Tag: CAS

  • September Specialty Series: Using AAC (Alternative and AugmentativeCommunication). A mother’s story.

    September Specialty Series: Using AAC (Alternative and AugmentativeCommunication). A mother’s story.

    To continue my September Specialty series, I want to introduce Merry. Merry is an amazing mom, and I wanted to feature a mother because in my opinion, parents are the experts on their child.  I think it’s important professionals keep this in mind, so I’ll say it again.

    Parents are the experts on their child.
    Her daughter is using an AAC (Assistive & Augmentative Communication) device at the age of 2 ½!!  I thought she was the PERFECT guest to talk about AAC because many parents aren’t even told it’s an option, or they are told their child is too young.  I’m a big believer that mothers know their child better than any professional and are their biggest advocate.  Merry is proof of this!  Thanks Merry for guest blogging!

    Tell us a little bit about yourself and your child with apraxia.
    I am a young stay-at-home mom with no background or experience with speech or medicine. I’m actually a funeral director by trade and education. However, I consider myself very science-minded and I try to do things in an evidence-based manner whenever possible. I think that’s been very helpful to me in my journey as a special needs parent.
    My daughter, Elanor, is my only child. She is 2 ½ and absolutely loves music, dancing, animals, and most children’s television programming. She is especially fond of Blue’s Clues. She has a lot of trouble learning to speak due to childhood apraxia of speech. She also has dyspraxia, which is basically a full-body apraxia. This makes a lot of other things hard for her, including things like running, jumping, or putting on shoes. She has had her communication device for about a year now. It is an iPad mini with a communication app called Speak for Yourself and an amplified case called an iAdapter. We call it her talker.

    When and how did you discover your daughter would benefit from a device?

    I remember being at a friend’s daughter’s birthday party when Elanor was about a year old. There were several parents all bunched into a corner talking about their children’s speech problems. Most of their kids were older, and some were already in speech therapy. My husband and I looked at each other kind of pridefully, because that was one problem we knew for sure that Elanor didn’t have. At one year Elanor may not have been walking (or anywhere near walking) but she had a good number of words, probably about 10.
    At 15 months when Elanor stillwasn’t walking, we followed a random tip and pursued ear tubes for her. We had heard that fluid in the ears could mess with a child’s balance, and that seemed to be Elanor’s problem. We had about a month of many many doctor’s appointments to look at her ears and talk about tubes. It was during this time that my husband and I kind of looked around and realized she hadn’t said anything in a while. Sometime between 12 and 15 months she lost all of her words and most of her sounds and we had barely noticed. It was assumed at this point that the ear tubes would fix everything. She had ear tube surgery at 16 months and walked two days later, but she remained nearly silent.
    At that point we were already in the process of getting early intervention from the county due to the walking issue. At the first assessment they were no longer concerned about her walking but shared our concern over her speech. We were told to come back in a month if she still had no words. It was during this nearly silent month that I happened to read something in a mommy forum about apraxia of speech. A lot of it really seemed to fit. Elanor couldn’t stick out her tongue, she couldn’t pucker to kiss. She had a lot of trouble eating. Her speech had progressed backwards instead of forwards. The symptoms really seemed to match. Of course, I couldn’t be sure about any of the main symptoms of apraxia (like inconsistent errors in speech) because in order to see those symptoms she would have to be able to speak, which she really couldn’t.
    During one of my many googling sessions I came across a video on YouTube of a child with apraxia using a communication device. He was using Proloquo2go (a communication app on the iPad) to ask his mother for a snack. I remember how incredibly happy he was to be able to tell his mom exactly what he wanted. I knew then that I wanted that for Elanor. I made an appointment for a speech evaluation with a private clinic. We discussed a communication device at the very first appointment and things went from there. Elanor was 18 months old when she started using her device. Here is a video of the first time she ever used it:

    What advice would you give to other parents who have been told their child is not a candidate for AAC.

    Here is what I have to say to them: your child deserves an opportunity to communicate their thoughts and needs without having to wait to learn to speak and they CAN do it. This recent blog post from a Speak for Yourself creator basically blows away the entire concept of needing certain skills to be able to use a device: http://www.speakforyourself.org/2014/07/22/myth-augmentative-alternative-communication-aac-pre-requisite-skills/
    I know that Elanor continues to be one of the youngest AAC users that many speech pathologists have ever seen. This isn’t because toddlers can’t do it, it’s because they haven’t been given an opportunity to do it because people think they aren’t ready. They are. Your child is too.

