Childhood Apraxia of Speech Therapy Fundamentals: Part 2 - Types and Variability of Practice

Childhood Apraxia of Speech (CAS) is neurological speech disorder that causes children to have difficulty with the motor planning, sequencing, and programming necessary to produce volitional speech. Therapy needs to address the core problem of motor planning for speech in the most effective way possible. Every child is different, so therapy must be customized. Therapy for a young child who is nonverbal will be different from therapy for an older child who is using multi-word sentences, but the speech is hard to understand. However, the basic underlying fundamentals of therapy for apraxia are going to be similar. These underlying fundamentals are based on current research and professional consensus.

How is therapy for Childhood Apraxia of Speech structured?

We've already discussed the fact that therapy for a motor planning problem needs to involve lots and lots of practice. The next question is how to structure that practice in order to get the best results.

Blocked versus Random practice

Blocked practice is practicing one target at a time, over and over again. This is where the therapist starts when trying to teach something entirely new. If you have a child who can't make a /b/ sound and you are trying to teach it, you are going to practice /b/ over and over again in blocks until the child experiences some success. A blocked practice structure is great at establishing a new skill, but doesn't carry over well outside of the therapy session. When the child begins to perform well in a blocked structure the therapist will move to a random practice structure.

Random practice is when several targets are practiced during a single activity. Now the therapist will practice that same /b/ sound, but will also throw in one or two other sounds the child can make too. The therapist will switch between the two or three sounds randomly. This increases the motor planning demands of the task because the child has to switch between different targets. It also makes the task a little more like real world speech demands when you are not saying the same sound over and over and over again.

Variability of practice

Therapy practice needs to vary in speech context, social context, and environmental context. Targets need to be practiced in multiple speech contexts. That /b/ needs to be practiced at the beginning, middle and ends of words. It needs to be practiced in multiple syllable structures. It needs to be practiced in phrases, sentences, and in conversation.

Therapy practice needs to vary in social context as well. Practicing a /b/ with the speech therapist is different than practicing it with Mama or Grandpa. Practicing a /b/ in a speech therapy session or during a practice session at home is different than practicing every /b/ word that comes up when reading a bedtime story with Daddy.

Finally, variability can also include environmental variation. The child should be working to improve their production of speech targets in therapy, at home, at the grandparent's house, in the car, at the grocery store, at school or daycare, etc.

The greater the three kinds of practice variability the better the child will internalize the new target and be able to use it spontaneously in a variety of contexts. This is why the participation of the parent is so important. The speech therapist cannot achieve social and environmental variability by him or herself. The practice the parents do at home and out and about during their daily life is an essential part of the therapy picture.

Summary

Therapy sessions for Childhood Apraxia of Speech need to involve lots and lots of speech productions. When learning something new, the therapist will used a blocked practice structure and only target that new skill. Once your child learns the new skill, the therapist will switch to a random practice structure and randomly switch between the newly learned skill and some old ones in order to improve performance when the demands of the task are harder. The speech skills also need to be practiced in different speech contexts, social contexts, and environmental contexts. Home practice is essential for this variability in practice.

You just finished Part 2 of a three part series on Childhood Apraxia of Speech Therapy Fundamentals.

Read the other two parts of the series:

Childhood Apraxia of Speech Therapy Fundamentals: Part 1 - How Much and How Often?

Childhood Apraxia of Speech Therapy Fundamentals: Part 3 - Methods and Content

You might also be interested in the following articles:

What is Childhood Apraxia of Speech and How is it Diagnosed?

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

Childhood Apraxia of Speech Therapy Fundamentals: Part 1 - How Much and How Often?

Childhood Apraxia of Speech (CAS) is neurological speech disorder that causes children to have difficulty with the motor planning, sequencing, and programming necessary to produce volitional speech. Therapy needs to address the core problem of motor planning for speech in the most effective way possible. Every child is different, so therapy must be customized. Therapy for a young child who is nonverbal will be different from therapy for an older child who is using multi-word sentences, but the speech is hard to understand. However, the basic underlying fundamentals of therapy for apraxia are going to be similar. These underlying fundamentals are based on current research and professional consensus.

How much therapy is usually necessary to treat Childhood Apraxia of Speech?

