Apraxia Therapy Materials: The Big Book of Exclamations

Book Review: The Big Book of Exclamations

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

Target audience.

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

How to use The Big Book of Exclamations

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

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

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

What is inside the Big Book of Exclamations?

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

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

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

Our experience using The Big Book of Exclamations

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

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

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

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

Bottom line: Highly recommended.

You might also be interested in the following articles:

Apraxia Therapy Materials: Talking Carl iPhone / iPad App

Apraxia Therapy Materials: Doodle Buddy iPhone / iPad App

Apraxia Therapy: Two-Word Combinations

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

Scaffolding

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

Tapping

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

Use signs and gestures.

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

Slow it down. Be direct.

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

Break it down.

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

Carrier phrases.

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

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

Practice, practice, practice.

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

Review.

Two-word utterances - Apraxia Therapy techniques

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

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

You might also be interested in the following articles:

Apraxia Therapy: Communication Boards

Apraxia Therapy: Gestural Prompts

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

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

Types of Speech Disorders

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

Articulation Disorder

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

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

Phonological Disorder

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

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

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

Expressive Language Delay

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

Childhood Apraxia of Speech

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

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

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

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

Academic Categories vs. Real Life Diagnoses

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

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

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

What is Childhood Apraxia of Speech (CAS)?

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

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

How is Childhood Apraxia of Speech Diagnosed?

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

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

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

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

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

What happens next?

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

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

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

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

NutriiVeda for Childhood Apraxia of Speech: Information and Resources

What is NutriiVeda?

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

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

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

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

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

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

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

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

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

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

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

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

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

What are Omega-3 fatty acids?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Testy Yet Trying: Childhood Apraxia of Speech Reference Posts

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

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

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

Gestural Prompts for Apraxia – Therapy Techniques

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

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

These are the gestures we are using as our hand signals. You can use a different signal, it just needs to be consistent.

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

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

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

Mini Review - First Hundred Words

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

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

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

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

Two word combinations – Therapy Techniques

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

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

Children with apraxia have trouble with motor planning. Research has shown that therapy is more successful when it is multisensory. Try to stimulate them as many ways as possible. One way to do this is to use a tapping technique. Use your hand to tap out two syllables as you say them. So, “big dog” should be said simultaneously with two taps of your hand on your knee (or claps, or snaps). If your child will tolerate it, tap gently on their knee, or hand, or arm. Or help them to clap the syllables themselves. Also try using a singsong voice. So say, “biiiiiiig dog”.

This might sound counterintuitive, but encourage signs and gestures. Typically developing children combine single words with a gesture before they start using two word phrases. So, if they want to tell you “daddy’s shoe” they might say “dada” while pointing to his shoe. One of Ava’s first two “word” combinations was saying the word “more” out loud while making the sign for milk. It’s a stepping stone to saying two word phrases and it can be very effective. As another example, spread your hands wide as a gesture for big while saying the word “ball”.

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

You can also put a long pause in between the two words. Again, it gives them extra processing time. It also shows them that it is ok if it takes them a long time to get that second word out. When Ava is trying a new two word phrase that it hard for her, there’s a huge pause between the first and second word. You can see her working at getting that second word out. I think it helps if you model that pause to begin with. Only put the pause in if necessary though, and phase it out as soon as possible.

Use carrier phrases. I deliberately taught Ava the word mine. In a household with two young children that seems like a tactical error (and boy does she use it a lot these days), but I wanted her to then use the word “my ______” . Once you teach the carrier word, it can then be combined with so many other words. “My shoe. My hat. My milk. My cup. Etc.” This one works particularly well because you can make it into a game and get lots of repetitions. So, she says, “My shoe.” You playfully return, “No, mama’s shoe!” She indignantly returns, “My shoe!” You continue back and forth as many times as you can. As another example, Ava’s very first two word combination was “Papa house.” Then she used house as a carrier word. She said, “Mama house, my house, papa house, dada house, etc.”

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

So, quick summary.

Two word utterances - Therapy techniques

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

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

Fish Oil Supplementation

I first read about Omega 3 fish oil supplementation in The Late Talker book. They devote an entire chapter to the topic. As an SLP I am frustrated that there isn’t more research out there and I would hesitate to recommend something with so little research. As a parent of a child with suspected apraxia I have a completely different opinion. There’s almost no evidence of harm, and the possibility of hope. Why not try anything that might help?