    A big myth regarding AAC is that the child will “give up” trying to talk if they are given a device.  However, research refutes this.  As a mother though, how do you respond to this?

    Using a communication device is hard. It’s slow. It is so much easier for me to say things out loud than to say them on the Elanor’s device. For Elanor that’s not true because speaking is so difficult for her, but the moment she can speak a word intelligibly she will always choose to speak it because it is faster and easier. Not only that, but not everyone has a device. Everyone around her is speaking aloud all the time. She would obviously prefer to be doing that.
    I also think this worry about your kid “giving up” on speech is really misguided because the device helps with speech so much. There are a lot of theories I’ve heard about why this is the case. What I know for sure is that it works. The more we push Elanor to use the device the more her speech blossoms.
    Here she is a couple of weeks ago telling her Daddy “I don’t know”, her first real sentence.

    Who programs the device and who teaches your child how to use it?

    Me and me. I know this is different for some people who get their device through their child’s school, but since we bought it ourselves we are in charge of it. Programming Speak for Yourself is actually really easy. That’s one of the reasons I chose it over some other communication apps. There’s also a Speak for Yourself User’s Group on Facebook that is incredibly helpful with any questions about programming or anything else.
    I am able to quickly add words and pictures to Elanor’s device to make it more personal. She has all her family members and friends names and pictures in there, every cartoon character, every cartoon. Her device is really very specialized for her.
    Here she is asking to watch Blue’s Clues:
    Video: https://www.youtube.com/watch?v=rZAPrJu89VU
    As far as teaching her how to use it, I mostly do that through modeling. This means that I speak through the device just like she does. If you think about it, children learn to speak by hearing us do it. It doesn’t make sense for them to learn to use a communication device without seeing someone do that too. I get guidance on how to do this from Elanor’s speech therapists and also from the creators of Speak for Yourself, who are incredibly involved and helpful. Sometimes it seems tedious, especially if it doesn’t seem like Elanor is paying attention. I learned pretty quickly that she is always paying attention, even if it doesn’t seem like it. It is incredibly rewarding to see her use a word or sentence I showed her days before when she seemed entirely uninterested.

    Many parents of children with apraxia report increased frustration and tantrums due in part to their inability to speak or communicate in some way.  Did you have a similar experience and find that the device reduced your child’s frustration?

    I didn’t have that problem before we got the device because she was so young when we got it. She has had some means of communication, whether it be ASL or her device, for a long time. However, now that she has become more verbal I have noticed some frustration when I don’t understand what she is trying to tell me verbally. I usually have to redirect her to the device, where she can usually tell me what she was trying to say. That’s why it’s so important for me to keep modeling and using the device with her even though she is able to talk more now. It is an amazing source of relief for both of us!
    This video shows her right after I spent about 5 minutes trying to figure out what she was asking for:

    How did you pay for the device?  Are there funding sources?

    The first device we had was an iPad 2. My parents bought the iPad (around $500) and my husband’s parents bought the Speak for Yourself communication app ($200). We later replaced the iPad 2 with an iPad Mini, which we paid for ($300), and we used GoFundMe to crowdsource funds for the amplified iAdapter Case ($400).
    Compared to dedicated devices like a Dynavox, it’s pretty inexpensive to purchase an iPad mini and communication app. We’re talking the difference between $500 and $5000-$10,000. That being said, $500 is still a lot to come up with out of nowhere. For funding sources I suggest family members, churches, and local charities. I know most churches would love to fund something like this for a child in their congregation.  CASANA also gives away iPads once a year to kids with apraxia, so that’s something to look into as well.

    Do you have any additional comments/recommendations/or final thoughts that you want to tell parents who are experiencing the pain of having a child who struggles to speak?

    I just want to say that having this device has helped my daughter immensely in ways I never knew it could. I am a part of many groups of parents with children using AAC, and all of these children are doing better than they would be without a device. Their speech isn’t hindered, it’s helped, and their parents have been given a chance to really know them.
    Almost every day on online apraxia groups I see parents complaining that their child can’t tell them things. They don’t know their child’s favorite things. They don’t know what their child did at school that day, etc. I sympathize with these parents, but I can’t empathize with them because I honestly don’t know what that’s like. Elanor can tell me all those things and more with her communication device.
    I guess in the end what I want to tell all the apraxia parents out there is that you can know your child, and they can have a voice now.There’s no need to wait until they can speak. This technology is available and it is amazing. It can change both of your lives forever.
    Incredible Merry!  Elanor is so lucky to have a mama like you! 

