he has some sort of mild cold that would work itself out. Eventually it got to the point that he couldn't play because every time he tried to run he'd start coughing uncontrollably. After two weeks of a cough I decided a visit to the pediatrician was in order. Diagnosis: Walking Pneumonia.

A week or two later (last Friday), Ava started running a 102 something fever. Her appetite was non-existent and she was a little more tired than usual, but there were no other obvious signs of illness. Michael hadn't been showing symptoms for well over a week, so I thought it was more likely that Ava had picked something up at school than that she'd come down with his pneumonia. I decided to wait it out assuming it was a cold or virus. Friday, Saturday, and Sunday passed in a very similar manner with fever, fatigue, and lack of appetite. Monday a cough began to creep into the mix.

I looked up fever in the pediatrician office's handy manual Monday night and it said to call for an appointment if a fever lasted more than three days with no obvious source. Oops. So, I finally called Tuesday (Day 5). Bottom line: pneumonia. Lovely.

The silver lining to this mess is that they prescribed Ava the same super-effective on this particular bug antibiotic they gave Michael. 24 hours later and she's already much better.

Hindsight is always 20-20.

As a side note, Ava is a serious trooper. The times in my life that I've run a high fever I'm completely wiped out and pitiful. Ava pretty much went about her daily activities in a relatively cheery manner. She didn't want to eat and was a little more sensitive than usual, but other than that she was fine. The pediatrician commented on how cheery she was. It reminds me of the time when she was a baby and we took her in for something (I don't remember what) only to find she had a double ear infection. We never would have known. The child is amazing.

Corrections

My daughter has reached the age where she feels it is critically important to correct me all the time. Let's take some recent examples.

Me: Ava is three years old.
Ava: You mean three and a half, Mama.

Me: Let's put on your shorts.
Ava: You mean skirt, Mama.

Me: That's a lovely path you colored.
Ava: You mean arrow path, Mama.

My husband was taking a home video of Ava. They were discussing some coloring she had done in her coloring book. At one point, he corrected something she had said. She looked up from her coloring book and gave him a top class evil eye. "Turnaround is such fun," I thought when he showed me the video.

I'm so glad he caught that on tape. When's she's giving us the well-practiced version of that look at 16 I'll be able to refer to how she was practicing it at three. And I'll be able to pull out the video to prove it.

Case Study of Apraxia - Audio Samples from 21 - 30 months

About a year ago I pulled a bunch of speech samples from home videos and posted them on the website. A lot of people had trouble making the audio links work so I'm reposting them now in a single post for anyone who is interested in hearing what Ava sounded like just before starting therapy and through the first few months of progress. These samples begin with a short video taken at 21 months of age just before she started therapy. There is a monthly audio sample between 21-26 months and then a final sample at 30 months.

Let's begin with a frame of reference for this age group. Even dated research used a cutoff criteria of not having a spoken vocabulary of at least 50 words by the age of two to qualify children as "late talkers". More current research shows that the average number of words girls produce at 24 months is 346 and boys produce 252. A vocabulary of below 92 for girls and 63 for boys puts a 24 month old at the 10th percentile.

This is one speech delayed child with suspected Childhood Apraxia of Speech. As I know now, Ava's apraxia is mild and she made (and is continuing to make) swift progress in therapy. Do not listen to these samples and think that your student/child should sound just like Ava at the same age. All children are different. Their speech problems are different and their responses to therapy are different. I'm reposting these because I remember searching for some examples when Ava was first being diagnosed and wanting to hear some examples of other children who were struggling with severe speech delay. This is just one example of what a speech delay sounds like and the way the speech changed over time with excellent therapy. She went from almost no sounds/words at 21 months to singing a fairly recognizable rendition of a nursery rhyme at 30 months. I wanted to document that progress.

It has come to my attention that Blogger posts these videos/audios in flash format which does not play in Safari (on the iPad/iPhone) so you'll need to view/listen to these on a PC. Sorry!

