My toddler isn't talking!!! What do I do?

My Toddler Isn't Talking!!! What do I do?

I have been approached more times than I can count by concerned parents who have a 1-2 year old and are concerned about their speech progress.  I'm always excited when parents come ask me questions, because it gives me a chance to let them air some of their concerns and also to give them some comfort and guidance.  Every parent I know wants the best for their children and not speaking or learning to talk slower than peers is very concerning. When I am approached, I ask a few questions to ascertain the child's progress and compare it to developmental norms.

The first thing I always ask is, "How many words do they have?" 

Children should start speaking around age 1 (some speak a little earlier, some speak a little later, but it averages to 12 months). By age 2, children should have 50 words and begin putting 2 words together to form simple sentences (for example, "more juice" or "mommy walk"). At 3, children should be using 3-4 word sentences and have approximately 1000 words in their vocabulary.

Secondly, I ask, "What percentage of the time can you understand them?"

By age 2, your child should be at least 50% intelligible.  All children babble or use jargon (groups of sounds strung together that sound like words with intonation, but aren't really words), but by age 2, someone who has never met your child should be able to understand half of what they say. (By 3 that intelligibility increases to 75% and by 4, 100%). 

Thirdly, I ask, "Can your child follow simple 1-2 step commands?"

At 18 months, a child should be able to follow simple 1-step commands (for example, "pick up the shoe"). By 2, however, your child should be able to follow 2-step commands (for example, "pick up the block and put it in the toy box"). At 3, a child should be able to follow 3-step commands (for example, "pick up the shoe, put it by the front door, and come back here"). 

Lastly, I ask, "What have you already tried?"

Perhaps not so surprisingly, answers vary widely here.  Some parents have tried everything from reading every day, talking all the time, using flash cards, singing songs, teaching sign language, and using pictures around the house.  Often, others are so overwhelmed they don't even know where to start and haven't done anything and don't know if they even should do something. 

My number 1 recommendation is READ. Read everyday. Read all the time. Read to your child. Talk about the pictures. Make funny animal noises when you read about animals, act out stories like the three little pigs or Goldilocks, do crafts with the characters in the story, eat green eggs and ham.  Reading is the only research-proven method to increase vocabulary in children.  Again--Reading is the only research-proven method to increase vocabulary in children.  No matter how many flash cards you try, your child will not learn as much as quickly or as effectively as if you read. For more information and ideas of how to teach vocabulary while reading, see the references at the bottom of this post.

I also tell parents to TALK. Talk all the time. Talk about everything you're doing.  For example, if you're making dinner, narrate what steps you're following.  "Right now I'm cutting the tomato.  Tomatoes are so lovely and red. I love tomatoes. They are delicious. I have to be careful with the knife when I'm cutting. Now the tomatoes go in the bowl." There are two kinds of "vocabulary-building" speeds your child uses: slow-mapping and fast-mapping. For fast-mapping a kid can hear a word 1 or 2 times and remember it and use it correctly. For slow-mapping, a child needs to hear the word 30 times to remember it and use it correctly.  For a child who is slower (for example a child with a language disorder) that child will need to hear the word 100 times or more to remember it and use it correctly. If you narrate what you're doing just like the example, you have used the word "tomato"4 times. That means if your child is "slow-mapping" their vocabulary you'll need to say it 26 more times.  Repetition is how kids learn so get ready to repeat, repeat, repeat.  You'll feel like a crazy person talking to yourself, but your child will be able to really soak it all in.

Lastly, I often tell parents to SABOTAGE. Your child has favorite things.  All children do. Whether it is goldfish, Thomas the Tank Engine, or bubbles, your child has some favorites.  Communication is all about using language to get something you want.  

If your child's favorite things are easily accessible it's time to put them out of reach and require your child to ask you for them.  The official therapy name for this strategy is "withholding." For example, if the goldfish are currently on a lower shelf, put them on a higher shelf so you have to get them instead of your child helping themselves. You are withholding something your child wants until they can ask for it. If Thomas is on the floor, put Thomas in a rubbermaid bin that your child cannot open by themselves and have them ask you to open it. We use this strategy a lot in therapy and I've seen kids make huge strides. If your child is not talking at all, start with having them point or bring the bin to you.  After a few weeks of that, move on to grunting. After that, move on to using a single word (train, fish, etc.). Soon, your child will realize that in order to play with the bubbles, they must ask you--they learn that communication is key to getting what they want.

