Gestural Prompts for Apraxia – Therapy Techniques

Using hand signals (sometimes referred to as gestural prompts or visual cues) paired with specific speech sounds has been very successful at helping children with apraxia learn and use those sounds. Every professional book I have read about apraxia has a section on this technique. Every speech pathologist I’ve been working with uses gestural cues. It has worked exceptionally well with Ava. I’m going to explain the therapy technique, give you a specific example of how we’re using the technique with Ava right now, and then give you descriptions of several of the prompts we’re using right now.

Using hand signals is very simple actually. You just make sure your child is actually watching you, and then use the signal as you say the word. For example, right now we’re trying to get Ava to use the /t/ sound at the ends of words. She’ll say “ha” instead of “hat.” I will repeat the word emphasizing the /t/ sound at the end and at the same time I make the hand signal for /t/ (tapping the index finger on your upper lip right under the nose). The visual cue in addition to the auditory cue really seems to help her focus on that missing sound. Almost all the time now, she’ll then repeat the word adding the missing sound. She often uses the gestural cue herself when she repeats the word correctly. We’re also using the technique in the middle of words. Ava will say “tu uh” for “turtle”. If I use the hand signal for /t/ while emphasizing the /t/ sound that should be in the middle of the word, she will repeat, “tu tuh.” She still can’t make the /r/ or /l/ sound in that word, but she can add the /t/ in the middle.

These are the gestures we are using as our hand signals. You can use a different 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 ok. 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.

Other than tapping, this is the technique that has been the most successful with Ava. I highly recommend it.

Insurance Coverage - So Intimidating

It’s incredibly depressing. I looked up whether speech therapy is covered by our insurance policy. Essentially the answer is not unless your child has speech and then loses it due to head injury or stroke. They don’t cover developmental delays.

My understanding after doing a bit of research is that I can appeal that. I can argue that Ava does not have a developmental delay. A developmental delay implies that if left alone, she’ll eventually catch up on her own. That is definitely not the case. Ava has a neurological speech disorder. She will only catch up if she has intensive, specific types of therapy.

I’ve read that if you make the right kind of appeals with the appropriate insurance diagnostic codes (neurological disorder, lack of muscle coordination problem, etc.) and you have a lot of persistence and luck you can get some insurance coverage. To be honest, I read a little bit about the process, I get discouraged, and I promise myself I’ll look at it again next week. Well, that was three months ago.

This therapy stuff is expensive and it is putting a significant strain on our family’s budget. I’m already having to fight balancing budget needs with Ava’s need for intensive therapy. I think to myself, “Does she really need to see Ms. E twice a week, or would once a week be enough?” The real answer is that she definitely needs twice a week. Three times would be even better. I hate letting money dictate my decisions about what is best for my daughter, but that is a practical reality.

Having some insurance coverage would make a huge difference, but I don’t know where to start. I’m paying two different therapists out of pocket. Neither therapist submits to insurance for you. I don’t even know how to do it myself. I guess I need to find out. I understand that the appeals process can take months, so I suppose I should get started soon.

Nutriiveda for Apraxia?

So I was doing a bit of reading at the CHERAB website. This non-profit organization was founded by Lisa Geng who is one of the authors of The Late Talker book. I came across a page I linked to through their site with glowing anecdotal reviews about a new (to me) nutritional supplement. This site has been collecting testimonials and surveys from parents who have tried Nutriiveda and most have been positive.

I had never heard of it before, so I did a little web searching and discovered that this product is being primarily marketed as a meal replacement / weight loss product. That fact alone initially turned me off. I kept researching though. I came across this testimonial on a personal blog by another mom with a child who has apraxia. I re-read the description of the product and the information on the CHERAB website.

My decision about whether or not to try the product came down to two main points. First, just like with Omega-3 fish oils, there seems to be no downside and the possibility of hope. I hate to not try something that might help. Second, Ava is going through a terrible picky eater stage. She won’t eat any meat other than an occasional chicken nugget or fish stick and any veggie other than a carrot stick with dip. Supplementing her with something that has a great nutritional supplement aspect is appealing. One serving has 3 grams of fiber, 20 grams of protein, 100% of many vitamins and minerals, and only 5 grams of sugar.

So I ordered some. I’ll let you know what I think when I get it, and if and how it works over time.

Songs and Rhymes – Therapy Techniques

Songs and nursery rhymes can be powerful tools for getting little ones with apraxia to verbalize. The singing activates different areas in the brain than those typically used in speech production and that often helps children successfully produce words.

