Saturday, April 30, 2011


I'm going to begin with the basic facts.
A few months before Ava was born we decided to move Michael into the guest bedroom and to give Ava his old room. My dad painted his room a wonderful shade of green and we bought beautiful wall decals to decorate the room. Well, the wall decals didn't go up for months and months, but we finally made the time. I entertained both children while Daddy painstakingly arranged the decals around the room and the room came out beautifully. Note exhibit A: beautifully arranged wall decals.

Last night we noticed a brand new arrangement of wall decals (exhibit B). Michael had borrowed bits and pieces of other arrangements to make a new one of his own. He climbed up on a chair in his room (multiple times I assume) to arrange the stolen elements next to one of the pictures in his room.

Initial reactions.
Parents: Did you do this?!?
Michael: No. (obviously a lie)
Parents: Why did you do that? Mommy and Daddy worked hard to make your room pretty!
Michael: I'm sorry. (looking pitiful and crushed)
Parents: (starting to feel a little guilty) Well, it does look very nice sweetheart, and we can tell you worked hard on it. But Mommy and Daddy worked hard on your stickers and we would like for you to leave them where they are from now on.

At that point we returned to the regularly scheduled bedtime routine and put Michael to bed for the night.

Parental Discussion
Dala: Why is it that our first reaction to creativity and initiative is to crush it? I'm feeling a little guilty.
(can still hear banging from upstairs indicating that Michael is actually awake and playing rather than sleeping)
Daddy: It did look pretty nice didn't it?
Dala: Yeah, and he must have worked hard on it.
Daddy: That's it. I'm going upstairs right now to talk to him about it.

5-10 minute delay

Daddy's report.
Dala: So, how did that go?
Daddy: He obviously felt proud. We went over and I picked him up so we could look at it. We talked about how nice it looked. He was relieved that we liked it.
Dala: You're such a good Daddy.

Your thoughts?
What do you think? Was our initial reaction as out of line as we thought? Would you let your kids intentionally rearrange their room decorations?

Friday, April 29, 2011

The Weekly Review: Week Seven

Blog Post I Agree With Most:

Swistle apparently encountered the same ad on Amazon that I did. She took the time to write a post about it. I looked at it for about half a second, decided that it kind of freaked me out and moved on. Swistle does a nice job of explaining why the picture is so freaky. You wouldn't think a woman in a swimsuit would elicit this kind of reaction.

Sibling Interaction of the Week:

I had my arms around Michael as he sobbed because he had gotten hurt. I hadn't quite figured out what was hurt yet, he hadn't calmed down enough to tell me. I just knew it involved falling from the playset in the basement. Ava ran over and wrapped her arms around him too. The kiss she delivered next was really sweet. (Small scrape on the temple, btw - nothing that won't heal up in a day or two.)

Quote of the Week from Michael:

"The Easter Bunny is so nice!"

Ava's Sweet (annoying?) Habit of the Week:

Every time Ava wakes up she now insists on bringing her baby kitty and water cup downstairs. Sometimes we also need to bring mama kitty and her blanket too. It's adorable, but trying to balance Ava along with all of the extras on the way down the stairs is a bit of a challenge. And then you have to remember to bring them back up. Otherwise, she inevitably realizes they're missing after you've read stories, sung the songs, kissed her head, and turned off her light.

Success of the Week:

Weeks ago I started trying to figure out how to get some money from an old 403B I had from when I was working in the schools (Institution A) rolled over into an IRA (Institution B). Oh my goodness they wanted me to jump through some serious hoops. First, the form was a nightmare and asked for information that was extremely difficult to find. Then, instead of doing the logical thing and sending their stupid form back to them, I first had to send it to Institution B to get their approval. Then, Institution B needed to send the form back to Institution A. Then, if all went well, Institution A would finally send the check to Institution B.

Really, what century is this? Shouldn't I just be able to make a request for an electronic transfer that will be complete in three days? Anyway, I jumped through all their hoops and the transfer is finally complete. Yea! Now, I just need to make sure that Institution A actually closed my account. If not, I'm sure they'll go ahead and charge me their $20 annual fee even though I no longer have any money with them. They're nice like that.

Thursday, April 28, 2011

Illustrated Early Chapter Books

First, I just have to say that I wrote this post twice. The first time I wrote it I walked away without saving (always a mistake, I know) and came back to find the computer had mysteriously rebooted and it was gone. After crying a bit and wallowing in self pity I decided that I liked the post enough to try to recreate it. The second time I wrote it I saved about 30 times - every time a child interrupted me. And without further ado, here is version 2.0.

You start with a baby who looks at the pictures in picture books for about five seconds before wanting to chew on the book. Ideally, you end up with a young child who enjoys listening to chapter books. How do you get from point A to point B? (I'm just talking about listening to books here, not the child reading the books for him or herself.) In my mind I think of the progression as something like this:

  1. Picture Books
  2. Early Readers: These are books with multiple chapters, but each chapter is a separate story. Examples include the Frog and Toad series by Arnold Lobel and the Little Bear series by Elsa Holmelund Minarik.
  3. Illustrated Early Chapter Books: These are books with multiple chapters that tell a single story. They are illustrated on every page.
  4. Early Chapter Books: These are books with multiple chapters that tell a single story. There are usually only one or two illustrations per chapter. An example is the Magic Tree House series by Mary Pope Osborne.

Picture books are plentiful, beautiful, and easy to find and enjoy. Picture books are an interesting genre because they can be very simple and very complex. Some picture books have no words at all, and some are actually written at a fifth or sixth grade reading comprehension level. You can read picture books to children forever. You just need to start simple and gradually get more complex.

Early readers are also pretty easy to find. Step into Reading is a early reader program that goes through four steps in increasing difficulty. I Can Read is also a early reader program that has four levels. The Frog and Toad books are actually I Can Read books Level Two. I highly recommend any of Arnold Lobel's books as great early readers. The thing about early readers is that they are typically a single story or the books are broken into chapters but each chapter tells a different story. In the Frog and Toad books, for example, all the stories are about the same two characters, but the stories can be read in any order.

There are many early chapter book series. Magic Tree House is one of the most popular. These books are longer, often around ten chapters long. They are also much more sparsely illustrated than picture books or early readers. There are usually only one or two illustrations per chapter. It is a big jump, particularly if you are trying to transition to chapter books with a preschooler, from early readers to early chapter books. They just still need the pictures.

That's why I started looking for illustrated early chapter books. They were much harder to find than I expected. (There are a few, like the Magic School Bus series, that I'm not discussing here because they are just deal with topics that are not right for a preschooler. I need something that works for a preschooler, not just a grade school aged child.) Here are five series I found that are illustrated early chapter book series that would be interesting to a preschooler.

