Tips for carryover in Childhood Apraxia of Speech: Part 2 of 2

By Laura Smith|January 5, 2016|#knockoutapraxia, Apraxia, apraxia blog, Childhood Apraxia of Speech, Therapy for apraxia|

We all know Childhood Apraxia of Speech is rare!  The odds then of having a mother who is an SLP?  Probably substantially rarer right?  When I first started on this journey, I knew of none.  Now I know at least 30!  We have a unique perspective for sure, and I wanted to team up with two other moms to tell you what we do in our own homes with our own children with CAS.  This is Part 2 of a 2 part series.  Our first one can be found here:

Tips for Carryover in the Verbal Child with CAS: Part 1 of 2

So, if you haven’t read that already, please do!  If you have, let’s continue!

Powerful Motivators

Sound familiar?  This was first and foremost in my last post on home strategies too.  Speech is hard!  Our kids have to not only think about what they want to say but how to say it, and that’s where we come in to help.  I can remember when Ashlynn started saying the final /k/ in the word “book” instead of substituting a /t/.  She loves books and even still looks forward to me reading a book to her before bed.  It’s a powerful motivator, and after I knew she could say “book” and not “boot,” I had her say it correctly before I read her the book.

A huge motivator for my son too is really as simple as just saying “wow, I loved how you said your lifty sound (our reminder word for the L sound) in the middle of that word!” he gets so excited when I notice the work he puts into speaking. His face just lights up and it is so cute.  I try to do this as much as I can so that he can feel noticed for doing right instead of just maybe feeling corrected all the time.

Motivation is an essential element for making progress and one to always keep in mind for home practice as well as during therapy with his regular SLP.  In fact, this is one of the top characteristics that I look for in an SLP for my son. He is a pretty easy-going, compliant client for any SLP, so he’ll do a lot of “work” in a therapy session without a lot of reinforcement.  While this may sound like a wonderful “problem” to have, I know that he needs motivation and reinforcement to keep his forward momentum going in his speech therapy, since we all know this is a marathon and not a sprint for kids with CAS.  We actually switched SLPs at one point because he wasn’t having fun and staying motivated during his therapy sessions with a former SLP.  I need an SLP who recognizes this critical component of therapy and want to stress its importance to all parents of kids with CAS.  For my little guy, the best reinforcement is when I get down on his level and play with him.  Having fun and playing games of his choosing is a way to keep our relationship strong, which carries over into the rest of our daily activities/practice opportunities.

I completely agree! Therapy with an SLP needs to be meaningful, motivating, functional, and encouraging in order to work. It’s the same at home. Use the moments when your child is engaged with something they love and use that as an opportunity to get the best results.

Praise!  Lots and Lots of Praise!

I currently have a new young client, and she thrives on getting stickers.  When we first started, she would get a sticker for even just looking at my mouth when I asked!  As I was talking to her mom one day, her mom said something so simple but profound, “what person doesn’t like praise?”  She was right!  Aren’t you motivated to work harder at your job or help your spouse more when you get praise and you feel appreciated?  Make sure to acknowledge your child’s hard work!

EVERYONE likes to feel successful. Children are no different. Praise becomes motivation as well so these two things really go hand in hand in my opinion. Once you start focusing on praising and positivity you will see willingness to participate increase. There was a time when I was so frustrated at my son’s eating, or lack thereof, that at the end of the day I realized that all I had been doing all day was talking negatively to him about not eating. It made the situation worse. In the morning, I started making sure I found things that he was good at in regards to eating and said things like “You are really good at using your tongue to taste food. You are my expert taste tester” I can’t say it helped him eat anymore, but it certainly made both of us in a better mood and he was willing to “taste test” more and smile at the thought of trying food instead of crying. It is no different with speech. Sometimes you just have to find the words that work best for your child. We’ve all said this a million times…it’s a marathon, not a sprint. It takes time to find what works best for you and your child. It is also important to remember that what works best for you and your child may not work best for your spouse and your child. Encourage your spouse, partner, family, whoever to find something that works for them, but don’t make them do everything the way you do it (oh and don’t forget praise for them either).We all have such different relationships and communication styles with our children.

