If this is your first visit, I’d like to tell you how I recommend for new moms to navigate the site because I have TONS of info on here that may not be apparent to you with your first click!

The site is organized in chronological order with the newest entries listed first here on the home page. However, most of the best information for parents is in the older articles. What I recommend for first-time visitors is to take a look at the yellow category bar near the top of this page. Find the topic which most interests you. Once you’ve clicked on that section, scroll down to the bottom of the page and select Older Entries. Keep clicking until you’re at the “beginning” of each section, so that you can read the older articles first.

You may want to scroll thru the podcasts too until you find show titles that are most applicable for your child. 

Thanks for stopping by, and I hope you find what you’re looking for to help your baby! If not, leave me a comment with your questions, and I’ll try to point you in the right direction.      

This week we’re going to discuss how to interpret test scores from speech-language evaluations and other standardized and criterion-referenced developmental assessments. This may not be the most interesting topic we’ve ever covered, but I routinely get questions about this on the website, in e-mails, and from parents I work with wondering exactly what it all means.

If you have general questions about results of your child’s testing, we’d love to hear from you! Please call us with your questions or comments. Our call-in number is 1-718-766-4332. We’d love to hear from you!

You can listen live by clicking this icon.

If you can’t join us live, you can always listen later anytime using the blogtalkradio icon in the right hand column or on the home page.

Our show is also available for FREE download on itunes. Visit the itunes store and search “Teach Me to Talk with Laura and Kate.” For you itunes novices, choose subscribe, and the show will download so you can listen later with your ipod.

Hope you’ll join us! Laura

If you want to hear the complete discussion, please listen to the show #13 by clicking the blogtalkradio link from this page or the home page.

For those of you who would like to review the entire list we found at  www.sensory-processing-disorders.com here goes:  

Gross Motor

If a child is…

Possible visual problems may exist if the child…

Does not make eye contact with others or holds objects closer than 3-4 inches from one or both eyes

 THESE ARE THE FOLLOWING LANGUAGE MILESTONES THAT A CHILD SHOULD HAVE MASTERED BY THESE AGES FROM THE ARTICLE ON THIS SITE TITLED “WHEN TO WORRY”

For those of you who may be new to the field of pediatric therapy, let me break it to you, and not so gently.  You can’t judge normal by the highest functioning kid on your caseload that you just discharged because he no longer met the eligibility requirements for your agency or program.  While you can call a kid “within normal limits” when he barely meets all the skills on the criterion-referenced checklists you’re using,  you can’t really resassure his mother that he’s “fine” since those are designed so that kids who barely make it to the shallow end of the bell curve still pass.  

You surely can’t judge normal by comparing clients to your own children, if you even have any, unless you have a whole houseful of kids and wonderful genes so that each one of your children is without quirks!  To top that off, sometimes a ”mother’s love” blinds us to issues with our own children!  We can diagnose difficulties in other people’s kids all day long, but some of the worst cases of old fashioned denial that I have encountered professionally have been in families whose parents have the credentials of someone who should know better!         

The only way to make sure you are keeping your finger on the pulse of normal is to see lots of kids and often. 

How exactly do you do this?  One way is to constantly aquaint yourself with mothers who have children the same ages as kids you treat, or involve yourself in a group with kids the same age.  If you’re an elementary school SLP, this might mean that you find yourself a Brownie or Boy Scout troop to befriend.  If you’re a preschool therapist, coach a sport at the Y or in your community leagues.  Since I specialize in birth to 3, I volunteer in the nursery at my church once a month on Sunday mornings and teach a class of 2- year- olds every Wednesday night during the school year. 

Churches and community organizations rarely turn down a capable and willing adult volunteer.  Just wait until they find out you’re a “professional!”  You’ll likely get to name the time or commitment you’d like to fulfill.  

Another ”must” that they don’t tell you about in grad school is to commit your milestones to memory.  Know them so well that you can quote them verbatim when someone asks, “How many words should my child have by X months of age?”  If you’re constantly saying or thinking that you need to “wait until I score the test to see if this child qualifies,” then you don’t know normal well enough.  Learn your stuff!  The parents of the children you see are counting on you to know!        

How can I find my state’s program?

To find the program for your state, search or Google the phrase “early intervention” and your state’s name.  Your child’s pediatrician should also be able to give you the contact information for your state’s program.   Or you can go to the following website and click on your state to find information for the Part C (Early Intervention) Coordinator for your state http://www.nectac.org/contact/ptccoord.asp .

How do I get my child evaluated? 

In most states parents can make the initial referral, and all it takes is a phone call.  You’ll be assigned a service coordinator or case manager who will walk you through the process and coordinate your child’s evaluation from an early intervention specialist (who is usually a licensed physical or occupational therapist, a speech-language pathologist, or an early childhood education teacher, also called developmental interventionist in my state.)

If your child does qualify for therapy through your state’s program, your services will be free or based on a sliding scale according to your income.                

Why seek out services?

Typically, children who participate in early intervention experience significant improvement in development and learning. Research tell us that babies and toddlers with delays or conditions likely to cause delays benefit greatly from  services during critical developmental years of birth to 3.  Services benefit families by teaching parents what they can do to help their children at home.  Support is also provided for parents which results in reducing stress.  Early intervention services can also decrease the need for costly special education programs later in life by working on problems early in the child’s development.

How does  a child qualify for services?

Child eligibility for the program varies by state but can generally be determined in two ways:

1. By developmental delay - A child may be eligible for services if an evaluation shows that a child is not developing typically in at least one of five skill areas: cognition, communication, physical/motor, social and emotional , or self-help/adaptive skills.
2. Automatic entry  - A child may be eligible if he or she receives a  diagnosis of physical or mental condition with high probability of resulting developmental delay, such as Down Syndrome.

How are services provided?

Services may be provided in the home, at daycare or preschool, or at a designated center or clinical setting, depending on the needs of the child and family, state requirements, and the availability of services in a given area.

There are many things that you can do at home to work on the prerequisite skills necessary for spontaneous phrase production.