When your child has improved in asking for items, you can start to sabotage situations to require them to ask for more things.  For example, if your child loves Goldfish, start by giving them 1 instead of the 10 you usually give them. They will have to ask for more. If your child loves bubbles, give them the wand, but keep the bubble solution so they have to ask for more. You can "lose" items, you can withhold parts of items, you can give them items that don't work, you can give them items they didn't ask for, etc. All of this sabotage has one goal: communication. A little frustration can help your child realize that they must communicate with words to get what they want.

One final note: Many parents ask me very specifically about sign language.  Sign language is a fantastic tool for learning spoken language.  My personal advice is to teach specific words.  For example, don't teach the word "more." Instead, teach the words for what the child might want more of (cracker, juice, blocks, cars, etc.).  When you generic words (like "more") your child will learn that one word will get them all kinds of things.  The sign for more will get them crackers, pancakes, juice, cars, etc. If you teach the child specific signs though, you are giving them a chance to build and expand their vocabulary and teaching them that they must use a specific word to get what they want.

If you have any concerns about a child who does not meet the developmental norms we talked about in the beginning, do not hesitate to get an evaluation from a speech language pathologist.  Early intervention can work wonders and can eliminate or diminish many speech and language disorders.  For every $1 spent in Early Intervention, you will save $7 in later therapy, so never be afraid of getting an evaluation to ensure that your child receives the most effective, efficient therapy available to them.

References

• Language Development Information 
• Teaching Vocabulary While Reading
• Sabotage and Withholding
• Early Intervention

Cycles Approach

The Cycles Phonological Pattern Approach

Many children and some adults have difficulty producing the sounds of speech.  The child might have a lisp, a problem with r, or just be so difficult to understand you don't know where to begin. A basic guideline to see if your kids may need some help is:

By 2, a child should be 50% intelligble.

By 3, a child should be 75% intelligible.

By 4, a child should be 100% intelligible.

While there are many tools SLPs use to address many of these concerns, I wanted to write a special article on my personal favorite-- The Cycles Phonological Pattern Approach. Also called the "Cycles Approach," this treatment technique for articulation disorders was created by Barbara Hodson to treat extremely unintelligible children. The original approach has eight underlying principles:

1. Typical children learn language by listening.
2. Gaining sounds (also called phonological acquisition) is a gradual process.
3. The sounds around a target sound (also called phonetic environment) can help or inhibit correct sound production.
4. Children use sound and movement sensations to self-monitor their productions. 
5. Children generalise new speech skills to other targets (for example, if they are learning /s/, they may use /s/ for /s/, /z/, /th/, and /f/ because they are similarly produced.
6. A good developmental ‘match’ facilitates learning (for example, if the child is 3, the clinician should work on sounds that a typical 3-4 year old would make)
7. Children learn best when they are actively involved/engaged in therapy
8. Enhancing a child’s metaphonological skills facilitates and enhances the child’s speech. improvement and also development of early literacy skills. (For example, working on learning what a syllable is can help both reading and speaking) (See CPPA by Caroline Bowen)

Additionally, Dr. Hodson uses a very specific pattern for target selection (what the therapist will work on during therapy) which begins with easier, earlier developing speech patterns and then advances to more difficult speech patterns.

