Windows

Speech is a window into someone's mind. For Michael that window is wide open. His mind forms a thought, his mouth speaks it, and I comprehend it. The process is effortless and easy. In fact, that boy's mouth has no filter. Every thought just comes out of his mouth in a continuous stream. I will admit that occasionally I wish for a pause button.

And then there is my daughter. It is painfully obvious that she has just as much to say. She'll come running in from the other room just bursting with something she wants to share. She'll tell me a one or two or even three sentence story and then pause excitedly for my reaction. In a typical conversation I would effortlessly understand her and immediately respond. Instead, I pause while my mind tries frantically to figure out what she said. Often I fail. So far, she doesn't seem too upset. She'll often just run off back to whatever she was doing. But I missed it. I missed that window into her mind and that opportunity to know her better and share her thoughts. And I'll never get that particular opportunity back. I just have to wait for the next one and try again.

Speech-Language Pathology Topics: Consonants

What are consonants and why are they important to speech?

Consonant sounds are produced by constricting or interrupting the air flow at some point during the production of a sound. In contrast, a vowel is a sound produced with a relatively open vocal tract. Consonants are combined with vowels to make syllables and words. When consonants are produced incorrectly, that makes speech very difficult to understand.

There are 24 consonant sounds used in spoken American English. These sounds may or may not match up with English letters and the phonics typically associated with those letters. Here is a chart of the 24 American English consonant sounds. The symbol on the left is the phonetic symbol most Speech-Language Pathologists use to represent each sound. On the right is an example of a word with that consonant sound. The letters used to spell the sound are in bold.

What are the characteristics of consonants

What makes a "p" different than an "v"? The consonants sound different from each other because they are made in different ways. They differ in their place of articulation, their manner of articulation, and their voicing status. Speech-Language Pathologists use a consonant chart to keep track of the consonants and their characteristics.

What are the different places of articulation?

A consonant is made by constricting the airflow between where it starts with the exhalation in the lungs and where it exits the mouth at some point. One reason sounds differ is because the point of constriction happens at different places. If the point of constriction is at the lips (/p/, /b/, /m/, /w/) then the place of articulation is bilabial. If the point of constriction is just behind the top teeth (/t/, /d/, /s/, /z/, /n/, /l/, /r/) then the place of articulation is alveolar. Here is a list of the places of articulation and a picture to help you visualize those places.

• bilabial - constriction between both lips
• labio-dental - constriction between top teeth and bottom lip
• dental - constriction between top and bottom teeth
• alveolar - constriction between the tongue and the alveolar ridge (top of mouth just behind top teeth)
• palatal - constriction between the tongue and the hard palate (roof of mouth)
• velar - constriction between the tongue and the soft palate (roof of the very back of the mouth)
• glottal - constriction at the vocal folds

What are the different manners of articulation?

A consonant is made by constricting the airflow between where it starts with the exhalation in the lungs and where it exits the mouth at some point. One reason sounds differ is because the method of constriction happens in different ways. If the airflow is completely stopped and then released in a puff of air (/p/, /b/, /k/, /g/, /t/, /d/) then the manner of articulation is a stop. If the the airflow is redirected through the nose (/m/, /n/, /ng/) then the manner of articulation is a nasal. Here is a list of the manners of articulation.

• stop - airflow is completely stopped and then released
• fricative - airflow is constricted causing slight hissing noise
• affricate - This is a combination of a stop and a fricative. First the airflow is completely stopped and then it is constricted causing a slight hissing noise with the consonant.
• nasal - airflow is redirected out the nose
• liquid - airflow is constricted significantly more than a vowel, but not enough to cause a hissing noise with the consonant
• glide - similar to a liquid, but with slight movement during the production of the consonant

What is voicing?

There is a third characteristic of consonants. /s/ and /z/ are made with exactly the same place and manner of articulation and yet they are different. /z/ is made while vibrating the vocal folds. If you place your hand on your throat while making a /z/ sound (buzz like a bee) you will feel the vibration of your vocal folds. /s/ is made without vibrating the vocal folds. If you place your hand on your throat while making an /s/ sound (hiss like a snake) you will not feel the vibration. So the third characteristic of consonants is the presence or absence of voicing.

Why are consonant characteristics important to understand when planning therapy for Childhood Apraxia of Speech?

First of all, understanding the characteristics of consonants can help you understand why some consonants are harder than others for your child. Affricates are going to be harder than stops or fricatives because they require more complicated motor planning. Words with consonants that are all produced in the same place (dot) are going to be easier than words with consonants that change place (pod). Words with consonants that move from the very front to the very back are going to be even harder(back). Voiced sounds are going to be harder than their coresponding voiceless sound because the motor planning is more complex. Speech-Language Pathologists take all of these factors into account when choosing targets for speech therapy.

You might also be interested in the following articles:

Speech-Language Pathology Topics: Vowels

Voicing Pairs

Random Example of the Complexity of Motor Planning

Simultaneous Relief and Sadness

Oh my goodness is she talking. The other day Ava commented that, "Daddy put peanut butter on Ava's really really big pancake." That's a 10 word sentence coming from my little girl who's only 27 months old. It is such a relief. 6 months ago she had only three words in her vocabulary and couldn't imitate. Now she's talking in multi-word sentences. Obviously her language is fine.

However...

More and more, I can't understand her at all. I'm pretty good if she's talking about something immediate and in front of us (like Daddy and the pancakes). If I have some context and we can see and point at it I can understand most of what she has to say. But if she's talking about anything else I'm clueless. You often can't understand a word of what she's saying. If she starts rattling off her opinion of a tv show I haven't watched or telling me about something she did at her grandparents' house I often have no idea.