You two have already covered most of this topic, though I’d like to add the reminder to remember how hard our kids are working every single day, every single time they open their mouths to speak.  We witness it everyday and know how hard they are working.  We must be our children’s biggest cheerleaders.  Smile, laugh, and remember to have fun.  We’re in this for the long haul and want to enjoy our journey together as much as possible.  

Know your cues!

Since we are SLP’s, we already know tips and tricks to cueing speech sounds.  However, parents might not.  That’s why it’s so important parents are able to see therapy in action, whether that be in the room, or videotaped.  Most kids with apraxia respond well to cues.  Cues can be touch cues, visual cues, verbal cues, or even sign cues.  If you don’t know the cues your SLP is using, you’re probably going to be less successful at helping your child carryover his/her targets at home.  

If the child cannot say the sound or is getting frustrated, it’s not a good target.

If you have your powerful motivators, are using your cues, and your child is still not producing the word correctly, move on.  Ask your SLP for different targets.  Therapy for apraxia is hard enough.  Home practice should be easy, not miserable.

If this was a post on facebook, I would try to like this comment a thousand times! Remember that old saying “pick your battles”? It applies to home practice too. They need to stay confident in order to want to keep working because let’s face it, they have to work really hard. If they stop wanting to work because something is physically unachievable at that time, you might as well throw in the towel. I sit in on every session and watch very closely to what they are doing. I make sure I am using the same verbal and visual cues that our SLP uses. This is extremely important for me in order to stay consistent, but it is also important to see how he reacts to cues in therapy so I can use that information to troubleshoot at home. Being in the room or behind a two way mirror also helps me to be able to ask questions based on what I have seen and tried at home and what I see in therapy. If something isn’t working at home, I tell our SLP. Sometimes I have suggestions on what could help based on his personality and sometimes we really have to work together to figure it out. It is a collaboration for sure.

When there is a word or phrase that you know your child will have difficulty with, try to set them up for success to produce it correctly by giving the cues they need to say it accurately – it may be visual or verbal cues or a direct model.  If I can intercept an incorrect production, I try to do so.  The more he practices it correctly, the better off for everyone.  This applies best to emerging skills or those currently being targeted in therapy.  When your child reaches a higher level of proficiency for a skill, I will often let him try it on his own and only cue if there is an error. 

It’s impossible to correct/cue for every speech and language error every time it happens during your daily interactions with your child.  I don’t want to present the idea that I catch and correct every error that my son produces every day because I’m an SLP.  That’s not realistic or accurate.  Early on in his therapy, and even now, when we have so many goals that need addressed, I have often felt overwhelmed when trying to work on them.  I feel the need to work on everything all the time.  It’s been helpful to me to choose one goal or one goal area to target at a time.  Right now, we’re working most on language goals and using helping verbs, prepositions, and articles (the “little” words in sentences), and those are what I cue for 75% of the time.  The other 25% are mostly speech errors on sounds that he can produce (consonant blends) or the occasional newer speech target (long vowels).  Soon, I’ll probably switch my focus back to cueing/working on speech goals (especially those vowels!) a majority of the time, and put the language goals on the “back burner.”

It’s a marathon, not a sprint!  

There’s that phrase again! Once our kids have finally passed the hurdle from being non-verbal to verbal, many times they rely on practiced or known “motor plans” to communicate…..which is AWESOME!  Our kids go so long not being able to say a single word despite having what they want to say in their head, I can only imagine how nice it must be to go on auto-pilot every once in awhile.  Unfortunately, sometimes their motor plans contain poor grammar.  

The most common one I see is the child referring to themselves in third person, instead of saying “I.” Ashlynn definitely did this!  It makes sense though right?  We always teach them their name, and then when they finally get it, we are so proud.  Also, it has all the elements I just talked about right?  It’s a powerful motivator to say your name, they get lots of praise and reinforcement when they say their name, and parents probably practice this target throughout their day (distributed practice). I have many, many blog posts where I outline her sayings such as: Ashlynn happy, Ashlynn play boats, Ashlynn want muffin etc.  It took months, MONTHS, and that was with me correcting her EVERY TIME to break that and say “I” instead.  That is apraxia.  You can then only imagine how much longer that would have taken without that home element!