Speech Sample - Ava - 21 months old - Childhood Apraxia of Speech before therapy

This is a video I took while reading a book with a 21 month old Ava before bed. At this time she had about four consonants, three vowels, and four "words" in her spoken repertoire. It was fairly obvious that she would be getting anywhere near 46-342 more words in the next three months. This is a good example of how to use picture books to encourage a speech delayed child to vocalize. Turn the book reading into a "conversation" by asking questions and pausing for a contribution from your child.

Speech Sample - Ava - 21 months old

Here's something from about three weeks later. Ava has found something interesting on the floor. It looks like a sticker of an eye that has fallen off of something and she is pointing to it and "talking" to her Daddy about it.

This was taken about two weeks before she was evaluated by early intervention, about four weeks before a private SLP and I began speech therapy, and about six weeks before she began receiving speech services through early intervention.

It was however, after I had accepted that there was a significant delay and that I needed to schedule evaluations. I began to consciously try to encourage more vocalizations and one method of doing that is to "echo" back what you hear from your child. You hear my husband doing that with Ava during this clip.

Speech Sample - Ava - 22 months old

Here's something from about one month after the last sample. At this point Ava had qualified for early intervention services, but hadn't begun receiving them yet. I was not yet doing structured speech therapy with her at home, but she had seen a private speech therapist for a few sessions.

Ava was laying on a blanket and I put my head beside her. She was quite offended that I was trying to share her blanket and was trying to persuade me to move off. She keeps pointing to a spot off of the blanket and telling me to move "there" while I keep pointing to a spot on the blanket and insisting that I stay. After quite a bit of back and forth I tell her I'll get off if she says "please" (we had taught her the sign for please and I'm actually asking her to use the sign). She uses the sign and I move.

During this interaction I am focusing on getting as many conversational turns in as possible without frustrating her. I've made the situation into a game where she is vocalizing over and over for me. In this one minute interaction I get 10 utterances and a sign. There -may- have even been one two-word utterance of "No, there!", but I can't swear that she really intended two words of if her Daddy and I were reading too much into that one.

Speech Sample - Ava - 23 months old

Again, this is about one month after the last sample. At this point Ava was about six weeks into receiving speech services. Ava and I were laying on the floor and she was making some observations about the striped shirt I was wearing.

This speech sample shows a great deal of change. At 22 months, Ava produced 10 utterances in a little under a minute. Those utterances included four different words. She used one consonant (/d/) and three vowels (/Ɛ/, /Λ/, /OƱ/). In the 23 month sample she produces 13 utterances total in just over a minute. Two of them are two-word utterances. Nine different words are used. She went from using one consonant to using seven. In the last sample she used three vowel sounds and in this one she uses six vowel sounds.

Speech Sample - Ava - 25 months old

This is about six weeks after the last sample. It is a bit of a therapy session I was doing with Ava. We were using a few of the Kaufman Cards. She had just turned 25 months old.

In the previous sample, Ava used the following consonants: /b, d, t, m, n, w, j/. All but one of those (mama) were used in one-syllable CV words.

In this sample Ava produces five different two-syllable words. Four of them were imitated correctly and one was imitated incorrectly, but still with a two-syllable non-reduplicated word. She uses /b, d t, p, m, n, h/ in this sample. She has added the /p/ and /h/ syllables in the six weeks since the last sample. She has also moved from productions that were primarily the CV syllable shape to productions that are non-reduplicated CVCV in syllable shape which is much more complex.

Speech Sample - Ava - 25 months old

This sample was taken three weeks after the last one. Ava is almost 26 months old. The most striking thing to notice here is how Ava moved to using multi-word utterances. In this sample she produces 10 utterances. 2 of those are one word (both two-syllable). 5 of those are three words (4 syllables per utterance). One utterance was four words long (5 syllables)! This is a huge increase in average sentence length in three weeks.

Speech Sample - Ava - 26 months old

This is the last monthly sample I have. It was taken about three weeks after the last one and Ava is 26 months old. At this point Ava was about four months into receiving speech services. Ava was asking me to get something down from a shelf.