  1. Mr. Putter and Tabby by Cynthia Rylant: This series is about an elderly gentleman named Mr. Putter and his cat Tabby. They have many adventures, often with their neighbor Mrs. Teaberry and her dog Zeke. The adventures are often simple, but the stories are sweet, the relationships are genuine, and the mishaps of the characters make Michael laugh out loud. They paint a porch, fly a (model) airplane, go on a train ride, bake a cake, in addition to many other activities. We've read almost all of these books and have enjoyed every one. There are three or four chapters in each book and each page has a full color illustration. These books are a great transition from early readers to early chapter books.
  2. Cowgirl Kate and Cocoa by Erica Silverman: This series is about a young cowgirl on a working cattle ranch and her talking horse Cocoa. The books are beautifully illustrated on each page and the stories are accessible for a preschooler. These books are also usually four chapters long. I thought that the cowgirl and ranch theme might turn him off, but Michael enjoyed these and looked forward to the next one.
  3. Henry and Mudge by Cynthia Rylant: This is another series by Cynthia Rylant. This one is about a boy and his really big dog named Mudge. Again, the pair have really simple adventures. One story is about a mud puddle, another is about camping, a third is about catching a cold. Somehow, even though the main character is a boy, Michael likes the Mr. Putter and Tabby series more, but this one is still a great illustrated chapter book series. These books are also usually three or four chapters each and are illustrated on every page.
  4. Mercy Watson by Kate DiCamillo: These are books about a pig and her misadventures. The books are beautifully illustrated and extremely well reviewed. These books are longer, around 8-10 chapters each. We read a couple of these and then abandoned the series. I think that the jump in length was a little too hard and the content was just a little too old. It's close though, and fits the criteria of an illustrated early chapter book so I wanted to mention it just in case it works for you. We'll revisit them in a few months.
  5. Flat Stanley by Jeff Brown: This series is about a young boy who became flat (only one inch thick) when a bulletin board fell on him. He has a series of adventures and solves mysteries as only he can, because he is flat. This series is a little higher level for two reasons. The books are longer, around 9-11 chapters each. The illustrations are not on every single page, and the illustrations are black and white line drawings rather than full color illustrations. We have only read two of these so far, but Michael seems to like them and the stories are able to appeal to him as a preschooler so I'm including the series in this list. Definitely try the other ones first though. They are more appropriate.

That's it. That's all I could find. If you know of any other series that meet my criteria of an illustrated early chapter book series that would appeal to preschoolers, please let me know. I'd absolutely love to find more. Otherwise, enjoy the ones I have found. I hope you like them. Let me know if you read them.

Wednesday, April 27, 2011

Free iPhone/iPad apps

If you search in the app store, you will find 24 programs that are flash card style programs. All of them are free in April in honor of Autism Awareness Month. That gives you a few more days to check them out if you are interested. I haven't tried them all yet, but there are three main kinds: flash cards, receptive identification, and problem solving. The pictures are very nice and you might be able to use the flash card programs to try to get your little ones to say some words. Michael enjoyed the one problem solving program I let him try, so if you have older children the more advanced programs might be nice too.

Our Favorite Television Shows

I'm going to start this discussion with a slight tangent. Some time ago I read a study about trying to reduce sibling rivalry. Now, I don't have the study in front of me, so I might not get all of the details right, but this was the main idea. In the study they had a control group and an intervention group. The intervention group read stories about siblings who were fighting and then resolved their problems. The authors of the studies expected that the group that read and discussed the stories would show reductions in sibling rivalry behaviors compared to the control group. In fact, they found the opposite. The children who read the stories got worse. They fought more and engaged in a wider variety of undesirable behaviors. It turned out that they were learning new ways to fight from the books. It didn't matter that the stories in the books ended happily. What was important was the fact that the books featured fighting to begin with. The lesson I took away from this was that I wanted to avoid books and television programs that featured conflicts. I didn't want to teach them anything negative they didn't already know.

So, when I'm choosing shows for my kids to watch I'm looking for shows that are high in cooperation and being nice and low on any kind of conflict scale. I also like shows that have a slower tempo and haven't been jazzed up too much.

Current Household Favorite: Handy Manny
Right now the children love Handy Manny. We don't actually get the Disney Channel, so we watch the episodes available on DVD. It doesn't seem to matter how many times they've seen them, they want to watch more. Handy Manny is a repairman and his tools. Each episode features something that needs to be fixed or assembled and Manny works with his tools as a team to "get the job done". There are a few extremely mild conflicts (the two screwdrivers are a bit competitive with each other, the wrench tends to be scared of things, and the neighbor Mr. Lopart often refuses help when he needs it), but nothing major. Overall I like how the show teaches teamwork and always features Manny and his tools helping someone.

Second Place: Wonder Pets
Wonder Pets was the first show I introduced the kids to. The episodes are about a team of pets (Linny the Guinea Pig, Tuck the Turtle, and Ming-Ming the Duck) who help animals in trouble. The theme of this show is also teamwork. The music is wonderful in this program. Again, the conflict in this show is low. Most episodes have none at all. Occasionally the animals in trouble are in trouble because they're arguing (two seal siblings fight over a fish treat for example). Occasionally Ming-Ming and Tuck argue. These things happen in a minority of the episodes though, and even when there is a conflict it is usually mild. Great show. I cannot recommend it enough. It plays on Nick Jr. I believe and is also available on DVD.

Third Place: Curious George
Curious George plays on PBS and is about Curious George the monkey. The episodes are usually about a preschool appropriate science, math, or engineering concepts (examples: measuring, tadpoles, shadows, balance). The episodes are entertaining. My only objection is that George is often unintentionally "naughty" and doesn't usually deal with the same consequences for those behaviors that the typical child might get if they were "naughty". That's a mild objection though and overall I think the program and its content is wonderful.

Honorable Mentions: Blues Clues and Special Agent Oso

Blues Clues is a Nickelodeon program featuring a dog named Blue and her caretaker. The show is a bit difficult to describe but it is educational in nature and really appealing and engaging at the same time. The only reason it is not higher in the list is because it is never the first, second, or third choice for my kids. I wish it was.

Special Agent Oso is a Disney program about a teddy bear who is a Special Agent. His assignments are to help children with tasks they're having difficulty with (playing hide and seek, making a card, sorting recyclable items). The task is always broken down into three simple steps. I like this show, but since we don't get this channel we've only watched a few episodes on the computer. As far as I know it is not available on DVD. This show is also a bit faster paced than I would like, but only a little.

Do you guys let your little ones watch television? If so, what programs do you like?

Tuesday, April 26, 2011

Apraxia Therapy: Gestural Prompts

What are Gestural Prompts?

Gestural prompts (sometimes referred to as hand signals or visual cues) are hand signals made by the adult or child as cues to help the child try to make certain target sounds. Using these prompts or cues paired with specific speech sounds has been very successful at helping children with Childhood Apraxia of Speech learn and use the target sounds. Every professional book I have read about Childhood Apraxia of Speech has a section on this technique. Every Speech-Language Pathologist I know who works with children with Childhood Apraxia of Speech uses gestural prompts.

How do I use Gestural Prompts?

Using gestural prompts is a straightforward technique. Make sure your child is watching you (otherwise they will not see the prompt). Use the signal as you make the sound. If you are trying to cue a sound in a word, make the hand signal when you say the target sound. So if you are cueing a /p/ at the end of a word, make the /p/ prompt when you say the /p/ at the end of the word.

For example, let's say you're working on the /t/ sound. The gestural prompt for /t/ is tapping your index finger on your upper lip right under your nose. If your child says "ha" instead of "hat", ask him/her to look at you. Then repeat the word "hat" and make the /t/ gestural prompt as you emphasize the /t/ sound at the end of the word. You can also use the cue to emphasize a sound in the middle of a word. Let's say your child leaves the middle /p/ out of the word "puppy." You can pair the gestural prompt for /p/ (close your fist and then pop it open) paired with emphasizing the /p/ sound in the middle of the word "puppy".

Why do Gestural Prompts work?

Children with Childhood Apraxia of Speech respond well to being cued in multiple ways. Emphasizing the /t/ sound is an auditory cue. Using the /t/ gestural prompt is a visual cue. If they mimic the gestural prompt, it is also a movement or tactile cue as well. It grabs their attention and stimulates multiple pathways in the brain at the same time. This is what makes the technique so effective.

What are some common Gestural Prompts?

