When a child is diagnosed with a speech problem such as CAS, their parents enter a world of therapists and services that is new and unfamiliar to most of them. The process of evaluation and development of an intervention plan can be intimidating. It may be tempting for parents to rely on the therapist to “fix” the problem. However, when parents make an effort to understand their child’s diagnosis and become active participants in the intervention process, there are benefits not just for the child but for the parents and therapists as well.

Therapy for CAS is intensive and requires focus and participation on the part of both child and therapist. Parents can share information with the therapist about the child’s personality and preferences that can be used to motivate the child. They can help the therapist understand how the child responds in frustrating situations and how they manage challenging behaviors at home. This information can help the therapist and parents provide consistency in working with the child in therapy sessions and at home.

The need for multiple repetitions to develop motor skills to an automatic level is well established and forms a basis for treatment of CAS. Given the number of hours per day a child spends with family versus therapist, opportunities for practice are multiplied when parents encourage speech practice outside of therapy sessions. Extending therapy targets into the child’s home environment promotes motor learning that goes beyond acquisition of motor skills. *Motor skills* are established through many repetitions of a movement. *Motor learning* is established when the motor skills are carried over to a functional task. For example, a child can produce multiple repetitions of a target phrase such as “More, please” in therapy, demonstrating intelligible production of that phrase in practice. Using the phrase in therapy to request more time with a toy is the beginning of motor learning. Having opportunities to ask for “More, please” many times during the day at mealtime and snacktime brings the motor learning into the “real world” where a child experiences the power of using his or her voice.

The therapy process affects the entire family, not just the child with CAS. Parents and other family members who are actively involved in the therapy process are more likely to be comfortable giving valuable feedback to the therapist. Such feedback can help the therapist determine the next steps in the continuing evolution of therapy goals. It may also help the therapist recognize what they do that works well for the child and their family and what they do that is not as effective. As a young clinician who had no children, I was eager to assign parents “homework” sheets for speech practice at home with their children. Many times the sheets were taken home and forgotten. As an older and (hopefully) wiser clinician, I have learned to request feedback rather than wait for it to be offered. And I have learned the value of teaching parents ways to insert speech practice into daily interactions.

(Dr. Ruth Stoeckel has worked in a variety of settings, including schools, private practice and clinic. She is currently employed at Mayo Clinic in Rochester, Minnesota. Her clinical interests include childhood apraxia/severe phonological disorders, autism, cochlear implants and early language development. She frequently presents at workshops and conferences on childhood apraxia of speech and has published CAS treatment efficacy research. Ms. Stoeckel is a member of the Childhood Apraxia of Speech Association’s Professional Advisory Board.)

One of the first questions that parents of a child newly diagnosed with apraxia ask, is, what can I do at home? The fact that you are asking that question and reading this article are great signs that your child will make big strides toward recovery. In my opinion, the single biggest factor in the improvement of speech for your child is your commitment and involvement.

Since you have found the Apraxia-Kids website, and are continuing to read this article, I will assume that you are more than committed, and are willing to get involved in the treatment of your child.Congratulations!Your child is very lucky to have you, as you are one of the special parents that truly want to get involved.

Communication Is the Start

Now lets get into the good stuff. What can you do at home? Well, the first thing you have to do is to help your child communicate. It is especially frustrating for a child that has good comprehension skills and understands what you are saying, but can not communicate their desires. Just imagine, if today you had no voice.What would you do? You would not let yourself be cut off from the rest of the world; you would alter your method of communication.

As an adult, you might start writing messages on paper, type them on a computer, point, sign, gesture anything to get your message across. Now think about your child. Your child doesn’t have the same skills to express himself as you have as an adult. Your child probably does, however, have one very import thing in common with you a desire to communicate. So, you will have to help him. Although this doesn’t directly help your child to speak, it will certainly go a long way towards lowering his frustration level (and yours), and help him to understand the power of communication.

The question is, how? Well, this can be done in a variety of ways. One of the simplest ways to help your child communicate is to create picture boards. The concept is simple. The child uses a board containing a number of pictures that he can point to in order to get his message across. A number of picture boards can be created with different themes. For instance, you can have a board that contains breakfast foods like: toast, juice, milk, cereal, pop-tarts. You can create a board with toys and games your child might ask for, a board for places you child likes to go, a board with facial expressions representing emotions. Anything that you might want to hear from your child is a candidate for a picture board.