Intensity of Speech Therapy

It is essential that a child with Childhood Apraxia of Speech get as many opportunities as possible to actually produce speech. You cannot improve motor planning skills if no speech production is happening. Therapy for CAS needs to focus on getting as many speech productions as possible from the child during each session. A child is not improving their motor planning skills when they are just listening or watching the therapist or other children. For this reason, it is usually recommended that speech therapy sessions be individual (one-on-one) rather than group (one therapist with several children). It is also recommended that the therapist stay very focused on having the child practice rather than on having the child listen and watch while the therapist "teaches". Therapy for Childhood Apraxia of Speech needs to be very intense.

Frequency and Duration of Speech Therapy

Children with Childhood Apraxia of Speech typically need a lot of therapy to show improvement. One study (Campbell, 1999) showed that "the children with apraxia of speech required 81% more individual treatment sessions than the children with severe phonological disorders in order to achieve a similar functional outcome."

The professional organization of speech language pathologists, the American Speech Language Hearing Association (ASHA) reports that, "There is emerging research support for the need to provide three to five individual sessions per week for children with apraxia as compared to the traditional, less intensive, one to two sessions per week (Hall et al., 1993; Skinder-Meredith, 2001; Strand & Skinder, 1999)." ASHA's technical report also states that, "In view of the Committee's information indicating that children are being enrolled for treatment of CAS at increasingly younger ages, careful consideration should be given to the length of the therapy session. If repetitive practice of speech-motor patterns is targeted in a therapy session, many children in the younger age ranges can remain engaged for only a maximum of 30 minutes per session."

Given a choice, therapy for Childhood Apraxia of Speech should be broken into many shorter sessions per week rather than one or two long sessions per week. This makes sense from a motor planning perspective. You will learn a new motor task (just like riding a bike) faster if you practice a little almost every day rather than practicing for several hours only once a week.

Summary

Ideally, therapy for Childhood Apraxia of Speech should be individual sessions 3-5 days a week. Those sessions should be focused on getting as many productions from the child as possible. Sessions should be no longer in length than the amount of time the child can focus on intense practice. These guidelines are most important when the Childhood Apraxia of Speech is judged to be severe.

You just finished Part 1 of a three part series on Childhood Apraxia of Speech Therapy Fundamentals.

Read the other two parts of the series:

Childhood Apraxia of Speech Therapy Fundamentals: Part 2 - Types and Variability of Practice

Childhood Apraxia of Speech Therapy Fundamentals: Part 3 - Methods and Content

You might also be interested in the following articles:

What is Childhood Apraxia of Speech and How is it Diagnosed?

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

Oral Apraxia - Mealtime Consequences?

I have a question for those of you with children who also have oral apraxia. Oral apraxia is problems with the motor planning of non-speech movements like sticking out the tongue or blowing kisses or bubbles. Both of my children have oral apraxia. Ava has both oral apraxia and childhood apraxia of speech. Michael just has oral apraxia.

I have noticed that both children often seem to bite themselves while eating. Several times a week someone will end up in tears during mealtime because they've bitten their tongue, inside of the mouth, or lip. I was wondering if this is pretty typical for toddlers and preschoolers or if you have noticed the same thing happening with your children with apraxia. Any thoughts?

Speech-Language Pathology Topics: Voicing Pairs

Here's a quick speech lesson of the day. Don't you always want a speech lesson on Mother's Day? (Happy Mother's Day everyone!)

Say, "Ssssssss" out loud like you're making a snake sound. Draw it out as long as you can and while you're doing it place your hand on the front of your throat near your adam's apple. Now say, "Zzzzzzzzz" out loud like you're making a bee sound. Draw that one out as long as you can too while keeping your hand on your throat.

The first thing you should notice is that your throat vibrates while you make the /z/ sound, but it does not while you make the /s/ sound. That is because /s/ is a voiceless sound. You can make the sound without vibrating your vocal chords. The reason you feel your throat vibrating when you make the /z/ sound is because it is a voiced sound. You have to vibrate your vocal chords to make the /z/ sound. Other than that one difference, voicing, the /s/ and /z/ sounds are made in exactly the same way. You raise your tongue tip near the roof of your mouth behind your teeth and blow. So /s/ and /z/ are a voicing pair. They are two sounds made in exactly the same way except that one is voiced and one is not.