In the last audio sample Ava produced 10 utterances in a little under half a minute. Those utterances included seven different words and ranged from 1 word (two syllable) utterances to 4 word (five syllable utterances). In this sample, Ava produces 13 utterances in a little under 30 seconds. These utterances include 12 different words and range from on word (one syllable) utterances to 5 word (5 syllable)utterances. The average number of words per utterance in the last sample was 2.2. In this sample it increased to 2.42. More importantly, there was significantly more diversity to the utterances in this sample.

Speech Sample - Ava - 30 months old

This is a short audio clip I pulled from a home video of Ava singing to me as we were swing on a deck swing. I was using the front facing camera on my phone and Ava was entranced at watching herself sing. First I got her version of the ABC song twice. Then I asked for the Itsy Bitsy Spider, then Row, Row, Row Your Boat, and finally Hush Little Baby. It was so adorable.

Here is a small audio clip from the concert. She decided to sing the Itsy Bitsy Spider as the Itsy Bitsy Butterfly instead, as she explains at the end.

Hair

I've been having fun fixing Ava's hair for school. I bribe her to sit still with a little tv in the morning and we end up with a cute hair style that will last through nap and still look nice in the evening. It also keeps the hair back off her face.

She has very fine, thin hair though, and so finding hairstyles that will work has been challenging. Did you know there are entire blogs devoted to little girl hairstyles? I found one that has hairstyles that work for Ava and I've been doing a different one each day to try them out. I don't always get a picture, but here are a few we've tried since school started a couple of weeks ago.

_______________________


Welcome to September and enjoy your holiday weekend!

Data and Diagnosis

Let's take some snapshots.

Ava just shy of two years old. No words. Three consonants and one vowel in her phonemic inventory. Not able to imitate. History of reduced babbling. Lots of red flags for Childhood Apraxia of Speech.

Ava at three. Decent phonetic inventory. Speaking in multi-word sentences. Significantly reduced intelligibility. Exhibiting many age inappropriate phonological processes. Diagnosis would look a lot like a phonological processing disorder with a motor-planning (apraxic) component.

Ava at 3 1/2. Intelligibility is improving. Many phonological processes are resolving - even the ones that are still age appropriate (cluster reduction, stopping of stridents, etc.). It would be difficult to describe Ava's speech problems as a phonological processing disorder at this point. She has numerous speech errors which are resistant to intervention due to the underlying motor planning component (stubborn, stubborn velars).

Same kid. Same neurology. The "diagnosis" looks different at different points. We get so hung up on a label. We need them for insurance and schools. Parents and SLP's tend to like them too. It is more important to understand the characteristics of the speech at that point in time and to have a plan to remediate the current spectrum of problems. Then you have to periodically re-evaluate with an open mind and be responsive to change.

Fascinating stuff.

(Typically, you'd never administrate the same instrument three times in five months. In this particular case it was done because of the timing of Ava's IEP. They assessed her at intake, at the end of the school year, and then at the beginning of this school year. The results are not simply an artifact of retesting though. She has indeed made progress in the areas noted. It's pretty amazing actually.)

First Day of School Pictures - 2012

I've seen a ton of sweet first day of school pictures floating around the internet. I particularly liked this one and combined it with the idea of holding a sign. This year was the first year both children were heading off to preschool/pre-K at our local public school and so I decided that I would get it done this time. I printed off the "signs" using microsoft word the night before while the kids were in the bath. I dragged the children into the driveway, cajoled smiles from them with silly sentences, and took a few pics with my phone before loading them in the car. Then I used PicMonkey to edit the pictures and add the text.

Ava Speech Update: Fall 2012

It's been a long time since I've talked about Ava's speech in more than a passing manner. Fall seems like as good a time as any to check in. It's been a long time and many of you started reading between my last update and this one so I'll begin with some background so you can understand how far she's come.