These are some commonly used gestures. You can use a different hand signal, it just needs to be consistent.

  • T - tap the index finger on the upper lip right under the nose
  • D - tap the index finger on the lower lip above the middle of the chin
  • P - close your fist and pop it open (into a "5" position)
  • B - use the ASL sign for /b/ and tap the hand gently against the side of your chin
  • M - gently pretend to pinch both lips closed together with your index finger and thumb
  • N - push index finger against one side of your nose as if you're trying to close one nostril
  • SH - finger across your lips like you're shushing a child

There are more. You can find a hand signal (or make one up) for any sound you might be working on. Here is a link to a great video of a woman demonstrating a hand signal for almost every sound. Some of her signals are different from what I described above and that’s fine. You can use any signal you’re comfortable with as long as that symbol is consistent. Also, don't feel like you need to learn all of these at once. Pick one or two to start with and if that goes well you can always learn more. Be sure to choose a sound that your child is currently working on and check with your SLP. She or he may already be using a hand signal for that sound. You would want to use the same gestural prompt in order to be consistent.

Other than tapping, this is one of the techniques I find to be most effective.

Note: You may have found this web page searching for information on PROMPT (Prompts for Restructuring Oral Muscular Phonetic Targets) therapy. PROMPT is a formal therapy technique conducted by PROMPT certified Speech-Language Pathologists that uses tactile cues (the therapist places his/her hands on the child in specific ways to try to stimulate sound production). If you're looking for more information on PROMPT, start here.

You might also be interested in the following articles:

Ava's Speech - What next?

Ava's speech continues to improve in subtle ways. She's talking all the time. Her sentences are often multi-word sentences. She's a full conversational partner in the household. She listens to the conversations around her and tries to participate. She initiates new conversations. She is trying to sing songs. Slowly she's starting to use consonants in the middle of words and put some on the ends of words. Her vowels are usually correct now. The consonants that are missing are still missing, but they are consonants you wouldn't necessarily expect a young two year old to be using like /f, v, k, g, r, l, ch, J, s/. She still has difficulty with more complex syllable structures like C1V1C2V2, but those would be difficult for many typically developing early two year old children too.

She looks so different from the child who less than four months ago had only three "words", very few sounds, couldn't imitate, and scored at the 4 month old level on the early intervention speech and language assessment. She had so many of the items on the checklist for early red flags for Childhood Apraxia of Speech.

Now her therapists are starting to hint that she's looking more and more age appropriate. They're starting to say that the remaining issues she has look more like articulation or phonological issues than apraxic issues. This is exactly why Speech-Language Pathologists are reluctant to diagnose Childhood Apraxia of Speech this early.

If Ava had/has Childhood Apraxia of Speech it is mild. Anyone with moderate or severe CAS would have improved much more slowly. She's in an odd place. She's outgrown many of those "early red flag" signs (although her history of those red flags will never change). She's not quite old enough for the classic signs of Childhood Apraxia of Speech to show up yet.

We're in an odd limbo place. She's made great strides that have brought her to a place that is almost age appropriate. You could argue that we could stop therapy or go to therapy fewer times a week. After all, I am a speech therapist and I'm working with her at home too. I'm also able to monitor her for signs of backsliding. However, it took therapy multiple times a week over several months (and possibly multiple kinds of supplements) to achieve those improvements. I don't want to stop too early. She wasn't making any improvements before the therapy (and supplements).

I'm just not sure what to do. Continue therapy for now? Reduce therapy and see if she's still improving or at least maintaining her skills? Stop therapy for a while and wait to see if she falls behind again?

What do you guys think?

Monday, April 25, 2011

Easter 2011

We had a wonderful Easter. I hope you had a great day too.

The morning began with the children discovering their Easter baskets. They enjoyed the candy and small toys included in their baskets. I had found some small pinwheels and included one in each basket. I didn't really think about it at the time, but they are a great oral motor activity. Ava had a lot of trouble getting her pinwheel to spin, but didn't give up. Of course there's always that one item that is more popular than all the rest. The kids loved the M&M filled gumball machines. They were the first things the children spotted and it was hard to get them to put the gumball machines down long enough to even look at the Easter baskets.

Mid-morning my parents arrived and the entire family participated in dyeing and decorating Easter eggs. Everyone had fun. We began by dyeing them and just as Michael was getting bored with the activity the first set were dry. He loved decorating them. We used the stickers in the egg dying kit and when those ran out I pulled out some art materials and glue and we used those too.

A couple eggs were cracked and therefore the children got to try hard-boiled eggs for the first time. I don't like hard-boiled eggs and never make them. So my kids had never tried them. My parents like them though and were able to set a good example. Michael refused to try a bite at first, but he'll do anything for his grandpa and eventually tried some. He eventually took a few bites of the white, but never tried the yolk. Ava finally decided she'd try a bite after feeling left out of all the attention Michael was getting. She spit the bite back out without even chewing it. I think she was startled that it was cold and didn't like the texture at all. I was pretty impressed she took a bite at all and praised her for trying it.

After lunch (breakfast for lunch - yummy) we were invited to a neighbor's house for an Easter egg hunt. The rain forced the hunt inside. This was the first year the children were old enough to really participate in an Easter egg hunt. Michael loved it. His bag was full at the end of the hunt and he thoroughly enjoyed discovering what was inside the eggs. Ava seemed a bit confused by it all, and entertained the adults by refusing to put any egg in her bag that wasn't pink. If she found a egg of any other color she'd toss it to the floor and practically run away. I slipped a purple one in her bag thinking it was close enough, but when she found it the purple one got tossed too. The other children were wonderful and began bringing all their pink finds to her for her bag.

It was a great family day and we all had a wonderful time.

Sunday, April 24, 2011

The Campaign Against the Mama Phase

About a week ago I complained about the over-the-top Mama phase Ava is going through. A very nice commenter, JR Morber, made some well thought out suggestions. She said that they used a combination of strategies to fight a Mama stage with her son. I'm going to summarize her suggestions in list form.

  1. Mama should be a little less effective at meeting the child's needs. Slow down. Make them wait.
  2. Refuse to respond to small requests unless Daddy can do it.
  3. "Pro-daddy praise campaign."
  4. Special Daddy-only activities.
  5. Re-arrange routines so that Daddy is taking the major role in care whenever possible.
  6. Resist stepping in during Daddy-child interactions.

It sounds like a thorough, well thought out plan. And it sounded like a lot of work. At the time I thought that things weren't bad enough to put that much work into trying to fix the problem. I was just hoping that eventually the phase would pass.

Well, things continued to get worse over the next several days. Then one morning Ava pitched a fit just because her Daddy said "hi" to her during a moment that she thinks of as a Mama time (getting her from her room when she wakes up in the morning.) That was it. We immediately adopted JR Morber's plan.

We're about two and a half days into the plan. Essentially, if my husband is home, he takes point with Ava. When she protests we make some excuse about Mama being busy and then I just leave the room so I'm not an audience for any complaints. Daddy has been making extra efforts to (although he's always good) be funny, nice, and entertaining. Daddy has dressed her, put her down for nap and bed, put her into the carseat and taken her back out, played with her during play times, helped her at the dinner table, etc. It's working beautifully. We're already seeing a big change and it is wonderful.

Thank you, thank you, thank you to JR Morber if you're reading this.

We'll keep this up for several more days and then hope that the good will towards Daddy lasts when we go back to taking turns with the children.