1.  Before you begin working on two-word combinations, be sure that your toddler is saying at least 35 words on his own (meaning without imitating you) in daily routines.  (This point is so important I’m repeating it in case you didn’t process it the first time.)

In my experience, many late talking children, especially those with apraxia, or motor planning issues, have single word vocabularies well in excess of 50 words before they can begin to consistently imitate two-word phrases, much less say novel ones on their own. 

If your child’s vocabulary is not this size, continue to work on adding new single words.

Some children can imitate phrases before they are truly using 50 words on their own.  In many cases, they are learning the phrase “holistically” or as one unit.  In other words, the entire phrase is just one long word to them.  Children with difficulty processing and understanding language often learn phrases in this way.      

The only way to know if your child’s vocabulary is at this level is to keep a list of all of the words he says on his own (not imitated) over 2 or 3 days.  I routinely ask the parents of children on my caseload to do this.  Most parents have good luck keeping a running list on the refrigerator or in the den.  Sometimes parents are surprised at the results.  Some parents underestimate their child’s vocabulary and are excited when they realize just how much he/she is saying.  Some are disappointed when they realize their child might be using a core set of words over and over.  If you’re not sure how your child is doing, I definitely recommend this exercise.       

2.  Your child needs to have a variety of words in his vocabulary from different grammatical categories before he can sensibly combine words into phrases. 

When analyzing the early vocabularies of toddlers, most of the words they use are nouns/names for people and objects.  This is the case in typical language development too.  But if you’ll think about it, a child needs more words than nouns, or names for things.  It’s hard to make a sensible phrase using two nouns.  (Other than those for agent + object such as “Daddy shoe.”) 

Children also need:

• Social words (such as bye-bye, hi)
• Requesting words (such as please, more, again)
• Verbs/action words (such as go, eat, sleep, drink, jump, open, push)
• Early pronouns (such as me, mine, my, I, you)
• Prepositions/location words (such as in, out, off, on, up, down, here, there)
• Negation (such as no and then later contractions including don’t, can’t)
• Adjectives & adverbs/descriptive words (such as big, hot, fast, yucky)

Be sure you are introducing and teaching words from these different categories so that your child has broad vocabulary base in order to make phrases.    

3.  Your child needs to be able to sequence two syllables together. 

If your child routinely reduces multisyllabic words to one syllable, such as “ma” for Mama, “bu” for bubble, “Mo” for Elmo, he needs more practice with sequencing syllables first before trying to learn phrases. 

Work on this by practicing words with reduplicated or repetitive patterns since this is the easiest and earliest form noted in typically developing language.  For example, all the “early” words - Mama, Dada, bye-bye, baba (for bottle), and night-night.  Try to target words with sounds he already tries to say. 

Don’t forget animal sounds since these are more fun to practice such as moo-moo, baa-baa, neigh-neigh, quack-quack, woof-woof, etc…

Use clapping or patting the floor to help him “feel” both parts of the word.  You can model this and wait for him to imitate, or use hand-over-hand assistance to make him do this.  This technique is very helpful for children with motor planning problems (apraxia).  The motor movements actually help them produce the word.  (That’s why signing is so effective too!)

4.  Your child needs to be able to say several different types of syllable structures.        

This is going to be a little technical to explain, so hang in there with me.  Toddlers with typically developing speech and language skills usually learn to say words with various patterns and syllable structures.  For example, a toddler who can say Mama, up, no, hot, and open is using 5 different kinds of consonant (C) and vowel (V) combinations.

“Mama” is CVCV.

“Up” is VC.

“No” is CV.

“Hot” is CVC.

“Open” is VCVC if he says “open” or VCV if he says “opu” (a typical way babies say “open.)

If your child can only use one or two syllable types, he is not going to be able to say lots of different phrases.  Even if he tries, you may not be able to understand him because it will be “off-target.”

Analyze the kinds of syllable structures your child says by carefully listening to how he says the words.  (A word of caution here - new talkers do not need to be constantly corrected for their first word attempts.  Do not take this as a license to overcorrect.  This should be a process of analysis, not an opportunity to prematurely begin work on articulation!)

Note if most of his words are the same patterns.  This is common for children who are late talkers and especially those with apraxia, phonological disorders, dysarthria, or whatever else you want to call it.      

If most words are the same pattern, you’re going to have to work on introducing new syllable structures.  This requires some thought and careful planning.  If you’re not naturally good at it, call in a speech-language pathologist to give you some assistance.  (Another word of caution - Your child may not be able to do this without special coaching, and you may not be able to teach him.  Don’t despair if you can’t get him to pronounce a new pattern.  I had to go to college for 6 years to learn how to do it!)

For children who did not babble or produce jargon (saying short syllable strings with inflection similar to adult speech), this step may be unrealistic for a while, since difficulties with verbal sequencing is likely the reason he is talking late.  Some therapists try to teach kids to babble or jargon by modeling this for them.  I must confess that I am horrible at this! 

Instead, I sing to them using very familiar songs.  Singing is the best way to practice sequencing because we get help from the melodic (The technical term is “prosodic”) qualities of speech.  Remember all the advice about using a “sing-song” kind of voice from the What Works article?    It’s the same idea.  I encourage kids to sing by “bouncing” or dancing during singing.  Sometimes I just hum the song to get them going.  Or you could use a single syllable he can say and repeat it to the tune of a familiar song.  There’s more about the benefits of singing later in this article.                  

5.  Your child needs to hear a variety of two-word phrases before he is able to imitate them.   

What can you do to work on this at home?  Frequently model short two-word phrases during the day.  Try to vary your categories too.  (See #2 above if you’ve forgotten this already!)  Don’t get stuck always modeling, “Noun + Verb.”  “Mommy sees.”  “Blocks fall.”  “(Name) eats.”     

Vary the way you model phrases. 

• Verb + Noun - “Read book,” or “Eat cookie.”
• Pronoun + Verb - “I run.”
• Pronoun + Noun - “My shoe,” or “You(r) turn.”
• Adjective + Noun - “Yucky milk.”
• Noun + Preposition - “Arm in.”

Expand his single words to phrases and repeat these to him. 