Ava was not talking at 22 months. She had a history of reduced babbling and an extremely limited phonemic repertoire (d, m, h and a couple of vowels). The only syllable shape she produced was CV. She used the word approximation "da" with an upward inflection for almost everything accompanied by pointing to the object she wanted. She could not imitate. She was beginning to give up on trying to talk at all turning to gestures instead.

At that point I abandoned the wait-and-hope-she-miraculously-catches-up approach and began to make phone calls. We briefly saw a local SLP who had put a flyer in the daycare who agreed that Ava's speech was significantly delayed and that she had many of the red flags for Childhood Apraxia of Speech. I called around and discovered that one of the national experts on CAS lives in our area and set up an appointment with her. We've been seeing her twice a month for well over a year and she's wonderful. We also had Ava assessed by early intervention, wrote an IFSP, and began receiving services. Finally I set up a program of home therapy with her.

At that point I knew Ava was delayed - really delayed. What I couldn't yet anticipate was prognosis. It would depend on how well she responded to therapy. Some children respond well to therapy and make progress quickly. In those cases, prognosis is pretty good. In other cases the children, parents, and therapists work hard, frequently and intensely and progress is still slow. In those cases, prognosis is poorer. You know you're going to have to work harder and longer. You know progress will be slower and that the child may not ever have typical speech. I didn't know which category Ava would fall into, but I feared, based upon how delayed she was that she would fall into the second category.

We were so lucky. Ava responded well to therapy. Really well. I was doing updates on the blog every 2-3 weeks and it was like I was describing a completely different child. First she was learning to produce new consonants and vowels. Then she added more complex syllable shapes. She went from one syllable to two and from one-word utterances to multi-word utterances. We went from almost no speech to lots of speech that was extremely difficult to understand because there were multiple errors in every utterance.

Slowly we worked on speech errors. Some sounds and categories of sounds she learned quickly and easily. /s/ and /l/ came relatively quickly even in blends. Now she uses them conversationally with no problem. Other sounds we've worked on for well over a year and they're still a struggle (/k/, /g/). As more sounds came in and fewer sounds are left that are in error she became easier to understand.

Right now she's intelligible most of the time. She struggles most with sounds produced in the back of the mouth. She fronts /k/ and /g/ producing /t/ and /d/ instead. She also fronts /ch/ and /J/. /th/ is produced as an /f/. There are plenty targets left to work on. The almost complete absence of back sounds certainly impacts her speech in a noticeable way. Her language helps her though. She's using long sentences in conversation. You usually have enough context from the conversation and from the rest of the words in the sentence to figure out the one or two words that would have been unintelligible in isolation. You can ask her to tell you a different way or give you a clue and she is able to rephrase her message to help you.

Ms. J (our local apraxia expert) has even suggested we take a hiatus from visiting her because Ava has made such great progress. We're stuck working on trying to break through on those back sounds and I can do that myself with her at home.

Ava is heading off to preschool next week and I am not worried about her speech significantly impacting her experience there. Yes, her speech is not typical, but she is understandable. I am so grateful that all her hard work has paid off. Prognosis is good. If we keep working, I expect that the remaining speech errors will be corrected in time. At some point, I truly think her speech will be typical. Until then, we'll keep working at it.

Slacker Parenting Win

Ava wakes at the crack of dawn. Ava has always woken at the crack of dawn. During the summer that is before 5am around here. Her first and second summer my husband and I took turns getting up with her, bleary eyed and a more than a bit grumpy. Her third summer, when she was 2 1/2 we split the difference. We got a tot clock and we'd set it for about 30-40 minutes after she woke up. She knew she couldn't leave her room until her clock turned yellow and that bought us an extra 30-45 minutes of sleep every day.

This summer she's been waking up just as early as always. She's older and more independent now though and I feel guilty locking her up in her room for over an hour after she wakes up. (I got used to the 7:05 wake up time we were able to get away with during the winter when it stays dark longer.) So we told her she could go downstairs and play quietly when she woke up but she can't wake anyone else up until her light turns yellow. If her light is blue, that means Mommy, Daddy, and Michael are sleeping.