Saturday, April 23, 2011

Apraxia Therapy: Communication Boards

Young children with Childhood Apraxia of Speech are often very frustrated, have very few words, and are resorting to gestures to try to get what they want. Often those gestures are not effective and their frustration just continues to increase. They can begin to give up trying to communicate. You want to give them some success at communicating and reduce their frustration. Communication boards are a great way to achieve these goals.

What are Communication Boards?

A communication board for a young child is simply a set of pictures placed in an area accessible to the child. The purpose of the communication board is to allow the child to communicate successfully without needing speech. Communication boards are considered to be a low technology form of augmentative and alternative communication.

Why would I give my child a Communication Board? Don't I want him/her to talk?

Yes, you absolutely want your child to learn to talk. Teaching your child with apraxia to talk is your long term goal. Communication boards can solve several problems in the meantime and get you closer to that goal.
  • Communication boards reduce frustration. When your child can successfully communicate with you they will be less frustrated and happier.
  • Communication boards teach your child about language and communication. If your child has no words, or very few words, they have not had the opportunity to learn how powerful and easy communication can be. Once they get a taste of successfully and easily communicating, they will want to learn more.
  • Communication boards increase vocabulary. Every picture you include on your communication boards is a word you are hoping they will eventually learn.
  • Communication boards encourage speech. Over time, your child may naturally try to vocalize the word as they point to a picture. Research has shown that this often happens. Therefore your communication boards can be a gateway to speech.

How are Communication Boards used?

Place the communication board on the wall in an appropriate area of your home at a height that is easy for your child to see and point to. You want them to actually be able to run over to the wall and touch the picture of the item or activity they want on the board.

For example, let's take snack time. You can't ask your child, "What would you like to have for snack today?" They don't have the words to answer you. So you put a snack time communication board up on the wall in the kitchen. The communication board has pictures of all of your child's favorite drinks and snacks. At snack time, you can now ask them, "What would you like to have for snack today? Go show me." Your child simply walks over to the board, enjoys looking at all the options, and points to what he or she wants.

How do I design and make a Communication Board?

First you need to identify topics your child would want to communicate about. Be creative in thinking about possible topics for communication boards. Possibilities include:
  • Food and drink items posted in the kitchen.
  • Television shows they can choose from posted in the living room near the television.
  • Table activities they can choose from (coloring, painting, puzzles, games, etc.) posted near the kitchen table or a play table if they have one.
  • Favorite toys posted in their play area.
  • Items of clothing, hair accessories, etc. posted in their bedroom.

Now you're ready to plan your communication boards. Write out a list of the specific items you want to include on each board. I would put no more than six to eight pictures per board for a young child. So, for example, on a snack time board you might include milk, juice, animal crackers, grapes, banana, and cheerios. Pick items you actually use in your household. No two communication boards are ever the same because they are customized for your household and your child.

Once you have your list, you can make your board using one of several methods.
  1. You can take pictures of your household items, have the pictures developed, and cut them out and glue them to a backing (construction paper, posterboard, cardstock, even regular printer paper).
  2. You can cut pictures out of magazines and then glue them onto a backing.
  3. You can use a computer program like Microsoft Word and import pictures you've taken digitally or pictures you've found online to make your board and then print it.

Can you give me some examples of Communication Boards?

Here are a couple of communication boards we used in our house. I made both of them on the computer. The kitchen communication board I made with pictures I took of actual items in the house with my camera phone. The television communication board I made with images I found in Google image search.

You might also be interested in the following articles:

Friday, April 22, 2011

The Weekly Review: Week Six

Blog Post I Liked Most:

Linda at All & Sundry took a picture every day for a month. I liked her pictures and I admire the commitment. No matter how hard I try, and even though my phone is always with me (therefore a camera is always handy), I never take as many pictures as I'd like.

Quote of the Week from Michael:

At dinner, my husband asked Michael where he got the toy bird he was playing with. Michael though for a minute obviously searching for a word he could not remember. Then he asked, "What's that place with the big M?" He was trying to remember McDonald's. We went there with some friends, had happy meals, and played in their playplace for almost an hour. It was the first time we'd gone to McDonald's in a long time and so he couldn't remember the name.

Ava's Mini-Fit of the Week:

I was getting Ava from her bedroom in the morning and my husband popped in to say good morning to her on his way to Michael's room. Ava started crying, "No Dada!" and shaking her head so vigorously that she lost her balance and slammed her head against her headboard. Sigh. When will this mommy stage pass? It seems to be rooted in the routines because although she didn't want to go downstairs with Daddy, she was perfectly happy to accept the homemade mini muffins he had made her for breakfast.

Project of the Week:

I'm continuing to work on revising the apraxia reference posts and collecting them in one place once they've been revised. It's taking up most of my spare time and so no new projects have been undertaken. This is where you can find the ones I've finished so far.

Book of the Week:

I don't get to read for pleasure very often these days. Life is simply too busy. However, I did read the newest book in one of my favorite series. Patricia Briggs has never disappointed me and this book is no exception even though it is the sixth in a series. I very much enjoyed River Marked which I read on the Kindle app on my iPhone. I love reading books in electronic form, by the way. I always have a book with me. I can carry many books at a time. Reading in dim light is never a problem. The ebook version is almost always less expensive than the paper version. I've been reading ebooks for well over a decade now. I started on a Palm and have continued ever since.

Thursday, April 21, 2011

Independent Entertainment

My children seem to be entirely dependent on me for their entertainment. "Mama, will you play with me? I'm lonely." Michael will say. Or Ava will demand, "Mama! Pay! (play)" We have a beautiful playset outside with three levels and a slide and some swings. We have a sand table and a box full of balls, chalk, bubbles, jump ropes, bats, and squirt bottles. However, when we're outside all they seem to want is for me to push them on the swings. They haven't learned to climb up into the swing and pump on their own yet. I need to encourage some independence in their play.

Last night after dinner we added two new things to the backyard. They are so simple and yet the children loved them and played with them independently for at least 20 minutes until it was getting dark and time to go in for bath. First we added a disc swing. When I bought it I daydreamed that we'd hang it low and the children would be able to get on it by themselves and swing without me. Well, as it turns out they cannot get on the swing by themselves. Ava cannot hold on even if we put her on and Michael can only hold on for about 30 seconds before falling off although he loves the 30 seconds. It looked like it was going to be a failure until Ava decided that she loved to grab the swing, pull it back and make it go "high!" She'll do it over and over again. Michael wanted to hit it with a bat and watch it swing around and absolutely loved it, but the swing was a little too low to make hitting it with the bat easy.

This gave us the idea to suspend a wiffle ball just at Michael's hitting height. He had a blast "whacking" the ball over and over again. He loved the sound of the bat hitting the ball. He loved watching it fly away from him and giggled every time the string brought it back bumping into him. It was hard to drag him away and he can't wait to try it again.

The two new additions were a complete success. Hopefully the newness won't wear off too quickly.

Wednesday, April 20, 2011

Apraxia Therapy Materials: The Big Book of Exclamations

Book Review: The Big Book of Exclamations

This is a review of The Big Book of Exclamations by Teri K. Peterson with illustrations by Chris McAllister. The author is a Speech Language Pathologist and designed the book as a combination of a tutorial to teach parents how to use a picture book to elicit utterances from their young children and a picture book designed to appeal to young children.

Target audience.

I'd say this book would be most appropriate for children between the ages of 12 months and 3 years of age. There are always exceptions where the book might be appropriate for older children. The book is designed to be used by a parent and child together and to leave the parent with some skills that they can then apply to reading other picture books with their children. The book is particularly useful for "late talkers" and children with Childhood Apraxia of Speech becuase it is designed to teach short phrases to children and provide many opportunites to practice those phrases in a fun context.

