Speech Therapy Progress - So Slow

I realized that I haven't done a speech therapy progress update in almost 5 months. I can't believe that much time has passed. I've been doing fewer progress updates because there is less progress to report.

Last time I wrote a progress update I said that we were working on final consonants and that she was using /p/ and /t/ spontaneously about 30% of the time and we had pretty much no other final consonants. Now Ava is using final /p/ and /t/ spontaneously at least 60% of the time in phrases and sentences. She's also using or approximating most of the other early emerging consonants spontaneously at least 30-50% of the time. She can imitate final /s/ and /sh/ as well, but is not using those spontaneously.

We still don't have /k/ reliably. I'd say I've seen relatively little movement on this phoneme in 5 months time. Even in direct imitation with multiple cues she will substitute /t/ for /k/ at least 3/5 times. I am frustrated with the complete lack of progress on learning a velar sound.

Right now I feel like I understand Ava at least 90% of the time in context and at least 50% of the time if I have no context. I think she is significantly less intelligible to strangers. She is speaking regularly in 3-7 word sentences, but most of those are word approximations.

She has /p, b, t, d, m, n, h, f, j, w, s, sh, ng, and vocalic /r/ in her phonemic inventory.

I feel like her language growth has been phenomenal over the past few months. Sentence length and complexity, expressive vocabulary, and morpheme use has all improved significantly (as you would expect for a child of her age).

Speech progress has slowed and is becoming difficult to track. We have shifted out of the stage where we see rapid progress from beginning therapy. Now I am beginning to see that the remaining errors are significantly more stubborn and progress will be measured in small increments rather than leaps. It is disappointing, but not unexpected.

I know slow progress is much more typical of apraxia and motor planning problems than fast or even steady progress. It's just that when things moved so quickly at first I got my hopes up. I was hoping that she would be the exception rather than the rule. Why is there always another reality check just around the corner?

It's All In a Self-Assigned Name

It won't come as a huge surprise that the variety of vegetables that Ava will eat is small. She'll eat canned peas, but not frozen. She'll eat raw carrots with ranch, but not cooked carrots. She'll eat sweet potato fries, but not mashed sweet potatoes. And regular fries of course. And that's about it. No corn, no green beans, no tomatoes, no broccoli or cauliflower.

I finally resorted to subterfuge. I went back to making baby food essentially. (I still love my Baby Cook.) I steam and purée vegetables like butternut squash and carrot in batches. I freeze the purée in ice cube trays. Then I defrost and mix the cubes into her food whenever it wouldn't be noticed. I can get two cubes into her morning yogurt, for instance.

A couple of days ago I was making a batch of sweet potato. I had steamed and puréed it and was in the process of spooning it into ice cube trays when Ava came by to check out the action. She observed in silence for a few moments and then demanded, "I want some icing!"

I thought for a moment about correcting her assumption that the puréed sweet potato was icing, but that just seemed a waste of a golden opportunity. Instead I said, "Well, you can have one taste." Then I let her try a taste from the tip of my finger.

She made a face and I thought that would be the end of it, but a moment later she piped up with, "Mama, can I have a bowl of icing?". You can bet that I scooped sweet potato right back out of the ice cube trays and put it in a bowl for her. She then proceeded to eat three small bowls (about 4 ice cubes) worth of sweet potato. I guess sometimes it really is all in the name.

(It probably helped that she was starving because she didn't like anything I served for dinner that night.)

Speech Sample - Suspected Childhood Apraxia of Speech - 26 months

This is an audio clip from a video we took on 5-14-2011. Ava was 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, three weeks prior to this one, 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 half a minute. 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.

Here is the new sample:




In this audio sample Ava's utterances were:
What that?
What that?
This there.
Uh huh.
No I think get down.
No get down.
I think down.
Not think up.
Down.
No think down.
Down.
I say down.

Speech Sample - Suspected Childhood Apraxia of Speech - 25 months (2)

This sample was recorded three weeks after the last one I posted (4-26-11). She's picked up two additional consonant approximations. She's approximating /g/ and /s/ in this sample. What is interesting is that both of those sounds disappeared later. We are working on /s/ now, but I have to remind her to make it. She isn't really making the /g/ sound at all any more.

More important than individual sounds is that she's 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.