Yes, once G moved into using short 3-4 phrases, this was a big milestone and so exciting!  However, those phrases were often learned as big chunks.  For example, he learned the phrase, “I like it!” but did not actually have functional use of the pronouns “I” and “it.”  He used the phrase as one unit and didn’t grasp independent use of those pronouns in other contexts or with other verbs.  However, once he did start using it, I made sure to model their use in other situations to get him to practice similar sentence structures.  I think of it as him having the motor plan for that sentence structure (subject-verb-object) and then we have to work on it growing and maturing to be strong enough to support more combinations of that sentence structure.  This “auto-pilot” scenario still occurs right now too, especially with new-to-him phrases.  For example, when watching the weather forecast one day, they predicted snow showers on Friday.  G said a new sentence, “Snow on Friday!” which was fantastic to hear!  However, now any other time we watch the weather report and talk about the rain or snow forecasted, he defaults back to saying, “Snow on Friday!” whether it’s correct or not.  Now that I know this about him, I try to intercept that automated response and repeat the correct words (“Rain on Monday!”) before he has a chance to say the inaccurate one.

Don’t forget about Prosody!

Prosody is sometimes referred to as the “melody” of speech.  It can include things like inflections, syllable stress, and volume.  To have an apraxia dx, children have to have difficulty with this.  When we are trying to get them to say a word correctly, we can exacerbate disordered prosody, which we don’t want to do.  Always be mindful of using varying inflections, and stressing the correct syllable when speaking to your child or having them say a word.

Ashlynn had a habit of omitting medial consonants in CVCV words.  For example, daddy was da–ee and doggy was dah-eee.  When I would try to correct her, my first inclination is to of course tell her to say daDEE.  That is the wrong stress though for the word.  We don’t say daDDY.  We say DAddy.  Sometimes we can’t help but stress the wrong syllable, especially in the teaching phase; but it’s good to be mindful we want to move them to the correct stress as quickly as possible.

I feel prosody is often an overlooked, but important aspect to remember with CAS. If you question if you are encouraging or modeling something correctly, try saying it in a sentence naturally to your spouse and see what kind of inflection you naturally put on the syllables in that word, then you can model it better for your child if you understand how it sounds in a natural way. I tend to say a word a little sing-songy when I’m trying to model good prosody in a word or sentence that is hard for him. For some reason, it really works for him by emphasizing the left out stress in the syllable without taking away the naturalness of it. He can hear it and model it a bit better when I do it like this, but if you have concerns on how to address it, ask your speech therapist. It can feel tricky at times. Also, my son would say things too high pitched and he still does occasionally, but we were able to come up with a system that worked for him. We color coded his high and low pitches so if he was getting too high, I would say “I heard your purple voice, let’s try saying that with your green voice instead of your purple voice.” Colors clicked with my son, but you may find using animals or something more meaningful as a voice reference is easier for your child.

This is one of the trickiest aspects of CAS for me.  I was guilty of using unnatural prosody and stress A LOT with G, especially early on.  I wanted him to speak so badly and I was doing everything I possibly could to help.  Now that I know better, I do better. When working on a specific target, I do sometimes still stress sounds or syllables to help draw G’s attention to that sound and to help him produce it.  However, as soon as he produces the word or phrase accurately, I immediately return to normal prosody and try to elicit that immediately after.  We also use a sing-songy voice sometimes to help bridge the gap between an over-stressed isolated production and one with natural prosody.  I would say that I strategically use extra stress for omitted sounds, syllables, or words, but I try to use normal prosody first before doing this.  

Listen and give them time!