How to use The Big Book of Exclamations

This book is meant to be "read" with your child. I put the word "read" in quotes because the book is not a storybook with a typical story. It is designed to be interactive. It is designed to teach you how to use a picture book to prompt speech, and lots of it, from your child. The Big Book of Exclamations teaches you to interact with a child and a book the same way I was taught to do it as a Speech-Language Pathologist during a therapy session.

You can then apply the same concepts to any other picture books you are reading with your child. The idea is to spend five or ten minutes (or even longer) on each two-page spread. You don't need to read the entire book in one sitting. The activity is about the two of you enjoying the book, pictures, and conversation. It is about your child having fun talking about the book. Literally - talking about the book! How often does your child get to do that?

You can easily adjust the difficulty level up or down just by modifying what you say from two words at a time to one word at a time. Or, if your child can't say "bottle", change it to "ba ba." You want to model the exclamations yourself and then pause to let your child participate too. Encourage their participation. Enjoy it. Play with the exclamations and the pictures. Laugh at the silly things they see in the pictures and the silly things your child gets to say. Have fun telling the dog, No, no!" over and over again.

What is inside the Big Book of Exclamations?

This book is dense. Each two-page spread if full of tons of things to talk to your child about. The pictures and concepts covered in the book are perfect for an emergent talker. The illustrations are complex and beautifully done. You can see a sample page at the book's website. The book begins with two two-page spreads on how to use the book. The true beauty of the book emerges in the following six two-page spreads.

  • Wake Up! Good Morning!
    This scene has a mommy and daddy entering a nursery with a toddler aged boy and toddler aged girl to wake them up in the morning. There’s a pet dog and cat in the scene along with lots of nursery toys including cars, blocks, planes, and farm animals. The pictures have captions in key areas prompting you (the parent) to use key words like, “Hi, baby”, “beep, beep”, “uh-oh,” and “no no”.
  • Eat! Eat!
    This scene is of the family getting ready for breakfast. You have the mama, daddy, children and pets again and now you add a grandma. Again, there is lots going on here. You have all the items typically present in a kitchen, some playground equipment out a window, fruit on the counter, and much more. Captions include, “hot, hot”, “all done”, please”, and “dirty”.
  • Ready to Go!
    This scene shows the family in the foyer getting ready to go out. All of the previously introduced family members are present and now we add grandpa. In addition to the typical things you’d see in such a scene like a door, stroller, stairway, side table, phone, pictures in frames you have lots of action. Captions include, “bye, bye”, “wait, wait”, Dada help”, and “run, run”.
  • The Park!
    This scene shows the entire family at the playground. You have a slide, swing, bubbles, people playing ball and Frisbee, and even a birthday party going on in the background. Captions include, “swing, swing”, “up up up”, “pop pop pop”, and “weeeeee”.
  • Bath Time! Wash! Wash!
    This scene shows the mama and daddy giving the children a bubble bath. It’s a great bathroom scene. Captions include, “oh, oh, duckie”, “owie, “no bite”, “pop”, and “sh- sh- shhh”.
  • Bedtime – Goodnight
    This scene shows the entire extended family again in the nursery getting the children ready for bed. You’ve got a bedtime story, dim lights and the moon shining in through the window. Captions include, “shhhh- papa stay”, “stop”, “look, my book”, and “ni ni dada”.
  • The final page is a picture of the family waving good-bye to the readers and the page opposite is full of captions about being all done and wanting to read again.

At the end of the book the author includes two additional two-page informational spreads. The first is about typical language development and the second is about what to do if you have concerns about your child's speech development.

Our experience using The Big Book of Exclamations

We used this book with Ava when she was just starting to verbalize. When we got the book she wasn't even imitating reliably. She was engaged as soon as I pulled out the book and we spent several minutes just talking about the cover. The book worked exactly as intended. We spent half an hour or so on the first three two-page spreads. She did get antsy after the first couple. It is not like a storybook that holds their attention because they like the story itself. It is more of an interactive activity. I would plan on using the book for no more than 15-20 minutes at a time. It would certainly be worth it even if you were only using it 5-10 minutes at a time. Pick it up, talk about a couple of pages and then put it away and save the next set of pages for another day.

Even though the book is a bit expensive at $20, I feel the price is worth it for the experience. You can get hours of entertaining speech practice out of this book if used properly.

I do have one small criticism though. This book is designed to be read with a very young child cuddled in your lap engaging with the book. Yet it is a hardback book with paper pages and is rather large and unwieldy. Also, some of the illustrations disappear into the binding. I found it a little difficult and uncomfortable to hold when reading it with Ava. I wish the book were available in a ¾-size board book form. I would actually pay $5 or $10 additional dollars to get the book in that format and consider it an investment.

This book was not available through my local library system. I’ll admit that I did not check out local bookstores. Amazon does however, carry the book and so you can find it there for sure if you are interested. I believe the book can also be purchased through the book's website.

Bottom line: Highly recommended.

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I'm sad you yelled at me.

Michael is a really sensitive child. He gets really upset when he feels he's being fussed at or criticized. When I lose my patience and yell unfairly, I try to apologize and give him a hug. As I'm hugging him and apologizing to him I can feel the tension drain from his body and it is clear from his behavior that he is able to move on much better than when I don't apologize and hug him.

Now, I never really raise my voice significantly, but I do let my children know via tone of voice when I am frustrated with their behavior. Due to the nature of a toddler and preschooler sharing the same space, I find myself fussing several times a day. Typical conflicts usually involve sharing or following directions in a semi-timely manner.

Lately, Michael has taken to responding to every correction by saying, "Mommy, I'm sad that you yelled at me." accompanied by a really pitiful face. He's obviously fishing for an apology every single time he's being corrected. I'm torn as to how to handle the situation. I usually say something to the effect of, "Yes, Mama did probably fuss louder than she needed to, but I was frustrated that you ______" (fill in the blank with the current misbehavior of the moment).

I'm not happy with that response though. Am I really trying to teach him that it's all right to yell when you're frustrated? Nope. Perhaps a better response would be, "Sometimes mommies fuss when their children aren't listening. Next time, you can share with your sister and Mama won't need to fuss." I should still apologize when I cross the line and fuss out of frustration rather than a desire to correct misbehavior, but when the fussing is appropriate I should just say so?

Any thoughts? How do you other parents of little ones handle similar situations? How do you think I should respond?

Thanks for the Positive Reinforcement

I've gotten a couple of nice emails this week and a few thoughtful comments. I wanted to take a moment to say thank you to all of the readers that take the time to say something. I really enjoy hearing from you. I read every email and comment and make the time to reply. It encourages me to keep working on this website and lets me know that people are out there who enjoy reading the posts and find useful information here. So, thank you!

Tuesday, April 19, 2011

Favorite Children's Picture Books

I love reading with my children and I love children's books. I loved them as a child. I loved them as a teacher and Speech-Language Pathologist. And I love them as a parent. I will read to my children whenever they ask. At minimum we read before nap and bedtime. I wanted to share a couple of my favorite children's series and authors with you.