Transcript:
get down mama
get down mama
get down
get down
get down
uh huh
no mama get down
mama
mama scissors
dada scissors

Ava's Hello Bag

On our way home after being discharged from the hospital we stopped at the grocery store. Before the unexpected hospital adventure we had been postponing a trip to the store for several days and we had very little left in the house to eat. So we had to stop by the store just so we could feed everyone lunch when we got home.

I was carrying Ava around the store keeping her happy while my husband did the actual shopping and Ava spied something in a clearance bin that made her perk up. It was a Hello Kitty lunch bag. I pulled it out of the bin and told her she could carry it as long as she walked. It worked. She walked around looking at all sorts of things. But she never let that bag go. She was in love. We decided to bring it home.

Now I expected her to use the bag for all kinds of things. As it turns out, only two things ever go in the bag.

Compartment 1: Mama Kitty

Compartment 2: Baby Kitty

Ava carries her kitties in her kitty bag. It's adorable. They are in there and nearby all the time. They go up for nap. She takes the kitties out to sleep with them and then carefully returns them to their compartments and brings them downstairs with her when she wakes up. The bag and kitties travel from room to room with her and then go up for the night where they get to leave the bag to cuddle with her at night. Then back into the bag they go in the morning to come back down. So funny.

Home again.

We spent the night at the hospital with Ava. It was the first night we had spent there since the hospital stay when Ava was born. I would have been all right without having to do that again, but it was necessary. The nurses in the pediatrics ward were just as great as the nurses I'd had in the maternity ward.

I was worried we'd have another night as bad as the first and need another breathing treatment, but the oral steroids finally kicked in and the stridor improved through the night. We all got a decent night sleep all things considered. The nurse had to wake us every four hours so we could help her check Ava's vitals, but aside from those 10 minute awakenings we all slept through. Any mother of a newborn would think that's a great night's sleep.

And so we're home again. Things aren't quite back to normal, but we're heading there.

Wishes are not always granted.

We did go to our doctor's office. The receptionists listened to Ava strain to breathe in horror for a short period of time before sending us straight to the emergency room where her oxygen level was 91. I thought that sounded pretty good. Just like getting an A- on a test. Apparently not.

We pinned her down while she strained to breathe in enough air for the next scream during her breathing treatment. Then we pinned her down while they gave her a dose of oral steroids. She promptly choked half of that back up. Then they told us they just needed to observe her for two hours before sending us home.

An hour later the stridor was back. That earned us another delightful breathing treatment and an admission to the children's ward. And that's the current update.

How to properly ring in the change of seasons...

In our house, it wouldn't be fall unless we pick up a child from school with a 102.5 degree fever, wheezing, and the croup. Please, oh please let this pass quickly, relatively painlessly, and without a trip to the emergency room. And while I'm wishing, it would be awfully nice to not pass the illness around through all members of the family including the grandparents this time.

The first illness award this year goes to Ava. It is interesting though. The last time Ava was sick, last spring, she couldn't really communicate about it. This time, just as the 4 hour dose of acetaminophen was wearing off she came to me and said, "Mama, my mouth hurts." As pitiful as that was, I was grateful that she finally has the words to tell me.

Speech Sample - Suspected Childhood Apraxia of Speech - 25 months

This is a bit of a therapy session I was doing with Ava on 4-4-11. 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 C1V1C2V2 in syllable shape which is much more complex.

Wilbarger Deep Pressure and Proprioceptive Technique (Brushing Technique)

I have to admit, when our OT first introduced the "brushing technique" to us I thought it seemed a bit questionable. And yet I think it is working wonders.

First, some background. Ava seems to have a fair amount of tactile defensiveness. Prior to beginning occupational therapy she hated tags in her clothes. She never allowed me to fix her hair with barrettes or hair bands. She barely tolerated brushing her hair. For months, brushing her teeth involved pinning her down and brushing them as she screamed. She panicked every time she needed a band-aid. She is an extremely picky eater and her pickiness seems to be related to food texture. She doesn't like to get her hands messy and even as a very young toddler taught herself to use utensils rather than have to touch her food. Art activities were only tolerated when a paint brush or some other tool kept the paint from her hands.

Several weeks ago our occupational therapist gave me a surgical brush and showed me the brushing/deep pressure technique. At first it felt awkward and I was self conscious. Ava was a bit intolerant at first as well. After only a few sessions it became something we both enjoy. I tell her it is time for brushing and she hops right into my lap.