These boards can be easily created.You can simply get a piece of paper or cardboard and cut pictures out of magazines that represent the things you want on the picture board. If you can’t find pictures you want in a magazine, then take a picture of the items, get them developed and use those.Or, if you want to get a little more high-tech, you can use a digital camera to take the pictures, assemble the pictures you want on the computer and print out the completed picture board.That is what I did and I involved my son in the process. He helped me pick out items to photograph and put on the picture board. We hung up a number of them on the refrigerator, the wall of our family room and other places.

A high-tech version of the picture board is an augmentative communication device. These devices are portable picture boards, that when touched actually speak. If a child touches the picture of milk, then it says milk. I don’t personally know of many people that have used these. For one, they are very expensive. In addition, many children can improve their speech without them. However, for some children augmentative communication devices are great tools for learning expressive language skills (gaining experience at how words go together in our language) AND it gives them a way to communicate with those around them. If you are considering electronic communication devices it is advisable to find a speech language pathologist who has some expertise in AAC so that you purchase the best tool for your child.

Another tool that is commonly used at home is sign language. To this day I have mixed feeling about the use of sign language.I did use limited sign language with my son, and it was beneficial. However, when beginning the process of first learning some sign and then teaching it to my son, it was both scary and kind of fun. It was scary because, just like many other parents, I kept thinking that once he learned sign he wouldnt bother speaking. On the other hand it was fun because it was a new challenge for me, and it was something that our family was learning to do together. Many experienced therapists use sign language in therapy for children with apraxia (if even for a short while) but not as a replacement for practice on their speech production skills.

Sign language did help my son by allowing us to better understand basic ideas and words he was trying to express. Later on in his development, he utilized various signs to help remind him how to make certain sounds. And studies done by people much smarter than me have shown that sign language skills do not discourage the use of the spoken word. In fact, in many cases, just the opposite occurs. Children with apraxia often times need queues to help them speak. These signs not only help them communicate, but can help them learn and hone their speech skills.

One personal comment about teaching sign language. I feel that there is a delicate balance between teaching sign language and working with your child in other ways. I am firmly convinced that sign language can be beneficial to the recovery of your child. However, teaching sign takes time. I found that with my particular child, if I worked with him in other ways, I was getting him to produce real sounds.And then real words. However, working with him on both sign language and sounds was more than he could handle.There was a point in time when I decided that my time with him should be spent on working on things that are directly impacting his speech and I dropped the sign language. Of course every child is different, and yours may be better at handling various communication methods at the same time. Experiment, and be patient. And also you hopefully are getting the advice of a good SLP who is your guide in this process.

Encourage Speech

Now that youve got him communicating, you’ve got to encourage speech.The funny thing about raising a child with apraxia is that he didn’t wake up one day unable to speak. He or she never spoke or did not speak much and therefore you and your family adapted to the situation. You created a perfect home for a child with no or limited speech. The problem is that you want your child to learn to speak, and yet he is in your home environment that has become a place where he doesn’t really need to speak! I found myself desperate to respond to my childs attempts at communication. This meant responding to grunts, screams, rants, raves, kicks, hits, claps, pointing and on and on and on. Unfortunately, what this did is encourage my son to continue this practice. And it became habit. If this sounds like you, then youve got to break the habit. Not your childs habit – yours!

No parent should take my statements to mean that we have CAUSED our children to not speak. Nor am I suggesting the tortuous practice of demanding speech from a child who is truly not capable. But we also have to understand the reality that there comes a point in time – when you have gotten helpful therapy in place – that your home environment and your expectations have to change. Hopefully, a good SLP is holding your hand in this process of changing expectations.

Working with your child doesnt necessarily mean playing therapist. It doesn’t mean that you should commit x number of hours every day for homemade speech therapy. Helping your child with speech at home is more like a way of life. You’ll need to change your thinking and change your way of life. If you can do this, then you’ll be well on your way.