Iza Trapani

Iza Trapani takes classic nursery rhymes and adds extra verses to make the rhyme into a story. The Itsy Bitsy Spider tries to climb several things in addition to the water spout before finally succeeding in spinning her web. A family of bears is taking a boat trip down the river in Row, Row, Row Your Boat. In How Much is that Doggie in the Window a boy tries to earn the money to buy himself the dog he admires in the pet store window. In I'm a Little Teapot the teapot takes some children on an imaginary journey around the world. These are just a few of Iza Trapani's books. Her books are often available in both board book and paperback. I personally prefer the size and durability of the board books for reading with a young child in my lap. These books have a lot of longevity too. I've been reading them to Michael since he was a baby. When he was a baby he just liked the songs. When he was a toddler he still enjoyed the songs and he also loved the pictures and paid some attention to the stories. Now, approaching 3 1/2, he's noticing all of the details (and there are many) in the pictures and loves the extra verses in the stories. The books have grown with him. It's hard to choose, but these are our favorites:

Karma Wilson

Karma Wilson has written a lot of children's books, but we love two series in particular. The first is for younger children and are board books. We've only read two of the series although there are at least four. It is a series about a kitten named Calico. The books have a wonderful rhythm and the adventures of the mischievous kitten really appeal to the kids. The second series is about a bear and his group of forest friends and is a really wonderful series of books. We have all of them and they are great. They are fun to read, the illustrations are wonderful and the stories are sweet. They appeal to both my toddler and my preschooler. I'm going to list both Calico books and our four favorites out of the six Bear books currently available.


I'm going to stop there for now. I'll do more another time. Do any of you have favorite children's picture books you'd like to share?

Monday, April 18, 2011

Better Late than Never

Ava had her second playdate with Sara yesterday morning. Illnesses, a variety of other commitments, and some travel conspired to disrupt every attempt we made at setting up a second playdate. It took us two months, but we finally managed to get together again.

The weather was perfect. It was about 70 degrees and sunny. We spent about an hour playing in the backyard. Sara was shy at first, but then realized that we had fun things like chalk and bubbles and squirt bottles. They played in the sand table, climbed in the playhouse, and went down the slide. The girls are still at an age where they mostly just play in the same space rather than really playing together. They were usually doing the same things though, and it was nice to see the two small bodies side by side playing together.

If we can manage to get together regularly it will look so different a year from now. Michael and his friend are now talking to each other and I can hear sounds of preschool conversation drifting towards me from a bedroom or playroom when they get together. I hope that I will hear that from Ava and Sara in time.

Sunday, April 17, 2011

NutriiVeda and Apraxia: Two Week Update

We've been using NutriiVeda for about two weeks now. I'd say, on average, Ava has been getting about one scoop per day rather than the two scoops that are recommended. I find that she won't finish the yogurt if I mix in more than about 1/2 to 2/3 scoop into the four ounces of yogurt and we have yogurt 1-2 times per day. Since Ava is a pretty picky eater, I haven't found many other opportunities on a daily basis to sneak it in.

So, we've been using a NutriiVeda "dosage" of about one scoop per day with our two year old daughter for about two weeks now. My opinion is that I am seeing a difference in her speech. She is talking a lot more. She talks all the time. She's also trying to sing. She's never really done that before. Before, she would sing a single word if I paused while singing a song, but now she is trying to sing herself. She's trying to follow along with all the words. She has even tried to sing a song entirely by herself once or twice. Another thing Ava is doing that is new is self-correcting. As she was talking to herself, I heard the word "water" which she said as "wa wa." A moment later I heard her pause and correct it to "wa ter." I was amazed. She corrected the word entirely on her own showing that she's listening to her own speech more and can tell when she says a word correctly and when she doesn't.

None of this is proof of course. Perhaps she would have made all this progress without the NutriiVeda. However, until someone conducts a rigorous scientific study, we can't know for sure. All we can do is talk to parents who have tried it and ask them if they feel they saw improvement after starting to use NutriiVeda with their children with Childhood Apraxia of Speech. I'm saying that I think I'm seeing improvement. Use that information as you will.

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Saturday, April 16, 2011

How much contrary is normal?

Ok. I need some reassurance here. How much contrariness is normal for 25 months of age? My firstborn never really went through a huge "No!" and temper tantrum stage, so this is pretty new to me.

Ava seems to refuse to cooperate as her default response lately. Time to get dressed? Nope. It's a struggle. Time to eat something that isn't bread or fruit? Nope, absolute refusal. Time to go outside. Nope, she wants to stay in. Time to play? Nope, she'd rather watch television. These things I can mostly deal with. Mostly.

It's the next level of contrariness that really gets to me. If she accidentally bumps her brother and I ask her to say sorry she absolutely refuses. She runs away from us pouting and whining and would rather spend an incredibly long amount of time in time-out than just say "Sorry." If she's having trouble with something and you attempt to help, she'll throw down the offending item and refuse to play with it any more rather than accept assistance. If she wanted to go first and has to go second she will refuse to continue to participate in the activity. If asked to share something, or give back something she has taken she simply refuses.

And then there's her absolute refusal to let her Daddy do anything for her. If she wants milk I have to get it. If she wants down from her booster seat she'd rather stay in than let her father help her. If she has to go to the bathroom she'd rather wait an hour than let Daddy help. We were walking together tonight and she wouldn't even hold his hand. I do believe it's starting to hurt his feelings. And it isn't that she doesn't like him. She loves seeing him come home. She loves to tickle and wrestle with him. I think it is just another way for her to insist on getting her way rather than ours.

Someone please tell me that this is within normal limits for the age. And if it is normal, how long does this last? And could you possibly share some strategies for dealing with it?

Friday, April 15, 2011

Apraxia Therapy: Two-Word Combinations

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


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


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

Use signs and gestures.

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

Slow it down. Be direct.

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

Break it down.

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

Carrier phrases.

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

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

Practice, practice, practice.

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


Two-word utterances - Apraxia Therapy techniques

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

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

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The Weekly Review: Week Five

Blog Post I Appreciated Most:

You know how you sometimes you like hearing about someone else's misery because it makes you feel like you have some company? Well, Rude Cactus posted about the illnesses his family has experienced over the last month and although he has all of my sympathy, it makes me feel better about the fact that our household hasn't gone longer than a week without someone (or multiple someones) being ill for the past four months.

Apraxia Article of the Week:

This is a nicely done general introduction page about Childhood Apraxia of Speech. Note: It uses the out of date terminology "Developmental Apraxia of Speech" rather than using "Childhood Apraxia of Speech" which is now the preferred terminology.

Sibling Interaction of the Week:

This week Michael has started calling Ava by both her first and middle name. I tend to do that when I'm fussing at the children and it was pretty funny to hear Michael do it when he was fussing at his sister. Soon he started using both names every time he called her. Interestingly, it has apparently taught Ava her middle name. When a friend of mine asked Ava her name, she responded with both.

Quote of the Week from Michael:

Yesterday morning I was in a hurry to get the children out the door and to school so I gently asked Michael if he wanted another mini-muffin hoping to focus him on finishing his breakfast instead of playing. He replied in an annoyed tone of voice I completely recognized as my own, "I'm too busy working on my crane truck and I can't work with a muffin in my mouth!" I ended up letting him finish his crane truck and let him take a muffin in the car.

Ava's Song of the Week:

At the dinner table a couple of nights ago Ava started singing The Isty Bitsy Spider complete with hand motions and with an extra lyric about the moon going down thrown in for good measure. I almost wish I hadn't banned all cell phones from the table at meals because we didn't have a camera handy to catch it on video.

Project of the Week:

This week I'm working on adding a new section to my blog. I'm revising my reference posts and putting them all in one place so they can be accessed easily. It's a big project and I'm just taking it one bit at a time, but I think it will be a great collection of articles when I'm done. Hopefully people will find them to be useful. This is where you can find the ones I've finished so far.

Thursday, April 14, 2011

What makes Childhood Apraxia of Speech different from other speech disorders?