I’ve been singing to my children since before they were born. I love singing. I enjoy it. I happen to like kids’ songs. What can I say? I’m an educator. So I usually sing kids’ songs to my children. I sing nursery rhymes like “Jack and Jill” and “Baa, Baa, Black Sheep.” I sing lullabies like, “Rock-a-Bye Baby,” and “Hush Little Baby.” I sing classic kids songs like, “Sing a Song of Sixpence” and “This Old Man.” We do preschool fingerplays like “The Itsy Bitsy Spider,” and “Twinkle, Twinkle Little Star.” The beautiful things about these songs are that they are predictable. They fascinate children. Rarely do I encounter a child that does not enjoy participating in a performance of kids’ songs. Ava knows almost all of these songs.

For the past few weeks I’ve been using the cloze technique (reading, or in this case singing, the first part of the sentence and then pausing to let the child fill in the next word) when singing songs with Ava and she has been filling in the missing words. So when we do, “Baa, Baa Black Sheep,” she fills in the words I’ve bolded.

Baa, baa, black sheep,

Have you any wool?

Yes sir, yes sir,

Three bags full.

One for the master,

One for the dame,

And one for the little boy
Who lives down the lane.

And so in the 30-45 seconds it takes to sing this little song, she’s produced eight words. If you spend ten minutes singing songs from a nursery rhymes book (as we do every time we have an extended visit to the potty), you can get productions of 70-100 words. And they’re having fun the entire time. They don’t even know it’s therapy. You can incorporate this into reading time before nap and bedtime. You can do it any time really, just for fun. During car rides is another fun time to do this activity.

This activity isn’t about how perfect the production is. Obviously you’re not expecting to get perfect production of such a wide variety of words. It’s about making talking fun. It’s about them getting to participate in a fun verbal activity in a way they can be successful. It’s about just getting them to try. For example, Ava’s “lane” is pretty much just a long /a/ with no /l/ or /n/. But that isn’t the point. The point is the participation, attempts, and fun.

Oral Apraxia

Quick Definition for those who don't know: Oral apraxia is difficulty with the motor planning involved in movements of the face, tongue, jaw that are not involved with speech. Examples include making a kiss, blowing bubbles, and sticking out the tongue.

We had a very interesting therapy session yesterday with our early intervention therapist. I mentioned that I was hoping to try to stimulate the /l/ sound a little because Ava needs to use it regularly in the name of someone close to her. Right now she substitutes the /y/ sound for the /l/. Her therapist suggested that we try to get her to lift her tongue up by holding a lollipop up near her upper lip and getting her to reach her tongue up to lick it. I thought it sounded like a fun activity and Ava rarely gets lollipops so she was going to love the activity.

It was incredibly hard for her. I know that Ava has some oral apraxia. I know she smiled late, blew raspberries late, and made kissing sounds late. I know she has trouble imitating things like sticking out her tongue, blowing bubbles, and biting her lip. I had never seen the struggle so clearly though. She just could not get her tongue to move up at all. She wanted to. She was trying so hard her whole jaw practically quivered. She tried to compensate by using her bottom lip to try to raise the tongue up which didn’t work at all. We finally got some success by bringing the lollipop down to her tongue and then having the tongue follow the lollipop up as we raised it a little.

Michael saw his sister getting a lollipop and wanted some too. We figured letting him do it would be a good model for her. He couldn’t do it either. His attempts looked exactly like hers. It’s fascinating that his speech is pretty good with no real signs of verbal apraxia at this point (even though his early development was worrisome), but he does have oral apraxia. I knew he couldn’t blow bubbles, but since he was talking just fine, I didn’t really examine the issue closer.

I’m not sure what the significance of the oral apraxia is. I haven’t really had a chance to process this new information. I need to think and then research a little. It doesn’t really change anything. Yes, I saw it more clearly today, but it has always been there. Perhaps though, I can use the new insight to find some new strategies for working with her. If nothing else, it very clearly reminds me why it’s almost impossible to teach her a new sound (for example /l/ by lifting the tongue or /f/ by biting the lip) by simply having her watch me do it and asking her to imitate the motion. She can’t. She really just can’t.

This is a striking example of why you can’t treat apraxia like other speech disorders. With an articulation disorder or a phonological disorder the children can watch you and imitate the oral-motor actions. Often, children with apraxia can’t. You need to use alternate strategies.

The Weekly Review: Week Two

Blog Post I Enjoyed Most: I really liked this post on Balancing Everything. I’m a teacher and an SLP so education themed posts always interest me. I’m also fascinated by the idea of homeschooling. I don’t think I could do it, but I admire the people who do it well. This is a post by a mom who homeschools four children. She describes the activities they did during a week of science exploration. She includes great pictures of some of their projects.

Interesting Apraxia Article: Speech and Language Development in Infants and Young Children by Caroline Bowen. This isn’t actually an article about apraxia. It’s an article about speech and language development. You have to know what is typical before you can decide how worried you need to be.

