Three Little Boys
December 2014
I recently started speech therapy with three little boys. All were late talkers. The youngest, W., was two years, four months, the next, F., was 2 years, 8 months, and the oldest, J. was 3 years, two months old. The little boys began speech therapy within three months of each other. I saw each boy by himself with a parent watching. The boys demonstrated receptive language within age-appropriate expectations but were all well below age-level expectations in sentence length, speech intelligibly, and in their ability to imitate sounds, single syllables, and especially two syllable phrases. The first two were not really talking. W. was using just a few single words and was relying on gestures, vocal expression, and his parents to make his needs known. F. was using 10 to 20 fairly clear single words but had really no clear or useful two word utterances. J., the oldest, was consistently using two and three word phrases but was unintelligible: he was not using any consonants. J. had received a diagnosis of apraxia of speech from an Early Intervention speech-language pathologist in Portland, Oregon.
At its core, talking is making the tiny movements necessary to produce sounds and combining those sounds in meaningful sequences called syllables. Speech language pathologists describe this ability as speech motor planning and delivery. Motor refers to muscle movement. By the time most children are two, they have begun demonstrating this skill. The three little boys seemed to be having some difficulty with this process: getting their articulators to do what their brains were telling them to do. F. was having mild difficulty (clear individual sounds and words but no connected utterances; W. was having moderate difficulty (few words, willing effort at imitation but accompanied by lots of trial and error and a perplexed look on his face); and J. the oldest was having severe difficulty (consistent imitation of vowels but seemingly lacking any ability to imitate consonants). Especially when talking to parents, I think of a speech motor planning difficulty as poor coordination for speech: the child is clearly having trouble getting his mouth to do what his brain is telling it to do. In the field of speech language pathology the terms childhood apraxia of speech (CAS), developmental apraxia of speech, developmental dyspraxia, developmental verbal dispraxia, and many others have been used to describe this difficulty with speech motor coordination. The child may be inconsistent in his ability to produce speech sounds, show difficulty sequencing sounds into syllables and syllables into words, and be very hard to understand. Talking is delayed. It has always helped me to think of a speech motor planning disorder continuum, with children like F. and W. on the mild to moderate end of the scale, and children like J. on the more severe end. Since I think the terms above have been overused, I reserve childhood apraxia of speech for children like J. who at least for the moment are on the severe end of this speech-motor planning disorder continuum.
There are three issues that seem to me to be central when we think about treating children with speech motor planning issues. As a working clinician, I think of these as the problem of origin, the role of maturation, and the magic of confidence.
The problem of origin. Apraxia in our field has always referred to a neurological, brain based difference. The term was first used with adults who had suffered brain damage and lost much of their ability to talk. Certainly the term implies differences: innate, inherent, built-in, neurological, there-when- we- first- meet- the- child. And, aren’t brain differences irreversible?
The role of maturation. In my experience, some children who begin speech therapy with the label CAS do not fit that definition within six months to a year. Their symptoms have changed. Speech is not nearly as hard to produce as it was. Their ability to talk has improved, sometimes dramatically. Do they no longer “have” CAS? How can you have a neurological difference and then apparently not have it? Has the problem evolved? Resolved? Certainly the brain’s plasticity and constant development come into play.
The magic of confidence. What I have to do is show these little kids that their efforts at imitating my speech movements will pay off. When they succeed at the simplest level (see that their effort results in what they wanted) they gain a little bit of confidence. Then they use that confidence to make more attempts, and those attempts pay off. I need to get them to believe that when they try to say words, there is a good chance the words will come out. We do this by showing them results of their efforts, beginning with specific and consistent syllables or even sounds. I believe they have known for some time that talking is hard. My job is to create a fun activity, fashion a target that is doable, encourage them as they try, and then immediately reward them. I am simultaneously a situational engineer, a coach and a cheerleader.
My experience suggests children can evolve out of a CAS diagnosis. Change comes when treatment and maturation combine, spurred by the child’s increased confidence that he can successfully imitate speech sounds. Sometimes there is a sudden increase in ability, which appears to “jump start” expressive language, the ability to put words together.
When I treat children with speech motor planning problems, I follow several basic principles. First, in my experience, producing imitated responses to the best of one’s ability will eventually lead to the production of more clear spontaneous utterances. The concept of “to the best of one’s ability” means encouraging the child to produce an imitation that is consistent, may have substituted sounds that are age appropriate, and is as close as he can get at the moment to the target sound or syllable or multi-syllable utterance. We are looking for acceptable approximations that are consistent.