As you would expect for Childhood Apraxia of Speech, the longer the utterance, the less you can understand. It's killing me. She has so much to say. Her little mind wants to tell stories. She wants to engage in back and forth conversation. Instead she says something which I hear as, "Garble, garble, garble, garble, garble" and I just look at her and reply, "Uh huh sweetie." And then I try to change the subject. Sometimes I say, "I'm sorry, sweetheart, Mama didn't understand you. Can you tell me again?" But I only do that when I think I have some chance of getting it. Otherwise, she just gets frustrated at trying to tell me over and over unsuccessfully.

I know we're working as fast as we can. I know she's made phenomenal progress in a relatively short time. I know she can communicate so much more than before. But honestly, I feel that it is terribly unfair that she's worked so hard, she's finally got so much to say and is actually trying to say it, and she still can't communicate successfully much of the time with her loved ones. That sucks.

Free Speech Therapy Articulation Picture Cards: Final T

This version is out of date. Go here for new, easy to download, version and additional sets.

There are a lot of articulation cards available for working on just about any sound for your child. There are many commercial sets that you can buy and there are many that you can find for free online. I've done both. I was frustrated that most of those sets did not meet our needs very well.

When you are working with a young child who has Childhood Apraxia of Speech you need the words to be relatively simple in structure. Many of the lists were half full of two and three syllable words that are way too complicated for a young apraxic child to imitate. Also, children with apraxia need to practice their target sound paired with as many vowels as possible, and most sets are not designed with that goal in mind. Also, if you are working with a toddler, the words need to be relatively easily understood concepts for a young child. A word like "beg" is harder to understand and make a picture for than a word like "bed."

I have complied a set of 40 one-syllable words that I feel are easily understood or taught to a young child and I have made picture cards for them. I also have written out some directions for making the cards and some ideas for activities to do with the cards. The words are divided into levels by difficulty. I suggest you begin with the easiest cards and include the harder levels as your child is able to practice them too. I also describe the different levels of cueing you can use and provide suggestions for very simple one word carrier phrases you can use when you want to move to a two word level.

You are welcome to download the set for use with your child. I will be posting sets as I complete them.

For an easy to print version, download a .pdf of the five-page One-Syllable Final T Articulation Picture Cards file.

This is an old version of the card set. You can find the new version and additional sets in an easy to download format here: Free Speech Therapy Articulation Cards

Apraxia Therapy Materials: Kaufman Speech Praxis Kit 1 (Basic Level)

Therapy Materials Review: Kaufman Kit 1 (Basic Level)

This is a review of the Kaufman Speech Praxis Treatment Kit for Children (Basic Level). The kit was developed by Nancy Kaufman, MA, CCC-SLP. Nancy Kaufman is a nationally acclaimed expert in apraxia who has developed assessment and treatment materials in the area of apraxia. This kit contains a small manual that explains the treatment methods recommended and 201 picture cards sorted into category by syllable shape. The back of each card shows a hierarchy of acceptable responses for the picture on the card depending on the current performance level of the child.

Target Audience

The target audience for the Kaufman Kit Basic Level will usually be children between the ages of two and six. The pictures on the cards were designed with those ages in mind. These cards will be most useful for children who are struggling with producing simple syllable shapes and need to focus on the early emerging consonants /p, b, m, t, d, n, h/.

Description of the Kaufman Kit (Basic Level)

This kit is a boxed set of treatment materials including a 52 page manual and 201 stimulus cards sorted by type.

• Manual
  The manual is the same for both the Basic Level Kit 1 and the Advanced Level Kit 2 so some of the pages in the manual do not apply to Kit 1. The manual begins with a note to parents that describes Childhood Apraxia of Speech, gives an overview of the Kaufman Speech to Language Protocol approach to treating Childhood Apraxia of Speech, and briefly describes some things parents can do at home. The rest of the manual is pretty technical and written with a Speech-Language Pathologist in mind as the target audience for the manual. The rest of the manual describes the Kaufman evaluation hierarchy, treatment hairarchy, describes cueing techniques, gives examples of goals for IEPs and describes general treatment considerations.
  
  
• Stimulus Cards
  The cards consist of 201 full color 5" by 7" cards. The cards are seperated into sections that are color coded so that you can easily pull the cards, use them in therapy, and then sort them back into their sections. The early emerging consonants are included in kit one. Those consonants are /p, b, m, t, d, n, h/. Syllable shapes include CVCV, VC, CV, VCV, CV1CV2, C1V1C2V2, CVC, and CVCVCV. There are also more complex versions of some of those basic syllable shapes.
  
  

How to Use the Kaufman Kit Cards

Through formal or informal assessment, determine which syllable shapes are missing and which of the missing ones the child is stimulable for. Then work with the card sets for the missing syllable shapes that are easiest for the child. Remember that any of the responses on the back of the card can be considered to be correct. The responses on the back of the card are all acceptable, but get closer to the actual production of the word as you move from bottom to top. When you start working with a particular card, figure out which is the highest production the child can successfully imitate and start there gradually working your way up by using the cueing techniques described in the manual.

Therapy Activity Suggestions for Kaufman Kit Cards

• You can always simply drill the words offering a verbal reward, sticker, or turn at a game after every 5-10 responses.
• Make a laminated train engine and caboose. Line your cards up in between the engine and caboose making a word train and place a small reward (sticker, cheerio, etc.) on the caboose. Have the child say each word 1-5 times and when they reach the end of the train they get the reward. Then set up a new train.
• Tape the cards in a line on the wall. Make the room as dark as possible and let the child light up each card with a flashlight. They must say the word 1-5 times before they can light up the next word.
• Hide the cards around the room. Tell the child that you are playing hide and seek with the words and that they need to find 10 (or however many you hid) words. As they bring each word to you they need to say it 1-5 times before going to find the next word. Once they find all the cards they get a small reward. Then they cover their eyes while you hide a new set of cards. Or, you can trade and let them hide the words for you to find. They still have to say each word 1-5 times when you bring the card to them before you go find another.
• Lay the cards on the floor in some kind of pattern and play a beanbag toss game. They say the word the beanbag lands on 1-5 times before getting to throw the next beanbag.

