Strategies for Conversation with Children who have Childhood Apraxia of Speech

Children with Childhood Apraxia of Speech (CAS) tend to communicate more easily when there is less communication pressure. To reduce this pressure, try to:

• Make more comments in conversation than questions.  When you ask a question, it is demanding that the child responds right away and with particular information. Only ask questions when necessary.

• Reduce the frequency of asking the child to repeat something he has said, as this can lead to increased frustration and communication breakdown.  When you do not understand what your child has said, it’s OK to “go with the flow” and make a general comment (e.g., That’s cool!) to keep the interaction going.

• Make comments that are related to the activity you are engaging in with the child instead of aspects of the child’s speech.  For instance, while playing with dolls, you might say, “Oh no the baby’s crying,” or “She’s sleepy” rather than “Nice job talking,” or “You had a hard time saying that.”

• Avoid putting your child on the spot when greeting other people. For example, telling your child to say “Hi” or “Good morning” to someone can be a very demanding task with which your child may have difficulty, resulting in communication breakdown.

• Avoid putting your child on the spot in front of an audience by asking him to tell other people about something (e.g., Tell Sarah about your birthday party, Tell James what you did at school). 

• Try not to focus on “getting your child to talk” and rather focus and having fun with your child in conversation and play.

• Talk about things your child is interested in. When you do so, your child may be more likely to make a comment.  Just as adults enjoy talking about particular subjects, oftentimes so do children.

• Make conversation fun and light-hearted and maybe even silly, as this can reduce tension and create a more relaxed atmosphere, thereby increasing the likelihood of your child participating in conversation.

10-Step Plan for Improving Nutrition and Feeding for Children with Autism

1) Transition to a healthy diet: Avoid food additives, pesticides, refined sugars, processed foods, and trans fats

2) Get enough basic nutrients: Water, Macronutrients (protein, carbohydrates, and fat), Micronutrients (fat soluble vitamins and water soluble vitamins)

3) Take a multivitamin and mineral supplement: Containing 100-300% RDA of fat soluble vitamins (A, D, E, K), vitamin B complex (B1, B2, B3, B5, B6, B12, folic acid, biotin), vitamin C, minerals (calcium, magnesium, zinc, selenium, manganese, chromium, molybdenum); Avoid multivitamins that have artificial colors and flavors, potential allergens and herbs

4) Increase Omega-3 fatty acid: Eat fish and other foods that contain Omega-3 and/or with a supplement.

5) Improve feeding problems: Enroll in the feeding therapy program if: Restricted repertoire of foods (less than 20 foods), Foods lost from diet due to burnout, and foods not regained into the diet, Persistent refusal of novel foods, Refusal of entire food texture groups.

6) Heal the gut: Signs of gastrointestinal (GI) disorder include abdominal pain, bloating, gaseousness, diarrhea, constipation, reflux, vomiting, food refusal, limited variety of foods, mealtime tantrums, irritability, self abuse, sleep disturbances. Treat by modifying the diet, eliminating problematic foods, and/or taking supplements, including probiotics, antifungals, digestive enzymes, therapeutic levels of Omega-3 fatty acids, and glutamine

7) Identify food allergies and implement treatment: Foods responsible for 90% of allergic reactions include milk, wheat, soy, egg, peanuts, tree nuts, fish, and shellfish

8) Try an elimination diet: Most popular is the Gluten Casein Free Diet (GFCF)

9) Try high dose vitamin B6 with magnesium

10) Consider additional supplements: To enhance immune system: dimethylglycine (DMG), iron, magnesium, selenium, zinc, vitamins A, C, D, and E. To enhance cognitive function: carnitine, choline, coenzyme Q10, iron, zinc, ginkgo biloba. To enhance detoxification system: alpha-lipoic acid, glutathione, N-acetylcysteine, selenium, trimethylglycine (TMG), vitamin C, milk thistle

-Courtesy of Elizabeth Strickland

Ideas for Practicing Spatial Concepts “In/On/Under”

Our speech-language pathologists often help children with the spatial concepts "in," "on," and "under." Here are ways to practice the words with your child at home:

1.) Clean Up: While cleaning up toys, put toys in, on, and under the box. Sing a modified version of the clean up song:

 “Clean up, clean up,

Everybody everywhere,
Clean up, clean up,
Put the (name of toy) in/on/under the box.”

You and your child can take turns telling each other where to put the toy. Then you can ask your child where the toy is. This can be a silly game since you are putting toys on and under the box when they are supposed to go in the box.

2.) Hide and Seek: take turns hiding your child’s favorite toys. Hide the toys in, on, and under various locations at home. Then find the toys and talk about where the toys were hidden. Also, you and your child can take turns hiding yourselves in, on, and under various places at home.