Here are some of the articles I have found on the topic in addition to the Late Talker book. Read them and decide for yourself.

• Dyslexia, Dyspraxia and ADHD – Can Nutrition Help? This article nicely summarizes some of the actual research out there on fish oil supplementation and disorders. Note that in this article the term dyspraxia does NOT refer to apraxia of speech.
• Essential Fatty Acids This is a generic article on fish oil supplementation.
• Long-Chain Polyunsaturated Fatty Acids and Learning Disabilities This article talks about some of the research on fish oil supplementation and learning disabilities.
• Syndrome of Allergy, Apraxia, and Malabsorption: Characterization of a Neurodevelopmental Phenotype that Responds to Omega 3 and Vitamin E Supplementation This is a research article published in the Journal of Alternative Therapies in 2009. However, this research study did not have a control group, so although as a parent I am encouraged and interested, as an SLP I am still not convinced.
• The Omega Wave This is a pretty interesting news article on fish oil supplementation and learning disability, but it is just a news article, not a research article.
• Nordic Naturals Ultimate Omega LiquidThis is the product we eventually decided to use. We are not giving the recommended dosage for an adult. I am not going to tell you what we’re giving, because I’m not comfortable giving dosage advice. Make your own decision after reading the research yourself and consulting with your pediatrician.

You might ask how on earth we get our two year old to swallow a fish oil liquid. The answer is that we don’t. We disguise it as an after dinner “special treat”. Sometimes we mix it in with a couple of tablespoons of lemon flavored yogurt. Sometimes we mix it with raspberry sherbet. Sometimes we mix it in with those yogurt drinks they make with kids. She doesn’t even know it is there. Getting her to eat it is usually no problem at all.

The product is not fishy at all. If it tastes fishy or smells fishy it has spoiled. We store our bottle in the freezer to extend its shelf life.

Is it working? Who knows? Ava’s progress has been amazing. But we started the supplementation at pretty much the exact same time we started therapy. Who knows if it is the therapy or the Omega 3s or both?

Book Review – The Big Book of Exclamations

Quick Disclaimer – I bought this book myself from Amazon and am not being compensated in any way for this review.

This is a review of The Big Book of Exclamations by Teri K. Peterson with illustrations by Chris McAllister. I found this book because it is one of the first books to come up when you do a search for “apraxia” at Amazon.com. This book is not a parent resource in the way that The Late Talker was.

This book is meant to be “read” with your child. I put the word “read” in quotes, because the book is not a storybook. It is designed to teach you how to use a picture book to prompt speech, and lots of it, from your child. This teaches you to interact with a child and a book the same way I was taught to do it as a speech-pathologist during a therapy session. You can then apply the same concepts to any other picture books you are reading with your child. The idea is to spend five or ten minutes (or even longer) on each two-page spread. You don’t need to read the entire book in one sitting. It’s about the two of you enjoying the book, pictures, and conversation. It’s about your child having fun talking about the book. Literally – talking about the book. How often does your child get to do that? You can easily adjust the difficulty level up or down just by modifying what you say from two words at a time to one word at a time. Or from a word like “baby” changed to “be be”. You want to model the exclamations yourself and then pause to let your child participate too. Encourage it. Play with it. Laugh at the silly things the characters are doing and the silly things your child gets to say. Have fun telling the dog, “no no” over and over again.

Why then, did I buy the book if I already know how to interact with a child and a book in this way? Well, because this book is dense. Each two-page spread is crammed full of tons on things to talk to your child about. The pictures and concepts covered are perfect for an emergent talker. I wanted the pictures. They’re great.

Let’s talk about them in more detail. First, you can see a sample page here at the book’s website. Ok. The book begins with two two-page spreads on how to use the book. However, the true beauty of the book emerges in the following six two-page spreads.