Well, that worked when she was only waking up about half an hour before the alarm, but much longer than that and she'll sneak into our room wailing, "Mama! My light not turn yellow!!" Now, in a perfect parenthood world, I'd pop up happily whenever she wakes up and spend quality time with her, but I'm a night owl and I really wanted to try to hold on to sleeping in just a little. I had an idea...

I started setting out a bowl of dry cereal and some water by her computer before I go to bed. Now she knows that when she wakes up she can go downstairs and entertain herself and eat at the same time. It worked beautifully for a few days. My husband and I would wander down after our alarm went off and we leisurely got dressed/showered to find her happily eating Cheerios or Mini-wheats while playing educational software. That was pretty nice.

Then something even stranger started happening. My little early bird who has woken up with the dawn 99 out of 100 days for her entire life began sleeping in. She's slept till 7:45 for about five days straight (that was typed in a whisper to try to avoid the curse of saying such things out loud). My hopeful hypothesis is that now that she gets no attention for getting up early, she has no reason to get up when she surfaces with the light. Instead, perhaps, she has actually learned to roll back over and enjoy drifting back to sleep for one more cycle. Hmm. Slacker parenting = better sleep for my daughter. Who knew?

Maintaining Home Therapy Momentum

Ava's speech has improved so much in the past 15 months. A little over a year ago my 24 month old daughter had only a couple of "words", a handful of phonemes in her repertoire, and was beginning to give up trying - turning instead to gesture. I spent a huge amount of time worrying about her speech, scheduling evaluations, setting up private therapy and early intervention, and working with her at home. I designed my own therapy materials. I worked with her daily. I monitored every tiny bit of measurable progress. Not an hour went by without me being engaged with her speech delay on some level.

Almost 15 months later, Ava's made so much progress. She's gone from a place with no words to a place with sentences and conversation. She's moved from a speech sound inventory where it was easier to list the few sounds she did have to a place where it is now easier to list the ones she's missing. She moved from early intervention and IFSPs to school age services and IEPs. I no longer worry about her speech on an hourly basis. It no longer is the major focus of my life.

All of that is wonderful and it is difficult to express the profound sense of relief that comes from letting go of the level of worry I had at the beginning. The progress has, however, had a direct impact on my sense of urgency and our home therapy momentum. When I was profoundly concerned, it was easy to remember to sneak in speech practice daily - sometimes multiple times daily. Now I'll find that a few days have slipped by without a structured therapy session.

Spring has contributed to the problem. Our habitual therapy session was after dinner and before the play, bath, and bedtime stories that make up our bedtime routine. The beautiful weather and late sunlight have drawn our family outdoors for evening picnics and play in local parks and I won't realize until after I've put them to bed that speech got lost in all the business and enjoyment of the season.

I need to refocus a little and find a new routine that works. I have been trying to shift our therapy sessions to the mornings when I know we'll be out in the evening. I make an effort each night to plan the activity, time, and therapy focus for the next day. Time slips away so easily and her speech will not continue to improve without intervention. And so I need to find a new sense of momentum even though the urgency isn't as intense and the weather is beautiful.


________________________


Happy Mother's Day everyone!

Stream of Consciousness

Topic: Ava
Occasion: Third Birthday

My daughter turned three today. When you're pregnant, it feels all-encompassing. It is difficult to imagine the baby you'll soon be holding, much less the little girl she will become. It is difficult to believe that in a few short years, you'll hardly remember the pregnancy part of things.

Ava is such a wonderful part of our lives. She's the first person to wake up in our home. Through much effort, we've convinced her to stay in her room until a decent hour. When she does come to join us she's happy and cheerful and bubbling over with thoughts to share. She greets every part of her day with enthusiasm and often brings a smile to the face of others.

She's also a fascinating study in contradictions. She'll bound halfway across a room to reclaim a toy she wasn't playing with from her brother because she thinks it is "hers." And yet, most of the time she shares with her brother unthinkingly and with a truly generous spirit. He is never far from her thoughts. At the end of her speech sessions, her SLP gives her a treat and she asks for an extra to bring to her brother. Immediately after telling someone her favorite color she volunteers her brother's favorite. When discussing her birthday party she wants to be reassured that Michael will be there.

