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?