Go, Dog. Go

Go, Dog. Go

One of the very best ways to develop language is through reading stories, or what we in the biz call "narratives." All children can benefit from reading aloud, whether you are reading something simple like Go, Dog. Go or something much more complex like the Harry Potter series.  For early readers, especially children under 6 or so, Go, Dog. Go by PD Eastman (the same author as Are You My Mother) is one of my very favorite books. 

I find Go, Dog. Go to be one of the best "simple" books that both has a connected story, but can also be used for very specific tasks.  For example, the entire story is about the dogs all going to a big dog party in a tree, but there are several running themes throughout the book as well.  For example, the pink poodle and the yellow dog talk about their hats several times throughout the book.  These pages are fantastic for practicing greetings during a speech session.  Each time the poodle shows the yellow dog her hat, they both say, "Hello" and "Goodbye." The pages are full of prepositions and descriptions including color and size.  Additionally, the dogs are doing such fun kid-friendly activities like playing games, going to a party, stopping for birds crossing the street, and swimming that kids tend to keep attention much better than in other books on the same reading level.

While any reading is beneficial, reading to really help develop language is important.  In my practice, I do that in a variety of ways. One of those is thematic sessions in which the majority of the session revolves around the narrative, even though I work on different goals.  For example, let's pretend I'm working with a 3 year old boy with around 50 total words.  I might be working with him on following directions, greetings, attention, using expressive language, and also introducing some new vocabulary. How can I possibly do this with just one book? Well, I would use the book as a center of our activities.  We might work together on Go, Dog. Go for a month with several or all of the following activities:

• Use visuals and activities for big and little
• Great site for visuals that go with can be found here.
• Wear hats, put hats on, take hats off, etc.
• Count the dogs
• Match colors with trees or dogs
• Some good visuals can be found here.
• Color Go, Dog. Go coloring pages (for older kids we would follow specific directions like, "Color the dog's head purple." or "Draw stripes on the dog's feet"
• Coloring pages can be found here.
• Some of my favorite coloring visuals can be found here as well.
• Act out sleeping and awake
• Talk about fast and slow, play the game "Red light/Green light" during therapy
• Make crafts that associate with the book like a stoplight collage, gluing cotton balls to a poodle for hair, make cars out of cardboard boxes, etc.
• Practice "stop" and "go" with stop lights
• One blogger made adorable stop lights during an entire preschool Go, Dog. Go activity, find it here.
• Watch youtube videos of readings of Go, Dog. Go for homework to further familiarize the child with the story
• Two of my favorites can be found here and here.
• Give parents some dog activities to do for homework at home.
• Some great ones are found here and here.
• Make a sensory bin with Go, Dog. Go themed objects to find and discuss.

Also, I wanted to show some pictures for how I used some of the above resources recently.  I used them addressing several different goals, and my kid had a blast!  Although we've moved on to another book, the kiddo requests Go, Dog. Go almost every session.

After reading the book, we used a big and a little tupperware and then separated the big and little dogs into the appropriate container.  I've extended this activity with other visuals like planes, firetrucks, etc. essentially whatever will get the kid's attention.

We use these crayon visuals to have the kid request which color they want.  I've used this when matching colors to dogs or colors to trees in the book as well.  Additionally, with more advanced kids, I've used the visuals as a reminder of instructions (e.g., I would place a visual when the instruction was something like, draw pink polka dots or purple stripes).

Here is my sweet, sweet sensory box and visuals that I use.  We have several elements from the book including dogs, cars, hats, party blower/horn things, and balls of various colors (ever tried to find mini trees? Much harder than you'd think...) We use this box mostly for receptive language and trying to find specific elements.  We tested it out without the objects in the beans first to make sure that the kid could identify the elements.  After the initial test, we used the sensory box for an increased element of difficulty.  Sensory boxes are great for speech because they add a kinesthetic element that is hard to really get otherwise.  (Learn more at this great blog! or this one! or this one!) 