There are several things you can do to change your habits and encourage speech. Your child’s therapist needs to help you understand what your child is truly capable of saying and doing and what things he isn’t capable of yet. Then one of the first things you can do is stop responding to grunts!! Does this mean ignoring your child? Absolutely not! Let me give you an example. If you child points to the refrigerator and grunts, and you know she wants more juice and you know she can use say /mah/ and /jew/ you can say something like, “oh, you want more juice?” When your child verifies that you are correct, then you might say, “then tell me more juice.” Then you model one word at a time. You say, “more” and then wait for an attempt by your child. Then you say, “juice.” Again, wait for an attempt at the word. Or perhaps your child is currently only capable of producing the word attempt simultaneously with you. Fine! As long as they understand you expect a speech attempt. Then give lots of praise!T he idea is to illicit speech, not frustrate the child.

A friend of mine’s son had very severe apraxia and she found, through the guidance of her son’s therapist, that while he couldn’t produce many sounds or words initially, he could say ooh for no and ess for yes. And so in the example above, she would ask him, “Do you want juice?” and not accept a grunt or a head nod alone as a response. She would ask him to use his voice to say NO or YES in the closest approximation he was capable of. That is where her particular child had to start because that is what he was capable of doing. No matter, her son quickly learned that she was no longer going to be satisfied with a grunt or a pointing finger. He needed to now use his voice to communicate what he could, even if not perfectly.

So it is important that you use your therapist’s guidance, your knowledge of your child, and your best judgment when it comes to accepting an attempt of a word. As the child becomes more advanced, you can hold out for a more accurate attempt. At first you may accept virtually anything.

This may sound cruel. It may sound painful, but it works. Please, please, please, do not do this to the point of frustration for your child. Use your best judgment. Yes, there is a fine line between encouragement and frustration. However, this is a very powerful tool. If you can make this a habit, you can see remarkable results. Why? Because your child will learn that a shift has occurred and will quickly realize that in order to get what he or she wants, a speech attempt will be required. In order to expedite a response to their request, they will begin to attempt speech without your encouragement. When this happens, it will be a true break through.

A Letter Day

Another fun thing to do when working with your child is have a letter day. If you are working on the /b/ sound in therapy, then why not have a /b/ day. You can have your child point out and say as many things as they can that begin with the /b/ sound. You may be surprised at how many things they and you can find. This is a fun way to practice speech with your child without them even knowing it.

Notebook Fun

Kids love to route through magazines, and cut out pictures. One of the activities that you can do at home is create a special speech notebook. You can find pictures that contain sounds your child has in their current sound inventory. Then you paste them into a notebook with your child so that you can work on saying those words. You can add to the notebook as your child’s speech improves and new sound combinations are emerging. Make sure that the pictures you are selecting are consistent with your childs ability. You may want to get your SLP and your child to help you decide on words. But this is a wonderful way for you to work with your child on a daily basis.

Repetitive Childrens Books

Books with repetitive words and phrases are also a fun way to work on speech with your child. The Apraxia-Kids website Resource section has listings of children’s book titles that fit this bill. Children love these sorts of books anyway, but you can use them for speech practice. If you understand your child’s current capabilities you can select books that use words that start with certain sounds or that include various phrases. For example, take the book Chicka-Chicka Boom Boom. Perhaps your child cannot yet use the /ch/ sound or even attempt a Chicka. Instead, maybe as they become familiar with the book they can fill in the blank when you read boom boom.Or, perhaps they are only capable of saying boo boo, oom-oom or even oooh-ooh. Whatever the child is capable of you take it and you praise it!

Games

There are lots of ways to encourage speech. It’s important to remember that you should encourage speech always. Normal games can help speech when you have them say move five before they move five spaces. Ask your child questions that elicit speech. Always think of ways to give your child an excuse to talk. Remember the picture boards? Well, they too can be used to encourage speech. You can even use them to play a form of bingo. Make a stack of cards that have the same pictures as your boards. As you pick cards, have your child identify the picture, and cover their picture board with a chip. Of course they have to say the word first. There are many things you can do. Be creative.

I’ll never forget the time my sons therapist scolded me after a therapy session. After therapy, I was putting my sons coat on. He grunted because he wanted me to zip his coat, and I did exactly what he wanted. I zipped up his coat. Well, the therapist (God bless her) reminded me that after all the time, energy and money being spent on therapy, why would I respond to a grunt. Well, after that I didn’t. I encouraged speech, and boy did that help.