One of the biggest keys to success in our home is to listen. Ian needs extra time to speak, he needs to feel heard and this helps his confidence to continue to try even if he doesn’t always do it perfectly. Although it sometimes takes a painfully long time we let him finish what he is trying to say, and pause a moment before we answer, just in case he wants to fix something he missed on his own. I try to give opportunities for him to figure out and fix his mistakes on his own, and I’m not afraid to tell him if I didn’t understand something. We have always had a gesture or a word associated with a sound thanks to guidance from CAS specialists we have worked with, so if Ian forgets a sound in a word I try to first just do the gesture of the sound he missed or I do the word he may have left off of a sentence in sign language to help him remember without telling him first. Everything he has learned (from signs/visual cues to help with speech, to sounds, to words, to the prosody within those words and sentences) is still modeled heavily in our house whenever he doesn’t say it like I know he can. This is basically our everyday distributed practice. I do try to create moments to help him work on combining his new sounds with everyday speech, but for the most part I just go with the flow and most importantly I don’t give up. I guess I’m still afraid he will lose something and we might not see it again for months, or that he will get used to saying something that he already can say correctly the wrong way and have to start all over again, but whatever it is we never stop using everyday situations as practice. I’ve had to learn the hard way that thinking he has something mastered doesn’t mean I can give up correcting it. There have been times when his ability to speak correctly and efficiently waxes and wanes. I’m hoping it changes where one day he won’t need my help at all, but for now I can never let myself get lazy with helping him progress to the best speaker he can be and that’s why we use everyday moments to practice speech and not just ten minutes at a time.

I couldn’t agree with this more!  Ashlynn needs a TON of processing time.  As much as we work on speech, I also make sure to step back and just wait for her to finish a sentence or a thought.  She also has crippling word finding difficulties and though it’s tempting to want to fill in the blank or give her a word, I wait for her to try and come up with it herself.  If she can’t, I also use sign cues like Nicole, or I give her the first sound and see if she can access it on her own.  

While it’s true that all kids need time to accomplish something new on their own in order to feel independence and pride, this is especially poignant for our kids with CAS.  They often need extra time to formulate their replies and get their mouth to cooperate with what their brain wants to say.  I try to give G this extra time at home, in his safest environment, so he can build his confidence and skills to use his speech in the more hectic “real” world outside our home.  When listening to G, I too let him know when I do not understand what he’s saying and give him as many opportunities as possible to repair that communication breakdown (e.g. repeat, re-phrase, gestures, answer questions).  

When thinking about G and his speech therapy goals, it’s so important for me to remember to “give them time.”  Some days, I feel discouraged about G’s speech and language skills and that I should be able to do more for him.  When this happens, I try to think about what he can do now compared with 6, 9, or 12 months ago.  Of course, those gains don’t come without a whole lot of work from him and us, but the progress is there, and he will keep making it, because we won’t give up.  

I can’t thank Nicole and Kimberly enough for joining me on this journey and for guest blogging today.  When I had this vision for this blog post, it could not have been nearly as in depth or insightful as it is without their input!  Our children continue to make progress.  YOUR child will continue to make progress with the right elements and correct therapy approach.  

mommy-2Band-2BashlynnLaura Smith M.A. CCC-SLP is a speech/language pathologist in the Denver Metro Area specializing in Childhood Apraxia of Speech.  CASANA recognized for advanced training and expertise in Childhood Apraxia of Speech, she splits her time between the public schools and the private sector.  She is dedicated to spreading CAS awareness.  Her passion is fueled by all of her clients, but especially her own daughter who was diagnosed with Childhood Apraxia of Speech.  For more information visit SLPMommyofApraxia.com
12483712_10102672217441924_1074570947_nNicole Quaka M.A. CCC-SLP is a licensed speech and language pathologist in the Pittsburgh area who is currently a stay at home mom to her two boys. Her background is in adult swallowing and cognitive communication disorders related to TBI and degenerative neurological disorders. However, because of her eldest son’s diagnosis with CAS she has spent the last three years dedicated to continuing education on augmentative and alternative communication, childhood apraxia of speech, and related developmental disorders.
12476212_10153908135074903_1729160114_nKimberly Peterman M.A. CCC-SLP is a speech language pathologist in the Columbus, Ohio area who is currently a stay-at-home mother to her two sweet, active sons.  She has experience with clients from preschool age through mature adults, and particularly enjoys working with clients in the areas of articulation, stuttering, hearing impairment, and language impairment.  Since her oldest son’s diagnosis of CAS one year ago, she has devoted all of her SLP continuing education, time, and resources to his ongoing speech therapy and is grateful to be able to do so.

 

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