Sibling Moment of the Week You know the kind of awkward hug you give an ex-boyfriend when you encounter them on the street and you aren’t even sure that’s the appropriate way of greeting them? Well, I missed the very beginning of the interaction, but I walked in on Ava and Michael giving each other a very awkward hug. Then they just kind of stood there for a second. So, I said something to the effect of, “Oh, are you guys wrestling? How fun!” They immediately started giggling and kind of pushing against each other. Michael promptly pushed Ava over and fell right on top of her. They both busted out laughing and scrambled back to their feet with Ava pleading, “more, more.” So they go through the awkward hug process again, and again Michael topples Ava right over landing on top of her. Much laughter ensued. This went on several rounds until the game was ended by Michael’s head connecting with Ava’s check hard enough to leave a bruise. So, it didn’t end well but it was still a beautiful five minutes. Those moments when my children are playing with each other (not both playing with me, but truly playing with each other) captivate me. I love watching them bond as siblings.

Michael’s Question: We were reading Mouse Soup at bedtime. Michael knows his letters and a lot of sound correspondences, so I’m doing a little pre-reading skills work during our reading time. For example, I’ll point to each word of the title as I read it. Then I’ll ask, “Which word is mouse?” Then I pointed to the “m” and said mmmm, the “ou” and said ow, and the “s” and said sssss. I just kind of skipped the “e” since I figured that explanation was a bit too complex for now. He never misses anything though and interrupted the beginning of the story to ask, “Mama, why is that E there at the end of mouse?” To be honest, I didn’t quite know how to answer him. I said something about how sometimes “they” add a silent e to the ends of words even though it really doesn’t make much sense. I was so proud that he thought to ask the question though.

Ava’s new favorite word: No. (and not) She loves using it in the typical toddler defiant fashion. She’s also using it in a large percentage of her sentences. She’s obviously exploring the concept and testing it out. So, she’ll say something like, “Ava pink shoes. No mama pink shoes.” Or, she’ll say, “Mama no tickle.” Now imagine a negative attached to most of our conversations and you get the idea.

Birthday of the Week: Happy birthday to my wonderful husband. It was the first year the children could understand and participate in celebrating the birthday of one of their parents. They had a great time blowing up balloons and “helping” me put the letters on the cake. We were getting ready to surprise Daddy when he came home from work, but the kids managed to let the surprise slip before he got around the corner to where he could see the kitchen table. It didn’t matter though. He loved it anyway.

Good Luck

I feel like I’ve won the lottery. I know how astoundingly lucky we are that Ava has been so responsive to therapy (and fish oil supplementation?). I know that some children work just as hard, or harder, for months and see so much less progress. Their parents are right there with them feeling the frustration and fears too.

Three months ago all I knew was Ava had three words: /mo/ for “more”, /uh oh/, and /da?/ for everything else. I knew that she wasn’t even trying to talk anymore and was resorting to more and more gestures. I knew she didn’t even babble other sounds and that she couldn’t imitate. When she was evaluated by early intervention she tested at the 4 month old level. I had two different therapists besides myself tell me that Ava had many of the early red flag signs of apraxia.

I admit it. I panicked. As a speech-language pathologist I knew exactly what that meant. I knew we were dealing with a neurological motor planning speech disorder that can take several years of intensive speech therapy to address. And I so didn’t want that kind of struggle to be part of Ava’s life. I know hardships are a part of life, but she’s my baby and I didn’t want this one for her. I worked my way through the initial denial and then depression. I ended up in a productive place where I researched, planned and set up a therapy schedule for Ava.

I prepared my family for the worst. Severe apraxia seemed like a definite possibility given how behind she was. However, I told them that we wouldn’t know how bad it was until we saw how she responded to therapy. And it turns out, she responds well.

That changes things. The fear that she might still be using single words when she starts school is gone. Now, whether anyone will understand her…? We still have so far to go. By no means is her speech that of a typical two year old. But there’s been progress and that much is a profound relief.

A Baby's Smile

We were at the park enjoying the spring weather. I was letting Michael and Ava climb on some bleachers when I noticed a ten month old baby crawling around in the grass nearby. The baby was adorable. She caught sight of my legs first and I saw her gaze travel upwards towards my face. She looked at me. I smiled at her and she smiled back. It was so natural and easy. It was fun and intrinsically rewarding to connect with a baby through eye contact and smiles.

It reminded me again that my own little ones did not do that when they were infants. Now, I’m not saying that they never looked at my face, or returned a smile. That would be an exaggeration. It just wasn’t as natural and as easy as it was with this stranger’s baby at the park. It’s hard to express, but it is so obvious to me that the connection that most babies make easily and naturally with the people around them did not come naturally for my children.