Hone Their Skills

Now that youve got them speaking, you’ve got to get them speaking well. After all, the goal is clear and articulate speech, not just speech. Observing what your child does in speech therapy and consulting with their therapist is advisable. You need to fully understand just what your child is capable of doing, day-by-day and week-by-week. By understanding your child’s true capabilities, you won’t inadvertently put him in frustrating situations by asking him to do things they truly cannot do.

Remember the example above about your child wanting more juice? Well, initially for I want more juice, you may only be able to get your child to produce, Ahhh waaa mah ewe, one word at a time. Why? Because your child is not consistently capable of certain sounds yet or using those sounds at the ends or beginnings of words. And so you accept and praise their best attempt. But sooner or later, as they build some more skills, you have to start prodding and encouraging better and better articulation of the words. As an example, if you know your child can say juice clearly (you’ve heard them do it before and they do it with help from their therapist), then don’t let them get away with ewe. Again, you don’t prod to the point of total frustration. But if you know your child can clearly articulate the word, then don’t accept anything less.

It is this constant nudging and attention to speech that will get your child to improve faster than any other single thing you can do. Master this technique yourself, and your child is well on their way to mastering speech for themselves. Speech therapists can be very valuable allies and partners in helping you along this process.

Teach Your Child, Teach Your Therapist

There is a widespread misconception about the relationship between parent and therapist. Many parents feel that apraxia of speech is something that can be easily fixed by simply taking your child to therapy twice a week. I assure you, it cannot. On the other hand, many therapists feel that they are the only ones in a position to get the child to improve speech. This too is false. The best scenario for your child is to take a partnership approach with your therapist.

Therapists and their expertise is needed so that the parents clearly know what their child can do; what their child cannot do; what the starting point for therapy is; what the end point is; and what strategies and methods will get the child from start to finish. Therapists can be great teachers, guides and cheerleaders for families. Often, therapists need to gently wake up the parent to habits and practices that they perpetuate which are not helping the child. But surely, therapists and parents have to have high expectations for success.

Conclusion

My son has gone through several years of therapy and now has wonderful communication skills as well as pretty clear speech. We are now working on his r, sh, and th sounds. I’m confident well nail these this year. I’ll never forget the first Christmas my son could actually communicate. Not speak well, but at least verbally communicate. It was definitely my most memorable Christmas. Many of the things mentioned above I used with my son Trent. Does this mean this is a recipe for recovery? Of course not. All children are different. But I can say that in my experience in working with Trent, it made a huge difference. Not only in his life, but in our family’s as well.It feels great to get involved. And, when you are involved you don’t feel helpless because you’re not!

Every night before I go to bed, I stop in to give my children a kiss goodnight.On special nights, when I lean down and tell Trent goodnight, still in his sleep hell whisper back, night night Daddy. Even now, it brings a tear to my eye. By reading this, you’ve taken another step in the recovery of your child. Good luck, and God Bless.

[Tim Burns is on the board of Apraxia Kids and the father of a child diagnosed with apraxia. Tim was also the co-founder and a vice president of TechRx, the leading national pharmacy software developer.]

Over 200 parents were in attendance for the 2006 Apraxia Kids National Apraxia Parent Conference, in St. Paul, Minnesota. One very popular lecture session was “How To Help Your Child with Speech Practice At Home.” Children with apraxia of speech need many, many practice opportunities for their speech to improve and become more intelligible. Below are ideas from many parents at the conference concerning how to engage children with apraxia to do that ever difficult task of practicing speech outside of the therapy room.

