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?

Nutriiveda for Apraxia?

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

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

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

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

Songs and Rhymes – Therapy Techniques

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

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

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

Baa, baa, black sheep,

Have you any wool?

Yes sir, yes sir,

Three bags full.

One for the master,

One for the dame,

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

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

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

Oral Apraxia

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

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

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

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

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

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

The Weekly Review: Week Two

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

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

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

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

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

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

Good Luck

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

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

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

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

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

Structured vs. Unstructured Therapy

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

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

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

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

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

Therapy Progress - Practice and Generalization

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

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

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

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

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

Doing too well?

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

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

Daylight savings miracle

My children wake up early.  They wake up with the light to be specific.  So, in the middle of winter, near the solstice, they are sleeping till 7:30 or so which is wonderful.  In the middle of the summer near the summer solstice they are waking around 5am!!  Ava is particularly susceptible to the light and over the last month she moved from 6:30 to 6:15 to 6:00 and then started waking in the 5:00 hour.  It’s driving me crazy.  I need sleep too!!  And she’s waking up cranky because she isn’t really getting enough sleep.  Well, the daylight savings switch was wonderful.  Saturday morning she was up at 5:45 am.  Sunday morning it was 6:45 am.  Just like that.  I’ll take it. 

Now, what can I do to manipulate things so that perhaps I won’t end up right back where I was a month from now?  I have to find a way to keep her room dark.  I tried it when she was little, but then even the slightest change was enough of a cue to get her up.  I couldn’t block enough of the light for it to work.  Maybe now that she's older, blocking most of the light will work?  Also, then I didn’t have a sewing machine to use to make some light blocking tools.

I have a plan.  Light gets into her room from two main sources:  the window and under the door.  I’m going to make one of those door draft stoppers to block the light from getting in under her door.  Then I’m going to put up light blocking curtain liners.  But instead of attaching them to her curtains I’m going to just cover the entire window opening.  Seriously.  If it works it’ll be worth it.  I don’t care if we can’t open the windows any more.  I’m thinking I’ll sew velcro to the light blocking liner and then glue velcro to the wall around the window and just stick it up there attached on all four sides.  Ugly, yes.  But it’ll be hidden by the curtains. 

So that’s the plan.  I’ll let you know if it works.

Look what I made!

First let me say that I am not, by nature, an artistic person.  People who are genuinely creative are mystical beings who are worthy of my admiration.  However, about a year ago I decided to buy a sewing machine.  I didn’t know how to use one.  I bought it almost on a whim.  It’s shocking what curtains cost, really.  I bought a beginner’s sewing book and did little projects like making a pincushion and a sewing machine cover.  My first major project was the curtains for Ava’s room.  I was quite pleased with myself actually given that I hadn’t touched a sewing machine since one small unit in high school home economics.  I don’t make particularly beautiful things, but I like the idea of making practical ones.  Here are my curtains (see picture – I made the curtains, not the valance).

Not so long ago we converted Ava’s crib to its toddler bed form.  She was ready.  We did it spontaneously though, so I hadn’t bought any “big girl” bedding.  We still made it up just like her crib with her crib sheets.  She sleeps in it holding her stuffed kitties and covered by one of her baby blankets.  A couple of days ago I decided I’d try to sew a pillow for her.

I dug around in the box of old baby clothes and found a couple of old baby dresses.  I cut them up for the material.  I shredded all the scraps that were left over and a bunch of other scraps left over from other projects for filling.  The scraps are mostly fleece so the stuffing is really soft and fluffy.  I serged the edges of the material together leaving a small gap so that it could be filled.  I turned it inside out, filled it with the cut up scraps of material using a funnel, and hand sewed the gap closed.  Voila – pillow.  Ava loves it!  I finished it just in time for nap.  She grabbed it from my hands and ran upstairs to her room to put it in her bed.  She wouldn’t leave the bed to get dressed.  I had to put her pull-up and pajama bottoms on her in the bed and she didn’t want her usual books and songs.  She just went right to sleep that day.  It was adorable. 