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

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

When I tried it with Ava she loved it. She was engaged by the picture on the cover of the book and we spent several minutes just talking about the cover. The book worked exactly as described. We spent a half hour or so on the first three two-page spreads. She did get antsy after the first couple of pages. It’s not like a storybook that hold their attention because they like the story itself. It’s more of an interactive activity. I would plan on using the book for no more than 15-20 minutes at a time. It would certainly be worth it even if you were only using it 5-10 minutes at a time. Pick it up, talk about a couple of pages and then put it away and save the next set of pages for the next day.

I hesitated to buy this book because I thought $20 was a bit steep given that I already know how to read this way with my children. The content is definitely worth the price of admission though. I’ll use this book happily with Ava as often as she’s interested. I would also use it in therapy sessions with any child in the 12 month – 2 ½ year age range and perhaps even with children older than that where appropriate.

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

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

Bottom line: Highly recommended.

Book Review – The Late Talker: What to Do If Your Child Isn’t Talking Yet

This is a review of The Late Talker: What to Do If Your Child Isn’t Talking Yet by Marilyn Agin, Lisa Geng, and Malcolm Nicholl. Marilyn Agin is a developmental pediatrician that specializes in apraxia and Lisa Geng is a mother of two late talkers. This book’s target audience is parents, not professionals. They want to educate parents of toddlers who are late talkers. Their first chapter is a brief overview of normal speech development and the second talks about the consequences of speech delays. The third chapter briefly introduces you to speech disorders in general and Childhood Apraxia of Speech in particular. These first three chapters are a well written overview of the background information you need to know in order to understand what exactly the problem is with your child’s speech and why it matters.

Next the book begins to go into what you can do about it. Chapter four is about the various professionals you will meet when you begin to try to get help: developmental pediatricians, speech-language pathologists, pediatric neurologists, etc. Chapter 5 is about getting the right kinds of therapy. Chapter 6 is about insurance. Chapter 7 is about things you can do at home (several good ideas here). Chapter 8 is about fish oil supplementation. Chapter 9 is about your child’s frustration and how you can cope with it. Chapter 10 is about your frustration and fears as a parent and how to cope. Chapter 11 is a summary.

Pretty much every chapter covers a topic that is interesting as a parent who is dealing with a child who is a late talker. I highly recommend the book. I think it is a great place to start if you’re just beginning to research. I think it can be a useful review that might hit some areas you’re unfamiliar with even if you’ve been looking into CAS for a while.

If you have a Kindle, or a smartphone that runs Kindle, you can download a sample of this book for free. If I remember correctly, the sample includes the introduction and maybe even the first chapter. I was able to get the book through my local library. Even if I had purchased it, I would have felt it was money well spent. I also saw the book at my local Barnes and Noble. So it is pretty easy to get your hands on a copy of this book if you are interested.

If you've read it, or go out and read it, let me know what you think.

Therapy Resources – The /b/ list

Description:
My goal here was to collect a list of simple words and images that start with /b/. I needed them to be familiar to a young child. I wanted to have at least one word/image for each vowel sound. Some of vowels have several /b/ words because I was able to think of more of them. If your child can produce the whole word, great! Go for it. However it is perfectly fine if all they can produce is the /b/ followed by the vowel. For example if all they say for bottle is /ba/, that’s great. If they can say /ba ba/ that’s one step more complex. If they can say /ba ba/ three times in a row that’s even more practice. You will probably find that your child can make some of the /b/-vowel combinations more easily than others. That’s typical too. Don’t push too hard. It’s your SLP’s job to work on new things. You can just use these to practice things that your child already can do. The nice thing about this word set is that you know it combines /b/ at least once with each vowel.

Activities:
This, of course, depends on the age and attention span of your child. At the simplest level you can simply hold up each card and ask your child to imitate the word (or simplified version of the word). I’ll admit, bribery here can be useful (stickers, stamps, cheerios). You could also print out two sets and play a matching game with a few pairs at a time.

For an older child you could make a game board with the images and use simple game pieces and a die or spinner. If you had two sets you could play a card game similar to old maid or uno where each player is dealt some cards and tries to get matches by asking the other player for cards. If you have any other ideas, please contribute them in the comments or send me an email and I’ll include them here as well.

Tip: Print them and then “laminate” them by putting them between two sheets of clear contact paper. They’ll last much longer that way.


