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. 

Unlocked

Two months ago, when Ava had barely three words, and yet could understand everything going on around her I could see the frustration building. She had so much she wanted to communicate and it was all locked inside her. In fact, I think it was her frustration that was making her so stubborn about even trying to imitate. She wouldn’t even try. That was why we started by giving her completely new ways to communicate. We used signs and the communication boards and you could just see the light in her eyes. She was so excited to be able to communicate successfully.

We also started working on her speech. I worked with her at home and she was seeing first one (twice a week for half an hour – private therapist), then two (once every two weeks for an hour – local apraxia expert), and now three (once a week for one hour – state early intervention therapist) therapists. Once she experienced the tiniest bit of success, and the praise and attention that went along with it, she began progressing quickly and steadily. She went from simply learning how to and being willing to try to imitate, to imitating single syllables with familiar sounds, to imitating single syllables with new sounds, to repeating multiple syllables with those sounds, to spontaneously trying familiar and new words, and finally to making some two and even three word utterances. The progress in speech alone is wonderful and gratifying.

What is amazing is the personality and confidence explosion that is taking place at the same time. It’s like I’m finally getting to meet my daughter and she’s finally getting to meet the people around her too. Her bond with her family members has intensified exponentially. She and her brother are communicating and playing with each other so much more. She’s trying to sing. She’s engaging in imaginary play. She’s initiating play with other children instead of pushing away every advance another child makes. Today, at her two year pediatrician visit, she went through all of the usual things (being weighed, measured, having her ears examined and her heart listened to, etc.) with a minimum of protest. The last time we went, the doctor and I could barely hear each other over the constant screaming. Today we were able to carry on a conversation without raising our voices at all.

The changes are fairly dramatic and almost all positive. Fine, I probably could do without the loud and gleeful shouts of “no” which she seems to use just because she thinks it’s fun. Seriously, there’s an amused gleam in her eye. She obviously finds it entertaining. But overall I’m delighted to see her personality unlocked and I like the little girl I’m finally getting to know.