There are four main intervention procedures:

1. Cycles: Each target is presented for a 1 hour (normally that means 2 sounds per 1 hour therapy session, but could also mean 2 sounds for 2 30-min sessions). After each hour, other targets are introduced until you have an initial "cycle" of 6-18 hours (dependent on how unintelligible the child is). Each "cycle" is then repeated or phased out upon mastery of the target. The  very unintelligible child will take 3-4 cycles (approximately 30-40 hours) to become intelligible.
2. Focused Auditory Input or Auditory Bombardment: This is when a child listens to words that utilize their target sound at a slightly louder level than typical. The theory is that children learn sounds by listening and this will help them "tune in" to the targets they are working on.
3. Facilitative contexts, Active involvement, Self-monitoring, and Generalization: Using activity to learn and models and cues to help the child produce target sounds correctly each time, the child gains new auditory and kinesthetic memory for the correct production of each sound. The child actively participates in a drill-play activity (for example: playing candyland while producing target words on each turn). For homework, the child will listen to words read by their parent/guardian and then attempt to produce a few target words.
4. Optimal Match: Essentially, Dr. Bowen asks that you use developmentally appropriate targets to both challenge the child and allow the child to have success in therapy. (For example you would not work on the /r/ sound with a child who is 3, as that would not be developmentally appropriate for them to produce yet).

I love using cycles therapy with kids and adults. I have seen some amazing growth with my clients while utilizing this approach. When I use cycles therapy, it helps my clients to avoid boredom by working on different sounds. While I modify the cycles approach somewhat to better target the goals from my clients, I try to stick to as many of the main research-based principles as possible. Additionally, I like to utilize further articulation research and work on just voiceless sounds (t, k, s, sh, ch, f, p) to help those sounds generalize to the voiced sounds (d, g, z, dj, v, b). The evidence I have seen while using this approach is overwhelming that it is effective.  I will continue to use it with my clients and hope to see more exciting growth!

Resources

• CPPA by Caroline Bowen
• Published CPPA by Dr. Hodson
• When Should I Worry If My Child is Behind?
• Artic vs Phonology...What's a busy therapist to do?

Social Communication

Social Communication

The way we use language is called pragmatics. People use the social context of the situation to use words to mean different things. As my mother often said, "It's not what you say, but how you say it." If someone says, "Good morning," on the street they mean, "Hello." When another says, "Good morning," they may imply that their morning is excellent. When one says, "Good morning," sarcastically, despite the dictionary definition of the words, they mean that the morning is not good at all. Each use of the same phrase has a different pragmatic meaning. Typical developing children and adults become adept at using social cues including eye contact, tone of voice, distance from the speaker, etc. to decide each different meaning. Some individuals, such as those with autism, need to be explicitly taught these pragmatic skills.

According to the Audiology and Speech Language Hearing Association (ASHA), pragmatic skills involve three major communication skills:

• Using language for different purposes, such as
  • greeting (e.g., hello, goodbye)
  • informing (e.g., I'm going to get a cookie)
  • demanding (e.g., Give me a cookie)
  • promising (e.g., I'm going to get you a cookie)
  • requesting (e.g., I would like a cookie, please)
• Changing language according to the needs of a listener or situation, such as
  • talking differently to a baby than to an adult
  • giving background information to an unfamiliar listener
  • speaking differently in a classroom than on a playground
• Following rules for conversations and storytelling, such as
  • taking turns in conversation
  • introducing topics of conversation
  • staying on topic
  • rephrasing when misunderstood
  • how to use verbal and nonverbal signals
  • how close to stand to someone when speaking
  • how to use facial expressions and eye contact

 Those who demonstrate difficulty with pragmatic skills may

• say inappropriate or unrelated things during conversations
• tell stories in a disorganized way
• have little variety in language use

For those who have seen the movie, Guardians of the Galaxy, the character Drax (pictured above), is a perfect example of an individual with a pragmatic disorder. Here is a quote from the movie.

Peter Quill: [about Gamora] She betrayed Ronan, he's coming for her. That's when you...
[draws his finger across his throat in a cutthroat gesture]
Drax the Destroyer: ...Why would I want to put my finger on his throat?
Peter Quill: No, that's the symbol for slicing his throat.
Drax the Destroyer: I would not slice his throat, I would cut his head clean off.

From this small quote, you can see that despite a clear message from Peter, Drax does not understand the meaning because he only sees the literal meaning of the message. He is not able to understand the nonverbal signal or the verbal message because he is unable to see the double meanings in the way Peter uses the phrase. 