Even now, I’m having to explicitly teach Michael to look people in the eyes to connect with them. I’m teaching him to look in a person’s eyes when saying thank you or making a request. I think he’s slowly starting to realize how powerful that is.

Part of me reacts to seeing a beautiful baby by wanting another one of my own. But there’s the fear that I would be testing fate one too many times. Michael did not develop language, speech, or social skills typically, but has turned out mostly all right. He’s definitely within the typical range at this point and even ahead in some areas. Ava did not develop speech and language typically, and has what I can safely say at this point is a (thankfully mild) motor speech disorder. She’s making great progress and I am hoping that we can -maybe- catch her up by the time she starts kindergarten.

That’s two for two on atypical development though. Three is just not a gamble I’m willing to take with our lives even though I like smiling at the baby in the park. Besides, I’m not sure my husband and I could handle being outnumbered.

Structured vs. Unstructured Therapy

Ava is changing at the speed of light. Her willfulness seems directly linked to her language ability. As her language abilities increase, so does her desire to have her way. She can express herself better and she wants her commands to be followed. I suppose it could also be those “terrible twos” I’ve heard so much about. Michael never really did the terrible twos – at least not like this. (Is there such a phrase as the “whining threes”? If so, he’s definitely doing that!)

It’s actually more annoying than cute. I’m finding it difficult to get Ava to sit down for structured therapy sessions. She goes into complete refusal mode and bribery with food no longer works. I’m needing to be more indirect and incorporate small moments of therapy into all of our daily activities.

For example, Ava will run over to her communication board and point to the yogurt calling out "yo-yo, "yo-yo, peas". She loves yogurt and wants it for breakfast and for her after nap snack. She can’t produce a /g/ sound. If I ask her to repeat the word with a /g/ in the middle she’ll just say “yo-yo” again. If I ask her to say, “yo-dirt” (because she can make a /d/ and some consonant in the middle is better than none at all) she’ll say “yo-dur”. The entire exchange takes no more than 30 seconds and yet it is a tiny bit of therapy. Then, as she eats the yogurt I find a way to fit that word in several more times. I’ll ask her, “More yogurt?” and make sure she says, “yo-dur” instead of “yo-yo” in response.

I never push her or try to correct words that she’s doing her best on. I’m trying to improve her pronunciation of words that I know she can do a little better. They don’t have to be perfect. They just need to improve in one way. “Yo-dur” has a /d/ instead of a /g/ in the middle and is missing the final /t/, but it is still closer than “yo-yo” so it’s an improvement.

I liked direct therapy. It’s just so much more intense than the unstructured therapy moments that occur during the day. I get maybe 5-10 practices of “yogurt” during the 15 minute snack. I could get 10-20 during 3-4 minutes of a structured session. I’m not giving up on the structured therapy. I’m going to get a little more creative. I’m going to try to sit down with a game and see if I can get her to work with me if we’re “playing.” I’ll let you know how that goes.

Therapy Progress - Practice and Generalization

It’s been about a month since my last update on Ava’s speech therapy progress. This month her therapy sessions have been rather sporadic. Doctor’s visits, surgery, and a variety of illnesses have interfered with her therapy schedule. She’s seen Ms. J twice, Ms. A three times, and Ms. E four times. I’ve probably only worked with her about three times a week on average. So, there’s been less therapy overall, and the therapy has been a bit inconsistent. This winter has been hard on us.

This month she made the jump from talking with only one word sentences to frequently using two word sentences. She’ll occasionally use three or even four word sentences now too. For example she’ll say, “Ava no pink shoes.” She’ll also string together several two word sentences in a row to get an idea across. For example, she’ll say, “dada shoe,” “mama shoe,” “me no shoe.” The idea she’s trying to get across is, “Hey, why am I the only one here with no shoes on?” but she’s using the tools at her disposal to communicate the idea in a simpler way.

The jump to using more than one word at a time was huge and exciting. It opens up a lot of possibilities where communication is concerned. However, since that jump, progress is slowing down a bit. I’m not seeing huge changes week to week any more. That’s to be expected. She’s made some dramatic changes. She needs some time to just practice her new skills. She’s learning what it’s like to live in a world where she can talk to people and sometimes they can understand. She’s getting to have back and forth conversations with people for the first time.

About two weeks ago, Ava put two words together for the first time. Since then, she’s been practicing that skill. She combines things in new ways and puts new words together. She experiments with putting three words together. Her first two word phrases were adding an owner to an object (Papa house) and an adjective to an object (pink flower). One of her first three word phrases put both an owner and an adjective with an object (Papa pink flower). This week it’s all about negatives. “no, no, no” So she’s experimenting with adding a negative to her sentences. She said, “Ava no purple pockets,” when trying to explain that her purple jacket doesn’t have any pockets.