Practice Ideas

• During bath time with a net of animals – say the animal name then child repeats the name and then parent says the name again. At the end of the bath, parent and child put animals in the net and say “bye-bye cat” etc.
• Playing with sibling and repeating the words together.
• My son likes to wrestle on the couch or bed and have me gently push him to trip and fall back. We work on saying a word or phrase and after he attempts it, I tip him over or wrestle with him a little. The anticipation of getting to fall down or wrestle really pushes him to try the word or phrase. This is a good way to get lots of hugs and kisses back.
• My daughter loves to play with her babies. So we frequently have “speech therapy” with her babies who have to work on their “sounds” with my daughter’s voice. Since my daughter is nonverbal, the babies also “sign.”
• Use candy and when the child says a word 5 times, he gets a treat.
• Our son has a special Rubbermaid box that has toys in it. It only comes out during our speech at home.
• Hold Oreos near eyes to encourage eye contact during speech practice.
• Older brother encourages younger child with apraxia to repeat sounds when he’s in the car seat.
• Choose a toy with many parts – child has to repeat a sound before therapist/parent gives him/her the toy part.
• Use “Express Train – Conversation Station” CD – 12+ songs.
• Play Crazy 8s – practice for saying numbers and suits.
• Cut out pictures from magazines or clip art and place them on another piece of paper (can be in a certain shape i.e. frog). Put them on the floor. The child/parent picks a number and the child walks on that many papers. The child then picks up the paper and tells something about the picture.
• We talk about what we are doing and get him to vocalize the initial sound of key words i.e., “ba” for “ball.”
• When they have words, tell stories about what they are interested in.
• Practice target words outside while shooting baskets, kicking balls, swinging.
• Play a game that requires turn taking and to clarify “you” versus “me.”
• Play memory games and we have to say the names of the things as we turn them over.
• Provide real-life opportunities. Helps with getting own juice. Must verbalize what he is doing (repetition of a task frequently executed).
• We encourage our daughter to help our son, who has apraxia, say words and phrases.
• Used music to get child active in working on animal sounds.
• If your child is musical (just seems to like music) try singing/practicing the sounds/words you want to work on with the child.
• Practice five minutes per day: Fun bags: Each bag has a target sound (starting the word). I fill the bag with objects/pictures to match. I hide the objects around the room . . . . as the child finds the object, he/she matches it to the pictures (on the table). Say the word three times as they match the object/picture. /b/ bad, /p/ bag, /m/ bag, /w/ bag.
• Play grocery store: Child allowed to buy stuffed animals (example) with target sound (example – P buys penguin, platypus, puppy, pony, etc.).
• When child was really young and would make little attempt to repeat sounds, words, etc., we would play airplane. I would lie on my back with my son’s chest/tummy on my feet while holding his arms. (We were face to face). The plane would go up for an attempt and down when he would not make an attempt. He loved being raised up and this was a motivator for him.
• Mini M&Ms. Each M&M placed on a picture. Child earns one M&M for each word attempt.
• Use magnets on back of target words to make up stories on refrigerator. These stories can be retold to dad, sibling, etc later for second practice.
• Develop important play words early such as “come,” “run,” “throw it,” “my turn,” “your turn,” and use the teacher to set up actual practice with another normally developing child.
• Use Signing Exact English to emphasize the small words, endings, etc. to draw child’s attention to words he was omitting.
• Reading books, some books have her pictures posted in them. Working on simple sentences. “I want . . . . .,” “Please help,” and “I see . . . . . . “
• In the car while we drive, see trucks, cows etc. Then prompt with “what do you see, I see a . . . . . . “
• Incorporate words into daily routines, i.e., shades “up” and lights “off.”
• Work with my son using his PECS book to tell me what he wants.
• Make a place mat with the sound of the week.
• Use a View Master and carrier phrase or predictable phrase, “I see ___”.
• Take my son to different playgrounds he automatically calls equipment by name and identified for him at other sites.
• When reading books, I intentionally leave words out of the story (after it has been read several times) to encourage my son to “fill in the blank.”
• Create a picture book of words.
• Cell phone – practice calling and talking to people.
• Use carrier phrase from book: “When You’re Happy and You Know It”
• My son can say “pen” in reference to writing utensil but flounders over “open.” So I hold up a pen at the end of the word to give him a visual cue (and also a big round “o” with my mouth for “o” – pen.
• Make phone calls to grandparents, dad @ work and let them have a turn (great to use if older siblings go first) speaking/talking every call. Get an old cell phone for them to use to pretend at other times. This activity as beginning and ending, they see an example/model and they are motivated (talk to dad) in normal environment.
• Use grocery ad pictures to make magnets for the fridge so she can pick out a picture of what she wants. It is like a homemade PECS system.