Now, you are supposed to do the technique every 90 minutes to 2 hours all day long. We don't. We do the technique twice a day before nap and before bedtime. I am going to try to incorporate it right after morning dressing as well. However, even with a twice a day schedule I have noticed changes.

Ava now lets me fix her hair. She is more tolerant of a wide variety of clothing situations. She is more adventurous with touching art materials, sticky foods, and muddy or dirty things. She's allowing band-aids without much of a fight. For Ava, the brushing technique has worked wonders.

She's also having a bit of a speech and language and social developmental spurt and I'm not sure that is all coincidence. I think that she's feeling more comfortable in her own skin and less overstimulated by her environment. That translates into more mental resources left over for communication.

So what is the Wilbarger Deep Pressure and Proprioceptive Technique?

This technique of brushing the skin and joint compressions was developed by Dr. Patricia Wilbarger, an occupational therapist and clinical psychologist with 30 years of experience working with children with sensory processing issues. The technique involves running a soft surgical brush (it reminds me of the brush the hospital uses to clean newborn babies) over the arms and hands, back, and legs and feet of the child with a firm pressure. The brushing is followed by a sequence of gentle joint compressions of the fingers, elbows, shoulders, hips, knees, ankles, and spine. The entire process takes only minutes and is often soothing and enjoyable for both parent and child.

Here is a link to a youtube video of an OT using the brushing technique with a young toddler. The video is pretty different than the way we do it. Our way separates the brushing from the joint compressions and is smoother, slower, and more relaxing.

Instructions for the Wilbarger Deep Pressure and Proprioceptive Technique (brushing technique)

Before I explain how we do the technique I should say that this is just the way that we do it as shown to us by our particular occupational therapist for our child. The technique may vary in other situations. Also, I highly recommend that you only perform this technique after being shown how to do it by a certified occupational therapist (which I am not).

Brushing
Use a soft surgical brush. Use pressure firm enough that the bristles on the brush bend. You may do the technique through clothes. My daughter often seems to be a little hot and sweaty and the technique seems to be easier to administer through clothing. Never brush the tummy or face.

We sing a song as we do the technique. At first I would modify the "This is the way we wash our hands, wash our hands, wash our hands. This is the way we wash our hands so early in the morning." song. The first verse would be, "This is the way we brush our arm, brush our arm, brush our arm. This is the way we brush our arm, brush our arm with Mommy." (and so on for each body part). Now I just sing the numbers 1-10 to the melody of a lullaby. It is soothing and peaceful and helps us keep a calming rhythm during the entire technique.

Sit down with crossed legs and invite your child to sit in your lap. Their back is towards you. Begin on whichever side of the body is most comfortable with you. We begin on the right. With a firm pressure, stroke up and down the full length of each body part in the sequence described from 3-10 times (as many as your child will tolerate) moving smoothly from one section of the body to the next.

1. Right arm and hand. (Both sides.)
2. Back. (Have child lean forward so you have room.)
3. Left arm and hand. (Both sides.)
4. Left leg and foot. (Both sides.)
5. Right leg and foot. (Both sides.)

Joint Compressions
You've now worked your way around the body in a circle with the brushing. Set the brush down and move right into the joint compressions. These are difficult to describe in text, which is why it is so important to have an OT demonstrate the technique for you. I will try.

1. Right elbow. Bend elbow 90 degrees supporting elbow from bottom with left hand and holding the wrist with your right. Gently push elbow down into your left hand 10 times.
2. Right shoulder. Straighten child's arm. Place left hand on top of shoulder still holding wrist with your right hand. Hold arm away from body and push straightened arm towards the shoulder 10 times.
3. Right hand's fingers and thumb. Gently squeeze each finger and thumb between your thumb and finger (one at a time) starting at the base of the finger and sliding towards the tip. Do this once per finger.
4. Left elbow. Same technique as before.
5. Left shoulder. Same technique as before.
6. Left hand's fingers and thumb. Same technique as before.
7. Left hip. Cradle the left hip from the bottom with your left hand. This is kind of like having your child sit on your left hand with the left side of their bottom. With their leg bent bring their leg towards their tummy almost like they are going to hug their legs. Place your right hand on their left knee and press down toward their hip 10 times.
8. Right hip. Same technique as before.
9. Knees and ankles. With the child still in your lap place both feet firmly on the floor with their legs bent at a 90 degree angle. Place your hands on top of their knees and gently press down towards the floor 10 times.
10. Back. Set them down on the floor right in front of you and have them cross their legs and sit up straight. Place one hand on their chest and the other on their back and press gently towards the floor 10 times.