3.) Be silly: Whenever the opportunity arises in which an item (food, toy, garbage, etc.) is supposed to go in, on, or under, be silly and pretend that you are going to put it in the wrong place. For instance, when throwing away garbage, say that you are putting the garbage under the garbage can because that’s where it’s supposed to go. No! Where does it go? It goes in the garbage can!

Ideas for Practicing Pronouns “I/You” in Daily Routines and Play

Here are some strategies and activities to try at home to help your child practice the "I" and "you" pronouns.

Strategies:

• Model the language that you want your child to use; speak from his/her perspective. 
• Use a pointing gesture.  At first, take your child’s hand and have him/her point to himself/herself while you say “I.” Make his/her hand point to you while saying, “You.”
• Fade out the models/cues over time.  For instance, have your child independently point to himself/herself while saying “I” and independently point to you while saying, “You.” Later fade out the pointing cue altogether.

Activities to try at home:

1.)    Have a picnic/teaparty with pretend food. Set up bowls in front of you and your child. Take a single food out of the bin and ask, “Who wants ______?” For example “Who wants a banana?” Your child says either “I do,” or “You do.” Model what your child should say and use gestures.  For instance, take your child’s hand and have him/her point to himself/herself while you say “I do.”  Take his/her hand and have him/her point to you while you say, “You do.”

2.)    While reading a book, pause each time before you turn a page. Ask, “Who will turn the page?” Your child responds either “I will,” or “You will.” Give him/her a choice between the two options.  For example, ask him/her “I will or you will?” Hold your child’s hand and point to him/her while saying, “I” and make him/her point to you while saying, “You.”

3.)    When making a puzzle, take out all of the pieces and put them in a container.  Your child decides who gets to pick out a piece.  Ask your child, “Who picks a piece?”  Your child responds, “I pick” or “You pick.” Again, model the responses and use gestures.

4.)    Share a snack, such as crackers, from the same container.  Ask your child, “Who wants a cracker?” Have your child respond either “I want one” or “You want one.”

Home Fluency Recommendations: A Parent's Guide

Wondering how you can help improve your child's fluency at home? Here are some strategies you can use:

• One factor which may affect fluency is the rate at which the child and those around him talk. Often times, children try to talk fast to keep pace with the adult’s rate of speech. When children hurry, especially if they are only two, three or four years old, they often repeat and hesitate because their tongues, lips and jaws simply cannot move as quickly in a coordinated manner. That said, if the adult attempts to slow their rate of speech, your child may naturally slow his rate to match that of the adult. 

• Young children’s disfluencies have been known to increase with the more questions they are asked. Much of adults’ verbal communication with children is question-asking in nature. Questions put children ‘on the spot’ to elicit a response. That said, try to reduce by the number questions you ask by 50%. Rather, try “commenting” on what your child is doing. For example: Wow, that ice cream must taste so good! Rather than, “Is that ice cream good?” Also, be sure to leave silences, rather than feeling the need to talk consistently.

• Avoid putting your child “on display” by asking them to perform for others. Examples include: “Tell Grandpa what you got for your Birthday,” Or “Tell Mom what we did today.” Alternatively, you might retell the story and allow your child to contribute when/if he wants.

• For children as young as three, disfluencies may decrease on occasion if adults echo a portion of what they have just said rather than engage them in a conversation. Please note: if your child stutters, simply echo fluently what he said without calling his attention to the stuttering. The suggestion would be that only the two parents do some echoing and plan to stop the echoing gradually in one to two months. However, if the child responds negatively to the echoing or considers such to be teasing, discontinue this strategy immediately.

• Children’s disfluencies may increase when they try to get us to listen to them. Many young children want us to look at them and want to be able to see our eyes when they talk. They do not want us to continue with our activity of the moment, such as fixing a meal or reading as we listen. They would like 100 percent of our attention. If it isn’t possible to give your undivided attention at the moment, ask your child to wait a moment.

• For some children ages 2 to 4 years, disfluencies appear to occur to their stage of language development, at least in part. The child is learning new words and linking them together in sentences. Children often are disfluent at this stage of vocabulary acquisition and language formulation. Your goal as a parent is to reduce language development pressure. You can enjoy being together without trying to “teach” or “direct.” For example, try table top crafts or sand box activities, or an activity that lends itself to ‘doing’ without feeling a need to talk constantly. Therefore, the focus is shifted on the activity itself, rather than the speech.

Pragmatics - Social Language Use and Tips

A child may have perfect articulation and grammar but still have a communication problem if he or she has not mastered the rules of pragmatics, or social language use.