Note: For the purposes of this discussion I am not going to include speech disorders such as fluency disorders (stuttering) and voice disorders (problems with the quality of the voice). I am going to focus on the speech disorders that affect articulation (how the speech sounds are produced).

Types of Speech Disorders

In order to understand what makes Childhood Apraxia of Speech unique, you first have to understand a little bit about the main types of speech disorders.

Articulation Disorder

A child has an articulation disorder when they have difficulty producing a specific sound correctly. Speech language pathologists see a lot of children who have trouble producing the /r/ sound, the /l/ sound, or the /s/ sound for example. The child may have trouble with more than one sound, but the difficulty is with the specific speech sound. They typically have trouble making the sound any time it comes up. So, you wouldn't typically see a child who can make a /s/ when it is at the beginning of the word, but can't when the /s/ is at the end of the word. To put it simply, an articulation disorder is a disorder at the level of specific sounds.

Usually this kind of problem doesn't impact intelligibility (how easily a stranger can understand them) too much and is relatively easy to treat in therapy. The therapist would work on helping the child learn to make the sound correctly first in isolation, and then at the beginning, middle, and ends of words. They would then move up to working on the sound in phrases, sentences,and eventually conversation. Articulation disorders respond well to being treated once or twice a week in small groups of children who are all working on the same sounds.

Phonological Disorder

A child has a phonological disorder when the speech errors they are making fall into patterns. Let me explain. Make a /k, k, k/ sound out loud. Now make a /g, g, g/ sound. Both of those sounds are made in the back of your mouth with the back of your tongue. Now make a /p, p, p/ sound and a /b, b, b/ sound. Both of those sounds are make in the front of the mouth with your lips pressed together. All of the consonant sounds in our language can be categorized by the place in the mouth in which they are produced and by how they are produced. Some sounds are front sounds and some sounds are back sounds. Some sounds are short and quick (/p/, /b/) while some sounds are long and drawn out (/m/, /sh/). Children with a phonological disorder have trouble with whole categories of sounds. They might take all back sounds and produce them in the front of the mouth so that words with /k/ and /g/ are pronounced with /t/ and /d/ instead. Or they might make a pattern of errors that has to do with syllable shape. They might leave off all consonants at the ends of words. In two syllable words they might always leave off the second syllable. You get the idea. A phonological disorder is not about having difficulty with a specific sound. It's a problem consistently demonstrated as a pattern.

To diagnose a phonological disorder a speech-language pathologist is going to analyze patterns of errors. The more patterns a child has difficulty with the harder they will be to understand. This type of disorder can significantly impact a child's intelligibility and is more difficult to remediate than a simple articulation problem. Children with a phonological order will typically be producing a lot of speech and will usually be able to imitate, they will just be difficult to understand. Their errors will be consistent.

When treating a child with a phonological disorder the speech-language pathologist will treat the patterns rather than specific sounds. The way the SLP structures therapy will be different than with a simple articulation problem and that difference is important if you are going to see the most improvement in the shortest amount of time. A phonological disorder is a significant speech disorder that takes a lot of therapy to address. You can address it in a group setting particularly if you group children together who are making errors with the same patterns.

Expressive Language Delay

I'm just going to touch on this briefly because this is another reason that a very young child might not be talking yet. Language is separated into two broad categories: receptive and expressive. Receptive language is how well you understand the language that you hear. Parents usually have a sense of whether their child understands what they're being told. For example, usually you'd expect a young child to follow simple directions like, "Get your baby." Expressive language is how well a child can formulate what they want to say. You might have a child of normal intelligence who understands everything they hear, seems to have a normal set of speech sounds based upon the sounds you hear when they babble or use the few words they do have, and yet is not expressing themselves normally for their age. In this case you would be seeing an expressive language delay.

Childhood Apraxia of Speech

Childhood Apraxia of Speech is distinct from other kinds of speech disorders. It is not a problem with a specific sound, groups of sounds, or patterns of production. Childhood Apraxia of Speech is a neurological motor planning disorder. The child knows what they want to say (therefore not expressive language delay). The speech structures and muscles are physically capable of making the sounds. The problem is in the planning of the muscle movements necessary to make the sounds and the transitions from one sound to the next.

This brings the scope of the problem to a whole different level. Now you aren't just trying to fix the /s/ sound. You're not even trying to teach a child who is moving all their back sounds to the front to make them in the correct place. You have to help a child learn to program all the sounds and sound combinations. This is a huge task because the way the muscles have to move to produce /ba/ is different than the way they have to move to produce /be/. So you can't just work on a generic /b/.

Because the problem is with motor planning, speech is often very difficult to understand and errors are inconsistent. Often children with Childhood Apraxia of speech are using smaller numbers of consonants and vowels than children with other types of speech disorders. They also tend to have better speech production in words and phrases that have become automatic (like uh, oh or bye, bye) than when trying to say something new. This makes sense because they've practiced the automatic phrases over and over so the motor planning for that specific word or phrase has been learned. These kids often have trouble imitating because they are being asked to produce something new on demand and they have trouble with the motor planning of anything new.

When treating a child with Childhood Apraxia of Speech or suspected Childhood Apraxia of Speech research has shown that the best results are obtained when therapy is intensive (several times a week) and individual (one-on-one). This is because the speech-language pathologist needs to get as many productions as possible during therapy and that is much harder in a group setting.

Academic Categories vs. Real Life Diagnoses

When you look at these four types of speech disorders on paper they seem very distinct and separate from each other. In real life, things are messier. Often a child's speech problem is due to a little bit of this and a little bit of that.

Also, with a very young child or an older child who isn't talking yet there just isn't enough speech to analyze. You can look for some red flags that make you suspect one disorder is more likely than another, but you cannot be sure. The speech-language pathologist has to make an educated guess based on all the information and design the most appropriate treatment plan possible.


Today we were getting ready to go outside. It was an amazing spring day. The temperature was about 65 degrees with a light breeze. The sun was shining brightly. When playing in the sun short sleeves felt wonderful. We had just finished putting on shoes and socks and were heading out the door to play when Ava said, “toe” and looked at me expectantly.

I had no idea what she meant. She repeated herself politely once or twice in response to the apparently blank look on my face. When I responded with, “I have no idea what you want sweetheart, can you show me?” she started to get frantic chanting over and over, “Toe! Toe! Toe! Toe! Toe!” It was obvious that she wasn’t going outside until I figured out what she wanted. I felt terrible and as she got more and more frustrated and anxious so did I. Finally, when she started heading for the coat closet I realized that she was asking for her coat.

I wasn’t expecting the request because it was so nice outside so I didn’t have any context to guess until she gave me a clue. In retrospect, “toe” for “coat” makes perfect sense. She leaves off the /t/ at the ends of words and she can’t make a /k/ sound so she used a /t/ at the beginning instead. That turns coat into toe. The whole exchange couldn’t have taken more than 60 seconds, but it was a pretty intense 60 seconds and we were both relieved when we finally figured it out.

Wednesday, April 13, 2011

What is Childhood Apraxia of Speech and How Is It Diagnosed?

What is Childhood Apraxia of Speech (CAS)?

Childhood Apraxia of Speech is a relatively uncommon speech disorder. It is a neurological disorder caused by problems with motor planning and programming of the movements necessary to produce speech. Its cause is unknown.

Children with Childhood Apraxia of Speech do not have a problem with the actual structures and muscles involved in speech production. There is no evidence of weakness in the muscles of the face, jaw, lips, or tongue. Children with CAS also generally do not have problems knowing what they want to say. They can formulate the message in their mind and the muscles are capable of producing speech. The message just doesn't travel from the brain to the mouth properly.