There are lots of voicing pairs. /t/ and /d/ are voicing pairs. /t/ is voiceless while /d/ requires vibrating your vocal chords. /p/ and /b/ are voicing pairs. /p/ is voiceless while /b/ requires vibrating your vocal chords. /k/ and /g/ are another example. /k/ is voiceless while /g/ requires vibrating your vocal folds.

What does any of this have to do with apraxia? Well, making a voiced sound is a more complicated motor task. To make a /b/ you have to do everything you have to do to make a /p/ and then coordinate vibrating your vocal chords at the right time for the right duration. So often, children with apraxia will find voiceless sounds easier. /t/ and /p/ are often easier than /d/ and /b/. Just another example of how complicated the motor planning of speech is and why our children sometimes seem to have trouble with a sound or word for no reason when there really is a reason after all.

Speech-Language Pathology Topics: Complexity of Motor Planning - An Example

Childhood Apraxia of Speech is a neurological disorder of the motor planning of speech. Here is one small example of how complicated that motor planning can be.

You might think that a /b/ is a /b/ is a /b/. Or you may have thought, correctly, that making a /b/ at the beginning of a word is different than making a /b/ in the middle or at the end of a word. But it gets even more complicated than that.

Say the word "book" five times in a row out loud, but before you say it the last time, freeze your mouth in the position it is in when you are about to make the /b/ sound. Your mouth should be pursed a little, almost like you're about to give someone a kiss.

Now say the word "bee" five times in a row out loud. Again, stop before you say it the last time freezing your mouth in the position it is in when you are about to make the /b/ sound. Your lips should be pressed together, almost like you just put on chapstick or lipstick and are spreading it evenly around.

Even though the words "book" and "bee" both begin with the /b/ sound, the motor planning for producing the /b/ is very different. For the first /b/ in the word "book," the motor planning involves the muscle motions necessary for lip rounding (because the following vowel is a rounded vowel). For the second /b/ in the word "bee," the motor planning involves the muscle motions necessary for lip spreading (because the following vowel is a vowel that involves lip spreading).

The difference between those two initial /b/ sounds is just one small example of how complicated motor planning really is. I just thought the example was interesting and I wanted to share.

Ms. J and Magic

I haven't spoken much about Ms. J recently. She's the local apraxia expert we're fortunate enough to be seeing twice a month. We saw her again yesterday morning. She is so good. She has amazing one-on-one sessions with Ava. I shamelessly eavesdrop through the door. She takes my 26 month old little girl and gets her to work on her speech for 50 minutes straight and enjoy it the whole time.

She's also magical. I will go and she will tell me work on something (the one I remember most is "work on two-word phrases"). I will tell her, "Sure!" while thinking to myself, "Yeah, right! There's no way Ava will be doing that in the next two weeks, she isn't even close." Every single time, Ms. J has been right. Every single time. She was right about the two word phrases. She was right when Ava first started being able to imitate final consonants. She was right about using the hand signals.

Well, this time she told me to work on the /k/ sound. I've been trying off and on to stimulate a /k/ production from Ava. I'll say, "Say /k/." Ava will respond, "/t/". Every time. She just can't make a /k/ or /g/ in the back of her mouth. Think about it for a second. Try to explain how to make the /k/ sound. It would go something like this:

1. Bring the back of the tongue up to the roof of your mouth so that you completely block all air flow from your mouth. Leave the front of your tongue down.
2. Build up air pressure behind your tongue.
3. Now, let the air out in a little explosion by dropping the back of your tongue down. If you do it right, it will make a /k/ sound.

Ok. Now imagine trying to explain that to a two year old. Just not possible. So, when we're trying to stimulate a sound a child isn't making we have to use indirect methods. Sometimes you're lucky and the child can imitate the sound even though they aren't using it on their own. Or sometimes it is a sound that is easy to see, like /m/, because you make the sound with your lips. Then you might be able to help the child make the sound by showing them how. But /k/ is made in the back of the mouth. You can't just have the child watch you.

