He was 3 years old and needed an iPad to help communicate. The director of student services had asked me to go listen to him and see what I thought. While I didn’t know what to expect, I was looking forward to observing this little guy. It is scary to think that this little guy had speech that was unclear enough to necessitate other kinds of intervention like an iPad app for communication.
The use of Augmentative and Alternative Communication (AAC) is indicated in cases where young children are highly unintelligible. As therapists, parents, and educators, we want to overcome any barriers to the growth of language. Moreover, we want to ensure that children can make their wants and needs known so that we reduce any negative behaviors that are associated with communication.
The word “apraxia” is thrown around when considering children like this little guy. While there is certainly controversy over how apraxia manifests itself in a variety of children, I feel as though “apraxic tendencies” are a better way of describing some speech behaviors. It’s not just about “labeling” a child, instead, it’s more about generalizing a speech characteristic. When you examine a student’s speech and behaviors, we might be led to other thoughts. Also, I get concerned when parents hear the word “apraxia”- it can lead to feelings of helplessness when there might be more hope for a child’s improvement given speech and language therapy.
Not everyone who is hard to understand is apraxic.
They might have qualities of apraxia, but it does not define their communication. In many ways, the treatment of this child was guided by Caroline Bowen (her book is fantastic!) and Edith Strand’s work on Dynamic Temporal and Tactile Cueing (DTTC).
The first thing that stood out to me was the little guy’s syllable patterns and his stimulability. For a lay person, this means words like “computer” become “puter” and that trying a new sound (“say ssssss”) is hard to do.
Bowen’s citation of Adele Miccio’s work was incredibly helpful in developing new sounds for this child. Check out the link to the stimulability cards here(from Caroline Bowen’s website). This method targeted new sound generation through picture cards that combined gestural cues and voice cues (i.e.; look at me, do this!). Once we began to grow the little guy’s repetoire of sounds, we were able to discern what areas we really needed to work on first.
DTTC was helpful for a few reasons. One, it gave us a foundation of visual and verbal cueing again (i.e.; look at me, do this…) that allowed for the little guy to connect with me. Later on, these visual cues of looking at my face were helpful because now I could just “mouth” multi-syllable words (almost as though I was lip-syncing) and he would begin to produce the words with less effort.
Two, some tactile cues were helpful to get the little guy started. Educators are familiar with PROMPT, and I used modified techniques to help this child when visual or verbal cues were not enough. While PROMPT is realtively well known in the educational field, I get concerned when parents or teachers start to talk about it as the only way to help children with speech intelligibility concerns. No one technique is the answer for all students. We should always let the student’s observable speech and behaviors drive what we need to help them. Some techniques might be more helpful at different stages in therapy.
Three, working on prosody was critical to help the little guy with connected/conversational speech and overall intelligibility. When we consider the idea that we talk in strings of syllables, it’s important to keep conversational speech in the forefront of our minds. We can work on single words for a LONG TIME; without paying attention to what our children will sound like when talking in longer utterances, it is necessary to make sure that prosody and overall intelligibility are worked on.
It’s been some time for this little guy (and he’s not so little anymore!). We are now able to work on isolated sounds such as /l/. We still have to be mindful of syllables and connected/conversational speech, but it’s getting easier. For new and seasoned professional’s Caroline Bowen’s book and website are very informative!
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