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.

Lost

On a sad note, we realized a couple of nights ago that one of our kitties is lost. She must have slipped out of the house earlier in the week when the weather was nice and we were playing outside. We had left the door open. Things have been so crazy this week with the illnesses, hospitalizations, and surgeries that we didn’t even realize she was missing for a couple of days. I feel terrible. We’ve searched the house and the neighborhood, but there’s no sign of her. Our chances of finding her seem poor. She was a great kitty. I'll miss her.

Two-word combinations begin

I swear my daughter must be sneaking out of bed in the middle of the night to read my blog. She reads it to find out what I’m saying she can’t do. Then she proceeds to do that very thing over the next few days simply because she loves proving me wrong.

Just last weekend I was doing some research watching some old home videos trying to see differences between the speech development of Ava and Michael. The major thing that stood out to me was the ease with which Michael could combine words. Ava struggled to do so. A couple of days later I wrote a post on the topic.

Since then, Ava has begun combining words. Frequently. Many times each day. She will do it in imitation succeeding about half the time. She’ll also do it spontaneously. Last Saturday morning, when we picked Ava up from my parents’ house, my dad said, “Listen to what Ava can do.” He told her, “Say Papa house.” Ava then repeated, clear as day, “Papa (small pause) house.” I was amazed and excited and so proud. We heaped praise upon her. As we were driving home the little show off then said, “Mama house.” It was the beginning of something new.

We were walking into her school where they’ve decorated the entryway for spring with construction paper flowers. Ava stopped, pointed, and said, “Pink flower. Red flower. Purple flower.” Seriously! Who is this child? She likes to label things by owner. So, “Mama shoe. Dada shoe. My shoe.” She even said, “Mama no shoe,” once. It’s crazy.

Now, I don’t want to give the impression that all of this is coming out perfectly or easily, or that she is successful all the time. It’s still pretty obvious that combining words takes effort. Many speech sounds are being left out and the words don’t at all sound like adult pronunciations would. She also doesn’t succeed all the time. Often, when asked to say a two word sentence the words will still come out as two of the same word. And she still uses one word sentences most of the time. However, this is a huge breakthrough. She is using two word phrases some of the time. I guess the tapping and encouragement made sense for her. I can’t believe this is the same child that scored at the four-six month old level in speech and language only two months ago.

So what does this mean? Well, I still believe that we are dealing with a disorder. The history is too atypical for the speech problems to be a simple delay or just due to the hearing loss due to the fluid in her ears. I do think, at this point, that I feel fairly safe in saying her disorder is on the milder side. Children with a severe disorder work just as hard, and don’t have the same kind of response to intervention. If I had spent two months working intensively with Ava and had seen very little progress that would indicate a more severe disorder. Given the extent of her delay two months ago, I feared something quite severe. I told my family that I wasn’t going to make any predictions though until I saw how responsive she was to intervention. I told them I’d know more in 3-4 months. Only two months later I can say that she’s been very responsive so far and that is a very good sign.

We’ll continue to work with her. She still needs to fine-tune many vowels. She’s missing lots of consonants as well. I’d like to try to start to get her to add final consonants to the ends of her words. And, of course, we want her to continue to use those two word phrases and to add more of them gradually increasing to three or even four word sentences. I’ll consult with Ms. J this weekend and let her expertise guide me in determining which of those things is most important and guide me in how to best achieve those goals.

You might also be interested in the following articles:

Apraxia Therapy: Two-Word Combinations