Ava just melts into my arms by the end. It is a really peaceful time where we are completely focused on each other and we both enjoy it. The trick is to find the time in a busy day to work it into your routine.

Speech Sample - Suspected Childhood Apraxia of Speech - 23 months

This is an audio clip from a video we took on 2-12-2011. Ava is 23 months old. 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.

In the last audio sample, four weeks prior to this one, 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/).

Here is the new sample:




In this audio sample Ava's utterances are:
"brown" /baƱ/
"brown" /baƱ/
"black" /bæ/
"brown" /baƱ/
"white" /wæ/
"two" /tu/
"there" /dæ/
""black" /bæ/
"more" /mɔ/
"no, no" /noƱ noƱ/
"yeah" /jæ/
"no, mama" /noƱ mama/
"no" /noƱ/

That's 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. In four weeks, Ava made huge strides in her speech.

Speech Sample - Suspected Childhood Apraxia of Speech - 22 months

This is an audio clip from a video we took on 1-15-2011. Ava is 22 months old. At this point she had been evaluated by early intervention and had begun seeing a private SLP twice a week for 30 minutes. I was not yet working with her in any structured way and we had not begun receiving services from early intervention yet.

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.





As you can see she had made significant progress in a month. In the first video and audio sample Ava was mostly saying "there" over and over. In this audio clip you hear "there"(deh) "no"(oh) "yeah"(eh-uh) and "uh-oh". That's three vowels and one consonant. Still, it is four distinct utterances.

Speech Sample - Suspected Childhood Apraxia of Speech - 21 months

I decided to go back into the family video archive and try to pull some audio files that are representative of Ava's speech at different points in time. I've already posted something recent and a video from November of 2010 when Ava was 21 months old.

Here's something from about three weeks later (12-19-2010). 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.

Keep in mind that she is almost two years old here.

They Called

Our diagnostic evaluation is officially scheduled. December 15. I spoke with the coordinator of the diagnostic team that will be evaluating Ava. They'll be sending someone out to her school the week before her evaluation to observe her and then we are supposed to allocate all morning starting at 9am for the actual evaluation.

I was nervous as soon as the person on the other end of the line identified herself, so my initial impressions probably aren't super accurate, but I didn't get a great vibe. I can't even quite pinpoint why exactly. I just got the feeling somehow that she already didn't think Ava will qualify.

My thoughts scatter in so many different directions when I think about the evaluation and they're all contradictory. First, I feel I'm embarrassed because I might be wasting their time - Ava probably isn't severe enough any more to continue to qualify for services. The next moment, I'm scared that I'll get that same terrible feeling I've gotten after her initial evaluation and after her formal articulation test. The one that sinks down to the pit of my stomach when I realize how far behind her peers she still is. I worry that she'll do too well and then I feel guilty that I can possibly want her to do poorly. What kind of thought is that for a mother?

I need to just relax. The evaluation is almost three months away. It doesn't do anyone any good to spend those three months obsessing over what may or may not happen. And ultimately, whatever happens, it will be fine. Everything will work out.

It is so easy to dispense such advice, even in my own mind. Now to just follow that good advice...

Wishing for Another Year (Upcoming Evaluation Anxiety)

In quiet moments I am beginning to experience a sense of unease about upcoming changes. In five and a half months Ava will age out of early intervention. Before then she will be evaluated by our local school district to determine if she will continue to qualify for services.

Things are going so well right now. Ava has been making steady progress in speech. We finally identified a need for OT and are just now beginning to receive those services as well. The combination of speech and occupational therapy services is powerful and she is making progress.

I am both profoundly grateful for that progress and somewhat fearful of it at the same time. I am happy that Ava's ability to communicate is improving and her frustration is decreasing. I am happy that she's making progress towards her feeding goals. I am delighted to see her become a bit bolder with sensory exploration and a little less overwhelmed in environments that used to be overstimulating for her. At the same time, I am afraid that she will have made just enough progress that she will not qualify for services at the next level.

I feel like we are standing before a diverging path. One path takes us down a road where we can continue intense intervention through these early years and maybe, just maybe find ourselves in a place where she no longer needs extra help later on. I desperately want that path for her.

The other path involves being denied services. We will try to provide her with as many services as possible without help from the school district but it won't be the same. I worry that the second path will involve less intense intervention that results ultimately in her needing extra help for a much longer period of time.