Pros and Cons of the Kaufman Speech Praxis Kit 1 (Basic Level)

Pros: This kit provides materials for systematically building speech from least difficult to most difficult in terms of syllable structure. Within each syllable structure, there is also a hierarchy of acceptable responses from the least motorically complex to most motorically complex (and accurate). That makes this kit ideal for working with children who have Childhood Apraxia of Speech particularly those children who are minimally verbal.

Cons: This kit is very expensive. It is only Kit 1. There is another kit that includes the later developing consonants and more complex syllable structures that you might want when a child outgrows Kit 1. That kit is also very expensive. There are only a few words (usually 6-12) in each category so if you are looking for a wide variety of words to increase generalization, that is not the purpose of this kit. Also, if your child needs practice with a wider variety of consonants, they will not be included in this kit.

For the price, I expected a big manual that was designed to educate a parent or novice SLP with little apraxia experience about the disorder itself. Then I would would like for the manual to explain in an accessible way the theory behind the Kaufman method and why it is so appropriate for treating the disorder. The manual should make it very easy to understand how to use the materials with children and give concrete examples of therapy activity ideas. To put it simply, I was underwhelmed with the manual.

Bottom Line:

If you already have the knowledge and expertise to understand how to best use these materials and you have several minimally verbal children on your caseload, this kit would be well worth the purchase price. If you do not meet both of those criteria, I believe the price is prohibitive.

You might also be interested in the following articles:

Apraxia Therapy Materials: The Big Book of Exclamations

Apraxia Therapy Materials: Webber Jumbo Articulation Drill Book

Free Speech Therapy Articulation Picture Cards: Final N

This version is out of date. Go here for new, easy to download, version and additional sets.

There are a lot of articulation cards available for working on just about any sound for your child. There are many commercial sets that you can buy and there are many that you can find for free online. I've done both. I was frustrated that most of those sets did not meet our needs very well.

When you are working with a young child who has Childhood Apraxia of Speech you need the words to be relatively simple in structure. Many of the lists were half full of two and three syllable words that are way too complicated for a young apraxic child to imitate. Also, children with apraxia need to practice their target sound paired with as many vowels as possible, and most sets are not designed with that goal in mind. Also, if you are working with a toddler, the words need to be relatively easily understood concepts for a young child. A word like "beg" is harder to understand and make a picture for than a word like "bed."

I have complied a set of 40 one-syllable words that I feel are easily understood or taught to a young child and I have made picture cards for them. I also have written out some directions for making the cards and some ideas for activities to do with the cards. You are welcome to download the pictures for use with your child. I will be posting sets as I complete them.

For an easy to print version, download a .pdf of the four-page One-Syllable Final N Articulation Picture Cards file.

This is an old version of the card set. You can find the new version and additional sets in an easy to download format here: Free Speech Therapy Articulation Cards

Free Speech Therapy Articulation Picture Cards: Initial B

This version is out of date. Go here for new, easy to download, version and additional sets.

There are a lot of articulation cards available for working on just about any sound for your child. There are many commercial sets that you can buy and there are many that you can find for free online. I've done both. I was frustrated that most of those sets did not meet our needs very well.

When you are working with a young child who has Childhood Apraxia of Speech you need the words to be relatively simple in structure. Many of the lists were half full of two and three syllable words that are way too complicated for a young apraxic child to imitate. Also, children with apraxia need to practice their target sound paired with as many vowels as possible, and most sets are not designed with that goal in mind. Also, if you are working with a toddler, the words need to be relatively easily understood concepts for a young child. A word like "beg" is harder to understand and make a picture for than a word like "bed."

I have complied a set of 40 one-syllable words that I feel are easily understood or taught to a young child and I have made picture cards for them. I also have written out some directions for making the cards and some ideas for activities to do with the cards. You are welcome to download the pictures for use with your child. I will be posting initial sets as I complete them.

For an easy to print version, download a .pdf of the four-page One-Syllable Initial B Articulation Picture Cards file.

This is an old version of the card set. You can find the new version and additional sets in an easy to download format here: Free Speech Therapy Articulation Cards

Apraxia Therapy: Articulation Practice

What is Articulation Practice?

Articulation practice is practicing making specific sounds. Children with all types of speech sound disorders have to practice making sounds.

• Children with a simple articulation disorder only have trouble with one or two sounds and they practice those sounds first in isolation, then at the beginning, middle, and ends of words, then in phrases and sentences, and finally in conversation.
• Children with phonological disorders have trouble with groups of sounds or patterns of sounds and their speech therapist chooses words in those groups or words that have those patterns to practice.
• Children with Childhood Apraxia of Speech have trouble with the motor planning of speech movements. They need to practice all possible combinations of sounds in as many contexts as possible as often as possible to try to make that motor planning smooth and automatic.

How does Articulation Practice need to be different for children with Childhood Apraxia of Speech?

1. Children with Childhood Apraxia of Speech need many more repetitions than children with other types of speech disorders in order to show improvement. It takes a lot of practice to improve motor planning.
2. Children with Childhood Apraxia of Speech need to practice speech in a way that builds complexity much more gradually than children with other types of speech disorders. Instead of working with words as the smallest unit of complexity, they will look at specific types of syllables and work their way up from the simplest syllable shapes to more complex ones. For example, a Consonant-Vowel (CV) syllable shape such as the word "boo" is a very simple syllable shape. Another very simple syllable shape is Vowel-Consonant (VC) such as "at". A complex syllable shape is CCVCC such as "blast". Yes, boo and blast are both one-syllable words that start with B, but one is much simpler than the other.
3. Children with Childhood Apraxia of Speech need to practice consonant sounds paired with as many vowels as possible. For children who do not have difficulty with motor planning, it is enough to simply practice beginning, middle, and ending consonants without thinking about the vowels in between. Children with motor planning problems have to practice each consonant with each vowel because a consonant paired with one vowel requires different motor planning than that same consonant paired with a different vowel.
   
