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

The Weekly Review: Week Five

Blog Post I Appreciated Most:

You know how you sometimes you like hearing about someone else's misery because it makes you feel like you have some company? Well, Rude Cactus posted about the illnesses his family has experienced over the last month and although he has all of my sympathy, it makes me feel better about the fact that our household hasn't gone longer than a week without someone (or multiple someones) being ill for the past four months.

Apraxia Article of the Week:

This is a nicely done general introduction page about Childhood Apraxia of Speech. Note: It uses the out of date terminology "Developmental Apraxia of Speech" rather than using "Childhood Apraxia of Speech" which is now the preferred terminology.

Sibling Interaction of the Week:

This week Michael has started calling Ava by both her first and middle name. I tend to do that when I'm fussing at the children and it was pretty funny to hear Michael do it when he was fussing at his sister. Soon he started using both names every time he called her. Interestingly, it has apparently taught Ava her middle name. When a friend of mine asked Ava her name, she responded with both.

Quote of the Week from Michael:

Yesterday morning I was in a hurry to get the children out the door and to school so I gently asked Michael if he wanted another mini-muffin hoping to focus him on finishing his breakfast instead of playing. He replied in an annoyed tone of voice I completely recognized as my own, "I'm too busy working on my crane truck and I can't work with a muffin in my mouth!" I ended up letting him finish his crane truck and let him take a muffin in the car.

Ava's Song of the Week:

At the dinner table a couple of nights ago Ava started singing The Isty Bitsy Spider complete with hand motions and with an extra lyric about the moon going down thrown in for good measure. I almost wish I hadn't banned all cell phones from the table at meals because we didn't have a camera handy to catch it on video.

Project of the Week:

This week I'm working on adding a new section to my blog. I'm revising my reference posts and putting them all in one place so they can be accessed easily. It's a big project and I'm just taking it one bit at a time, but I think it will be a great collection of articles when I'm done. Hopefully people will find them to be useful. This is where you can find the ones I've finished so far.

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.