Next, it is very important to carefully choose what you are going to ask the child to imitate. I prefer sounds or syllables that will immediately produce a result: something desirable to the child will happen. It is also very important, especially at first, to model an utterance that is within the child’s ability to produce. I use toys, especially cause and effect toys with most of the children I see. If I am just beginning with a child like J., who is able to imitate vowel sounds, I might use a foam toy rocket propelled by squeezed air and say “let’s make it go UP. You say “UH.” When the child imitates me, if the attempt is to the best of his ability and is understandable, I will immediately squeeze the rocket launcher and the rocket will fly. In other words, there was a request to imitate followed by a response to the best of the child’s ability, followed immediately by the desired result. I have for years referred to these utterances as functional phrases. A slightly higher step might be asking the child to imitate the very useful utterance “go,” which of course requires a consonant and a vowel. In the beginning, I will accept, if it is consistent, substituting a “d” or “t” for the “g” in “go.” This might also require allowing the “o” vowel to be produced as an “uh” again if it is consistent. What you are after is convincing the child that his efforts will pay off. I might load a bubble wand with liquid, model “go,” and immediately blow a bubble if I get an acceptable response. When this step becomes consistently doable, I will add a second syllable to the selected utterance, for example, adding “ball” to the modeled utterance “go ball,” and being very happy to accept “doe bah.” Again remember you need to immediately reinforce the child’s effort by rolling or bouncing or throwing the ball. All of this is based on picking sounds, syllables or phrases that, first, have sounds the child can make, or that you have heard, then increasing the degree of difficulty in small steps.
I believe in the value of practice. Once the sound or syllable or phrase is selected, the child needs repeated efforts at getting his or her mouth to do hard things then getting immediately rewarded by seeing the toy do what was asked, or by getting to play with the toy itself. I am satisfied when I can get at least 50 repetitions in a half hour visit and am very happy when we can bump this number closer to 100 responses.
To me, the emphasis on practice also suggests your session has structure, that you have chosen sound, syllable or phrase targets that are doable for your child and that you have chosen and have at the ready enough desired toys or activities that match your child’s interests and that can be used to elicit and reward the sounds you want.
I also think pacing is important. In my experience, I am going to be more successful with a two or three year old boy if I am moving rapidly, if I am presenting modeled utterances at a fairly rapid pace.
As I explain to parents what I am doing with their children, I often talk about supported wall walking. This is the idea that in speech therapy I am asking the child to do difficult things out of his comfort zone, as if I have him up off the ground on a waist high brick wall and am gently pushing him forward. I can’t push too hard or he will fall but I need to push a little or no movement will happen. I also have to be ready to catch him if he falls, which to me suggests reducing the length or complexity of an imitation I have asked for and still make it functional so he can get the desired object.
Another important principle is choosing words of importance to the person or family, such as a family member’s name or one’s own name or even bye bye. In F.’s case, his mom was very interested in him learning to say “mommy” instead of his habitual “mah ee.” I was of course delighted because practicing “mommy” gave F. a chance to produce two intact but slightly different consonant/vowel syllables together which was a step up for him since his “shortcut” was to drop the second consonant. Practicing “mommy” would also pave the way for many other CVCV utterances. Plus, it was a very functional phrase. Another example I have used for years is teaching children with speech motor planning issues to say “bye bye,” a very functional and oft-used expression. To the consternation of some families, I sometimes start by encouraging them to let the child hear “bye bye,” as in, “Let’s tell Grandma ‘bye bye’,” then modeling and accepting “bah bah” (usually an easier approximation).
Finally I have had success with some children if I can get focused mouth attention from them. I usually do this by tapping my own chin as I am modeling a sound or syllable and encourage them to watch my mouth.
These principles and others have helped me help little kids realize they can talk. What about the three little boys? At this writing, after five months of speech therapy, all are making progress. F. is using three and four syllable slightly slurred utterances at home and is beginning to be willing to accurately imitate two and three syllable utterances in speech therapy, where each syllable is a different “shape.” W., the youngest, appears to have had his expressive language jumpstarted: he is consistently and rather suddenly using clear three and four word sentences to communicate. Interestingly, these utterances are marked by a definite pause or pulse between words, some.what.like.this, resulting in speech sounding labored and somewhat effortful. But he is talking and clearly relishing that fact, as is his family. And J., although still rattling off three and four vowel-only “word” unintelligible utterances, is using some consonant vowel combinations in spontaneous speech and is very willing to repeat utterances and add the required consonants. Stay tuned.
© 2014 Glenn Weybright. All rights reserved.