• When he says, “Car” to ask for a car, model, “Want car.”
• When he sees a car and is labeling “car,” model, “There’s car.”
• When he’s making the car move, model, “Go car.”
• When you are playing cars with him, take it from him and teasingly model, “My car.”

Remember that lots of the language directed to a late-talking toddler should be at or just above his expressive language level.  For new talkers, you should be using mostly single words and short, two-word phrase utterances when you’re talking directly to them in play and in daily routines.     

6.  Your child should be able to imitate two-word phrases before he can consistently produce them on his own.

(Okay - here’s another disclaimer.  Sometimes kids with apraxia can say phrases on their own initially better than they can imitate them due to the difficulty with imitating anything, especially a challenging sound sequence, which usually includes phrases.) 

Teach phrase patterns so he has a model of what words to combine.  Use predictable patterns for extra practice since motor planning will be easier if one word is changed. 

The ones I start with first are:

More + (Noun he says frequently)         (Noun he says frequently) + please

More  + please                                      Bye-bye + (Name/noun he says frequently)

If your child has used sign language, it may be helpful to model the sign as you are saying the word. 

Even if your child has “dropped” signs in lieu of words, you may want to pull them out again as a strategy to help him “motor plan” for phrases.

Another way I use signs at this level is for me to sign the word, but not say it, as a cue to help the child know what to say.  If he can’t do it with this no verbal cue, I mouth or even whisper the word.  Sometimes kids can even say a phrase in unison with me, but not repeat it.  If your child is interrupting you while you are modeling, he’s indicating that this technique will work for him, especially if he’s doesn’t “finish” the phrase without you.          

One mistake many people (including therapists) make when practicing phrases is to break up the phrase into single words.  For example, they have the child repeat, “more,” then “milk.”  This is okay for one time or perhaps two, but please resist the urge to split up phrases every time you practice!  This defeats your purpose!  Model the phrase with the words together.  You already know he can say single words.  You’re working on phrases!

If a child keeps repeating the first or second word as the phrase, such as “ball ball” for cheese ball, he is having difficulty with motor planning.  Keep using these strategies.  He needs them!   

Another thing I do is to model the phrase using a sing-song tone of voice.  Again, this helps with motor planning/programming because of the rhythm and prosodic (melodic) qualities.  Your kid won’t sound like this forever, but doing this now may give him a shot at being able to produce phrases sooner.

When he’s imitating those well, move on to other patterns including: 

            Hi + Name/Noun                       Night-night + Name/Noun  

                                                                  (For you purists out there, “good night” is usually too hard!)

When he’s doing these well, I listen for words he says frequently to model and prompt as phrases.     

If he says, “go” and “choo-choo,” I model the phrase both ways to see what’s easier for him to imitate, “Go choo-choo,” or “Choo-choo go.”  I always keep these kinds of “probes” in context too.  Don’t sit down with your word list while he’s having a snack and try to see what he can imitate.  Keep it real!   

7.   Some kids need an “in-between” step when making the leap from single words to two-word phrases. 

Some kids need that extra practice with sequencing before they are able to try phrases.  I like to use the same word for this kind of practice.  Use words in a repetitive pattern like “up, up, up.”  Location words/prepositions and verbs/action words usually lend themselves better to this kind of practice.  Try, “Walk, walk, walk,” as you’re walking or making an animal walk in play.  Try, “Down, down, down” when you’re going doing the stairs.    

Another way I practice is to label pictures in a book or toys placed in a line on the floor sequentially.  (This is a great way to work in a language focus for kids who line up all their toys!)  Start with all of the same kinds of objects.  For example, if he’s lined up all his trains, point to each one and say, “Choo-choo, choo-choo, choo-choo.” 

Instead of counting objects or pictures of like items, I practice labeling them.  For example, in a counting book with a picture of a group of dogs, I point to each one and say, “Dog, dog, dog.”   

I also practice with different pictures or objects in play when a child’s sequencing is better.  Try to stick with words she can already say.  For example, when playing with dolls, place a few items in a row and label, “Baby, milk, sock.”  Pause between words, but not for too long or you’ll defeat the purpose of practicing to improve sequencing.   

8.  Take advantage of “automatic” speech.  

When something is familiar to us, it becomes “automatic.”  When you’ve heard something over and over again, your brain “recognizes” and “predicts” the next part.  Use this with your child.   

One way to practice this is with books with repetitive themes.  Look for ones with a tag line that’s repeated over and over.  Again, make sure this makes sense to your toddler.

Another way to practice this is by singing familiar songs.  When your child has heard a song many times, his brain begins to expect what comes next.  You can use this to get new words by singing a line from the song and pausing for him to complete the next word.  Toddlers usually do this best when you leave the blank at the end of the phrase.  For example, sing, “Row, row, row your” and wait for your child to sing, “Boat.”  This works best when it’s an age-appropriate word.  The next line in this song illustrates my point.  “Gently down the _______.”  I don’t know a two-year old with typically developing language skills who says, “Stream” in everyday conversation.  Be sure you’re using common sense in choosing which words you expect him to say.           

When you’re singing, be sure to slow down the rate so he has time to catch up.  This is the main reason you should sing, and not rely on CDs.  You can control the speed!  Some children’s CDs and toys sing so fast that I can’t even keep up.

Don’t forget to try other familiar sequential phrases such as, “Ready,” and pause for him to say,

“Set - Go.” Or “1″ and wait for him to say, “2 - 3.”  Make up your own cute phrases at home during daily routines and say them over and over so your toddler expects what’s coming next.  We had lots of these in our house (and still do!)       

9.  Try wholistic phrases if your toddler is really struggling.

As a rule, I don’t model lots of these unless I don’t think I can get phrases any other way.  Sometimes children with apraxia can imitate or “pop out” a holistic phrase and then it becomes part of their core vocabulary.  Good ones to try are:

I did it             I got it             There it is        Here you go      See ya              Where (did it) go?

Right there      Right here        That one         This one           No way!                        Oh man!

Gimme 5          

I also try funny, novel sequences such as, “Oooh - Yuck,” “Uh-oh Spaghettios,” or “Oopsy daisy” to help move sequencing along if I’m not having any luck with more traditional combinations.  