   Here is an example: Say "bee, bee, bee" and then pause before making the next /b/ sound. Your lips are pressed together. Now say "boo, boo, boo" and then pause before making the next /b/ sound. Your lips are pursed as if you're about to blow a kiss. The motor planning for a /b/ paired with the "ee" is different than the motor planning for a /b/ paired with the "oo".

What are some speech therapy materials that can be used to practice articulation in a way that is best for children with Childhood Apraxia of Speech?

• The only formal speech therapy materials that I know of that addresses syllable shapes is the Kaufman Kits (level one and level 2). The Kaufman Kit is designed to work systematically through the simplest syllable shapes in approximate order of difficulty. Alternately, you can simply take free word lists you find online and sort them by syllable shape and start with the simplest ones first gradually working your way up to harder syllable shapes.
• I am not aware of any articulation picture sets that make a deliberate effort to include all vowels. I am currently creating my own picture sets to try to address this issue. The sets are designed as much as possible to include words that are familiar to young children or that are easily taught. The sets will include only one-syllable words and will include at least one example of all possible vowel pairings. Eventually I would like to create multi-syllable words lists as well but that will not happen for quite some time. Look for the sets to begin to appear on this site shortly.

Key Points to Remember about Articulation Practice for Childhood Apraxia of Speech

1. Many, many repetitions.
2. Move from simple syllable shapes to more complicated syllable shapes.
3. Pair each consonant with as many different vowels as possible. Some pairings will be easier than others. Practice them until they become automatic.

Note: Remember that your child's production does not have to be perfect. For example, say you are practicing "spoon" because it has the "ooh" vowel paired with a final /n/. Your child says "soon". Great! They may have left out the /p/ in "spoon", but they correctly pronounced the vowel and final /n/ that you were looking for. Treat that as correct (for now - until you start working on the /sp/ blend) and heap on the praise.

You might also be interested in the following articles:

Apraxia Therapy: Communication Boards

Apraxia Therapy: Gestural Prompts

Apraxia Therapy: Two-Word Combinations

Speech-Language Pathology Topics: Vowels

What are vowels and why are they important to speech?

A vowel is a sound produced with a relatively open vocal tract. In contrast, consonant sounds are produced by constricting or interrupting the air flow at some point during production. You can maintain a vowel until you run out of breath. For example, take a deep breath and say "eeeeee" for as long as you can. You can keep making that sound until you get bored or until you run out of breath. However, when you make the "p" sound, you can't draw it out. You simply make the sound once and then have to move on. Vowels are essential to speech because they are the core of every syllable we make. Every word has at least one vowel. When vowels are produced incorrectly, that makes speech very difficult to understand.

What are the characteristics of vowels?

What makes an "e" different than an "o"? The vowel sounds are different from each other because you change the shape of your mouth when making each vowel. There are two main ways you change the shape of your mouth. Some vowels are made in the front of the mouth, some in the center, and some in the back. At the same time, some are made with the mouth relatively closed while some are made with the mouth relatively open. Speech-Language Pathologists use a vowel chart to keep track of the vowels and their characteristics.

If you say "beeeeeeee" and then say "baaaaaaaa" (as in "bat") you'll notice that you open your mouth more to make the "baaaaaa" sound. Next, say "beeeeeee" again and then "baaaaaaa" (as in "body"). This time you'll notice that the first sound is made in the front of the mouth while the second is made in the back.

What is the difference between a simple vowel and a diphthong?

A simple vowel is a sound made by keeping your mouth in a single position. When making a diphthong vowel, your mouth changes position. So, when making the /aI/ sound as in "bike" your mouth starts in a very open position and then closes for the second half of the diphthong. This second chart shows the five common diphthongs in American English and how they move in the mouth.

Why are vowel characteristics important to understand when planning therapy for Childhood Apraxia of Speech?

First of all, understanding the characteristics of vowels can help you understand why some vowels are harder than others for your child. Diphthongs are going to be harder than simple vowels because they require more complicated motor planning. If your child has an easier time with front sounds, they'll probably have an easier time with front vowels. If you are trying to help your child learn a back consonant (like /k/) it should be easier for them to make when paired with a back vowel because that makes the motor planning simpler.

Remember that Childhood Apraxia of Speech is fundamentally a problem with the motor planning of speech. The child has to form a motor plan to get from one sound to the next in a word including the consonants and the vowels. So if your child is working on /b/ words, the motor planning will be different if they are saying "bee" instead of "boo" because the vowels are produced in completely different ways. When you set up practice word lists, you want to pair /b/ with as many different vowels as possible to maximize generalization.

You might also be interested in the following articles:

Voicing Pairs

Random Example of the Complexity of Motor Planning

Apraxia Therapy Materials: Webber Jumbo Articulation Drill Book

Book Review: Webber Jumbo Articulation Drill Book

This is a review of the Webber Jumbo Articulation Drill Book by Sharon Webber, M.S. and M. Thomas Webber, Jr. The book is designed to be a resource for Speech-Language Pathologists that offers a kind of dictionary of words, phrases, and sentences that can be used in therapy for the most common consonant sounds in the English language.

Target Audience

This resource is useful for Speech-Language Pathologists working with all ages. If you need to target specific speech sounds, this book is a wonderful resource for you. The pictures are essentials with young children and the word, phrase, and sentences lists work well with older children and even adults.

How to use the Webber Jumbo Articulation Drill Book

You need to know what sounds you are going to target and in what context (Do you need to target the sound at the beginning, middle, or ends of words? Do you need to target the sound in words, phrases, or sentences?) Once you know what you need to work on, you simply turn to the appropriate section of the book, copy the page, and use it in therapy.