To summarize, Ava continues to amaze me. She’s made huge progress this month. Last time I wrote an update she was a one word kid. Now she can occasionally string together four. So much going on in that two-year old mind – I am thankful that she can now share some of it with me.

Doing too well?

Just when I think I have a handle on things, something new hits me out of the blue. Apparently Ava is doing so well, that she’s in danger of “graduating” from early intervention services. I didn’t even know that was possible. It’s a good thing no one is keeping track of all the things I don’t know.

I thought that once she qualified for services that she would automatically continue to receive them until she turned three years old. Then we’d have to re-evaluate to see if she qualifies for school-age services at that time. Ms. A, our early intervention therapist, just mentioned this in passing during our therapy session Friday morning. At the time, I was busy trying to keep Ava engaged and Michael from interfering too much and I didn’t really process the significance of what she was saying. Later, it occurred to me that I really should have asked more questions. I guess I’ll ask her what she meant when we see her next week. I’ll try not to worry too much until then. Worrying doesn’t do me any good.

After two word combinations start - What's next?

You’ve finally gotten to the point where you’re hearing some two or even three word combinations.  It’s wonderful and every time you hear one a scene not unlike a New Year’s celebration unfolds in your mind. So, what’s next?

You have so many choices here, and they will vary from child to child.  I’m just going to walk you through my mental processes where Ava is concerned.  I could choose to work on specific sounds she’s still missing.  She has no /k/, /g/, /z/, /l/, /J/, /f/, /v/, ...  I could choose to work on final consonants.  She doesn’t use any.  So “dog” is /da/,  “milk” is /mi/, “book” is /buh/, and so on.  The way I would approach that would be to choose words that end with a sound I know she can make and try to get her to imitate putting that final sound on the word.  However, I’m not going to do any of those things.  

 They wouldn’t be bad things to work on exactly, but those aren’t the right choices from a motor speech perspective.  Remember when I talked about why apraxia therapy needed to be different from other kinds of speech therapy?  Some therapy is designed to address specific missing or mispronounced sounds (articulation therapy).  Some therapy is designed to address patterns of errors like the fact that Ava is dropping all consonants at the ends of words (phonological processing therapy).  And then there’s the motor speech therapy that is best for apraxia. 

Ava has trouble with motor planning.  Combining syllables and words is difficult and effortful.  Even though she can do it successfully some of the time now, it tends to be through the use of carrier phrases or words and phrases that we use a lot and are over-practiced.  Or they are combinations that are very simple from a motor planning perspective.  So, for example, “mama’s milk” /ma ma mi/ is pretty simple because the consonant is the same and she only has to change the vowel.  That’s just like “baby” /ba bee/ and “banana” /nah nuh/ are fairly simple for the same reason.   It’s the same consonant with only a changed vowel.

The next step we’re going to focus on, therefore, is to stick with working on two syllable or two word phrases, but to try to make them more complicated.  Try combinations where the vowel is the same, but the consonant changes (beanie, beady, kiwi, teeny, teepee).  Then try combinations where both the vowel and the consonant changes (pony, kitty, me too, my toe, no way, see me).  So that’s the idea.  Casually, through the day, I’m still very much doing all of the things I talked about in my therapy techniques to stimulate two word phrases post.  During my focused therapy sessions, I’m trying exercises to increase the complexity of the two word or syllable phrases she can produce. 

Therapy Schedule

Our schedule has finally settled down.  From start to finish, it took about two months from when I started to make phone calls to experts asking if I was worrying too early, to having Ava’s therapy schedule in its current final form.  That’s pretty quick.  I feel lucky.  I’ve read stories from many other parents talking about it taking much longer.  In that time we had Ava evaluated by our state’s early intervention program.  She qualified.  We had our IFSP meeting and a therapist was assigned.  We also found two different private therapists.  We had her hearing evaluated unsuccessfully twice, found out she had fluid in her ears, had surgery to put in PE tubes, and during surgery had a hearing test done to confirm that she can hear. 

So, this is what the complete picture looks like now.  I do focused therapy one-on-one (with no brother around) with Ava at least three days a week for about 30-45 minutes.  My therapy is guided by Ms. J.  Ms. J. is a local therapist who is an expert in apraxia.  She has a private practice but she only sees her private clients two weekends a month.  So Ava works with her for an hour twice a month and then she tells me what to focus on for the next two weeks.  Once a week for an hour we receive services from Ms. A who is our early intervention therapist and a former student of Ms. J (who works at a university).  In addition, Ava gets pulled out of her preschool program twice a week for half an hour by Ms. E., the first local therapist, I contacted. 