10.  Listen for any “pop out” phrases and try to elicit them again in similar situations. 

Pay attention to any “accidental” phrase he might use and try to get your little guy to say it again.  You may have to set up the same situation later to see if lightning will strike twice.  Remember that repetition is what increases the strength of your child’s brain’s motor pathways or connections for speech.  Do all you can to help your child be able to say the phrase again, without lots of obvious pressure.  Sometimes the more you push, the harder it is for him!  Set up the situation and wait (and hope and pray!)    

Hope these ideas help at home!  If you need clarification, please feel free to leave a question or comment!  I love to hear from you!  Laura 

EDIT TO ADD -

11.  Try carrier phrases.

Use simple phrases with the same words at the beginning so that your toddler only has to “plan” to change one word at a time.  For example,

There’s a ___________.

That’s a ____________.

I see a _____________.

I want _____________.

I like ______________.

Give me ____________.

• Repeating or the last few words of the question rather than answering
• Answering incorrectly such as shaking their heads “yes” when you ask them a question with 2 choices 
• Giving an off-target response such as answering, “Two,” when you ask, “What’s your name?”
• Not responding or ignoring questions

By 30 months of age, most toddlers with typically developing language skills are consistently answering yes/no questions, choosing between 2 options (”Do you want your Dora shirt or flower shirt?”) and answering simple “What” and “Where” questions (”What do you want to eat?” or “Where did Daddy go?”). 

By age 3 most children with typically developing language skills correctly answer common questions related to themselves such as, “What’s your name,” “How old are you,” and ”Are you a boy or a girl?”      

Listed below are the tried and true ways I recommend that parents work on answering questions with their children at home. 

Basic Questions 

Children learn to answer, “What’s that?” questions to label items before they begin to answer other kinds of questions.  If your child is not consistently answering this question, practice often with words you know he can say across different contexts.  For example, if says, “Shoe,” ask him, “What’s that,” while pointing to his shoes, while looking at pictures of shoes in catalogues, while reading books, and while playing with a doll or toy characters.    

Toddlers also begin to answer questions by making verbal choices.  Offer choices for everything throughout the day. ”Do you want milk or juice? Which one should we play - blocks or cars? Should we read Good Night Moon or the Elmo book? Do you want a hug or a kiss? Does the cow want to eat or sleep?”  If he is not yet using words, he can respond with a gesture such as pointing, looking, or even grabbing the one he wants.  When he is talking or signing, you should wait him out for a verbal response, especially for words you know he can say or sign.   

One way to make sure that your toddler understands choosing is to offer a non-preferred item as a choice.  This is an especially effective technique for children who only “echo” the last words they hear.  For example, ask if he wants to play with bubbles or a sock.  If he repeats “sock,” make him take the sock.  You can also use this with favorite snacks and a not-so-desirable option.  If he echoes and says the wrong item, make an effort to have him take the item he doesn’t want, even if he’s initially upset or confused.  Give him a second chance by saying, ”You said, ____.  What do you want,  ______ or _____?”  Sometimes I hold the “correct” choice forward or shake it to call attention to it.  I also the exaggerate the ”preferred” item as I say the word and whisper the non-preferred choice.           

Ask early “where” questions that she can ”answer” with a point, look, or by retrieving an item.  For example, hide a ball in your hand and ask her where it is.  Ask her where common objects are in your home so that she can go get them.  Ask her to locate family members by pointing or looking as you are seated around the table during meals.  Have Dad or an older child model the correct answers as you ask your child.  Practice these kinds of tasks often knowing that you are building a foundation for verbal responses. 

When your child correctly ”answers” with a non-verbal response, use words to describe what he did.  As he’s pointing to family members when you’re asking, “Where’s _______,” say the family member’s name or a response such as, “Right there.”  When he’s answering a location questions, use the correct words.  “Yes!  It’s in the box.”           

Moving On 

Work on yes/no questions by giving them as “choices.”  For example, “Do you want cookies - yes or no?”  Shake or nod your head to cue your child as you say the words “yes” and “no” so that he can associate those gestures with words and use them if he can’t or won’t say the words just yet.        

When he’s answering “where” questions accurately without words, begin to model verbal responses by giving two choices for more complex questions.  Say, “Is your hat on your head or on your feet?”   ”Is the ball on the couch or the floor?”  “Is the dog eating or sleeping?”  Again, use visual cues to help him.  I use an exaggerated point to help cue the correct answer.  

Higher Level Questions

For answering questions about recent experiences, use the choice method or the review method.  Ask her, “What did you do at school today?”

Use the choice method to help generate an answer if she doesn’t respond to your first attempts.  Try, ”Did you paint or play in sand?” Again try to vary the order of your choices so she is listening for the “correct” answer.  (A little foreknowledge of what she actually did is required for this to be effective!) 

Practice the review method in daily routines and especially at the ends of specific play times.  Narrate what you did and then ask questions. For example, “Today we played with the farm, ate Oreos, and blew whistles.” Then ask her what you did giving visual cues (pointing or holding up the objects) as she answers.  

When you come in from playing outside, have her tell Dad what she did.  Start with a review of activities by saying, “We played on the slide and then on the swings.”  Then have Dad ask, “What did you play?”  Model what she should answer if she can’t do it.  

Another great time to practice is at meals.  Review what she ate for dinner by saying, “You ate chicken, macaroni, and peas.”  Then ask, “What did you eat for dinner?”  Point to her foods as a cue of what to respond.  Fade the review and pointing when she begins to answer on her own. 

A very effective way to cue answers to questions is to have one adult “ask” the child questions and have another adult “whisper” the answers if he needs help.  Fade the coaching as he becomes better.   

For children with better language comprehension skills who understand humor, try using a ridiculous choice to entice her to respond without echoing. You might say, “Do want to eat ice cream or poop?” Exaggerate the silliness of your offer so she knows you’re kidding and gets the “humor” in this question.  (Beware the “poop” jokes.  This may catch on and be a loooong phase at your house!)