    To read more about Merry and Elanor visit her blog: http://aacabc.blogspot.com/
  • My apraxia star sparkled at her first Walk for Children’s Apraxia of Speech

    My apraxia star sparkled at her first Walk for Children’s Apraxia of Speech

    Apraxia Stars

    That is what we as the CAS community have come to refer to our children with apraxia.  I was able to attend my first Walk for Apraxia in Denver today as a mother first supporting my daughter, but also as an SLP walking for my clients, two of which came today.

    Aren’t they cute?  Ashlynn started to get the idea this day was all about her when she recognized her name on a sign.  She’s smiling from ear to ear!  She didn’t yet know what the day was really about, but she was starting to realize it was all about her.
    There were pre-walk activities to keep the kids busy.  Her and her brother met firemen and were able to sit in the firetruck!  She had her face painted and got a balloon!  She was around other kids who may not have been the best talkers, but you can’t help but notice their smiles. Their gestures. Their kindness.  Their social maturity without any words at all.  These were her “peeps.”  All sharing one small commonality, apraxia, but all showing their special uniqueness.
    Then team members began to arrive!  Ashlynn’s Aunt and fiancee were the first to show up.  Then came another Aunt and cousin, and holding up the rear was her Grandma. It was hard to know if she realized they were all there for her, but I think she started to get the message.

    Then the medal ceremony began.  All the kids with apraxia were called up one by one, and given a medal to go around their neck.  Each name brought cheers from the crowd.  My mom didn’t hear the announcement, and asked innocently, “What is the medal for?”  As we thought about it, the medal was for them being exactly who they are.  
    What a gift.  
    To be given a medal for simply being who you are.  

    I got to thinking about stars again today.  Stars aren’t as bright and flashy as the sun.  They don’t command one’s immediate attention like the moon.  However, when one focuses on the sky, the stars are what’s written about in poetry, gazed upon in stories.
    The stars, beautiful in their simplicity.  Shining brighter than ever in their subtle ubiquity.  
    Yes the stars are the metaphor for our children, and they sure shone bright today!

  • The high of summer! The fear of “back to school.”

    The high of summer! The fear of “back to school.”

    Oh summer, how I love thee. Filled with swimming lessons, play dates; visits to the park and zoo.

    During summer, I get to see my children be children. Their carefree smiles light up a room, and the echoes of their laughter can be heard long after they lay down their head. Yes, therapy appointments are a way of life for Ashlynn, but even speech and occupational therapy bring positive updates from the session and we can quickly return to our days of play.

    This summer I signed up to a few good facebook pages I found: MamaOT and Inspired Treehouse. I LOVE these pages! Instead of the packet of ideas I would get heaped upon my shoulders during the school year, these pages provide an idea a day to do with your child. Simple, easy, fun! When I just get one idea a day, the load seems MUCH more manageable. I was so inspired, I tried to do the same for speech and language on my SLP Mommy of Apraxia page, since I’m usually doing something related throughout my day with my kids since that at least, comes naturally to me. I really think they helped Ashlynn, and I felt good about incorporating some sort of speech, sensory, or occupational/physical therapy at home.

     My husband and I also saw HUGE improvements this summer in the motor realm. Ashlynn climbed a play structure that she had yet to conquer at our nearby park. Who knew how much core stability, bilateral hand coordination, and crossing midline play a part in climbing a simple play structure! Well, I’ll tell you who know.

    Parents of children who have dyspraxia!

    At the local amusement park, she was riding the tea cups independently. My husband shot a video. During the first two go rounds she was just sitting there, but by the third go round she figured out how to spin the wheel to spin her teacup! You should hear my husband cheer. Who knew how much core strength, bilateral hand coordination, and crossing midline play a part in being able to operate a simple teacup ride.

     Oh yeah, parents of children who have dyspraxia.

     However, now summer is coming to an end. I see facebook posts ripe with updates along the lines of “I’m so happy school is coming up!” Or memes like this one:

    Not me. School. Sigh. What can I say? I have a love/hate relationship with school.

     I firmly believe school helps children develop their social skills and gives them important language models, which is especially important for kids with speech and language delays. The first week my daughter went to school shortly after she turned three, she came home singing a tune I actually could decipher, and at that time she was nonverbal! That my friends, is the power of school!

