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.