• My son likes to play on the glider on his swing set. We catch and hold the glider up until he attempts the “magic word” for that day and then he is rewarded with our giving the glider a push to make it go higher. This can be repeated several times during 10 minutes on the glider.
• Wordsmart CD. Five-set CD cartoon based. Has some good visuals on how to make various sounds and words.
• Use signing for something he wants. He likes popcorn and work on the sound “pop” as we sign “popcorn.”
• In the morning working with her on puzzles and her words and sounds. Having her use any sounds in identifying shapes, colors, objects.
• Throwing a ball, going down the slide, or pushing the swing and have my child say “ba” or “da” each time.
• We bake cookies, and she helps with the ingredients. I have her say the words before we add to mix.
• Play card games such as Old Maid. Have her say her matches when she gets one.
• Our son loves the alphabet and we let him come up with a word that corresponds with the letter. We draw the word he says (i.e. A – apple) and then he repeats it.
• We read books together. She will repeat the words. She also will look at pictures and tell me what they are.
• Go to beach, playground. Do things that are fun and work on sounds that apply. Sand, ocean, waves, swim, slide, swing, etc.
• When working on multisyllable words, I (the parent) breakdown the word and have my son repeat each syllable for me. Then at the end, I say “now put it together.”
• Practice ten repetitions to get what you want (Playstation). Incorporating it into play (role playing with Barbies, animals).
• While doing everyday things if he wants something and cannot say the word, I use the opportunity to practice. This approach helps because it is not so structured and he is rewarded with whatever it was he wanted.
• My son is 6 years old so I use books to help work on sounds and reading words. It keeps him positive and he feels great that he read a book. (These are small, one sentence booklets).
• Practice speech with my child while he is on the swing, balance ball, etc., so he is moving (being active) and practicing speech.
• Playing Caribous or Uno to work on conversational speech.
• Using the alphabet sponge letters w/paint. Practice “buh buh buh” for B; “duh duh duh” for D while she presses the letter to the paper.
• Playground – sports and balls. Use gross motor play to practice “game” language – “push, oops, my turn, your turn, yeah, great job, throw.”
• I ask lot of questions about everything he eats/plays with. (i.e. Ice cream: “Is it white or purple? Is it hot or cold? Is it wet or dry” Is it yummy or yucky? Do you put it in your mouth or ear?”) Lots of laughter and speech.
• Playing Go Fish or Memory with target words.
• My son loves Thomas the Train. Each time he would attempt to say train or track or the name of the train – he would get another train or track. We would have it built when we were done.
• Elefun game – turn on, big nose, up up up, down down down, colors. Blowing bubbles – pop pop pop.
• Playing with trains, cars, and airplanes – practice making sounds that they make and say what they are.
• My daughter is practicing the “s” sound. She trails her finger from my elbow to my hand while saying ‘sssss” sound (like a snake). I catch her snake in my hand. We do this 10 times a night while settling for bedtime.
• I take a box or ice cream pail with a cover and cut a slit on top and the child gets to put the word or poker chip in the box/pail after they say target word/sound.
• Photo books of real life experiences (zoo, rodeo) – cloze activities.
• I play with my grandson with his Disney figures with a pirate ship, playhouse, cars, and pretend they have a party, go for rides in the little cars and go “in” and “out” doors of playhouse or garage. We use words to name and describe what we play with.
• Play Monopoly and say the numbers and she counts. Reading and have her fill the word on simple words.
• After he repeats a word or phrase three times, he bowls his super heroes over. We set them up like bowling pins and bowl them over with a ball.
• I have him catch me doing speech errors.
• Use cards and slide under a door to another person as soon as utterances or verbal goal is met.
• Easy button (from Staples) as an instant reinforcer.
• Building a puzzle, piece by piece, after repeating, initializing, or spontaneously using the correct sounds or words.
• Make up “silly” sentences using a series of cards spread out on the floor. (working on sentences).
• Word bingo with Cheerios.
• Integrate sounds into a song (old Macdonald, wheels on the bus)
• Popsicles – my son has to say “pop” to get a taste. It’s the only time he gets to eat popsicles, when we are practicing.
• Race car truck. Roll the dice. Say a word or sound that many times and race to the finish.
• Writing stories to go along with a picture and then saying the words and practicing the sounds. Making up songs. (first grader)
• Sequencing. Dress a snowman. First – show complete snowman – made by an adult. Then – make small parts hold by adults face. Then – hold second part (near face to get eye contact). Finally, complete the snowman – put all three parts together then put together facial parts. Choose target words you are working on. Practice putting three to four cards together then depict making a snowman. Practice dressing the snowman and share the snowman story.
• Incorporate the youngest child into the activity that is happening with the oldest ones activity. Make it a family effort.
• My son gets to lick a lollipop in between repetitions of his words. Five words then a lick. He knows he has to put it down when it is time to work. Sticky but it works.
• Match target sound with appropriate toy – “jump” while moving action figure.