Ms. J took an indirect approach to getting Ava to make a sound in the back of her mouth. Essentially she had Ava open her mouth wide. Then she used a tongue depressor to hold down the tongue tip which will often force the back of the tongue up. Ava hated the tongue depressor and was happy to open her mouth wide if only the tongue depressor stayed put away. Then Ms. J had Ava imitate a kind of growling, "scary" sound. With the mouth wide open and the head tilted slightly back, making that noise is a giant step towards making a /k/ sound because you're making a sound way in the back of the mouth by moving the back of the tongue up. That's the first step we needed. Hopefully over the next two weeks I will be able to use that technique to shape a true /k/ sound from Ava.

If you had asked me two days ago if I thought there was even a possibility of getting a /k/ out of Ava in the next couple of weeks I would have said, "No way, absolutely not." One visit with Ms. J later and I think there's a distinct possibility. Magic I tell you. Magic.

Subtle Problems are Harder to Explain

I was talking with our early intervention therapist about Ava's speech trying to figure out what it is that still worries me. Ava is doing so much better. She looks more age appropriate. That is good, of course, but I know both as an SLP and as her mother that there is something there I need to pay attention to.

Yes, Ava is still missing individual sounds (k, g, f, v, r, l, etc.), but all of those sounds develop late anyway and aren't always present in a young two year old anyway. And, some of them are starting to emerge a little. I'm seeing hints of an /f/ and hints of a /k/ for example. So, I'm not crazy worried about the missing sounds. Sure, the fact that they're missing makes her harder to understand, but in a relatively age appropriate way.

Yes, she still exhibits quite a few phonological processes. The big ones are final consonant deletion (leaving off those final consonants) and syllable reduction (taking a three syllable word and saying it as a two syllable word). Again, phonological processes are a normal part of speech development, and it isn't too age inappropriate for her to still be exhibiting some. It's particularly reasonable given that she's only been talking at all for a grand total of three and a half to four months. So, to summarize, I'm not too worried about the phonological processes either.

What I do see are signs of a motor planning problem - apraxia. I have a little girl who has a lot to say. She understands what she hears. She has a great vocabulary. She wants to put together 4-5 word sentences which is pretty darned good for a just turned two year old. However, whenever the syllable structure gets complicated she struggles. Whenever she tries to put together over three syllables she struggles. Whenever she's trying a new word or sentence structure that is complicated she struggles.

Yes, her motor planning problem is mild, but it is definitely there. And, more importantly, it is holding her back from her potential. I think without the apraxia she'd be startlingly articulate. As it is, she struggles to express everything she'd like to. I'm told that she's extremely quiet at school and hardly talks at all. At home she's trying to talk all the time, but she doesn't at school. Is it a confidence issue? It is because the processing demands are higher in a higher stress environment? Is it just her personality to be shy at school? I don't know, but I want her to get to a point where she is able to say everything she wants to and she isn't being held back by the apraxia.

And so we will continue to work on it. It is so easy to get distracted by the sounds she can't say or the phonological processes she exhibits, but the bigger issue is definitely the motor planning. The best strategies I've found to help with the motor planning problems are the tapping and the visual prompts. We'll stick with using those in context to help her say the things that she wants to say. And we'll see how her speech continues to develop over the next several months.

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:

Apraxia Therapy: Communication Boards

Apraxia Therapy: Two-Word Combinations

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?

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:

Apraxia Therapy: Gestural Prompts

Apraxia Therapy: Two-Word Combinations

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.

You might also be interested in the following articles:

Apraxia Therapy Materials: Talking Carl iPhone / iPad App

Apraxia Therapy Materials: Doodle Buddy iPhone / iPad App

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.

If you found this information useful you might also be interested in the following articles:

NutriiVeda for Childhood Apraxia of Speech: Information and Resources

Omega-3 Fish Oil for Childhood Apraxia of Speech: Information and Resources

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.

Scaffolding

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.

Tapping

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.

Review.

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

You might also be interested in the following articles:

Apraxia Therapy: Communication Boards

Apraxia Therapy: Gestural Prompts

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.

Toe?

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.

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.

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 Pursuit History: This article discusses the history of using NutriiVeda with children with apraxia and gives a detailed testimonial.
• Theories Based in Science to Support Whole Food Therapy for Autism, Apraxia, Traumatic Brain Injury, Seizure Disorders: This article discusses theories about why the ingredients in NutriiVeda may help children with apraxia and other special needs.
• Anecdotal SLP Children NutriiVeda Testimonials: This is essentially a long list of testimonials from parents of children with special needs who have seen improvement using NutriiVeda.