Hope this is helpful to you in your speech therapy journey.  Enjoy and Happy Speeching!

References

• All Go, Dog. Go images were taken from google images.  Additionally, the visuals I pictured were taken from the various references I posted above. 

Speech, Disabilities, and Church

Speech, Disabilities, and Church

Many families have adults and/or children with with special needs. Many of these same families also attend church.  While some big churches have programs for children and adults with special needs in the church, I believe it is safe to say that most churches do not have such programs in place.  Some difficulties that families of those with special needs face during church are:

• Loud microphones for sermons, choirs, prayers, etc.
• Quick speaking with complex language during sermons, sunday schools, children's meetings, etc.
• Very few visuals other than text (for example, in a sermon, they may use flash a scripture on a video or presentation, but they very rarely will have a visual of that scripture or scripture story)
• Required quiet attention of an hour or more with very few sensory breaks
• Loud music from organs, pianos, or instruments
• Lots of people in very little space, often families share pews or sit close together in chairs

Church congregations often have some advantages for those with special needs as well:

• People tend to be more forgiving of those with special needs 
• Teachers, Church leaders, Pastors/Reverands/Bishops/Preachers typically want to help
• Most churches have a very routine order to their services, classes, and activites

Families of those with special needs can help their church help their family member with a lot of education and some assistance to help teachers, leaders, etc. know how to help the family member.  Here are some examples:

• For family members of Deaf individuals: you can provide American Sign Language classes to help your church members communicate with your family member.  You can help them understand how to communicate through sign or writing, you can also help them understand how to get their attention, how to make sure that your family member understands, and talk about the wonderful culture that they are a part of.
• For family members of those with Autism Spectrum Disorders: You can wear headphones during services if the noise gets to be too much, you can hep the teacher learn how to make visuals for sunday school lessons to help the child or adult understand the lessons, ask the church to provide an aide for lesson times that can go with the individual and help them during lessons, ask the church to provide an area where the individual can go where it will be quiet should they require a break, and provide education to the church members of the specific struggles of your family member.
• For family members of people who stutter: You can provide education to the children about what stuttering is and what strategies they can use to help the individual (like waiting for them to finish speaking instead of speaking for them), you can allow the individual to participate in choirs or singing which will help them overcome their stutter during church and focus on their strengths.
• For family members of those with language difficulties: You can ask teachers and leaders to repeat important parts of lessons and stories before asking questions of the individual, supply teachers with pictures that correspond with lessons and stories to help the child understand the lesson, you can ask for the lessons beforehand to go over with your loved one before church to improve their familiarity
• For family members of those who struggle with articulation: help teachers and others in the classroom understand your family member's particular difficulty and also to clarify what was said by repeating it back and being clear when you don't understand
• Look at pinterest for some great boards with visuals, schedules, story pictures, etc
• For example: Great Pinterest Board for church visuals

Family members and those with disabilities can have a great time in their church family.  Be open to how you can help those around you help you. 

Here are some additional resources.  I don't have every church (because I don't know them all), but I tried to get a fairly representative sample.

• Strength in Weakness: The Bible, Disabilties, and the Church
• Disability Resources
• The Church and People with Disabilities
• Pastoral Statement of US Catholic Bishops on People with Disabilities
• Muslims with Disabilities
• Disability Inclusion

Apraxia

Apraxia

Apraxia of speech is a motor speech disorder in which a child or adult has difficulty speaking syllables, words, and sentences with motor-planning instead of muscle movement.  Essentially, the brain (which is healthy) has difficulty telling the muscles (which are healthy) what to do. Some doctors also refer to apraxia as verbal dyspraxia. CAS (Childhood apraxia of speech) is prevalent in about 1 out of 1000 children (or somewhere between 3 and 4% of children diagnosed with speech disorders.  It is typically found more often in boys than girls and is associated with a few diseases including Fragile X syndrome.  As a speech disorder, it is fairly rare. 