I know it isn't that simple. I know there are always options even if they aren't the ones I want most. I just feel like this transition from the early intervention program happens so quickly. Many children are just settling into a program of services when they "age out" and have to go through another round of testing. Then, even if they do qualify, they go through another round of getting to know new therapists when the old ones were working perfectly well to begin with.

I find myself wishing that early intervention went just a year longer. Of course, I'm sure I'd still dread the transition even then, but at least she would have had the same set of therapists for 18 months rather than for 6 months by then.

Speedy Progress Right Off a Cliff

So Ava continues to do well with her feeding hierarchy. She's pretty much just accepted that she has to take a bite of the food she doesn't like in order to receive more of the food she wants.

Her technique so far has been to pop that food in her mouth and let it sit front and center on her tongue as if I had put something horrendously nasty in there. She grabs her milk and swallows it down as if it were a pill-tasting it as little as possible. In the name of substantial progress, I was letting the fact that she was treating perfectly yummy food like dirt go.

Well, yesterday morning, in the middle of our weekly OT session I had set her plate up with small pieces of sausage. They were the size of large blueberries. A bowl of cheerios to use as a reward had been set to the side. She asked for cheerios. I told her she'd need to eat a small bite of sausage first and I stepped away from the table to grab a knife. Usually I cut a tiny sliver off the larger piece of sausage for her to try.

Well, when my back was turned she popped the entire piece of sausage in her mouth and tried to swallow it whole by gulping several large gulps of milk. I turned around to see her choking back up all the milk and finally (thankfully) the piece of sausage too right back into her lap.

I calmed her down, cleaned her up, and told her I was proud of her for trying such a big piece. I then tried to explain that we can't swallow such big pieces without chewing them first. I'm pretty sure she didn't really get it.

So now we're working on teaching her to put food in the side of her mouth and to chew it up in an exaggerated way. We're teaching the technique with foods she likes first. Once she's really good at it, I'll have to insist she actually chew the things she doesn't like before swallowing them and getting a reward.

I'm pretty sure that this next step forward is going to be a big struggle.

Nine Months Ago

After listening to Ava sing the Itsy Bitsy Butterfly, I found myself trying hard to remember what she was like before.

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

At 21 months of age, you want most typically developing children to have a spoken vocabulary of at least 10-24 words. By 24 months of age you want to see 50 spoken words and some two-word combinations. You also expect those words to contain almost all vowel sounds and a wide variety of consonants. You would expect a typical history of cooing, laughing, smiling, and babbling as an infant.

Ava did not have a typical history of cooing, laughing, smiling, and babbling as an infant. At 21 months she used no more than 4 different vowel sounds and 3-4 consonant sounds. Her spoken vocabulary at that time is well represented in this video I took one day (11-30-2010 to be exact) while we were reading a story before bed. She had about three words: "de" (that or there), "uh" (used in a variety of ways for emphasis), and "oh no".

I remember taking this video. It was after I had finally accepted that there was a problem and I needed to pursue getting Ava evaluated. I took the video thinking it might be helpful to show it to someone because I knew she often wouldn't "talk" at all in front of strangers. As it turned out, I never used the video for that purpose, but I wanted to share it now. It is a good representation of what Ava's expressive language looked like before we started intervention.

Therapy and Hierarchies of Difficulty

In general, therapy consists of breaking complicated tasks down into a hierarchy of components and then working on those components from easiest to hardest. So in speech therapy we start with sounds in isolation, then at the syllable level, then at the beginning, middle, and ends of words, then in phrases, then in sentences, and finally in conversation.

In OT we've been working on getting Ava to try new foods. Prior to OT, the only options I could think of were to try to make her try a bite (ha, ha) or to just put it on her plate and hope that eventually she'd try it if she were hungry enough and if everyone else around her was trying it. Well, nothing was working. She was never hungry enough to try something out of her comfort zone. She didn't respond to playing (let's play airplane type activities). She didn't respond to comments that her brother was doing a good job trying it. She didn't even respond to bribery (eat just a little and I'll give you a treat).

Our OT introduced a hierarchy for getting Ava to try new foods. I never would have thought of it on my own, but it is working.

The lowest level is just getting her to touch the food. I used tricks like asking her to test if it is too hot for me while pretending to be busy pouring a drink so I couldn't do it myself. I wasn't asking her to eat it yet - just to touch it.