Here's another great example from the movie:

Rocket Raccoon: [about Drax] Metaphors go over his head.
Drax the Destroyer: NOTHING goes over my head!... My reflexes are too fast, I would catch it.

Drax is unable to understand that metaphors cannot literally go over his head and that Rocket Raccoon is implying that he doesn't understand figurative language.  In fact, a tumblr user named merryweatherblue wrote a fantastic article about taking her brother who suffers from autism to see Guardians of the Galaxy and how he completely identified with Drax because her brother has many of the same troubles with language.

In addition to defining pragmatics, ASHA also has several ideas to help those with pragmatic difficulties understand social communication. Parents, siblings, caregivers, teachers, and friends can use some of these techniques to help those with pragmatic disorders utilize appropriate social language and understand when their communication partner uses it as well.

Using Language for Different Purposes

• Ask questions or make suggestions to use language for different purposes:
• Respond to the intended message rather than correcting the pronunciation or grammar. Be sure to provide an appropriate model in your own speech. For example, if an individual says, "That's how it doesn't go," respond, "You're right. That's not how it goes."
• Take advantage of naturally occurring situations. For example, practice greetings at the beginning of a day, or have the individual ask peers what they want to eat for dinner or request necessary materials to complete a project.

Changing Language for Different Listeners or Situations

• Role-play conversations. Pretend to talk to different people in different situations. For example, set up a situation (or use one that occurs during the course of a day) in which the individual has to explain the same thing to different people, such as teaching the rules of a game, or how to make a cake. Model how the person should talk to a child versus an adult, or a family member versus a friend of the family.
• Encourage the use of persuasion. For example, ask the person what he or she would say to convince family members or loved ones to let him or her do something. Discuss different ways to present a message:
• Polite ("Please may I go to the party?") versus impolite ("You better let me go")
• Indirect ("That music is loud") versus direct ("Turn off the radio")
• Discuss why some requests would be more persuasive than others

Conversation and Storytelling Skills

• Comment on the topic of conversation before introducing a new topic. Add related information to encourage talking more about a particular topic.
• Provide visual cues such as pictures, objects, or a story outline to help tell a story in sequence.
• Encourage rephrasing or revising an unclear word or sentence. Provide an appropriate revision by asking, "Did you mean...?"
• Show how nonverbal signals are important to communication. For example, talk about what happens when a facial expression does not match the emotion expressed in a verbal message (e.g., using angry words while smiling).

 

References

ASHA Social Language Use (Pragmatics)

Guardians of the Galaxy Quotes

Tumblr article on Drax and Autism

ASHA Pragmatic Language Tips

Stuttering

Stuttering

The Basics 

     Stuttering is a fluency disorder marked by repetitions (ba-ba-ball), prolongations (baaaaaall), and blocks ([pause] ball).  This disorder is increased by stress and can cause significant emotional trauma.  Some people who stutter (PWS) are made fun of, others feel like they can’t communicate appropriately, and others are just embarrassed by the way they sound.

     Stuttering therapy has two basic branches, “stuttering modification” and “fluency-shaping”.  Stuttering modification focuses on the stutter and how the PWS can get out of the stutter. This technique places the stutter at the forefront.  Fluency shaping focuses on building fluency and almost ignores the stutter- focusing instead on good, steady speech. This handout will focus on fluency-shaping.

What is it?

Stuttering is a communication disorder involving disruptions, or “disfluencies,” in a person’s speech. In addition to producing disfluencies, people who stutter often experience physical tension and struggle in their speech muscles, as well as embarrassment, anxiety, and fear about speaking

Definitions

“Stuttering” is made up different patterns and severities of three different kinds of disfluencies: repetitions, prolongations, and blocks.

Repetitions: Consist of a repeated word or syllable. “ba-ba-ball” is an example.

Prolongations: words consisting of an elongated sound. “baaaaat” is an example. 

Blocks: a space of time in which the person is trying to speak, but cannot “get the word out.” Ex: [pause while opening and closing mouth to make the /b/ sound] “ball.”

Causes

There are no known causes for stuttering.  There have been some links to family history and some genetic studies done, however no strong association has been found.  Stuttering is not a “nervous” or anxiety-related disorder and cannot be caused by family relationships.