     On the other hand, school brings new fears and new worries. I always thought, once she starts talking, I’ll be okay.

     Not true.

    Now I’m worried about her phonemic awareness skills, language lag, slow processing speed, and being able to write.

     My God how much do kids need to do and know now just to be ready for Kindergarten???

     I’m not looking forward to the IEP meeting, the parent/teacher conferences, the comparisons I try not to make when I’m visiting her classroom.

     Quite frankly…. It SUCKS. Apraxia STILL sucks!

     So no. I’m not ready for Ashlynn to go back to school. My SLP friend and mother to two young boys with apraxia who has a blog: Landon Journey just posted this song lyric the other day:

    If I could make days last forever
    If I could make wishes come true
    I’d save every day like a treasure and then,
    Again, I would spend them with you.

    As my brother says though, “Life’s not fair. Get used to it.”

    So farewell summer! I bid you adieu. You have been so kind to us this year. We have made castles in your warm sand, felt the glow of the sun upon our face, cooled off in your waters, and celebrated the milestones and successes at our pace. Though I’m anxious for the coming school year, I have faith you will be waiting on the other side.  Welcoming my children to your sunshine, casting light onto their beauty.

  • Apraxia Intensive Training Institute 2014

    Apraxia Intensive Training Institute 2014

    The Apraxia Intensive Training Institute (aka apraxia bootcamp), is an intensive training sponsored by the non-profit organization CASANA of apraxia-kids.org.

    WHAT IS SPECIAL ABOUT CASANA?

    I love CASANA for SOOO many reasons.  As an SLP but parent first of a child with apraxia, CASANA was literally built on the backs of mothers who had children with apraxia.  Sharon Gretz is the founder and executive director and she attended EVERY session.  This is her baby, next to her two human babies of course.  It was apparent she wanted to make sure that professionals she’s endorsing will do right by the kids they see, just like apraxia expert David Hammer did right by her son Luke.  Kathy Hennessy is a mom of not one, but two children who grew up with CAS; and she is the the Education Director for the organization.  She too attended every session.
    I get chills thinking about these women, because they are so inspiring to me.  They know the struggle.  They’ve lived it and they want to ensure that no parent who has a child with apraxia has to feel isolated and alone in their fear of the unknown. More importantly though, they want to ensure that quality therapy is a right that every child with CAS receives.  Our success is their mission, but it’s more than professional.  It’s personal.  
    WHAT WAS THE TRAINING LIKE?
    At first, it was so surreal.  Here I was, one of 24 out of a 100 applicants in the country picked for this training.  Beside me were seated fellow SLP’s of esteemed caliber and success in treating apraxia.  In front of me stood three top experts in the field, two of them published in the research.  
    The training was longer and more intense than ANY conference past, present, or probably future.  We were expected not to be “talked at” but to critically analyze, bounce ideas of of, and problem solve aloud what we knew.  Our mentors only initially acted as guides, mentally exercising our brains, challenging our beliefs, therapy practices, and perceived truths.  We worked from 8:15 to 8 or 9 at night.  We spoke of nothing but CAS.  Eventually, we “local experienced experts” had to let our guard down and problem solve in an environment of mutual respect and learning.  
    It was the three E’s:
    Exhausting: At one point during a differential diagnosis section, Ruth Stoeckel was asking thought provoking questions.  We all had answers, brilliant answers, but she wanted more.  I finally shouted out in exasperation, “Ruth!  Just tell us what you’re looking for!!” 
    She didn’t.
    We were forced to think and problem solve some more.  If we are to be true experts in the field, she needed us to come up with it on our own.  Her telling us was simply too easy.
    Emotional: There were tears.  Lots of tears.  Tears as experienced, awesome SLP’s realized maybe we could have done better with some previous clients.  Not maybe…certainly.  As a professional I loved their passion, but as a mother, it brought me to tears.  I told one SLP, as a mom, I don’t care if you’re not the best…because your heart, caring, and critical analysis is what will make you my child’s “life changing” SLP. 
    Exhilarating: A famous quote this bootcamp came from my recently, dear friend Ashley, who was presenting her video case study.  After being constructively criticized, stripped down, and vulnerable she said with poise, “I’ve found right after the confusion comes the learning.”  Brilliant Ashley!! 
    I have to admit, wearing two hats at this conference was hard.  The compassion and love these colleagues feel was tangible, and they have to be able to turn it off and let loose or they would never enjoy life.  On Friday night they were all sharing therapy ideas around copious bottles of wine, and I had to slip away.  I felt glad they could escape the pressure they feel to do right by their clients with this challenging disorder, but I also felt jealous they could turn it off…if only for a moment.  
    Having a daughter with it leaves no such luxury.  I cried heavy tears that night.
    WHAT IS THE BEST TREATMENT APPROACH FOR CHILDHOOD APRAXIA OF SPEECH?