Symptoms

Some symptoms as explained by the American Speech Language Hearing Association (ASHA) are:

• inconsistent errors on consonants and vowels in repeated productions of syllables or words
• lengthened and disrupted coarticulatory transitions between sounds and syllables
• inappropriate prosody, especially in the realization of lexical or phrasal stress. (Reference)

While these are not the only symptoms, these are the most indicitive of apraxia. Severe phonological disorders which use consistent patterns are not apraxia of speech, however apraxia can occasionally have patterns of difficulty with specific sounds or patterns.  Additionally, apraxia of speech also is seen in apraxia of limb movement (inconsistent movements of arms and legs) as well.

Apraxia can also affect a child's language development.  Children with apraxia frequently have difficulty with grammar, expressive language, reading, and writing. 

Causes

ASHA has identified several causes of CAS (Reference).  Neurological difficulties such as stroke, infection, brain surgery, etc., neurobehavioral disoders including autism, epilipsy, and other syndromes, and idiopathic speech sound disorders.  Essentially, should a child have some sort of trauma to the brain or a syndrome or disease which affects the brain they are at higher risk.  Additionally, like all speech and language disorders, occasionally there are some children who are just born with these difficulties and will require therapy in order to resolve their problems.

Treatment

Treatment is focused on increasing intelligibility using both articulation and language therapy together.  Traditional articulation approaches may be used in conjunction with therapy focusing on increasing general intelligibility and language abilities. Treatment can also utilize tactile and visual cues to help increase motor planning skills. Children with CAS also benefit from using melodic tones when speaking to improve speaking functions. 

Treatment is also more beneficial when given intense treatment more frequently (3-5 times a week) alone rather than in groups. 

References:

Childhood Apraxia of Speech

ASHA Technical Report

Building Vocabulary

Building Vocabulary

 

Vocabulary.  Vocabulary essentially is a list of all the words that we know.  For adults (and children over 12), that vocabulary can extend to an amazing 50,000+ words.  We use vocabulary every day to talk about the world around us and get our wants and needs met.  We use vocabulary to communicate and without it, we would very much struggle to do so.  There are four basic types of vocabulary:

1. Expressive Vocabulary: These are the words that you use when you speak. 
2. Receptive Vocabulary: These are the words that you understand when someone else speaks to you.
3. Reading Vocabulary: These are words you understand when reading them
4. Written Vocabulary: These are words you are able to use in writing.

Think about the following words and what category they might fit in: cup, explain, expedition, therefore, and peacock.  Some of those words might fit into multiple categories, while some might only be used by you in one.

How many words should my child know?

Well, that is a fairly difficult question, but we can estimate a child's expressive vocabulary.  Keep in mind that typically, people's receptive vocabulary is slightly larger than their expressive vocabulary. Here are some numbers according to the Linguisystems Milestones Guide.

12 months: 2-6 words
15 months: 10 words
18  months: 50 words
24 months: 200-300 words
30 months: 450 words
3 years: 1,000 words
4 years: 1,600 words
5 years: 2,200-2,500 words
6 years: 2, 600-7000 words
12 years+: 50,000 words+

 How to Help

Read. Read. Read. Read.  I can't reiterate enough that reading is the most important thing you can do to help build your child's vocabulary.  Recently, the Barbara Bush Foundation posted on their Facebook page quoting, "Reading aloud is recognized by experts as the single most important activity parents can engage in to develop strong language skills in their children." 

"We can model reading, keep them reading independently, and just teach them more and more vocabulary in a contextualized, functional way through text and stories so they can connect it to what they know."--Dr. Carolyn Ford

Here are some additional ideas from the American Speech Language Hearing Association (Reference):