For learning to answer the familiar name/age/gender questions, practice, practice, practice.  A good way to begin working on this is to ask older children first so that your child can hear a model and it becomes a game.  I also ask these questions with ”yes/no” choices too.  “Is your name Daddy/sibling’s name/pet name/character name?”  Model an exaggerated, “Noooooo” with a big head shake and grin.  Ask a couple of “no” responses, then ask the correct version. 

To help children learn gender, label “boy/girl” everywhere you go.  I also use children’s clothing magazines with stereotypical pictures such as girls in dresses and with long hair and boys in pants since there are lots of pictures for practice.  Be sure to ”teach” this concept for a long time before you begin “testing” by asking, ”Is he a boy or a girl?”  You don’t want to let a child repeatedly make a mistake in answering since he then “over-learns” the incorrect response.  Gender is often a difficult concept for children with language delays.  

If you have any other “tricks” for teaching your child to answer questions, please feel free to share them with us by leaving a comment!   Laura               

Below is a list of the most common diagnoses associated with pediatric speech-language problems with a basic explanation for each one.  Please remember that this is a listing of specific speech-language diagnoses and not necessarily a medical or educational label.  For example, a child diagnosed with autism may exhibit characteristics of apraxia, a child with Down Syndrome may have dysarthria, a child with dyslexia may also have an auditory processing disorder, etc… 

The speech-language diagnosis may be just a part of a condition that affects a child’s overall developmental picture, or it could be the only issue a child faces.  I have often evaluated children whose parents referred them for what they thought was a speech or language delay, when in fact their children were exhibiting delays in other developmental domains as well.  This also happens with other disciplines too.  My colleagues who are physical and occupational therapists often end up referring children for communication assessments when parents initially sought their help for what they assumed was just “late walking” or “difficulty with feeding” not realizing that their child was behind in other areas too.  Many children with developmental difficulties have issues that overlap the motor, social, cognitive, adaptive, and communication domains. 

When in doubt, get an evaluation.  Be sure to ask the professional if there are other developmental concerns as well.  You’d rather know, and the sooner, the better.  All of the current research tells us that early intervention gives a child the best chance of minimizing long-term difficulties.  Waiting until your child is school age to see if he will “outgrow” a problem puts him at a serious disadvantage, especially when it comes to communication difficulties.   

Apraxia  

Apraxia is a neurological speech disorder that affects a child’s ability to plan, execute, and sequence the movements of the mouth necessary for intelligible speech.  Apraxia can also be referred to as developmental verbal apraxia, childhood apraxia of speech, or verbal dyspraxia.  Most SLPs use the terms interchangeably.  Characteristics of apraxia include:

• Limited babbling is present in infancy.  These are quiet babies.  
• Few or no words when other babies are talking by age 2
• Poor ability to imitate sounds and words
• Child substitutes and/or omits vowel and consonant sounds in words.  Errors with vowel sounds are not common with other speech disorders.
• His word attempts are “off-target” and may not be understood even by parents. 
• He may use a sound such as “da” for everything. 
• Often his errors are inconsistent, or he may be able to say a word once and then never again.  The child understands much more than he can say.   
• There is sometimes (but not always) a family history of communication difficulty.  (i.e.  “All the boys in our family talk late,”  or “My husband’s grandfather  still has trouble pronouncing some hard words.”)  

There has been controversy in the field of speech-language pathology in giving this diagnosis to children under 3.  However, the kinds of therapy useful for children with apraxia are often not introduced if the clinician does not suspect this as the root cause for a child’s communication difficulty.  If you suspect this as your child’s problem, initiate a conversation with your child’s pediatrician and begin speech therapy with a clinician who has experience treating children with apraxia.  If your therapist says that he/she does not believe that this can be diagnosed before age 3, look for a new therapist!

An excellent resource for parents and professionals working with children with apraxia is www.apraxia-kids.org. Another comprehensive resource for an explanation of apraxia is http://www.kidspeech.com/index.php?page=56.

Many children with apraxia also have difficulty with sensory integration, or how he processes information from all his senses including visual, auditory, tactile, and proprioceptive.  (For more information about sensory issues, go to  http://www.kid-power.org/sid.html .) 

Feeding issues are sometimes present because of the sensory issues a child exhibits such as poor awareness in his mouth so that he overstuffs to “feel” the food, or to the other extreme, he is so sensitive that he gags when new textures are introduced.    

For more answers to a parent’s questions about apraxia on this site look under Amy’s question in the comments section under Ask the SLP or go to this link http://teachmetotalk.com/2008/01/31/ask-the-slp/#comment-24.     

Phonological Disorders

A phonological disorder is difficulty with the “rules” or “patterns” for combining sounds intelligibly in speech in English.  For example, phonological process patterns include prevocalic consonant deletion (leaving off consonant sounds that precede a vowel such as “at” for hat), syllable reduction (producing only one syllable in a multisyllabic word such as “bay” for baby), or reduplication (simplifying a multisyllabic word to a duplicated pattern such as saying “bubu” for bubble or even “dog dog” for doggie).  

There are many patterns for analyzing a child’s speech according to a phonological processes model.  All of these processes are common in typically developing children as well.  It becomes a problem when most children are maturing in their patterns of production, and a child is not.  For example, final consonant deletion (leaving off ending consonant sounds in words) typically disappears between 2 1/2 to 3 years of age.  If a child is not including final consonants by this age, it would be considered “disordered” or “atypical” since most of his same-age peers are now using a more mature pattern.  

A child with only a phonological disorder exhibits typically developing language, meaning that his vocabulary and utterance length are the same as his peers, but he continues to exhibit patterns that are consistent with a younger child’s speech errors.  A child with phonological disorder needs speech therapy to learn new patterns.  The most popular approach for therapy for this disorder is the Hodson cycles approach.  A pattern is targeted in therapy for a certain number of sessions, then a new pattern is initiated.  Once all of the patterns are addressed, the cycle starts over.  Your child’s speech sounds begin to improve, even if it’s not “perfect” through the first few cycles.  This approach has lots of research to support it.  It’s generally used for highly unintelligible kids over 3.  For more information on this approach, ask your child’s SLP if it’s right for your child because even the veterans know and use this technique.                     