Cures/Solutions

There is no known cure for stuttering.  However, that being said, many young children who stutter developmentally (start stuttering young) will naturally recover (stop stuttering as they grow older).  Speech therapy can help stutterers grow more confident in their speech, learn to control their symptoms (e.g., repetitions, prolongations, and blocks) and to deal with the emotional and social side effects of the stutter.

 Stuttering Facts

•Most teenage PWS will never be fully fluent.  However, many learn to manage their stutter and the accompanying emotions in such a way that they can continue to live their life normally and achieve near-fluent speech. 

•PWS  are normally fluent when whispering, speaking in a group, and singing

•Stuttering is universally found in all languages

•PWS tend to stutter less when they are relaxed and rested versus when they are stressed , excited, or fatigued.

•80% of stutterers are male

•Some famous people who stuttered include: James Earl Jones (Darth Vader), King George VI of England (The Kings Speech), Winston Churchill (Prime minister during WWII), an d Lewis Carroll (Author of Alice in Wonderland) 

  

Ways you can help

1. Don’t tell the child “slow down” or “ just relax.”

2. Don’t complete words for the child or talk for him or her.

3. Help all members of the class learn to take turns talking and listening. All children — and especially those who stutter — find it much easier to talk when there are few interruptions and they have the listener’s attention.

4. Expect the same quality and quantity of work from the student who stutters as the one who doesn’t.

5. Speak with the student in an unhurried way, pausing frequently.

6. Convey that you are listening to the content of the message, not how it is said.

7. Have a one-on-one conversation with the student who stutters about needed accommodations in the classroom. Respect the student’s needs, but do not be enabling.

8. Don’t make stuttering something to be ashamed of. Talk about stuttering just like any other matter

9. Speak with your child in an unhurried way, pausing frequently. Wait a few seconds after your child finishes speaking before you begin to speak.

10. Reduce the number of questions you ask your child.  Children respond better to you listening to their concerns, not answering questions.

11. Use your facial expressions and other body language to convey to your child that you are listening to the content of her message and not to how she's talking.

12. Observe the way you interact with your child.  Show the child that you are listening and decrease criticisms, rapid speech patterns, interruptions, and questions.

13. Above all, convey that you accept your child as he is. The most powerful force will be your support of him, whether he stutters or not.

Techniques

•Use slow, steady speech- some therapists will have the PWS speak to the rhythm of a slow metronome and slowly increase the speed as they increase fluency.  In many situations, asking the PWS to slow down or speak slowly can help the stutter to achieve fluency.

•Easy phrase initiation- the PWS should use easy phrase initiation (or a softer start to a phrase) to help relax and release tension in the mouth and throat.

•Breath management- the PWS should manage his breaths to speak easily on one breath. In other words, he should speak without running out of air or straining his air supply taking frequent breaths.  This may require a verbal cue such as, “take a deep breath and continue”.

•Deliberate flow between words- another technique is to continue to “speak” between words.  So instead of saying “The dog sat” a PWS using this approach might say “The—dog—zat” continuing to use voicing so as not to interupt the breath and muscle flow.

Other suggestions

•The PWS should be listened to patiently, not be hurried and not interrupted

•NEVER finish a PWS word unless asked to by the PWS

•Don’t fill in words or supply answers

•Don’t look pained, pitying or impatient

•Do not withdraw eye contact, glance nervously at the PWS or stare vacantly into space

•Speak naturally

•Maintain an unhurried, calm and interested manner

•Try to help the PWS maintain a calm and relaxed environment

•Help the child avoid bullying by maintaining a kind classroom atmosphere. If bullying becomes a problem it can be beneficial to educate the class about stuttering, what it is, how the PWS controls it, and how the classmates can help him achieve better fluency

•Some reactive methods to bullying are: avoid, ignore, inform, confront, and to make light of stuttering in general.

 

Information collected and compiled from

•The National  Stuttering Association www.nsastutter.org

•The Stuttering Foundation www.stutteringhelp.org

•Clip art from http://kidshealth.org/kid/feeling/emotion/stuttering.html