Then I made a second one so that when one set of bedding is in the wash she can use the other one.  I added a border to this one so it looks slightly more fancy than the first one.  The first one is the pink one.  The second one is the purple one.  Ava, of course, won’t touch the second one because it is purple and not pink.  She’s recently decided pink is her favorite color.  And it’s icing on the cake that I did the entire project from stuff I had lying around the house and so it didn’t cost a penny. 

Unexpected Crisis

Saturday night got exciting at about 11pm.  There’s nothing like a “Should we go to the emergency room or not?” situation to fully wake you up.

Ava came down with a cold Thursday morning.  (Somehow that never fails to happen the day –after- you visit the pediatrician for a check up.)  It was just a normal little kid cold: tons of snot, fatigue, crankiness, and a fairly impressive wet cough, but nothing particularly scary.  In fact, I commented Saturday afternoon that things seemed to be getting a bit better because now I was only having to wipe her nose once every half hour instead of once every 5 minutes.  

Just as I was drifting off to sleep at around 11pm Saturday night I hear Ava start to cough and cry and cough and cry.  It went on and on.  We very rarely go into our childrens’ bedrooms at night, but something just seemed off here.  My husband volunteered to go check on her.  Moments later he was back in our bedroom with Ava.  She was wheezing.  The cough was croup and she was having trouble breathing.  That was causing her to panic which just made things worse.  

It was Ava’s first time, but not our first time.  Michael’s colds often end up with croup/wheezing in the middle of the night.   Once it was bad enough that we did end up in the emergency room with him.  We knew what to try first.  We turned on the shower as hot as possible to get the bathroom steamy.  I sat in there with Ava cuddled close to my chest rocking and singing to her.  She was extremely hot.  So hot I didn’t even bother with a thermometer.  We just got a dose of ibuprofen into her as quickly as possible.  She completely freaked out about taking the medicine which made the wheezing worse, which made her panic…  Then I just continued to sit there with her rocking and singing in the warm steamy bathroom while my husband prepped her room. 

He got two humidifiers going and removed her smoke alarm.  Humidifiers trigger our smoke alarms, so if we need the humidifiers we have to pull the smoke alarm down.  This took him a good 20 minutes and in the meantime, the ibuprofen kicked in and the wheezing calmed down and she had almost drifted off.  However, when I stood up to take her back to her room, the wheezing instantly came back.  By the time I was in the armchair in her room I was practically starting over.  Twenty minutes after that I laid her down in her toddler bed which flared things up again so I crawled in with her.  My presence kept her calm, but it also kept her awake so I slipped out of her bed and sat right next to her waiting to see if the wheezing would stop.   We knew that if she continued to have trouble breathing even while resting, we’d need to go to the ER.  About an hour later it finally faded and I slipped out of her room. 

I finally went to sleep around 3am and was back up with the kids at 7am.  I do not function well on four hours of sleep, so Sunday was a bit of a blur.  I do remember that Ava’s temperature at one point was 102.7.  And she wasn’t nearly as hot as she had been in the middle of the night.  Getting the infant drops into her was predictably difficult again.  The highlight of the day was discovering that they make chewable bubble gum flavored acetaminophen that Ava can now take because she’s two.  I told her it was candy.  She loved it.  Is that wrong?  Technically, I lied, but if I had told her it was medicine she would have refused to try it.  I know her.  She definitely would have refused to try it.  Anyway, hopefully we won’t have any repeats of croup in the middle of the night.  And hopefully this cold will pass soon. 

Of course, I have the cold now.  And my voice is on its way out.   Parenting two little ones is enough of a challenge with a voice.  Without a voice it’s crazy.  And therapy will pretty much be out until my voice is back.  Life is always interesting.

After two word combinations start - What's next?

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

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

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

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

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

Therapy Schedule

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

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

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

Friday – 60 minutes at home with Ms. A

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

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

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