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.

Omega-3 Fish Oil for Childhood Apraxia of Speech: Information and Resources

What are Omega-3 fatty acids?

Omega-3 fatty acids are molecules that are necessary for human health but cannot be produced by our bodies. They have to be obtained through our food. They are most commonly found in fish and some nuts. Omega-3 fatty acids are essential to brain function and play an important role in growth and development. There are several types of Omega-3 fatty acids, but most research indicates that EPA and DHA have better established health benefits and these types are found in fish oil rather than in nut oils.

Here are a couple of web pages that discuss the general health benefits of Omega 3 fatty acids.

• Omega-3 fatty acids: This article defines Omega-3 fatty acids, discusses their health benefits, gives some dosing guidelines, and discusses precautions and interactions.
• Omega-3 Fatty Acids: Fact Sheet: This WebMD article discusses the basics, benefits, types, food sources, and supplements.

What does Omega-3 Fish Oil supplementation have to do with Childhood Apraxia of Speech?

Many parents of children with Childhood Apraxia of Speech first encounter the idea of supplementing with Omega-3 fatty acids in The Late Talker book. That book devotes an entire chapter to the topic. Most of the evidence is anecdotal. Some families have seen dramatic improvement after a plateau when adding Omega-3 fish oil supplementation was the only change. Given that there is evidence of general health benefits, few drawbacks, and the possibility of helping a child communicate better, many parents choose to try it.

There is some preliminary scientific evidence that Omega-3 supplementation does help with related disorders like dyspraxia (neurological motor planning disorder of the limbs) and autism.

Here are a few resources that discuss Omega-3 supplementation and Childhood Apraxia (or related conditions).

• Dyslexia, Dyspraxia and ADHD – Can Nutrition Help?: This article is in .pdf form. It nicely summarizes some of the actual research out there on fish oil supplementation and disorders. Note that none of these studies are actually about children with Childhood Apraxia of Speech. These are studies with related disorders including dyspraxia.
• Therapeutic Use of Fish Oil for Apraxia, Autism and Other Communication Impairments: This article is structured like a FAQ covering topics like dosage, brand, and tips for getting your child to take the supplement among other topics.
• Syndrome of Allergy, Apraxia, and Malabsorption: Characterization of a Neurodevelopmental Phenotype that Responds to Omega 3 and Vitamin E Supplementation: This is a research article published in the Journal of Alternative Therapies in 2009 (also a .pdf). This study was conducted with children diagnosed with Childhood Apraxia of Speech. However, this research study did not have a control group, so although as a parent I am encouraged and interested, as an SLP I am still not convinced.
• Scientists Characterizes New Syndrome of Allergy, Apraxia, Malabsorption : This is a science news article about the Journal of Alternative Therapies study. It summarizes and discusses the results of the study.
• The Omega Wave This is a pretty interesting BBC news article on fish oil supplementation and learning disabilities, but it is just a news article, not a research article.

Omega-3 Fish Oil Supplementation for Childhood Apraxia of Speech: Review of Product Purchase and Impressions

After carefully reading the chapter in the The Late Talker book and all of the articles referenced above we decided to purchase the Nordic Naturals Ultimate Omega Liquid. The Nordic Naturals brand has a great reputation for quality and we wanted the product in the most concentrated form possible given that we weren’t sure how well our two year old daughter would take it. This product also has a blend of the different types of Omega-3 fatty acids and we wanted that as well in order to get the closest possible approximation to the therapeutic doses described in the book and articles.

The product is lemon flavored and does not smell or taste fishy at all. I have been very pleased with the quality of the product. I suppose you could try to give it to your child straight off a spoon or medicine dosing cup, but we’ve never tried that. If the product starts to smell or taste fishy, it has spoiled. After doing some research, we decided to store our bottle in the freezer to extend its shelf life.

We mix the Omega-3 supplement in with about two ounces of yogurt. At first we bought lemon yogurt, but when we ran out we tried random flavors and they all seem to work. We’ve also mixed it in with yogurt drinks and that has worked as well. I simply use a medicine dispenser I borrowed from an infant ibuprofen bottle to measure the right dosage and then squirt it into the yogurt. Stir and serve.