Tuesday, Thursday – 30 minutes at school with Ms. E

Friday – 60 minutes at home with Ms. A

Every other Sunday – 60 minutes at private practice office with Ms. J

At least three weekdays / week – 30-45 minutes with mama SLP at home

It’s a bit of a patchwork quilt and in an ideal world I would love a bit more consistency, but it seems to be working so I’m not complaining.  That’s what we’re doing right now.  If you’d like to share, I’d love to know what you guys are doing with your little ones. 

Unlocked

Two months ago, when Ava had barely three words, and yet could understand everything going on around her I could see the frustration building. She had so much she wanted to communicate and it was all locked inside her. In fact, I think it was her frustration that was making her so stubborn about even trying to imitate. She wouldn’t even try. That was why we started by giving her completely new ways to communicate. We used signs and the communication boards and you could just see the light in her eyes. She was so excited to be able to communicate successfully.

We also started working on her speech. I worked with her at home and she was seeing first one (twice a week for half an hour – private therapist), then two (once every two weeks for an hour – local apraxia expert), and now three (once a week for one hour – state early intervention therapist) therapists. Once she experienced the tiniest bit of success, and the praise and attention that went along with it, she began progressing quickly and steadily. She went from simply learning how to and being willing to try to imitate, to imitating single syllables with familiar sounds, to imitating single syllables with new sounds, to repeating multiple syllables with those sounds, to spontaneously trying familiar and new words, and finally to making some two and even three word utterances. The progress in speech alone is wonderful and gratifying.

What is amazing is the personality and confidence explosion that is taking place at the same time. It’s like I’m finally getting to meet my daughter and she’s finally getting to meet the people around her too. Her bond with her family members has intensified exponentially. She and her brother are communicating and playing with each other so much more. She’s trying to sing. She’s engaging in imaginary play. She’s initiating play with other children instead of pushing away every advance another child makes. Today, at her two year pediatrician visit, she went through all of the usual things (being weighed, measured, having her ears examined and her heart listened to, etc.) with a minimum of protest. The last time we went, the doctor and I could barely hear each other over the constant screaming. Today we were able to carry on a conversation without raising our voices at all.

The changes are fairly dramatic and almost all positive. Fine, I probably could do without the loud and gleeful shouts of “no” which she seems to use just because she thinks it’s fun. Seriously, there’s an amused gleam in her eye. She obviously finds it entertaining. But overall I’m delighted to see her personality unlocked and I like the little girl I’m finally getting to know.

Sometimes I just want to be me

In an alternate reality I live in a world where I am completely selfless, well-rested, and perfectly healthy. In that reality, I have the energy and enthusiasm to devote hours of my time to my children. I would play with them, do enrichment activities with them (cooking, art, music, physical play, literacy, etc.), and make sure that Ava and I get at least 30 minutes of direct, targeted therapy time every day.

In this reality, our household has spent more time sick this winter than well. This makes everyone tired and cranky in addition to the actual symptoms of the current illness (stomach bugs, colds, sinus infections, pink eye, etc.). I seem to be operating on a constant sleep deficit which is being exacerbated by Ava’s desire to wake with the sun. In our area, the sun is currently beginning to show up before 6am. And, to be perfectly honest, I am selfish. I want some time to call my own. I want some time separate from my children. I want to read, or blog, or play a game, or do a craft activity, or have a quiet moment where I do absolutely nothing. As a stay at home mother, I am with my children from the moment they wake till the moment they go to sleep all seven days a week. As much as I love them, that is a lot of time to spend with a two year old and a three year old who don’t know the meaning of independent play yet.

Each day, Ava wakes from her afternoon nap at least an hour earlier than her brother. This is supposed to be her therapy time. It’s the perfect time to do it in theory. She’s well rested and with a small snack, well fed. Sometimes I just don’t want to. I’d rather let her watch tv while Michael finishes his nap. This effectively extends my afternoon break from about one hour to about two. But I feel doubly guilty about this desire. First, tv is the root of all evil (ok, not really, but how many articles do we read about how bad tv is for our children?). Second, it’s her THERAPY. It should be non-negotiable. I shouldn’t even be considering letting it go. It doesn’t matter that she’s getting it elsewhere anywhere from three to five times a week. I have the skills to supplement her therapy myself. I should be doing it. Boy do I hate the word “should.” Anyway, sometimes I just want to be mama (and an imperfect one at that), instead of being a therapist.

And that’s my confession of the day.

Mini Review - First Hundred Words

This is a mini-review of First Hundred Words. Each time we see Ms. J (not including our initial visit), she sends something home with us to work on. The first time she sent home the book First Hundred Words with the instruction to use it to work on two word phrases.