I’ll admit it. I’m new to this blogging thing and I can’t figure out how to give you guys a link so that you can just download a nice quality version of these. The best I could do is the pictures. If you’d like me to send you a pdf, just send me an email and ask for the /b/ pictures. I’ll send them right along.
I found all the images via google image and tried to avoid the ones with watermarks. If any of you have suggestions for additional words to add to this list please let me know and I’ll put them in. I hope some of you find these to be helpful.

Words:

1. bug
2. bus
3. bun
4. ball
5. bottle
6. box
7. baby
8. bed
9. bell
10. bin
11. bit
12. bib
13. baa
14. bag
15. bath
16. bat
17. bam
18. bead
19. bee
20. beam
21. bean
22. beep
23. boo boo
24. boot
25. badge
26. book
27. bull
28. bush
29. boy
30. brown (say /bow/ like bow before a queen)
31. bow (say /bow/ like a bow in your hair)
32. bowl
33. bone
34. boat
35. bye, bye
36. bike
37. bite
38. bake

Does therapy for Childhood Apraxia of Speech need to be different than other types of speech therapy? - Parent Question

Let’s pretend we’re in a room together. We’re watching our young children play and talking apraxia because we’ve both been told that our children have a likely diagnosis of Childhood Apraxia of Speech. As a parent who also happens to be an SLP I have a unique perspective to share, so you ask me if it is true that therapy needs to be significantly different to treat apraxia. This is the way our conversation might go. It's just my two cents.

First let me give you some background on speech disorders. In my mind I separate them into three main types.

1. Articulation Disorder - This is when a child has difficulty pronouncing a specific sound correctly. Often the sound is /r/, /l/, or /s/. They may have trouble with two or three sounds, but the problem is with the sounds on an individual level. Usually this kind of problem doesn’t impact their intelligibility (how easily a stranger can understand them) too much and is relatively easy to address. The therapist would work on helping the child learn to make the sound correctly first in isolation, and then at the beginning, middle, and ends of words. They’d move up to phrases and sentences. This type of problem is relatively easy to address and if the child has a sound that simply won’t respond to remediation, the consequences aren’t that severe.
2. Phonological Disorder - Make a /k, k, k/ sound out loud. Now make a /g, g, g/ sound. Both of those sounds are made in the back of the mouth with the back of your tongue. Now make a /m, m, m/ sound and a /p, p, p/ sound. Both of those sounds are made in the front of your mouth with your lips. All of the consonant sounds in our language can be categorized by the place in the mouth in which they are produced and by how they are produced. Some sounds are front sounds and some are back sounds. Some sounds are stop sounds and some sounds are fricatives. Children with a phonological disorder have trouble with groups of sounds. They might take all front sounds and produce them as back sounds instead. Alternately they might take all back sounds and move them to the front. They might take sounds that are supposed to be long and drawn out like /s, sh, m/ and shorten them. You get the idea. The more patterns they have difficulty with the harder they are to understand. This type of disorder can significantly impact a child’s intelligibility and is more difficult to remediate than a simple articulation problem. When treating a child with a phonological disorder you treat the patterns rather than specific sounds. The way the SLP structures therapy will be different than with a simple articulation problem and that difference is important if you are going to see the most change in the shortest amount of time. A phonological disorder is a significant speech disorder that takes a lot of therapy to address. You can address it in a group setting particularly if you group children together who are making errors with the same phonological processes.
3. Childhood Apraxia of Speech - This is a completely different kind of problem. It is not a problem with a specific sound or even with groups of sounds. This is a neurological motor planning disorder. The child knows what they want to say. The mouth is physically capable of making the sounds. The planning of the muscle movements necessary to make the sounds is what is difficult. This brings the scope of the problem to a whole different level. Now you aren’t just trying to fix the sound /s/. You’re not even trying to teach a child who is moving all their front sounds backwards to bring them back to the right place. You have to help a child learn, at the level of muscle memory, how to produce all the possible sound combinations. This is a huge task because the way the muscles have to move to produce /baa/ is different than the way they have to move to produce /bee/ . So you can’t just work on a generic /b/. Therapy needs to be designed with a motor planning approach. Targets have to be carefully chosen. Therapy needs to be focused on getting the maximum number of productions possible. Therapy usually needs to be one-on-one in order to achieve this. Ideally, you’d have therapy multiple times a week and your therapist would be teaching you how to do carry-over activities at home. You want to be (gently, of course) focused on getting your child to incorporate his target productions into his daily routine as much as possible. You want him to be using his target productions with a wide variety of people in a wide variety of situations. You want them to learn and overlearn everything so that it becomes automatic. Typically, children with CAS need a lot of therapy to show improvement. Typically, especially early on, it has a pretty big impact on intelligibility and these children are extremely frustrated. Typically a child with CAS will not progress when the therapy type is not focused on motor planning. That is why it is important to know if your young child looks like a likely candidate for CAS. You need to get the right kind of therapy and a lot of it as early as possible. Go back to this post and read the three bolded sections near the bottom for some quotes directly from ASHA or research articles that pertain to the issue of appropriate therapy for CAS.