Is Omega-3 Supplementation working to help our daughter’s Childhood Apraxia of Speech?

To be honest, I cannot tell if the Omega-3 supplementation is helping for us. We started the supplementation and intensive therapy in the same week so it is impossible to tell if the improvement we have seen is due to the Omega-3 supplement, the therapy, or a combination of both. I can say that I have not really noticed any kind of regression when we miss her nightly dose several nights in a row for some reason. However, given the general health benefits and the possibility that it is helping in a subtle way I am certainly not going to stop using the product.

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

Many parents are anecdotally reporting improvement in their child's speech when using a meal replacement supplement called NutriiVeda. You can read my Information and Resources page on NutriiVeda for Childhood Apraxia of Speech here.

Testy Yet Trying: Childhood Apraxia of Speech Reference Posts

I am going to be working on something new over the next few days (or couple of weeks). I am going to re-work and add to some of my Childhood Apraxia reference articles and put them all in one place so they can be accessed easily. If you notice, there is a new link at the top of the page (or depending on when you’re reading this – there will be soon) to the reference posts.

I’ll be adding new ones as I finish polishing them. If you have a post that you would like to see added to the new page sooner rather than later, just leave a comment and I’ll put it at the beginning of my list of posts to work on. Please comment. I’d love to hear which posts you have found to be most useful.

As I finish each article, I will also post them on the main page so you can see the new content. I just wanted to let you know what was going on so you wouldn’t be confused by the return of some of these topics. I’m starting with the two supplementation posts: Omega-3 Fish Oils and Nutriiveda.

Therapy Progress - Steady Progress and Subtle Change

I was looking back at all of Ava’s progress reports and I realized that her progress has been very steady. Every 3 weeks or so, significant progress has been made. Here’s a quick summary.

• Beginning of January – Ava had only three “words” and very few consonants and vowels.  She couldn’t imitate.  She was starting to use gestures instead of even trying to communicate verbally.  We began therapy and Omega 3 supplementation in January.
• End of January -  At this point Ava would imitate when bribed with food.  She had learned several new consonant sounds and was using 15-20 words spontaneously.
• Middle of February - Ava was spontaneously trying to label things.  She had started two syllable words like “nanuh” for banana and “baby”.  She was making further progress on consonants and some progress on vowels.
• First Week of March - She started putting two words together make short phrases and sentences.  It was a huge step.  We were getting 3-4 syllables strung together at a time.  
• End of March -  Ava was continuing to practice multi-word utterances.  She was using them more frequently and would often use three word sentences.  Occasionally we would even hear a four word sentence.  We started using Nutriiveda.

 

At the moment, we’re trying to add a little clarity to Ava’s words.  Before, her words had no final consonants (“ha” for hat) and no medial consonants (“pu-ee” for puppy).  We’re using gestural cues to help her add those back in.  It’s working.  She’s occasionally doing it spontaneously (she’ll add the /t/ in the middle of turtle), but most of the time we have to remind her (using the cues).  When she’s imitating I’d say she’s successful about half the time.  It depends on the sound.  She does a great job with /t/ and /p/, but /d/, /b/, /n/ and /m/ are harder.  She doesn’t have /k/, /g/, /f/, or /v/ at all, so we aren’t even trying with those. 

All of these things are very concrete.  These are the kinds of things that speech pathologists choose as goals and can collect data on to track change.  I talk about this kind of progress because I am a speech pathologist and these changes make sense to me.  I’m proud of them.

There has also been a more subtle kind of change.  This is the change that my husband and parents notice.  It’s less about specific sounds, utterance length, and data and more about Ava as a person.  There’s been a change in her confidence.  She’s talking more.  She’s talking when she’s by herself in another room.  She’s chattering away in the back seat of the car.  She’s trying to sing, laugh, and make jokes.  She has conversations with her parents, grandparents, and brother.  She is no longer the baby who had to grab my hand and drag me to the refrigerator, pound on the door to get me to open it, and point to ask me for milk.  Now she can just ask, “Mi pea!” (Milk, please!)   It’s been a wonderful change to watch.

How do you measure progress in your little ones?