Taken from an ASHA article on the topic:

"Pragmatics involve three major communication skills:

1. Using language for different purposes, such as:

• greeting (e.g., hello, goodbye)
• informing (e.g., I'm going to get a cookie)
• demanding (e.g., Give me a cookie)
• promising (e.g., I'm going to get you a cookie)
• requesting (e.g., I would like a cookie, please)

2. Changing language according to the needs of a listener or situation, such as:

• talking differently to a baby than to an adult
• giving background information to an unfamiliar listener
• speaking differently in a classroom than on a playground

3. Following rules for conversations and storytelling, such as:

• taking turns in conversation
• introducing topics of conversation
• staying on topic
• rephrasing when misunderstood
• how to use verbal and nonverbal signals
• how close to stand to someone when speaking
• how to use facial expressions and eye contact

It is not unusual for children to have pragmatic problems in only a few situations. However, if problems in social language use occur often and seem inappropriate considering the child's age, a pragmatic disorder may exist. Pragmatic disorders often coexist with other language problems such as vocabulary development or grammar. Pragmatic problems can lower social acceptance. Peers may avoid having conversations with an individual with a pragmatic disorder."

Here are some pragmatic language tips for caregivers, also from ASHA:

Ask questions or make suggestions to use language for different purposes:

Desired Language Function	Suggested Question or Comment
Comment	"What did you do?" "Tell me about..."
Request	"Tell your friend..." "What do you want?"
Question	"Ask me"

• Respond to the intended message rather than correcting the pronunciation or grammar. Be sure to provide an appropriate model in your own speech. For example, if an individual says, "That's how it doesn't go," respond, "You're right. That's not how it goes."

• Take advantage of naturally occurring situations. For example, practice greetings at the beginning of a day, or have the individual ask peers what they want to eat for dinner or request necessary materials to complete a project.

Changing Language for Different Listeners or Situations

• Role-play conversations. Pretend to talk to different people in different situations. For example, set up a situation (or use one that occurs during the course of a day) in which the individual has to explain the same thing to different people, such as teaching the rules of a game, or how to make a cake. Model how the person should talk to a child versus an adult, or a family member versus a friend of the family.

• Encourage the use of persuasion. For example, ask the person what he or she would say to convince family members or loved ones to let him or her do something. Discuss different ways to present a message:
• Polite ("Please may I go to the party?") versus impolite ("You better let me go")
• Indirect ("That music is loud") versus direct ("Turn off the radio")
• Discuss why some requests would be more persuasive than others

Conversation and Storytelling Skills

• Comment on the topic of conversation before introducing a new topic. Add related information to encourage talking more about a particular topic.

• Provide visual cues such as pictures, objects, or a story outline to help tell a story in sequence.

• Encourage rephrasing or revising an unclear word or sentence. Provide an appropriate revision by asking, "Did you mean...?"

• Show how nonverbal signals are important to communication. For example, talk about what happens when a facial expression does not match the emotion expressed in a verbal message (e.g., using angry words while smiling)."

The Mealtime Environment

The structure of the mealtime environment can have a major impact on a child's eating behavior. Overall, strive for a positive environment that is predictable and supportive. To optimize the environment, implement the following:

• Schedule regular meals for the family. Have everyone remain seated at the table for the duration of the meal.
• Avoid grazing.This means only offering water between meals and snacks. This supports a regular hunger-satiation pattern and may lead to increased daily food consumption. 

• Create regular routines related to mealtime. For instance, have the family wash hands together or set the table together.
• Try starting and ending mealtime with a positive experience, such as washing your hands while singing a favorite song or allowing your child access to a preferred food.
• Have your child seated at eye level to others at the table. This may require use of a booster seat or highchair. 
• Be sure that your child's seating allows free use of hands for self-feeding.
• Minimize auditory and visual distractions at mealtime by turning the television off and keeping toys away from the table.
• Have everyone in the family eat the same foods at mealtime. Avoid short order cooking for picky eaters. 
• Model positive feeding behaviors for your child throughout the meal.
• Try limiting meals to 30 minutes and snacks to 10-15 minutes. 
• Avoid distraction as a tactic for getting your child to eat. Also, avoid sneaking in bites of food. These tactics may work in the short term, but in the long term they will not facilitate acceptance of foods which leads to improved eating behavior. Additionally, negative associations with foods and mealtime will be created. The ultimate goal of a meal should be creating positive experiences with food.
• Do not rush through meals. Your child may need extra time given developing self-feeding skills. Additionally, mealtime is meant to be a social experience. Talk with your child about the food you are eating, ask him questions about his day, or discuss his favorite things.

Links:

Parent's guide to feeding strategies & positive mealtime behavior
Chatterboxes feeding therapy
Feeding therapy FAQ