• Build on your child' s vocabulary. Provide definitions for new words, and use them in context: "This vehicle is riding on the highway. It is a car. A bus is another kind of vehicle. So are a train and an airplane."
• Encourage your child to ask for an explanation if he or she does not understand what a word means.
• Point out things that are the same or different. Play games incorporating these concepts that he or she will encounter later in the classroom in reading readiness.
• Sort items into categories. Now try to sort them by pointing out more subtle differences between objects (e.g., rocks that are smooth vs. those that are rough, heavy vs. light, big vs. small). Again, have your child identify the object that does not belong in a given category, but now ask him or her to explain why the item does not belong.
• Expand on social communication and narration skills (telling a story) by role-playing. Play house, doctor, and store using dialogue, props, and dress-up clothes. Do the same with a dollhouse and its props, acting out scenarios and making the dolls talk.
• Read stories with easy-to-follow plots. Help your child predict what will happen next in the story. Act out the stories, and put on puppet shows of the stories. Have your child draw a picture of a scene from the story, or of a favorite part. You can do the same thing with videos and television shows, as these also have plots. Ask "wh" questions (who, what, when, where, or why) and monitor his or her response.
• Expand on your child' s comprehension and expressive language skills by playing "I Spy": "I spy something round on the wall that you use to tell the time." After your child guesses what you have described, have him or her give you clues about something that he or she sees.

Introduce  New Words

For older children, you can use new words like "frustrated" in place of "mad." When a child asks what it means, you can briefly explain that it is a feeling when you're trying to do something, but can't. Continue to expand upon a child's sentences. For example, if a child says, "I want the dog" ask if they want the big dog, the giant dog, the tiny dog, or diminutive canine, etc.

Read a book that has a humongous hippo or an enormous elephant and discuss other words you know for big like huge or gigantic. You can also build word webs which connect words that mean similar things. There are tons of pen and paper ideas for vocabulary expansion.

Reinforce Words They've Learned   

Keep using new words.  Talk about being frustrated cooking dinner because the oven isn't cooking as fast as you want.  Talk about being frustrated when you have to clean up over and over because the house keeps getting dirty.  

You can play some vocabulary games (like hangman, scattegories, etc.) to help reinforce words you've learned.  

References

• Vocabulary Resource Page 
• Evidence-Based Vocabulary Instruction 

• Build Your Child’s Vocabulary! Top Speech Therapy Activities 

   

   

   

   

Early Intervention

Early Intervention

Many kids have some difficulty developing speech and language. In fact, three of my four siblings received some speech therapy as young children.  Some kids have difficulty pronouncing words, some have difficulty getting their message across and are frequently frustrated, some have feeding difficulties or stutter, some don't speak at all. Early intervention is speech (or other) intervention before age 3.

Early intervention is encouraged for all children who may need therapy.  Generally speaking, the earlier the intervention, the better, faster, and more efficient the therapy. Additionally, "the longer a child’ hearing loss is undiagnosed and untreated, the more difficult it will be for the child to develop speech and language skills." (Reference)

Why should I intervene early?

To sum up quickly (Reference):

• The brain is the most "plastic" (flexible) during the first 3 years of life. 
• The brain can be strengthened through positive early experiences
• Language skills develop from early social/emotional development and physical health 
• High quality early intervention can improve outcomes for children and families
• Early Intervention is likely to be MORE effective and LESS costly.

Who doesn't love more effective therapy for less money?!?!? Studies have shown that for every $1 spent in early intervention somewhere between $4 and $7 is saved in later therapy costs.

What can I do to help?

Early Intervention heavily involves family members and helps the family to provide therapy all the time.  Some advice from the Alexander Graham Bell Association is, "As with every aspect of raising your child, your full commitment and involvement in an early intervention plan is vital to the success of your child. Even with regular speech therapy, the vast majority of your child's learning will take place with you at home. At every stage of early intervention services, make sure you are aware of what things you can do at home to continue language development. 

What does the therapist bring to the table?

As with every aspect of raising your child, your full commitment and involvement in an early intervention plan is vital to the success of your child. Even with regular speech therapy, the vast majority of your child’s learning will take place with you at home. At every stage of your early intervention services, make sure you are aware of what things you can do at home to continue language development. - See more at: http://www.listeningandspokenlanguage.org/Early_Intervention_What_It_Is_and_Why_It_Is_Important/#sthash.Y5drLn7h.dpuf

A service plan developed as early as possible after the child’s diagnosis.