How is Childhood Apraxia of Speech Diagnosed?

A Speech-Language Pathologist (SLP) is the professional who typically diagnoses Childhood Apraxia of Speech. Diagnosis of CAS is complicated because there is a spectrum of characteristics that show up in CAS. Each child will exhibit a different combination of these characteristics. Some of the key characteristics the SLP will look for are:

  • Child makes more errors when attempting to produce longer words or phrases (multi-syllable words or multi-word sentences).
  • Child has abnormal prosody (unusual stress patterns, intonation, volume control, and rate issues).
  • Errors are inconsistent. If the child says the same multi-syllable word three times it will come out differently each time.
  • Child has a reduced number of vowels and demonstrates vowel errors.
  • Child has significant difficulty imitating words and phrases.
  • Child uses predominantly simple syllable shapes (they substitute shorter, simpler words for longer, more complicated ones).

Why am I being told that my child is too young to diagnose? Why will they only diagnose "suspected Childhood Apraxia of Speech"?

Childhood Apraxia of Speech is extremely difficult to diagnose in a young child for many reasons. First, most of the key characteristics described above are too advanced to test in a young child with very little language. Second, it is difficult to tell if the problems a young child is having communicating is due to apraxia or some other speech or language disorder. There are, however, certain red flags for younger children. If these things, or most of these things are present in a young child who is a late talker, it is much more likely that the child will go on to be diagnosed with Childhood Apraxia of Speech when they are older.

  • Reduced or absent babbling as a baby.
  • Extremely limited number of consonants (often only /b, m, p, t, d, h/ or fewer).
  • Use of grunting and pointing as a main mode of communication beyond 18 months of age.
  • Use of a single syllable or word universally. (For us it was “da”. Ava used it for pretty much everything.)
  • Most vocal communication is in vowels only.
  • May see groping or struggle behaviors when attempting more complex sounds or combinations of sounds.
  • Use of a limited number of vowels.
  • Vowel distortions present (the vowel sounds are not “pure”).
  • A word will be used for a short while and then will completely disappear never to be heard again.
  • May see signs of oral apraxia (child has difficulty imitating performing non-speech oral actions like sticking out the tongue, blowing kisses, making "raspberries", etc.).

What happens next?

If you are reading this because you are worried that your late talking toddler might have Childhood Apraxia of Speech I have two recommendations. First, get in touch with a Speech-Language Pathologist or your state's early intervention program (if your child is under 3 years of age). Get an evaluation. Early intervention programs will often evaluate your child for free. At best, you'll find out that you're worried a little to early. Or you might find out you were right. Your child does have a speech delay. But in that case you're ahead of the game. You've found out early and can get your child the right kind of help as early as possible and you will be glad you didn't wait. Second, I recommend the book The Late Talker: What To Do If Your Child Isn't Talking Yet.

If you've been recently told that your child has Childhood Apraxia of Speech or suspected Childhood Apraxia of speech you will be working on setting up a treatment plan with a Speech-Language Pathologist you trust. You will want to be sure that your child is getting enough therapy and the right kind of therapy.

Are there other online resources I can read to learn more about Childhood Apraxia of Speech?

Definitely! If you like this article and would like to read more reference articles I've written they can be found on my Childhood Apraxia of Speech Reference Posts page. To find resources on other websites, check out my Childhood Apraxia of Speech Resource page for some places to start.


I had this game when I was little and I grabbed it during the holidays for the kids. Then I forgot about it in the closet for four months. I pulled it out a few days ago to pass some time on a rainy morning. The children loved it. The funny part is how they play the game. They set the timer but stop the timer from running while they work together to fill in all the pieces. (Sometimes they work together nicely, sometimes lots of mediation from Mama is necessary to keep the peace.) Then they push the start button and run around excitedly shrieking until the timer finally goes off and the pieces pop out. Then they rush back over to the game to start all over again.

Tuesday, April 12, 2011

NutriiVeda for Childhood Apraxia of Speech: Information and Resources

What is NutriiVeda?

NutriiVeda is a powdered beverage being marketed primarily as a meal replacement shake to aid weight loss. You mix the powder into water, milk, or a smoothie. Nutriiveda has a proprietary blend of 7 Ayurvedic botanicals, 22 vitamins and minerals, high quality protein, soluble fiber, and essential amino acids. Each serving contains 153 calories, 3 grams of fiber, 20 grams of protein, 100% of many vitamins and minerals, and only 5 grams of sugar. It is available in chocolate and vanilla.

What does NutriiVeda have to do with Childhood Apraxia of Speech?

In December of 2009, parents of children with Childhood Apraxia of Speech began to try NutriiVeda with their children. Anecdotal reports began to surface of significant improvements in quantity and quality of speech production. The Cherab Foundation, a non-profit foundation trying to help families cope with their children’s communication impairments, began looking into NutriiVeda. They set up a sister site, Pursuit of Research to investigate the effect of taking NutriiVeda on children with communication impairments.

Here are a few web pages that discuss NutriiVeda and Childhood Apraxia.

NutriiVeda for Childhood Apraxia: Review of Initial Product Purchase and First Impressions

I purchased a one month supply (at 2 scoops/day) of NutriiVeda from the Pursuit of Research website. I found it to be cheaper there than on other sites where it was being sold as a weight-loss product. When I read my confirmation email I was surprised to learn that when I made my purchase I had actually signed up for a monthly automatic shipment program. That was not clear to me during the checkout process. However, the number to call and cancel was clearly listed in the confirmation email and their customer service was excellent when I called.

The product was well packaged in an attractive box and arrived promptly. The individual containers are attractive and the product appeared to be in good condition. I’m using the product with my two year old daughter who has suspected Childhood Apraxia of Speech. I found that if I mix about half to 2/3 scoop (vanilla flavor) in with 4 ounces of yogurt, my daughter will eat it with no problem. Depending on how often she eats yogurt in a day she’ll get anywhere from half a scoop of NutriiVeda a day to two scoops per day. We’ve been using the product for about a week. At only one week, I cannot claim that I see clear signs of improvement in her speech that I definitely attribute to use of the NutriiVeda product. However, we haven’t been using it very long. I will update in the future. The product has a nice side benefit of adding a nutritional boost to the diet of a very picky two year old, so in that way it is a win either way.

Two-week Update: About two weeks into using NutriiVeda (average of one scoop daily) I feel like I am seeing definite improvement. We are hearing a lot more talking. She's even attempting to sing. She is listening to her own speech and self-correcting which we had never seen her do before. Could it be coincidence? Of course. Until someone completes a double-blind scientific study we won't have hard evidence. For now all we have is parent report. I'm reporting that I feel like I'm seeing improvements that I wasn't seeing before starting to give her NutriiVeda.

Six-week Update: At about six weeks after starting to supplement Ava with NutriiVeda we are giving her about 1.5 scoops a day on average. I believe that she is speaking much more often, her sentences are longer, and she is trying to string several sentences together to tell a single story. She has also learned a new sound (/f/) and some other new sounds are starting to emerge. She is occasionally putting a consonant at the end of some of her words (the /p/ at the end of "up" for example). All of this is new. As before, there is certainly no proof that these improvements are due to the NutriiVeda and wouldn't be happening anyway, but the coincidence is interesting and I'm not complaining. We will be continuing to use NutriiVeda in our household.

Are there other supplements that might help with Childhood Apraxia of Speech?

There is some evidence that supplementation with Omega-3 fatty acids can be helpful for children with Childhood Apraxia of Speech. You can read my Information and Resources page on Omega-3 fish oil supplementation for Childhood Apraxia of Speech here.
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