This book isn’t simply a picture book like so many vocabulary oriented books. It is actually similar in concept to the Big Book of Exclamations. It consists of a series of two page spreads that feature a family in scenes that would be familiar to a young child. I’ve returned the book to Ms. J, so unfortunately this will only be a mini-review.

From what I can remember the picture spreads include a waking up scene, breakfast scene, bath scene, park scene, and bedtime scene just like the Exclamations book, but this book is longer and includes several other scenes as well. Because I don’t actually have the book any more I can’t tell you all of them, but one was a swimming pool scene and another was a drying off/getting dressed after the pool scene. These picture scenes are an entirely different illustration style from the Exclamations book, but I like them and there are so many details to find and discuss. This book is also much more reasonably priced than the exclamations book and is available in paperback which is a little easier to handle. I would definitely recommend it.

Here is a link to an article called Babies, Books and Speech Development. This is an article that reviews the Big Book of Exclamations and also gives some nice specific tips for using books to help encourage speech development. The article is definitely worth reading.

Two word combinations – Therapy Techniques

Making the jump between one word utterances and two word utterances is huge, especially for a child with apraxia. 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 apraxia 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. Also try using a singsong voice. So say, “biiiiiiig dog”.

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”.

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. Make sure that you 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.

You can also put a long pause in between the two words. 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. When Ava is trying a new two word phrase that it hard for her, there’s a huge pause between the first and second word. You can 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.

Use carrier phrases. I deliberately taught Ava the word mine. In a household with two young children that seems like a tactical error (and boy does she use it a lot these days), but I wanted her to then use the word “my ______” . Once you teach the carrier word, it can then be combined 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 a carrier word. She said, “Mama house, my house, papa house, dada house, etc.”

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.

So, quick summary.

Two word utterances - Therapy techniques

• 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

Good luck! Let me know what you think. Let me know if any of these work for you, or if you have other techniques I can add to this list.

Two-word combinations begin

I swear my daughter must be sneaking out of bed in the middle of the night to read my blog. She reads it to find out what I’m saying she can’t do. Then she proceeds to do that very thing over the next few days simply because she loves proving me wrong.

Just last weekend I was doing some research watching some old home videos trying to see differences between the speech development of Ava and Michael. The major thing that stood out to me was the ease with which Michael could combine words. Ava struggled to do so. A couple of days later I wrote a post on the topic.

Since then, Ava has begun combining words. Frequently. Many times each day. She will do it in imitation succeeding about half the time. She’ll also do it spontaneously. Last Saturday morning, when we picked Ava up from my parents’ house, my dad said, “Listen to what Ava can do.” He told her, “Say Papa house.” Ava then repeated, clear as day, “Papa (small pause) house.” I was amazed and excited and so proud. We heaped praise upon her. As we were driving home the little show off then said, “Mama house.” It was the beginning of something new.

We were walking into her school where they’ve decorated the entryway for spring with construction paper flowers. Ava stopped, pointed, and said, “Pink flower. Red flower. Purple flower.” Seriously! Who is this child? She likes to label things by owner. So, “Mama shoe. Dada shoe. My shoe.” She even said, “Mama no shoe,” once. It’s crazy.

Now, I don’t want to give the impression that all of this is coming out perfectly or easily, or that she is successful all the time. It’s still pretty obvious that combining words takes effort. Many speech sounds are being left out and the words don’t at all sound like adult pronunciations would. She also doesn’t succeed all the time. Often, when asked to say a two word sentence the words will still come out as two of the same word. And she still uses one word sentences most of the time. However, this is a huge breakthrough. She is using two word phrases some of the time. I guess the tapping and encouragement made sense for her. I can’t believe this is the same child that scored at the four-six month old level in speech and language only two months ago.

So what does this mean? Well, I still believe that we are dealing with a disorder. The history is too atypical for the speech problems to be a simple delay or just due to the hearing loss due to the fluid in her ears. I do think, at this point, that I feel fairly safe in saying her disorder is on the milder side. Children with a severe disorder work just as hard, and don’t have the same kind of response to intervention. If I had spent two months working intensively with Ava and had seen very little progress that would indicate a more severe disorder. Given the extent of her delay two months ago, I feared something quite severe. I told my family that I wasn’t going to make any predictions though until I saw how responsive she was to intervention. I told them I’d know more in 3-4 months. Only two months later I can say that she’s been very responsive so far and that is a very good sign.