What is inside the Webber Jumbo Articulation Drill Book?

You can view sample pages of the book.

The book has word lists, pictures, phrase lists, and sentences in initial, medial, and final positions for the following sounds: R, S, L, (Initial R, S, and L Blends), Z, SH, CH, TH (voiced and voiceless), F, V, K, G, P, B, T, D, J, H, M, N, and Y. It also includes an articulation drill record form, progress chart, homework helper note, and awards. There are a total of 6,420 target words, 3,120 phrases, 3,120 sentences, and 1,710 pictures.

Therapy Ideas using the Webber Jumbo Articulation Drill Book

• You can practice the words in drill format by simply going through one at a time. Each picture card has boxes at the bottom for you to keep track of correct and incorrect productions if you like.)
• You can make two copies of each page, cut the individual pictures out, and play a matching game or Go Fish style game with the pictures.
• You can cut out the pictures and glue them onto a piece of cardboard in a kind of snake and make a game board. Have the children spin a spinner or roll dice and say the words they land on the number of times that they rolled in order to move forward.
• You can cut out the pictures, glue them onto fish cut out of construction paper and then laminate the fish. Glue a small magnet on the back of each fish. Then make a fishing pole with a magnet on the end of the line and go fishing for the words.
• If you have a small bowling pin game, you can glue or tape words to each pin. The child knocks down the pins and then has to say each word before they can set each pin back up for the new try.
• Form a long train from the pictures. You can put an engine at the front and a caboose at the end. Put a small prize on the caboose like a sticker or piece of candy. When the child finishes saying each word that forms the train, they get the prize on the caboose.
• You can let the children color the black and white line drawing pictures.

Pros and Cons of the Webber Jumbo Articulation Drill Book

Pros: This book can be very useful. It gives you some words to use in therapy for all common consonants in all three word positions. If you use the words and pictures creatively, they can make articulation therapy fun and productive. It is also great to have phrases and sentences included as well.

Cons: Young children often need practice with simple, one-syllable words. Often, there are only a small number of simple one-syllable words included for each phoneme in each position. You may not find a lot of exactly what you are looking for. Also, some of the pictures are hard to interpret for little ones or may not be the best illustration for the word.

Bottom Line

If you are looking for a single resource that will have at least a few stimulus words for almost any sound in any context, this is a hard book to beat.

You might also be interested in the following articles:

Apraxia Therapy Materials: The Big Book of Exclamations

Apraxia Therapy Materials: Talking Carl iPhone / iPad App

Apraxia Therapy Materials: Doodle Buddy iPhone / iPad App

Home Therapy Plan - Rough Draft

Here's my first attempt (this time around) at structuring therapy sessions here at home.

1. I made Ava a speech bag to store her speech materials in. Since we're really fancy around here, her bag is a ziploc decorated with stickers.
   
2. I printed some very nice articulation cards I found at mommyspeechtherapy.com. I cut those out, paperclipped the different targets, and stuck them in the bag. Note: I printed these on cardstock at high quality to make the cards more durable and prettier.
   
3. I found a site with some free printable reward charts and printed a butterfly one for Ava.
   

Now, my original idea was that Ava and I would sit down together and my charisma and enthusiasm would result in her wanting to practice speech sounds with me in exchange for the pleasure of putting stickers on the chart after each set of cards.

Hahahahahaha.

After that complete failure, I offered her two froot loops of her choice after doing each stack of cards. ("Two pink mommy." Hmm... what will we do when we run out of red froot loops?) That worked much better. We ended up with only one sticker on the chart. So I stuck the chart up on the wall and now we'll put a sticker up on the chart after each session.

My goal is to try to get in four or five 10-20 minute sessions per week. We'll see how it goes.

Therapy Progress - Small Details Add Up to Big Picture Progress (At least, that's the plan.)

I realized that I haven't done a real update on Ava's therapy progress and speech in quite a while.

Here are her previous updates, in order, for anyone who is just tuning in and is interested in the background:

• Speech Therapy Progress: January 27, 2011
• Therapy Progress - Speed of Light: February 17, 2011
• Two-word combinations begin: March 5, 2011
• Therapy Progress - Practice and Generalization: March 21, 2011
• Therapy Progress - Steady Progress and Subtle Change: April 12, 2011

It has become much more difficult to track Ava's progress. The difference between "My baby isn't talking!" and "My baby is starting to use words!" is pretty clear and exciting. The difference between, "She can't even imitate." and "She can imitate." is also pretty clear cut. The increase from single words to two-word phrases was obvious as well as was the increase to 3-4 word sentences. Getting a new sound is another simple, observable change. Well, we went through all of those easy to track changes and they were wonderful and I was feeling great. Then there was the reality check of a standardized articulation test. Overall, things are getting harder to track now, but I'll try.

Big Picture

Ava is certainly talking a lot. She pretty much never uses a single word utterance any more. She's rarely uses a two-word phrase. Oddly enough, now that she is more ambitious in her speech she is actually harder to understand. When her sentences are longer and particularly when I have no context, I have a lot of trouble understanding her. It is frustrating for me and for her. I can handle my frustration, but watching her get upset when I don't understand just kills me.

So, I suppose the good part of the "big picture" is that Ava's gained enough confidence to try more. In terms of the length of her sentences, she's pretty much age appropriate. Also, the more she talks the more opportunities you have to practice, refine, and correct. The challenging part of the "big picture" is that the more she tries to say the harder she is to understand.

Details

Specifically, we are working on two main areas. We are trying to add final consonants (only the ones she can actually make) to her words. She does best with /t/ and /p/. Those sounds are easier for her because they are voiceless. She can imitate a final /t/ (like in hat) and a final /p/ (like in up) pretty much 100% of the time. She's also using them on her own when talking roughly 30% of the time. We're trying to work on final /d/, /b/, /s/, /n/, and /m/ as well, but those are all harder for her. She can imitate some better than others, and pretty much never uses them on her own.