Heavy involvement by families in the development and execution of the agreed upon plan.

A highly structured plan that provides clear and measurable goals.

- See more at: http://www.listeningandspokenlanguage.org/Early_Intervention_What_It_Is_and_Why_It_Is_Important/#sthash.Y5drLn7h.dpuf

A service plan developed as early as possible after the child’s diagnosis.

Heavy involvement by families in the development and execution of the agreed upon plan.

A highly structured plan that provides clear and measurable goals.

- See more at: http://www.listeningandspokenlanguage.org/Early_Intervention_What_It_Is_and_Why_It_Is_Important/#sthash.Y5drLn7h.dpuf

Along with families, caregivers, and other service providers, Speech Pathologists can provide a valuable resource for assessment, treatment, consultation, and advocacy for the client. Therapists should be providing intervention with four main guiding principles (Roles and Responsibilities):

Services are family centered and culturally and linguistically responsive.

The family of a child are the best speech therapists that are available to a child. The family will affect the child throughout their lives.  Additionally, because the family is so important, the family's culture, goals, beliefs, etc. should be respected and utilized during therapy.  "Components of family-centered practices include offering more active roles for families in the planning, implementing, interpreting, and decision making in service delivery. Family-centered practices can maximize time and other resources, create closer alignment between family and professional decisions and plans, and increase decision making by families."

Services are developmentally supportive and promote children's participation in their natural environments.

A child's natural environment should be where therapy occurs.  Additionally, therapy should be appropriate to the child's age and situation.  Most early intervention should be manipulating objects, experiences, and interactions that are appropriate for the child's age. 

Services are comprehensive, coordinated, and team based.

Early Intervention will not only take place between the Speech Language Pathologist and the family, but it may also include many other professionals (Occupational Therapists, Physical Therapists, etc.) in order to meet the child's overall needs.  By working together using a team approach, a family can have more focused, less fragmented therapy.

Services are based on the highest quality evidence that is available.

Clinicians should use evidence-based practice principles in order to treat the child using the highest quality therapy.

References

• Speech-Language Pathologists and Early Intervention 
• Roles and Responsibilities of Speech-Language Pathologists in Early Intervention: Guidelines

Picture Exchange

Augmentative and Alternative Communication
(Picture Exchange)

Augmentative and Alternative Communication programs (or AACs for short) can serve a lot of different populations with many different needs.  Essentially, should a person not be able to speak for whatever reason, they can use an AAC to get their needs met in a different way.  AAC devices can be low-tech (using pictures or letters that a person can point to or exchange) or high-tech (using highly sophisticated technology--think Stephen Hawking) 

Picture exchange is a one AAC system which uses pictures instead of words. While most people are able to use words to communicate, some children and adults have difficulty producing words.  For these people, using pictures is the easiest, broadest way to communicate. I have seen both kids and adults' language improve using some sort of picture communication and love seeing their amazing progress from non-communicative to being able to say exactly what they want.

From the PECS (Picture Exchange Communication Systems--a picture exchange method) website, "PECS begins by teaching an individual to give a picture of a desired item to a “communicative partner", who immediately honors the exchange as a request. The system goes on to teach discrimination of pictures and how to put them together in sentences. In the more advanced phases, individuals are taught to answer questions and to comment." 

Picture exchange is incredible for so many groups of people.  There are children who are speech delayed who will eventually learn to speak, but just need some help getting their needs met while they develop their spoken language skills, children who will use picture exchange throughout their lives, and also those who use picture exchange as a stepping block to a more technology-driven AAC device. A few quick examples:

• A 2 1/2 year old child with a speech delay who has only a few words (up, go, and car) could use PECS to ask for different kinds of foods, toys, and activities while he builds up his spoken language vocabulary.  This will help this child learn that when he communicates he is able to get what he wants, it reduces frustration for both the child and his parents and caregivers, and it helps provide multiple opportunities for language stimulation while using the picture during exchanges.  
• An 8 year old with severe autism with no spoken language and few readable gestures.  Picture Exchange will allow this child to communicate basic needs and request preferred objects and activities (like apples or computer time).  This communication skill may be used to help eliminate dangerous or destructive tantruming behaviors or self-harm behaviors as it removes frustration.
• A 5 year old child with cerebral palsy who has age-appropriate receptive language skills, but cannot communicate verbally might use picture exchange as a precursor to using a speech generating device.