Articulation Disorders 

An articulation disorder is difficulty with the production or pronunciation of speech sounds.  This difficulty may be present with an isolated sound such as substituting /w/ for /r/, difficulty with blends such as “st,” or with distortion of sounds such as a lisp.  Sometimes clinicians speak of phonological disorders and articulation disorders interchangeably.  I use the term phonological disorder when there seems to be difficulty with attaining a “pattern” of sounds and the term articulation disorder when a child has difficulty with only a couple of sounds rather than an identifiable pattern.   If a child is still exhibiting errors with even a few sounds after most of his peers can correctly use the sound, he needs therapy to help him.  For a list of ages when children acquire certain sounds, try  http://www.talkingchild.com/speechchart.aspx.  

For a good discussion of articulation and phonological disorders go to  http://www.psllcnj.com/articulation_disorders.htm .                            

Auditory Processing Disorder

An auditory processing disorder is difficulty with listening to, receiving, analyzing, organizing, storing, and retrieving information. It can also be called central auditory processing disorder (CAPD).  In young children this often looks like the child cannot understand what’s been said to him, even when his hearing and language comprehension skills are within normal limits.  A child may have difficulty paying attention to what someone is saying to him or difficulty following directions in the presence of background noise or when he’s more focused on something else.  This might be the kid that won’t look away from his favorite TV program when a bomb goes off, much less when you’re calling his name. 

This is commonly included as a receptive language disorder in children under 3, with an official diagnosis of auditory processing disorder coming later in the preschool or early school-age years since there’s no tests for this condition with younger children.  Children with sensory integration differences also exhibit auditory processing disorders.  It’s very common for children with autism and other learning disabilities such as dyslexia and attention deficit disorder to exhibit these characteristics as well.  I could not find a site for information for very young children with auditory processing disorder, but this is receiving lots of attention in the field of early intervention right now, so maybe we should have a good resource soon.   

Dysarthria

Dysarthria is a neurological speech disorder that affects a child’s muscle tone.  Weakness is noted in the muscles used for speech including his lips, tongue, soft palate, and cheeks so that his speech sounds slurred.  Dysarthria is present in kids with Down Syndrome, cerebral palsy, or any other condition that causes “low tone.”  Dysarthria may also affect a child’s vocal and respiratory quality so that he sounds hoarse or breathy. 

A child may also have feeding problems due to muscle tone issues such as difficulty sucking from a bottle because his tongue isn’t strong enough, keeping foods or liquids in his mouth because his lips aren’t strong, or chewing because of overall weakness in his jaws and cheeks.  A child may also drool because she can’t close her mouth consistently. 

A child with muscle tone issues may also have difficulty with gross and fine motor skills.  Physical and occupational therapy may be necessary to help meet milestones.  Low muscle tone never truly “goes away,” and there’s a difference between strength and tone.  All of us have varying degrees of muscle tone  ranging from high to low, and kids with even very low muscle tone can learn to walk and talk.  

For more information visit  http://www.stronghealth.com/services/childrens/conditions/Dysarthria.cfm. 

You might also try  http://www.kidspeech.com/index.php?page=75.      

Dysfluency 

Dysfluency is the more professional term for stuttering.  It is the repetition of individual speech sounds usually at the beginning of words or phrases.  Many children with typically developing language “stutter” when they move from using single words and short phrases to longer sentences and/or when they are under pressure to speak and can’t encode their words quickly enough.  Typical dysfluency can occur anywhere from age 2-4.  If it lasts for more than 6 months, seek a professional evaluation.  

Many times there’s a family history of stuttering if this is going to be a chronic challenge.  Kids who repeat individual sounds at the beginnings of words with facial grimaces or tremors, tense their muscles, blink their eyes repeatedly, or tap their feet are at greater risk for true difficulty with fluency than those who repeat whole words and who don’t seem to be phased physically by this.  

The best advice for parents when your child starts to stutter is to ignore it.  Do not tell him to slow down, stop and think, or any other comment that you feel might be helpful.  Relax his environment and do not put pressure on him to “perform” verbally including asking too many questions in a row, demanding that he answer silly questions such as, “Did you hit your sister?” when you know he did, or insist that he sing his new song from preschool for grandma, grandpa, and all of your long-lost relatives at Thanksgiving.  Don’t interrupt him when he’s talking, even when he’s struggling.  This is hard!  

Our oldest son had a terrible several month bout with stuttering while I was in grad school taking the class on dysfluency.  It was horrible for me!!  My professor’s advice was simple  - ”Ignore it and it will (probably) go away.”  Another piece of advice is to make sure his teachers at preschool, sitters, or even family members are on board with the “ignore it” method so that no one calls attention to this issue.  The unnecessary pressure will make it worse, not better, so tell all of your well-meaning friends and family that you are doing this one your way.                                   

Expressive Language Disorder 

Expressive language disorder is present when a child is not meeting milestones in the area of language usually involving vocabulary, combining words into phrases, and beginning to use the early markings of grammar.  A child with only an expressive language disorder doesn’t have difficulty pronouncing the words per se, but he has difficulty learning or retrieving new words and putting sentences together.  A child may rely on non-specific words such as “that” and “there” rather than learning specific names for objects.  She may have difficulty learning verb tenses (such as the “ing” for walking and “ed” for jumped) or have difficulty learning word classes such as prepositions or pronouns. 

An expressive language disorder can and often co-exists with a speech disorder such as apraxia.  I have treated kids like this with only expressive language delays/disorders, but more often than not, late talkers exhibit a speech AND a language disorder.  Sometimes children exhibit receptive language disorders as well, so it’s not uncommon to have several speech-language diagnoses at the same time. 

An expressive language delay would be a child who is acquiring vocabulary, combing words, and learning early grammar with the same sequence as his peers, but at a slower rate.  If there are atypical characteristics present such as your child has some skills at a higher age level but is still missing many lower age-range skills, it’s called a disorder.  Delays are typically easier to overcome, and most kids with delays eventually catch up.  A disorder is generally something a child will struggle with for a while, perhaps his entire life.    