The other thing we're working on is trying to get some new consonants. Specifically we are trying to get the /k/ sound. Ms. J says that she has gotten Ava to make a /k/ sound in isolation during her therapy sessions, but I just cannot get her to do it here at home. I even tried bribing her with M&M's, but still no luck.

Why these specific targets? Well, adding final consonants is huge. Leaving those sounds out makes her much harder to understand and as she starts to add those sounds back in, that should improve her intelligibility. Improving intelligibility (how well she is understood) is the reason for trying to get her to make the /k/ sound. /k/ will be the gateway sound for /g/ because they are a voicing pair. There are a lot of words out there that use the /k/ and /g/ sounds and right now she either leaves the sound out or substitutes a /t/ or /d/. If we can introduce the /k/ and eventually the /g/ she should get a big boost in her ability to make herself understood.

And so we march forward. We choose targets that we hope will get us that much closer to our overall goal of helping Ava express herself in a way that can be understood.

My goal for the next few weeks is to reintroduce structured home practice. She needs more repetitions. That is the core of apraxia therapy. Even if I have to resort to bribing the girl with candy, we will somehow get it done.

Complacency and Marathons

When I finally accepted that I needed to get help for Ava, she tested so low, and the label Childhood Apraxia of Speech was spoken out loud it had a huge, profound impact on me. I was very depressed. I had difficulty thinking about anything else. My mind constantly circled around questions that simply cannot be answered right now about how much progress Ava will make and what will the impact of all of this have on her childhood and future.

After a few weeks I passed through the "this has rocked my world and not in a good way" stage and into a more productive stage. There was a flurry of research, self-education, setting up appointments, starting therapy, getting hearing checked, surgery for PE tubes, learning and using sign language, making and setting up communication boards, IFSP meetings, considering and trying nutritional supplements, and blogging about all of the above. And, it was all worth it. We saw changes in Ava's ability to communicate - dramatic and celebrated changes.

I began to breathe a sigh of relief. Yes, the disorder is still there, but it is responding to treatment. I relaxed. I gave myself permission to stop pushing Ava so much at home. To be honest, she didn't respond well when I tried to sit her down at home and do structured therapy with her myself and so I stopped even trying. I switched to a more indirect method of working with her through books and songs and correcting the many utterances we get each day as a natural part of our daily life. So much positive change had taken place so quickly that I began to think that we were "okay." Perhaps we were lucky enough that Ava's apraxia was so mild that we could get her "caught up" in a 1-2 year time frame rather than a much more extended time frame.

Then, our first standardized articulation test was a bit of a reality check and I realized how she is still very far behind her same-age peers. I had become a bit complacent. The progress Ava had already made was such a relief that I forgot that there is still a long way to go. I haven't quite decided what to do about that yet, but over the next couple of weeks I'm going to be thinking about ways I can focus on Ava's speech more here at home again. I'd like to build in some speech time every day in a way that hopefully she and I can both enjoy. I need to remember that this journey is something of a marathon and that I cannot just simply hope that we've come far enough that the rest will magically take care of itself.

Apraxia Therapy Materials: Doodle Buddy iPhone / iPad App

Doodle Buddy is another iPhone / iPad app that can be a wonderful way to elicit speech or sound effects from your child. The program is free, but is overrun with really obtrusive ads. You can choose to pay $0.99 to remove the ads from the application.

This program does many things all of which can be used as a therapy activity.

• It is a drawing program. (Please don't laugh at my lack of artistic skills.) You can draw things for your child to label. Alternately, you can follow their instructions and draw what they tell you to. If they say "car," you do your best to draw one.
  
  
  
• The program has "stamps". There are tons of little pictures that your child can transfer to the screen just by choosing the one they want and then tapping as many times as they like. Even better, each stamp has a sound effect. So the frog croaks, the crying face cries, the dog barks, and so on. Your child can label the stamp or imitate the sound effect. Even if they are non-verbal and using signs, you can wait until they make the sign for "more" before you let them put more stamps on the page. Here is a sampling of the stamps available. There are many more than would fit on one page.
  
  
  
• There are backgrounds and themed stamps to go along with them. Some come with the program. Some you have to "buy" with points. If you are willing to install a few free programs on your machine you can get more points for free to get additional themes.
  
  So you pull up a background. Backgrounds (themes) include dinosaurs, cars, beach, farmyard, lake, princess, space, underwater, winter, spooky house, doghouse in backyard, desert, and more. You make up a story about the picture adding stamps as you go along. You get your child to repeat words that are part of the story. Here are some examples.
  
  Farm: Mama chicken was at the farm today. (insert chicken, have child say, "chicken"). She had three baby chicks with her. (insert three baby chicks counting, "one, two, three") They were lonely! They wanted to play with some friends. (toss in a couple of sheep and practice saying, "baa") I could continue, but you get the idea.
  
  
  
  
  Here are examples of the lake and princess themes as well.
  
  
  
  
  
  
My kids particularly enjoy the haunted house theme, the cars theme, and the farm theme. I'm sure your kids will have their favorites too. Really, the possibilities for using this program as a therapy tool are only limited by your imagination. (I make up really boring stories when put on the spot, but the kids don't seem to care. I get lots of speech and vocabulary practice in and that is all that really matters.)

You might also be interested in the following articles:

Apraxia Therapy Materials: Talking Carl iPhone / iPad App

Apraxia Therapy Materials: The Big Book of Exclamations

NutriiVeda vs NutriiVeda Achieve Comparison

Our first shipment of NutriiVeda Achieve arrived. As expected the product now comes packaged in a resealable 30-serving foil pouch rather than in two 15-serving canisters. The flavor is now French Vanilla rather than Vanilla. Here is a chart highlighting the main nutritional differences between the old NutriiVeda formula and the new NutriiVeda Achieve formula.