After her brother, her family members are close to her heart. She loves to name all the members of her immediate and extended family. Her favorite book is a small photo book with pictures of all her family members. She loves to hear stories about when she was a baby or about when her Daddy or I were babies.

If I ask her for a hug, she'll drop whatever she's doing and wrap herself around me completely. She really does give the best hugs. A hug from my daughter will instantly lift my spirits. A hug from me is the first thing she wants when she is hurt or scared. If I sit in my glider, she'll hop up on my lap and ask to rock with me. She loves to be held, tickled and snuggled and I dread the day when she'll decide she's too old for all that.

I miss the baby, but I adore the little girl who is appearing before me. She loves pink and purple. She has distinct opinions about what she'll wear. She'll put a jacket on only under duress. She still prefers to run around the house half-naked, but loves to wear play shoes. She'll appear before me at random moments asking if she's gotten them on the right feet. She'll let me fix her hair and asks to comb or brush mine. She begs to hear books and songs at naptime and bedtime and is starting to sing songs and tell stories herself. She'll reappear several times after going to bed just so she can be tucked in tight another time or two.

She's not fond of her bike, but she loves to run. She's fast too. She runs with all the speed her little body can conjure. She runs so fast that I worry when she happens to head downhill. When she stops, she'll come to me and place my hand over her heart so that I can feel how strong it is. She begs to race and loves to race Michael on his bike.

She loves to draw, paint, glue, and cut. She loves to play in water. If I give her some toys and let her fill the bathroom sink with water she'll disappear happily for an hour. She likes fast music. She knows how to put the electronic piano in demo mode. She'll slide open the piano, choose a fast song and dance or run to the beat.

There's so much more to say. All of these thoughts are just the ones that swirl to the top of my mind most easily. They are one tiny snapshot of who she is right now. She's my little girl. The privilege of getting to watch her grow and change over the next year is her gift to me.

Sometimes It's Just Normal

In retrospect, it is so clear that even as infants my children were not developing typical early communication milestones. The first smiles and laughs were not on schedule. We never really had cooing at all. Babbling was both very late and extremely reduced. This is for both children, not just Ava. In fact, all of those delays were even more extreme and exaggerated for Michael than for Ava.

Now Michael's speech started to kick in around the age of 15 months. It was odd. His first consonants were ones like /k/. He was using clicks in place of consonant sounds which was even more strange. I was so very worried.

In fact, I can remember having a conversation the night of Ava's birth with a fellow SLP about how concerned I was about Michael's speech. He was 15 and 1/2 months old that night. I know that it sounds strange that I just happened to be talking to a SLP on the night of my daughter's birth. However, that SLP was a close friend and former coworker who also happened to be a doula. She was my doula and with me for the birth of both of my children and so it was natural for us to be discussing Michael. She was there for his birth and she was a fellow SLP.

At 15 months all Michael had was a couple of vowels, a /k/, and a lot of clicks. However, by 24 months he was talking in 5 word sentences, had an age appropriate sound repertoire, and was intelligible enough that his speech was constantly commented on positively by strangers. It was such a relief. Over the course of those nine months, the worry I had carried in my heart for the first year and a half of his life faded and I was so grateful to let it go.

That history of Michael's delay followed by a remarkable recovery to above average was a huge part of why I delayed so long before acknowledging that Ava's speech was delayed. Then we fast-forward to the present day.

Now, at the age of 4, it is apparent that Michael does have some speech errors that are going to need intervention. He has a distorted interdental production of /s/, /f/, /v/, and /th/ that results in all of those sounds being produced in an identical fashion that is visually distracting and impacts his intelligibility on words that include those sounds. And so I worry.

I spend a lot of time worrying about speech. I worry about Ava's speech. I worry about Michael's speech. But sometimes, a speech error is completely normal - even adorable. Michael is completely convinced that one of his favorite foods is "grabioli" rather than "ravioli". I smile a little every time I hear him say that because it is such a normal speech error. I smile, and gently correct him. It is nice to occasionally engage in a correction that is without stress or subtext. Because sometimes it really is just normal.