    Isn’t that the million dollar question?  Usually at professional conferences, the speaker will talk about their treatment approach.  What they do and why it is successful.  You are talked at, occasionally invited to participate, and then sent home with an informational packet.  
    This was WAAAAY different.
    We had access to all the current treatment approaches: 
    PROMPT, KAUFMAN, SpeechEZ, ReST, DTTC…..you name it, we learned it, and if you think I’m blowing smoke, I can tell you that five of the programs agreed to produce an overview CD just for CASANA’s bootcamp and also agreed to answer questions gathered from the participants!  I’m telling you, CASANA covered their bases and made sure if they endorse an “expert” you are truly an “expert.”
    However, we didn’t just learn the approaches.  We had to analyze each approach.  I can tell you one thing though.  All these approaches had a common thread of incorporating principles of motor learning theory.  As for the research?  Well, that’s still up for debate; however, I can say we read a 2014 review and the method that has the most evidence but is probably the least well known is DTTC. Does that mean the other approaches aren’t valid?  No! We concluded a lot of the approaches could be contributed to the fact that the SLP was simply just an amazing SLP, or that there just isn’t enough research to prove this or that method has worked with a large population.
    WHAT DOES THE RESEARCH SAY?   
    Research for speech disorders is incredibly difficult to do, primarily tied into cost.  Sharon Gretz recognized this and that’s why CASANA is big on research.  Donations and money through walks help fund research.  This is another reason I have so much respect for CASANA.  Honestly, if we don’t have evidence based practice in the treatment of apraxia, how can we be sure this method or that method is sound??  In addition, though one method may work for one child, will the same work for another?  The answer?  We just don’t know!  We need research! 
    WHAT NOW?

    What now?  Another million dollar question.  Sharon Gretz minced no words. 
     “Well, you are nothing.” 
    We all laughed a nervous laugh. What do you mean we are “nothing?”  
    We learned we had to complete a case study that satisfied our instructors. We were told to be prepared to get it back.  They have had two previous cohorts and no one had ever turned in the perfect case study.  We were told they were investing in us.  From now on, we were their colleagues.  If we have a question, they will help us with the answer.  
    Say what?
    Yep…these busy, in demand apraxia experts are invested in us….and the kids we treat.  They  love kids with apraxia that much; however, we have to prove our worth.  They can’t endorse us and not be 100% confident we are doing right by these kids.  That’s why we should all expect our case study back again, and again, and again.   
    In the back was Sharon and Kathy.  I couldn’t ever help but think of them.  They had been burned by too many “experts” saying they would help their child; and here they stood, an advocate for those who are standing in their shoes.  
    I was proud and honored to be here.  I’ll complete my case study and know I earned it.  I will forever be committed to CAS, and I will never forget my experience at this “bootcamp.”
  • “I love you mommy!”

    “I love you mommy!”

    These words are cherished by any parent.  These words are eagerly anticipated.  When you have a child with a speech delay, the eager anticipation eventually gives way to desperation, and maybe, (though hopefully not) apathy.

    Ashlynn has been able to say “I love you” for awhile now.  Once she really got good at imitating, we had her imitate it every time we told her goodnight and tucked her into bed.  Now that she’s older, she automatically says it after we say it in any situation, and we are happy.  We are very happy.

    Today though, I heard these words spontaneously.  She said them in a moment of pure joy and blessed me with them.

    First, a little back story.  I’ve been home for a month now on summer break with my kids. It’s awesome and exhausting.

    I am admittedly not an artistic person, and I really could live without the messes that art creates.  I’m a writer.  Writing is so clean.  A pen and paper is all you need to create beauty out of words, which then are easily put away until later.

    Kids are not writers.  They do not yet appreciate the beauty within words, but they love a good mess.  A good mess and me are not on good terms.  However, kids and neatness are not on good terms either….so what is a mom to do?