We’ll continue to work with her. She still needs to fine-tune many vowels. She’s missing lots of consonants as well. I’d like to try to start to get her to add final consonants to the ends of her words. And, of course, we want her to continue to use those two word phrases and to add more of them gradually increasing to three or even four word sentences. I’ll consult with Ms. J this weekend and let her expertise guide me in determining which of those things is most important and guide me in how to best achieve those goals.

You might also be interested in the following articles:

Apraxia Therapy: Two-Word Combinations

Surgery

Ava’s surgery went well. It was a stressful day for everyone though. We needed to be at the hospital by 6:15 am. We couldn’t give her anything other than clear liquids and nothing after 5am. So we woke her up at 5:00 in the morning and gave her some apple juice. Then we dressed her and popped her in the car for the ride to the hospital. Michael spent the night and then the morning with his grandfather (my mother was still in the hospital).

Ava pitched a fit when they put on her identification bracelet. Then she pitched another fit when they took her vitals. Then we got to wait. They decided to give her something for her anxiety because they couldn’t imagine her separating from us any other way. It worked beautifully. A loopy toddler is actually cute and a bit funny. They took her back to surgery and as I understand it, they put her under first with the mask before putting in her IV. If she were only having the tubes put in, they wouldn’t have needed the IV at all.

Putting in the tubes went smoothly. She still has a lot of fluid in her right ear although the left was clear. We definitely made the right decision about the tubes. It’s been 2-3 months solid now that she’s had fluid in one ear and maybe both. That has a huge impact on hearing. After her ears were drained they did the hearing test. The audiologist said her hearing is great which is wonderful news.

When I got to the recovery area Ava was in a groggy panic. They let her wake up without me and with the IV still in and strapped to her hand and arm. She was extremely upset about the IV. They apparently wanted to leave it in until they were sure she wasn’t going to throw up. I asked them to take it out and explained that she wasn’t going to calm down until it was out. After that it was just a matter of giving her some juice and graham crackers and waiting an hour or so until they let us go home.

We were home by lunch and Ava was eating a cheese roll up as if nothing unusual had happened that morning. Overall, a decent experience. I’m grateful everything went well. It’s good to know she can finally hear because all the fluid is gone and that the tubes will keep it from building up in there again. It's also good to know for sure that there isn't an underlying hearing loss separate from the fluid in the middle ear issue.

So now, we can move on with therapy knowing that Ava can hear us clearly.

Apraxia and infant bonding

This topic is a touchy one for me. I think it is because it ties in to my opinion of myself as a mother. I was always good with kids. Good with babies. I had lots of younger cousins and entertained them at family gatherings well before I was old enough to babysit. Once in high school and through the first two years of college I did a ton of babysitting. Then I chose to work with children as my profession.

I just assumed I’d be a wonderful mother. Before Michael was born I imagined bonding with him as an infant. I imagined he’s be comforted by my arms, voice, and face. I imagined playing peek-a-boo, singing songs, exchanging smiles and baby-talk. What I got was a baby who cried almost nonstop for 8 months. He didn’t seem to be comforted any more by me than by anyone else. He didn’t smile on schedule. He didn’t laugh on schedule. He preferred looking past me at the lights behind me rather than looking into my eyes. We never played peek-a-boo. He didn’t babble. I thought people were exaggerating when they talked about bonding with their infants. I thought they were reading things into their children’s behavior that weren’t there. I just didn’t realize exactly how different Michael’s early development was.

Ava followed only 15 and a half months later. She was a little more typical. She didn’t have the fascination with lights and the eye contact avoidance. She didn’t cry as much. She did seem to prefer her parents somewhat to others. In comparison, she seemed like such an easier baby. In retrospect, she still didn’t smile, laugh, coo, or babble on schedule. We still didn’t have that give and take, that positive feedback loop that leads to the early bonding so many people have with their infants.

My husband and I just thought we weren’t baby people. We didn’t realize that we were having a perfectly normal reaction to the fact that our children weren’t as socially interactive as a typical infant. It’s hard to bond with a baby that doesn’t smile at you. It’s hard to bond with a baby that doesn’t play the typical back and forth infant games like peek-a-boo and other finger plays. Without that interaction, bonding is just more difficult and will happen slower.

When I was watching home videos I came across one of Ava when she had just started to smile. She was almost 4 months old. It was difficult to get her to smile, and when I did it was in response to tickling (a physical stimulus), not in response to a social overture. She almost seemed to be struggling. I can remember that Michael’s first laugh was in response to being thrown up in the air and caught again – also in response to a physical stimulus. And he was much older.

Looking back on it now, I think much of this could be related to the apraxia. The late smiles and laughs and the lack of babbling are all early red flags for apraxia. I never really reflected on the impact that has on the parent’s relationship with their baby – and their confidence in themselves as a parent.

Has anyone else had a similar experience? It would make for an amazing research study.