Card Set Game: Top-Bottom Puzzles

Usually I just do drill with Ava. She tolerates it fairly well if I bribe her with a treat (I use the Gerber Graduates Yogurt Melts so I don't even feel guilty). I give her one treat for every set (15-30 repetitions or so) and two treats when we're all done.

For variety, I decided to try the top-bottom puzzle idea from the card set game and activity ideas list I posted a while back.

I printed a fresh copy of the fronts of my Initial /s/ set. First I cut them out using a paper cutter. Then I chose 15 out of the 30 cards that I thought would divide well into top and bottom halves and cut those in half. (I'll save the other half of the cards for a different game another time.)

I shuffled the half-cards and started setting them out on the table. I separated the tops from the bottoms to make it a little easier this first time. Every time Ava saw a match, she said the word and set the match aside.

She really enjoyed the activity. I thought it was fun, but the actual speech practice was much less intense than our usual therapy session. It sounds terrible to admit that I prefer drill, but speech therapy for motor planning problems needs to be heavy on repetitions. The child cannot automatize motor sequences without actually talking, and talking a lot.

Using a game instead of drill significantly reduced our number of repetitions. Perhaps a compromise would be to do drill for the first 2/3 of a session, and bring a game out at the end of the session for extra motivation when the child is getting fatigued.

Trying for blends (/sn/, /bl/, and /pl/)

We've starting working on blends with Ava. She's had a lot of success with both /s/ and /l/. Typically, /s/, /l/, and all blends would not be sounds you'd choose to work on with a two year old child. However, Ava struggles to make herself understood. She has motor planning problems with speech and for whatever reason, /s/ and /l/ are easier for her than other sounds that would typically emerge earlier (like /k/). So, if we take the time to improve the sounds that are more stimulable, we'll improve her intelligibility sooner. Sure enough, /l/ is definitely popping into her conversational speech and it sounds great. To a lesser extent (mostly in initial position), /s/ is popping in as well. So, we decided to try for some /s/ and /l/ blends.

Her /sn/ words are: snow, snap, sneeze, snip, snail, snore, and sniff. She is pretty good with all those final consonants (notice, we aren't doing snake).

We are cueing her on multiple levels. First, we are using semantic/visual cues. For "snow" we use the visual cue for /s/ followed by shaking our head "no". For "snap" we use the visual cue for /s/ followed by tilting our hands on our head to visually cue "nap." For "snail" we use the visual cue for /s/ followed by pretending to hammer a "nail." And so on...

This works well when we keep the /s/ sound completely separate from the second part of the word. As soon as you ask her to imitate the blended word, she loses the second consonant. Snow becomes so. Snap becomes sap. Snail becomes sail.

Using an auditory prolongation cue was also unsuccessful. Ava, say "sssssssssno." Her response was simply "so".

Visual cues were unsuccessful. Semantic cues were unsuccessful. Auditory cues were unsuccessful. I finally tried incorporating some tactile cues. I happened to do this with feet because Ava thought it was funny, but you could do this with hands, fingers, or knees as well. I first grabbed one foot and giving it a light squeeze I asked her to say, "Hi sssssss." She repeated, Hi sssssss." Then I grabbed the other foot and gave it a squeeze and asked her to say, "Hi no." Again, she repeated, "Hi no." Then I squeezed each foot in succession as I said, "Now say ssssssss-no." She had the tactile cues of me squeezing each foot in succession with each part of the blend. She had the auditory cues of the prolonged /s/ sound followed by an emphasis on the /n/. She was also watching my face and mouth at the same time. This time she was successful.