The differences I see as most significant, nutritionally are the reduced sugar, added fiber, and added sodium. Although interesting, the added Omegas are not super significant for me because they come from plant sources rather than fish sources making them less appropriate as a supplement for apraxia. Also the dosage is less than generally recommended as a therapeutic dose.

I tried it myself. I do believe that the new NutriiVeda Achieve formulation results in a creamier "shake" (mixed with skim milk) than the original formula. I also think that the new formulation is a little more subtle than the old one. To be honest, I personally disliked the old one. I'm not in love with the new one, but I dislike it less. I found the old one difficult to mix into milk without ending up with lots of big clumps. The new one has the same problem.

The original NutriiVeda mixed beautifully into yogurt. It almost disappeared in terms of texture. If anything, it seemed to make the yogurt a little bit thinner. The new NutriiVeda Achieve seems to mix into the yogurt and give it a creamier, thicker, fluffier texture a little like a mousse.

When I gave it to the kids (occasionally I feed the mix to both kids - it's just simpler that way) Michael immediately noticed the change. He said, "This is a new yogurt. It tastes different. It tastes salty." Now, yes, the new NutriiVeda Achieve does have sodium while the old one did not, but you're also taking the word of a 3 1/2 year old that it tastes salty. I'm not sure he uses the term accurately. That might just be the only word he knows to describe a change in taste. On the other hand, they added sodium and removed over half the sugar content. It may actually taste saltier to him.

He continued to comment on the change as he consumed the bowl. He ate it, but I'm not sure he liked it. Ava ate hers and did not comment on the difference. We've only had one serving so far. I'll let you know if the difference in taste (or texture?) becomes a problem.

Bottom Line The new NutriiVeda Achieve is significantly different in taste and texture from the old NutriiVeda formula. I like the concept of increased fiber and reduced sugar, but I also need Ava to eat it. We'll see if she continues to eat the new formula. I'm not super fond of the increase in sodium. My opinion of the added Omega 3 and Omega 6 from plant sources is neutral.

Reality Check

When we started all of this Ava had too little speech to give her any kind of formal articulation assessment. You can't ask an essentially nonverbal child to label pictures in a book so that you can score how well they did making sounds. Now that Ava has so many words her early intervention therapist and I decided to give her an articulation test to see where she is.

The Goldman-Fristoe Test of Articulation 2 is very simple in concept. It is a book of pictures. Your child labels the pictures and the Speech-Language Pathologist transcribes how your child pronounces each word exactly as your child says it. The test is designed so that after all of the pictures have been pronounced your child has attempted to pronounce every consonant sound (and some blends) in every position (beginning, middle, end) of words in which they appear in the English language.

We gave the test to Ava. It took us two sessions. There are a lot of words on the test and it is hard to get a two year old to focus. She did better than I expected. She got sounds on the test that she doesn't usually get in regular conversation. I was feeling pretty good about the whole thing.

Then I scored the test. She got a standard score of 72. That's equivalent to the 7th percentile. That means that 93% of children her age perform better than her on this test. Wow! Seeing that number was a huge reality check for me.

I've been so focused on all the improvements. She's made amazing progress since we started getting her help. She had no words. Now she had more than I can count. She went from one-word utterances to two and three-word phrases. Now we are frequently hearing four and five-word sentences. She was a pretty silent toddler who wasn't even trying to talk any more - a toddler who had to resort to gestures and pulling me around to ask for what she wanted. Now she talks all the time. She communicates with her parents, grandparents, brother, teachers, and friends. She even talks to herself. She tries to sing and hum. I was proud. I was excited.

Now, with this new number (7th percentile!) I am sad and discouraged again. I know that this new information takes nothing away from all of her accomplishments. I do know that. I know that this new information is a valuable reality check. It gives me information I can use to go forward and plan our next steps. As a speech-pathologist the test results are interesting, valuable, and even a little exciting. As Ava's Mama, those test results make me sad. They are a reminder of her struggle and the long road that is still ahead of us. Reality really stinks sometimes.

Another Perspective (On NutriiVeda) Is Always Valuable

We've been trying NutriiVeda with Ava. I'm frustrated by the lack of anything other than anecdotal evidence of improvements, but given that lots of parents are seeing improvements with their children I had to try it. Tentatively, I feel like we've seen an increase in the amount of speech from Ava, and in the length of her sentences since we started using NutriiVeda about six weeks ago.

However, NutriiVeda is expensive and there is no scientific evidence. I came across a well written post on the blog of another mother with a daughter who has Childhood Apraxia of Speech. She tried NutriiVeda with her daughter for three months and did not feel like she saw significant improvements. She saw no regression when she stopped using the product. Check out her post on NutriiVeda. If you're thinking about trying NutriiVeda, you should read the opinions of people who tried it and didn't like it in addition to the posts of all the parents who love it.

While on the topic of the Apraxia Adventures blog, I really identified with her post on her son learning to kiss as well. I am way too familiar with that bittersweet feeling of being happy and sad (jealous!) at the same time.

Since both of my children have oral apraxia, I feel it when I see another woman's baby look at me and smile - so easily and naturally. I enjoy the smile. I enjoy the sweetness of it. And then I wish I had been able to experience that with my children. I wish it had been natural and easy. Or recently, I watched a video of a toddler Ava's age being interviewed by her mother about things like her favorite toy, food, game, etc. The video was adorable as was the toddler. Her speech was so clear. The sentences were so long. I want that ease for Ava. Will I always see other children through the lens of what I want for Ava?

Bah! Enough of this self-pity and sadness. Overall things are good. Improvements abound. I refuse to dwell overly long on depressing thoughts. I'll just share them briefly and then move on.

Six!!!