Receptive Language Disorder

A receptive language disorder is difficulty understanding language.  This is also called an auditory comprehension disorder.  Kids who have receptive language disorders don’t follow directions and not because they’re being disobedient, but because they don’t understand what’s being said.  They seem to ignore language because words don’t mean anything to them yet.  They often hate reading books unless mommy lets them flip through the pictures because it’s all about listening to words which may not make very much sense.  

When a kid gets a little better and understands a little more, signs of a receptive language disorder may be that he repeats a question rather than answering it or gives an incorrect response.  For example, if you ask a child with a receptive language disorder who has been learning his colors, “What are you drinking,” he’s likely to respond “red” because that’s the color of his cup.  Or if you ask a question such as, “Do you want milk,” she might answer ”no,” but then she still gets upset when you don’t give her the cup because she doesn’t understand that answering “no” means she doesn’t want it. 

I have seen many kids whose parents or daycare teachers label as “difficult” or a behavior problem when really there’s a major receptive language delay that no one recognizes.  Parents often overestimate what their language delayed/disordered child truly understands.  This is so sad to me because when everyone decides to work on teaching and helping him understand language BEFORE we expect him to talk and BEFORE we expect him to “obey,” then everyone benefits;  especially the kid who doesn’t understand why in the world he’s in trouble in the first place, even when his mother “told him not to do it!” 

Make sure your child’s receptive language skills are addressed, or the other speech-language problems are not going to significantly improve.   A child who doesn’t understand much really shouldn’t be saying much either.  To expect more is simply wrong and well above what he’s able to realistically accomplish.  Most SLPs think of working on receptive language hand-in-hand with expressive language, and this is absolutely the right way to go.  When parents get on board with this approach, wonderful things happen.        

For more information on improving receptive language, see the post titled, “Help Your Toddler Listen and Obey.”                                                

Social Function Words 

more, please, thank you, hi/hello, bye-bye, again, sorry, uh-oh, yes/uh-huh/okay, no/uh-uh

Common Action Words (Verbs)

eat, drink, go, stop, run, jump, walk, sleep/night-night, wash, kiss, open, close, push, pull, fix, broke, play,want, hug, love, hurt, tickle, give (”gimme”), all gone, all done, dance, help, fall, shake, see, watch, look, sit, stand (up), throw, catch, blow, cry, throw, swing, slide, climb, ride, rock, come (”C’mon”), color/draw      

Location Words (Prepositions)

up, down, in, out, off, on, here, there (Plus later ones such as around, under, behind, over at/after age 3)

Descriptive Words (Adjectives/Adverbs)

big, little, hot, cold, loud, quiet, yucky, icky, scary, funny, silly, dirty, clean, gentle, wet, soft, fast, slow, color words (red, blue, yellow, green, pink, orange, purple, black, white, brown) and quantity words (all, none, more, some, rest, plus early number words - especially 1, 2, 3)

Early Pronouns

 me, mine, my, I, you, it (Then toward age 3 the gender pronouns such as he, she, him, her )

Just in case you’re wondering, here’s a list of the most common nouns:

ball, book, choo-choo, train, bike, rain, bubbles, car, truck, boat, plane, baby, bowl, spoon, diaper, sock, shoe, shirt, pants, hat, star, flower, house, tree, brush, towel, bath, chair, table, bed, blanket, light, cookie, cracker, chip, cheese, apple, banana, ice cream, cereal (Cheerios/ “O’s”), candy, milk, juice, water, dog, cat, fish, bird, duck, cow, horse, bunny, bear, pig, lion, elephant, giraffe, zebra, monkey, chicken, butterfly, bee, frog, alligator, snake   

Plus names for people - Mama, Dada, brother and sister names, pet names, grandparents & other family members, and favorite characters such as Elmo, Dora, Diego, etc…     

“My 18mo son is not talking as well as my 4yo daughter did at this same age. She was a babblemouth and he doesn’t seem to want to talk at all. I have expressed my concerns with our pediatrician and was told to not be concerned. Family members don’t seem to be interested in the subject at all. I have a few questions for you and I hope you don’t mind. Why should I be concerned about my child learning to talk at a late age? Do all children who start talking at a late age fall behind in school? How can someone tell the difference between a ‘late talker’ who will catch up on his own, and a child who is not talking and is at risk for later difficulties? If my child is a late talker who will catch up on his own, then he will not need help from a Speech Language Pathologist, right?”

In order to be as thorough as possible, I am going to try to answer each of your questions separately.  

 “My 18mo son is not talking as well as my 4yo daughter did at this same age.”

First of all, there are gender differences between boys and girls and as well as differences between first and second born children, and I think you are seeing both of these dynamics in your family.  Overall boys are more likely to talk later and/or have other learning challenges than girls.  However, the developmental norms that experts use (including those used here on this site) consider gender differences and use those to devise the “averages” or “norms.”  Many psychologists that study birth order also note that first-borns are likely to be more verbal and are verbal at an earlier age than children born second or later in families.  Reasons cited usually include that parents spend more one-on-one time with their first and only children than with their subsequent children.                   

 “I have expressed my concerns with our pediatrician was told not to be concerned.”

This is a very common occurrence.  Many times pediatricians take a wait and see approach, and many times parents regret this.  Please see my lengthy commentary on this problem under ”When to Worry.”  If you feel in your heart-of-hearts that there’s truly a problem, there probably is.  Parents know more about their children than even the best doctor who only gets a snapshot of your child every few months (and then most of those visits are when he’s at his worst - sick!).  You are with him day in and day out, so you are the “expert” concerning him.    Trust your own instincts, even if you are in disagreement with your doctor. 