The next step was to get her to just give it a kiss. She didn't have to eat it, just kiss it. Now this required a combination with bribery. We needed to fill her plate with something she didn't like and something she did like. She didn't get more of the food she did like until she gave the other food a kiss. This step took a little longer, but eventually she realized that giving food a kiss was not a big deal.

The next step was to give the food a little lick (if it is solid - this would't work with a pudding or anything like that). So when she wouldn't eat sausage, I could put a piece on a fork and she'd lick it. Again, we have to bribe her to do it for a second serving of something she likes.

The next step is to eat some of the new food. Sometimes we cut it into a very, very tiny taste and put it on a fork for her. She'll put it in her mouth and wash it down with a big gulp of milk. She doesn't actually chew it, but still it is a big step in the right direction.

Other times we use a food mill. You can put food in it and the children can help grind it up by turning the handle. We tell them they're making "magic" food. Then she can try a small taste of the magic food before she gets to eat something else.

A month ago Ava would absolutely refuse to touch or even consider trying anything outside her comfort zone. She honestly preferred to go hungry. She rarely ate more than 1 out of 3 things on her plate. A month ago our OT introduced the hierarchy (touch, kiss, lick, tiny taste, regular bite...) to us. Now I can get Ava to at least taste a tiny amount of a new food at least 80% of the time. It is a huge change and I'm so proud of her. It's amazing what a little knowledge and some new strategies can do for a situation that seemed impossible to change.

Itsy Bitsy Butterfly

I asked Ava to sing to me the other day. We were sitting on the mostly finished deck in our swing. Using the front facing camera on my iPhone I managed to capture quite the concert. 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. (Yea! I finally figured out how to post audio!) She decided to sing the Itsy Bitsy Spider as the Itsy Bitsy Butterfly instead as she explains at the end.

OT and Pudding

Our occupational therapist showed up yesterday morning with a box of pudding. I'm not a huge fan of pudding myself, so I'm pretty sure my children have never made pudding before. They might have been served some at school or at my parent's house. Perhaps they've tried some at a buffet. We've never had any here at home though.

Our goals for the day were to work on feeding (she came at breakfast time) and to continue to work on sensory exploration. While I made breakfast (eggs, sausage, and dry cheerios) the OT made vanilla pudding with the children. The children enjoyed tasting the dry mix, measuring and pouring in the milk, and stirring the pudding. Then we let the pudding set while we ate breakfast.

Ava likes dry cheerios, tolerates a little egg, and traditionally won't touch sausage. That was exactly the mix that the OT requested. First we got Ava to touch the sausage in exchange for some extra cheerios. Then we persuaded her to kiss a piece of sausage in exchange for more cheerios. Finally, we did manage to get her to lick it in exchange for some cheerios. She did not eat any. However, a month ago, I couldn't even get her to touch something she refused to eat so getting her to lick something is significant progress.

After breakfast, our OT wanted the children to fingerpaint with the vanilla pudding on construction paper. We got all set up. Everyone chose their favorite color construction paper (orange for Michael and pink for Ava). Then the OT put a dollop of pudding on each piece of construction paper. Both kids took one look and absolutely refused to touch it.

The OT modeled making a sun on her piece of paper. The kids were still not tempted. She used some cheerios to give her sun a smiley face. Still no takers on the activity. She offered them a paper towel to help keep their hands clean. Nope. Then I remembered a comment from one of my readers about how her son would only play with shaving cream if there was a bowl of water nearby (Thanks Gentle Blue!). I went and got two bowls of water and finally we were able to get started. Michael went first and Ava started tentatively with one finger. We made dots and lines. We tried unsuccessfully to get handprints. Ava washed her finger off in that bowl of water after every single dot or line.

I got Ava to play a game where I would draw something with the pudding and then she'd "erase" it with her finger. She always enjoys that game. I tried to continue the playful atmosphere by dabbing some pudding on the back of her hand. It was a big mistake. She had a meltdown. We had to clean her hands off instantly and she refused to participate or even stay at the table after that. I felt terrible. Instead of the experience ending on a slightly positive or neutral note, I pushed her too far and it ended really negatively. Lesson learned I suppose.

It is fascinating to see the variety of rather common household substances (shaving cream, cornstarch and water, instant pudding) that the OT is using in therapy. It's been good. I've been very pleased with how things are going so far.