In a picture exchange system, a child or adult would present a communication partner a picture to express their want.  For example, if a child gave me a picture of an apple, I would know that they wanted an apple. As a bridge to spoken language, in therapy, I would also incorporate spoken language and gestures to ensure a multi-modal approach to language.  A script of how an exchange might take place is as follows:

Child takes apple picture out of picture book

Child gives apple picture to clinician

Clinician helps child point to the picture, "Oh, you want an apple."

Clinician holds up apple, "I want apple."

Clinician gives apple to child, "Here's your apple."

Child takes apple

Please notice that in this example, the child exchanged the picture, heard the word "apple," and saw the real apple. We've used three senses to communicate (touch, hearing, and sight), received three different expansions of the word apple, and the child successfully communicated! 

 

Typically, someone using picture exchange would have a book of pictures of objects and activities. Depending on the language abilities of the user, one person might only have one or two pictures to choose from but another might have 600 pictures to choose from. Additionally, depending on the language abilities of the person, other grammar principles might be used including nouns, adjectives, adverbs, etc.  

 

Typically, one would start with one picture exchanges (the "waffle" picture gets you a waffle) then increase to two pictures ("I want" and "waffle" would get you a waffle), then additional pictures and concepts (I want a big, green waffle quickly).

For some users, as you increase the number of pictures, they decide that talking really is faster and the picture exchange is just a bridge to using spoken language.  Picture exchange in this sense is fantastic because some users start getting the concept that if they say (or exchange), "grape," they give me a grape.  They start to understand that they can manipulate the world around them. 











Because Picture Exchange allows children to communicate their desires, it can help tantrums and increase socialization opportunities. (Reference)  Imagine taking a 7 year old child who cannot speak on a field trip to the zoo.  What do they want to see? What animal do they like best? When you eat your lunch, what do they want to eat first? How will they tell their friend their favorite part?  Does their friend want their apple? Think about all of the things that we think and communicate all day long.  That same child without picture exchange may not be able to communicate or socialize with anyone all day long.  With picture exchange, that child may be able to answer all those questions to not only their teacher, but also the friends from their class.  Think about that child returning to it's mom at the end of the day.  Can you imagine how happy that mother would be if she could ask a question about what her kid saw and that kid could answer with even one picture? 


There are informal picture exchange programs and also formal programs of picture exchange like PECS (Picture Exchange Communication Systems) which require specialized training in order to be able to properly utilize. Typically in my therapy, I use a more informal approach, unless I think that the child and parent really need a more rigorous program. Meta-analysis has shown that that utilization of PECS is promising in therapy and can result in gains for children with autism. (Reference)


One last note, parents frequently ask me about using sign language instead of picture exchange when their child is speech delayed, but the problem with sign language is that when you communicate through sign, you need someone to communicate with and you need to be able to produce the signs accurately.  If your community and support system is willing to learn sign to help your child, sign can be an amazing communication method.  Parents should be sure to teach signs for specific objects and be careful not to use one or two signs for everything (For example, make sure to teach "cracker, juice, hot dog, carrot, and bubbles" instead of only using the sign "more" to request additional food or play.  Another example is using the sign for "please" to mean, "please give me some food," "please let me play," "please let me stay up late," and "please let me wear the blue shirt")

References

• PECS website
• Effectiveness of the Picture Exchange Communication System as a Functional Communication Intervention for Individuals with Autism Spectrum Disorders: A Practice-Based Research Synthesis