Ava loves cucumber and dip. She ate all the cucumber on her own plate (about 1/4 of a rather large cucumber). Then she eyed Michael's plate and asked if she could have his cucumber. He had already decided that he wasn't going to eat his, so he gave his cucumber to Ava. That quickly disappeared too. At this point, the girl had consumed half a cucumber.

She looked down rather pitifully at her plate and said, "No more on Ava's blue plate!" Six!! That's a six word sentence from the same little girl who had only three words in her entire vocabulary four and a half months ago. I'm practically speechless myself in awe and gratitude. (Standard disclaimer: No, that sentence was not pronounced "correctly" with every sound present, but all the words were there and I could understand them.)

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

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.

What methods are used during therapy for Childhood Apraxia of Speech?

When reviewing the most effective methods for treatment of children with Childhood Apraxia of Speech there seems to be a unifying theme and that is neurology. CAS is a neurological disorder. The areas and pathways in the brain that are typically responsible for the motor planning of speech are not functioning properly. The purpose of therapy is to retrain those areas to be more efficient at their job and to recruit other areas and pathways in the brain to help when possible. The best way to enlist other areas of the brain to help out is to take a multisensory approach to therapy.

Multisensory Stimulation Techniques

Typically speech involves listening to a speech stimulus and responding appropriately. This uses specific areas in the brain that are separate from the areas that listen to and enjoy music. The speech listening pathways are different from the areas involved in watching and interpreting visual signals. The speech listening pathways are different from the sensory receptors that feel touch on the skin.

What does all of that mean for therapy? It means that when you use multiple sensory pathways when trying to stimulate speech, you recruit other areas of the brain to help out the speech areas that are struggling. So, the speech therapist may use music to try to elicit speech productions to enlist the help of the part of the brain that listens to and enjoys music. The speech therapist may use tapping (tapping, clapping, or snapping with each syllable) to enlist the part of the brain that involves rhythm and basic math. Tapping draws the attention to each separate syllable in a way that simply saying them separately does not. You can use tapping to engage multiple pathways by gently tapping the child's hand or leg along with the syllables which also engages the part of the brain that senses touch. The speech therapist may use visual hand signals paired with specific speech sounds to enlist the part of the brain that interprets visual signals. The speech therapist may use touch on the child's face to cue certain speech sounds or movements.

For children who are nonverbal, often big body motions like swinging on a swing or bouncing on an exercise ball paired with music can help elicit some first sounds. The therapist will try to engage different senses to find one type of stimulation that helps or a combination of stimulation methods that help elicit speech.

Manipulate rate

Sometimes slowing down speech can help. Doing things more slowly allows more time for motor planning. Your therapist may incorporate practice with slowing down speech production to try to help your child be successful at producing speech targets.

What does a speech language pathologist teach children with Childhood Apraxia of Speech?

This is an incredibly complex topic. I'm just going to try to give you a basic overview of the type of things your therapist will think about when choosing goals for your child.

Your therapist will choose targets for your child based upon their professional expertise, their assessment of your child's current skill level, their knowledge of which targets would be age-appropriate, what the child is stimulable for, and their assessment of your child's most pressing needs. (Your child may be missing 10 age-appropriate sounds, but one particular missing sound makes him or her really hard to understand. That would be the sound to work on first.)

When working with children with Childhood Apraxia of Speech therapists are usually following a therapy principle called a series of successive approximations. Essentially, the therapist starts with what your child can do and treats that as correct. Then they try to get that a little closer to "correct" and treat that new level as correct. Once that is well established, they make it a little harder and call that new level correct. For example, your child might be saying "ba" for "bottle," but not very often. First your therapist will treat that as correct, and just get your child to do it more often. Then the therapist will make the task a little harder and try to get your child to say "baba." Now "ba" is considered to be incorrect and "baba is considered to be correct. Once "baba" is well established the difficulty would be increased again to "bata." And so on.

Specific therapy targets will vary widely from child to child. The targets may include specific consonant or vowel sounds, eliminating a speech habit (like leaving off consonants at the ends of words), increasing the number of words in your child's vocabulary, increasing the types of syllables your child can use, and increasing your child's utterance length (from no words to one-word utterances, from one-word utterances to two-word phrases, from two-word phrases to three-word phrases, etc.).

Summary

Your therapist will carefully choose individualized targets for your child based upon their assessment of your child and their professional expertise. They will slow down their rate of speech and your child's rate of speech to allow for extra processing time. They will use multisensory therapy techniques in order to engage as many areas of the brain as possible to improve speech production. They will start with what your child can do and gradually increase their expectations over time as your child improves.

You just finished Part 3 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 2 - Types and Variability of Practice

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?

Apraxia Therapy Materials: Talking Carl iPhone / iPad App

If you have access to an iPhone or iPad there are a lot of apps that can be used to elicit speech from your little one. One in particular that can work well with a child at any stage is Talking Carl. (Note: There are other "talking" apps as well. Most are free or 99 cents. Just be sure to try a couple and choose the one you like best before you try it with your child. Some of them are not appropriate for children.)

Talking Carl is an interactive little monster with big eyes and a big mouth. He will giggle when tickled, and complain when poked. Children almost always crack up laughing themselves when they tickle or poke Carl. If you have a nonverbal child, just being able to get a giggle or an "ouch" in sympathy is good speech practice.

The other key thing Carl does is listen to what your child says when they talk into your phone and then repeat their words back to them. So if your child says, "Hi!" Carl will repeat, "Hi!" Carl will repeat anything the child says. If you are looking for a fun way to get your child to talk, this might do the trick for you. Check it out.

Here is a short YouTube video that demonstrates most of the things Talking Carl does (except the giggling). I chose this one because it was short, but did a nice demonstration of the speech repetition (not in English, but still a good demonstration).

You might also be interested in the following articles:

Apraxia Therapy Materials: Doodle Buddy iPhone / iPad App

Apraxia Therapy Materials: The Big Book of Exclamations