We continued to practice that way about three additional practice sessions and then I was able to fade the cues. First I was able to stop using the tactile cues. Then I was able to minimize the prolonged /s/ sound. Now I can simply show her the card and give her an auditory cue with a just the slightest prolongation of the /s/ and a slight emphasis on the /n/ and get a /sn/ blend production from her. It's like the motor planning finally kicked in and now she has it. We still have a lot of work to do. It is inconsistent and we get no carryover to other s-blends (/st/, /sp/, etc.). At least the variety of cues and prompts managed to help her experience some success with the specific blends we are working on right now.

I used the same strategies for /pl/ and /bl/. Our /pl/ words are plum, play, please and plane. Our /bl/ words are blue, blood and blow.

Quick summary of cues/prompt types you may find useful:

• auditory (slight separation of blend consonants, prolongation of first consonant in blend, emphasis on the second consonant of the consonant blend, clapping or snapping for each section of the blend word, etc.)
• visual (use gestural prompts for specific phonemes, use gestures to represent semantic cues, have child watch your mouth)
• semantic - assign meaning to the second part of a blend word (the "no" of snow, the "nap" of snap, etc.)
• tactile cues - tap or squeeze a hand, finger, or foot to emphasize each part of the blend word you are trying to produce in sequence

Lesson learned. (Or - How we called our pediatrician three times in five days and yet managed to miss calling the most important time.)

Let's start this story from the beginning. As I believe I already mentioned, Ava tripped at the play place in the mall Friday night. She fell rather oddly onto her arm and was significantly favoring her right hand. After determining that there was little or no swelling and her fingers seemed to move fine, we decided that a pediatrician call for that incident was unnecessary.

The next day Ava woke up from nap with a croupy cough. That was followed by labored breathing and we made an after-hours call to the pediatrician. A late night dose of steroids obtained from a 24 hour pharmacy saved us a trip to the emergency room. Our sincere thanks went out to the on-call pediatrician.

Monday, I was walking into a room when Michael was walking out and I managed to slam him in the forehead with the doorknob. I hit him hard enough that he fell back onto his butt gasping for breath before the screaming began. I comforted and hugged and felt around the forehead for lumps but found none. I mentally moved on once the crying stopped.

It wasn't until some extremely bizarre behavior began at bedtime that I remembered the bump on the head and became concerned. He was scared and asking to sleep with us (never in his entire life has he been afraid at bedtime - never). He was desperately thirsty and drank so much water that we had to change his clothes twice in a row. Again, very odd. I was worried about some kind of brain injury. Another late night call. We got the same on-call pediatrician. Who knows what she was thinking of us at that point, but she decided at home observation would be adequate. Turns out, he was fine thank goodness.

Yesterday Ava had a fever. She was complaining that her right ear hurt. At least it was during regular office hours this time. We went to the pediatrician and sure enough, she has an ear infection in her right ear. Ten days of antibiotics here we come.

As we were about to leave, I remembered Ava's hand and quickly told our pediatrician the play place story and showed her the bruising on Ava's hand. At this point, all four knuckles have dark bruises and the bruise shows up on the palm of her hand as well.

Our pediatrician took one look and sent us down for an x-ray. Our pediatrician's office is adjacent to the hospital, so at least this trip only involved an elevator ride and walk down a long hallway. She told me to just go home after the x-ray. She would call me and let me know. Well, I told the x-ray technician that we were just going to take off per our pediatrician's advice. He gave me a significant look and asked me to stay just 10 minutes while he made a quick phone call. I knew right then that the x-rays showed something and that he didn't want me to leave until he got a doctor to take a look.

As it turns out, there is at least one and probably two fractures in the bones of her hand. Just give me a parent of the year award. Yes, I let my two year old daughter walk around with a broken hand for five days. I only found out because I mentioned it in passing during the pediatrician visit in which her ear infection was diagnosed.

Here's her x-ray. It's pretty subtle. At least, it is subtle to my completely uneducated eye. But, I'm told there is a fracture. I have learned that it is possible to have a broken bone with no swelling and no restriction in movement. Our pediatrician told me that as soon as I noticed the significant bruising I should have called. Ahh, hindsight.

Later today I'll be setting up an appointment with a pediatric orthopedist. Let the fun and games continue.