I recently evaluated a little boy whose parents were told by his ENT  that beginning speech therapy before 2 1/2 is “crazy.”  I beg to differ.  There’s usually a difference between a kid referred in for early intervention at or before 2 and a kid who is still not talking at 30+ months.  Six months is a long time to wait for a toddler - that’s 1/4 of his whole life!  By 2 1/2 the negative patterns and high frustration levels are so much more of a habit than if we had seen a child and his family earlier.  It’s the information that parents get from a speech pathologist or other early intervention professional that makes more of a difference than anything in the outcome for the child.  Parents can immediately tweak what they are doing everyday at home, in addition to the real “therapy” he gets, and more often than not, the child starts to progress.  Waiting doesn’t make much sense to me, especially if you are truly concerned.  I have never heard of a parent that regretted pursuing an assessment before 2, and I have heard many that wish they had.  

 ”Do all children who start talking at a late age fall behind in school?”

Not all late talkers end up having academic problems.  However, late talking and other developmental problems that weren’t addressed (and many that were) show up in the case histories of children who later struggle in school.  There’s so much research that supports the value of early intervention (defined as the period between birth and 3).  The truth is we don’t know which of the children who talk late will end up doing fine and which ones won’t.  On the flip side, there are children who talk on time or even early who later fall behind in school.  There are many reasons for learning difficulties, and differences in processing language probably account for a larger percentage of problems in school than any other reason related to communication.  Experts agree that a child’s language skills at age 3 are the best predictor for future academic success.      

“How can someone tell the difference between a ‘late talker’ who will catch up on his own, and a child who is not talking and is at risk for later difficulties?”

No one has a crystal ball and can see the future for any child, but there are indicators and differences between kids who will eventually begin to talk and those who will struggle with communication throughout their preschool years and beyond.  One large factor is child’s comprehension level.  Is he understanding language?  Does he follow verbal directions during your daily routines and perform other cognitive milestones such as pointing to body parts or pictures in books when asked?  Kids who don’t understand many words generally don’t say many words.  Make sure he’s understanding you.

On this same note, how is his hearing?  Kids who can’t hear don’t talk either.  Ask your doctor to refer him for an audiological (hearing) assessment, especially if he’s had ear infections.  Your doctor may also be able to do a tympanogram in his office to detect any fluid in his middle ear.  Fluid can be present with and without a true infection.  You may never know if your child has fluid in his ears because he may not have shown any symptoms of illness such as a fever or obvious pain.  Even periodic short term hearing loss, the kind that’s present when a kid has fluid in his middle ear, can create lags in a child’s ability to communicate.  Kids with chronic ear infections may not correctly pronounce words because they don’t hear all the sounds.  Some children with untreated ear infections seem to learn “not to listen.”  To them it sounds like they’re under water half the time, so why bother?  (Let me also add that undetected hearing loss is much more rare these days since newborn hearing screenings are routine.  Many times parents assume their kid can’t hear when he doesn’t respond.  Usually a lack of response is related more to a kid’s ability to process language rather than hear.)                       

Another factor is how interactive and communicative your son is without words.  How does he let you know what he wants?  Does he point and try to talk?  Does he try to direct your behavior by pulling you up to assist him when he needs you?  Is he playing social games with you and other adults?  If he’s not trying to communicate using gestures or is not regularly interactive with you, insist on an immediate referral to a speech-language pathologist or early intervention program.  If he is, then keep encouraging him to let you know what he wants, with or without words.  Check out some of the other posts for other ideas.     

Another factor is how vocal he is.  Does he have any words?  (By 18 months he should have at least 15 words.) Does he attempt to make noise when he tries to communicate?  Is he babbling or using jargon (unintelligible longer strings of syllables that seem like he’s telling you something, even if you can’t understand).   Can he imitate animal or vehicle noises?  I have had some very quiet children pop out words “out of the blue,” but usually children make noise before they begin to use words.  If he is unusually quiet, go ahead and get a referral now.  You’ll need some tricks to get him going and help him find his voice.

Lastly, what is your family history?  Do you have other late talkers on your or Dad’s side of the family?  This characteristic does have a genetic link and can “run in the family.”  (Let me also note that knowing that other boys in the family talked late would not be a reason for me to delay pursuing additional help.)                        

If my child is a late talker who will catch up on his own, then he will not need help from a Speech Language Pathologist, right?

If I knew the answer to this one, I’d be really rich because then we could just line up every late talking kid from here to there and I’d lay my hands on them and know……..  But we can’t do that. 

The term “late talker” has come to mean anything from a kid who isn’t meeting expressive developmental milestones at 18 months, or 2, or even 3, who does eventally begin to talk.  It also applies to kids at 18 months who may not learn to communicate anytime soon, but you don’t know that yet.  Again - the truth is, I don’t know if your son will need a professional or not.  Neither do you until you get him evaluated. 

But in the mean time, there are LOTS of things you can do at home to help him learn to communicate, and that’s what this whole site is about.  If you haven’t already, please read through the other posts for ideas for you at home.  If you judiciously work on this for another few weeks or even a couple of months and he’s not any closer, please go ahead and discuss it with your doctor again, or better yet, make the call to an early intervention program, children’s hospital, or private clinic yourself.  All states are required to provide access to early intervention services for children.  Ask your pediatrician’s office who to call, search for it on the Internet, ask around, or look in the phone book.  You could also start with your local public school or health dept. and ask who you should call.  You don’t want to wait too long if he’s still not talking and you’re still worried.  That’s unnecessary guilt, and we mothers have too much other stuff that we heap on ourselves to feel unneccessarily guilty about!  

The worst thing that will happen from a referral to a qualified pediatric speech-language pathologist is that she/he will tell you that he’s fine and you’ll have wasted a couple of hours.  Or you could find out that he’s still fine, but you’ll get specific things to do at home to move things along.  Or you might find out that he needs services, and you’ll feel so much better that you did it now rather than later.  

Besides speech therapy with babies is FUN!  You’ll learn new ways to play and get great ideas for things to do at home.  In most state-funded programs now with the emphasis on natural environments, the therapist comes to your home, so it’s not even that much of a hassle (other than maybe cleaning up around the house a little bit which most of my families stop doing after they’ve known me for a while).  Even if you do have to take him somewhere, it’ll be worth the trip.      

Thanks so much for reading this site.  I really appreciate your questions, and I hope I’ve answered them.  Please let me know if there’s anything else I can do to help!  Best of luck to you and your son!  Laura