As you can see, at least on paper, there are some pretty clear differences between the main types of speech disorders and clear differences on how to treat them. In reality, it is always more messy. It can be difficult to tell the difference between a very young child with a severe phonological disorder and a very young child with CAS. I talk about the red flags for CAS in a young child here. If your therapist is not sure, he or she may begin with more general expressive language stimulation / phonological therapy. If your child does not make progress over several months using that approach, that’s additional evidence that you may be dealing with CAS.

There is no significant disadvantage in trying an intensive motor planning approach to therapy to see if your child responds. And if your child does have CAS, research shows that it is with this approach that the most progress is made.

(Note: there are several different packaged approaches / programs of intervention designed to address apraxia that you may have heard of such as Kaufman, PROMPT, Dynamic Temporal and Tactile Cueing, etc. All of these approaches are fundamentally based on motor planning theory.)

What makes a Childhood Apraxia of Speech diagnosis "official"? - Reader Question

I’ve had several people ask me how I got an official diagnosis for Ava this young. The answer is that technically I haven’t – you can’t. I have had two speech pathologists other than myself evaluate Ava and tell me that her likely diagnosis is apraxia. In the next month or so I’m expecting her to meet with two more SLPs both of whom have a great deal of experience working with children with apraxia. We’ll see if they agree as well.

How is a child “officially” diagnosed with apraxia?
To be honest, there isn’t a lot of good research out there about apraxia. The research just hasn’t been done. The research that has been done was pretty much all with older children, and tends to show some disagreement about what the criteria should be. So when diagnosing CAS, SLPs will look for the diagnostic criteria that are most commonly agreed upon.

An experienced SLP will spend time with your child administering a variety of tests/tasks designed to look for the following characteristics:

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

So if you have a little one, say a child between the ages of 18 months and 2 ½ years you’ll look at that list and think to yourself that there’s no way you can test most of those things with your child. There isn’t enough speech. You can’t test multi-syllable words. They don’t even have single syllable words. You can’t test imitation of words and phrases. They don’t have any. You can’t test if errors increase with increased length, because they don’t have long utterances. So that’s why you can’t get an “official” diagnosis of apraxia for a very young child.

What is my SLP looking for in order to give an “unofficial” diagnosis of CAS?
There isn’t enough research yet on young children who later go on to be diagnosed with CAS. Little ones with CAS look different than older children with CAS. There has been enough research, barely, to come up with official diagnostic criteria for older children with CAS. But, as we just discussed, the things that they look for in older children cannot be tested in younger children. There are, however, certain red flags for younger children. If these things, or most of these things, are present in a young child who is a late talker, it is much more likely that the child will go on to be diagnosed with CAS later.

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

Why should you care about a diagnosis at all? Official or unofficial?
I can think of two reasons you might care. The first is insurance. Sometimes people can get insurance to cover the cost of speech therapy if you can get an “official” diagnosis of CAS. The second reason is to be sure you are getting the appropriate amount and type of speech therapy. This second point is important enough that I’m going to devote a separate post to it. Children with CAS need intensive therapy and that therapy needs to be of a certain type. Usually a child with CAS does not improve when treated with the types of therapy typically used for other speech problems. If you have an official or unofficial diagnosis of CAS you’re going to want to be sure you’re getting the right type of therapy and plenty of it.