    Ashlynn begs to do messy things.  Play with play-doh and proceed to get it everywhere including in her hair, in her shoe, and ground into the carpet even though she’s playing on the tile in the kitchen.

    Let it go mama.

    Play with water in the sink.  Except the water inevitably ends up in a huge puddle all over the (small) counter, the floor, her shirt, her pants, and possibly needing a change of underwear.

    Let it go mama

    Play with the dirt outside.  However, the dirt somehow happens to turn into mud that gets under her fingernails, in her shoes, on her shirt, and again ground into the carpet that is INSIDE my house even though she was playing outside.

    Let it go mama.

    And I really have been trying.  Messes make her happy.  The tactile input is helpful for her SPD (sensory processing disorder).  I’ve really, really been trying to just accept the mess.

    Today I was at Target getting some odds and ends.  I’m not an impulse shopper.  I only buy necessities and if I do I usually have a coupon or it was on sale.  I saw the dollar bins and I decided to take a peek.  I’m also not a window shopper, so this is unusual as well, but you know, I’ve become more flexible this summer and I don’t know what has gotten into me.

    I ran across foam stickers and my memory instantly recalled paper after paper that came home in Ashlynn’s backpack this year full of random papers that had some scribbles and foam stickers on them.  I would never buy foam stickers.  What a waste.  They serve no purpose.  You put them on paper and then throw the paper away.  What’s the point?  Something in me though remembered all of those papers and thought Ashlynn really likes these things.  I stood there awhile debating.  They were only a dollar, but it seemed like such a waste!!  But I think, Ashlynn really likes creating with them and (and this is my internal argument that allowed me to buy them) they are good for bilateral hand coordination since you need both hands and fine motor control to get the paper off the back.

    I bought them.  Good.  Ashlynn will practice fine motor skills.  I’m a good mama.

    I brought them home and she was happy.  Not overly happy, but happy.  She was busily creating when she randomly walked over to me and tapped me on the leg.

    “Mama, Mama, MAMA!!”

    “What honey?”

    “I love you!!”

    I’m stunned.  What on Earth prompted this?  And that’s when I looked a few feet beyond her to the messy table, backs of foam stickers littering my carpet, and paper after paper full of foam stickers.

    I gave her the biggest hug.  I might have cried.

    As it turns out, a good mess and me have gotten closer.

  • Ashlynn summer speech therapy 3.9 years

    Ashlynn summer speech therapy 3.9 years

    Ashlynn received two grants to help with her speech and occupational therapy over the summer!  The United Health Care Foundation and the Lindsay Foundation made it possible!  I am so grateful.  Ashlynn will be back to getting intensive 1:1 speech and OT services.  

    As far as speech goes, Ashlynn communicates her wants and needs.  She has basic conversational skills and really does try to tell us what happened in her day.  Sometimes when she’s talking, I see my husband look at her with pride in his eye and I know what he’s thinking.   Even though we don’t always understand what she is saying, it is amazing to listen to her talk and try to tell us things.  She was silent for so long.  
    I love her speech therapist.  She was actually my mentor and is now one of my good friends.  She’s fun, but I also know she’ll push her.  However, I also know she’ll find the deficits and the continued deficits are hard to be faced with and make me sad.  I want to write it down though, because if I know anything about Ashlynn, I know she’ll overcome it.
    – She has significant word finding issues.  Sometimes, she needs so much wait time that eventually she even forgets what she wanted to say and moves onto something else.  
    – Her attention continues to negatively impact her progress
    – When something is hard, she changes the subject and tries to talk about something else
    – Auditory processing skills such as auditory discrimination between minimal pairs (sleep, seep) appear to be impacted.  
    – Grammar, including marking varying tenses and using s/v agreement along with pronoun usage are faulty
    – Syntax is jumbled, particularly for question forms
    – Still has a tendency to assimilate sounds she knows how to say (goggy/doggy), and continues to be inconsistent with her production of consonants in her repertoire (koys/toys). 
    – Needs continued work with /l/ and /r/
    – Continues to breakdown with novel multi-syllabic words
    – Receptive language skills continue to need monitoring
    That’s a long list, but I have to remind myself it used to be longer.  She’ll get there.  I know it.  There was a time I worried if she would ever make friends because she couldn’t talk to them.  Here she is at the splash park talking to perfect strangers and making friends.  One step at a time.