For most of us, and especially for children with severe speech production disorders, risk taking requires trusting that the situation or person to whom we are communicating is safe and predictable. It also generally requires that the effort be worth the risk. If these conditions are met most children will attempt to use what speech or communication they have to interact. The major issue, however, is how to create this environment? One proposition is the creation of boundaries. Boundaries, in this context, refer to the physical, mental, and emotional conditions that surround the child and are based upon realistic expectations for performance.

As a parent, it is difficult to always recognize that providing consistent boundaries and expectations for our child is a “good” thing to do. Especially for children with limited or unintelligible speech, we often feel the need to protect them from becoming frustrated. Often for parents, feelings of responsibility for the childs disability make them want to “do” for the child and keep them safe. Unfortunately, in order to take risks in oral communication, the child must venture out, must experience “controlled” frustration, and must realize that when communicating there are “rules and consequences.” It is reasonable to expect that a child use what they can produce in oral communication interactions. Even if this means using a vowel sound to get attention or to answer a simple question such as “Do you want this?” Simple speech productions can be used and shaped very effectively to interact or respond. The following ideas are presented to stimulate thinking and discussion of boundaries. The use of boundaries should be considered positive and, when implemented with a full understanding of the childs ability levels, provide a safe way to begin risk-taking.

A parent, caregiver or clinician may begin to create realistic boundaries by helping the child:

Learn that daily life routines have predictable sequences, and that these sequences, have outcomes or results. For example, something as simple as putting on a shoe has a sequence and within the sequence the child may need the parents help. If the parent does not put on the shoe, but waits until the child looks at them and then asks the child if they want help, there is an opportunity created for the child to use even a simple vowel /a/ for acknowledgement or to use the syllable /ya/. If the child does not immediately answer, the parent may tell them to say /a/ or yes and then proceed to put on the shoe. This way the child is learning that, in order to get something they want, they must interact and use something they have.

Learn what behaviors, within these events; will lead to successful outcomes or interactions. As stated above, using their voice or what speech they have, will lead to a successful outcome, e.g., getting the shoe put on. However, as children acquire more accurate speech-motor skill, they need to be asked for longer productions. For example, where a simple /ya/ may have sufficed before, now “more shoe”, “shoe on”, “mom shoe on”, or “put my shoe on” would be expected. The child, depending on their ability level, should be slightly challenged.

Understand what unsuccessful actions will lead to, in other words, results that do not produce the intended outcome that the child desires. Here, the child would learn that they would not get the help they wanted or that the shoe did not get put on. Obviously parents must make decisions about what aspects of a childs behavior they can use for these purposes. If, for example, the child does not like having their shoes on, then not getting help will not be reinforcing. They may be quite happy not using any speech because they are already getting what they want. It is important that the parent recognize what events are essential and reinforcing to the child and use these especially when beginning.

In order to reinforce these realistic boundaries and provide the support that will lead to trust and risk-taking the parent or caregiver should:

• Determine (with their speech and language clinician) what speech productions are usable and how these can be combined to produce the most functional and interactive communication.
• Choose routines, or activities of daily living (as above) or games that will allow the child to interact using these sounds, syllables or words.
• Determine the rules to be followed (or the number or steps) within the activities, routines or games that are expected from the child. In other words, set a limit on the number of things the child must do to complete the task. Make sure they know how many turns or words they have to say before the task is over. In younger children, or with more severe speech disorders, make the number of turns or responses few.
• Create situations in the home (or school) environment that provide the child with multiple opportunities to use their sounds, syllables or words with familiar and unfamiliar people for communication, e.g., asking for something, saying no or yes to something, saying hello to someone, calling attention to themselves, etc.
• Provide positive reinforcement when the child uses their speech to interact. Again, make sure that the consequences, for the child using speech, are rewarding and actually lead to something the child considers fun or important.

Finally the main goal of oral communication should always be to increase the childs competence and feelings of self-worth. When the above steps are considered and implemented the child will find safety in clear expectations and a reason to communicate that is well worth the effort.

[Deborah Hayden, M.A., CCC-SLP, SL-P(C), Reg. CASLPO, is the Founder and Executive Director of The PROMPT Institute (https://www.promptinstitute.com) and an Adjunct Specialist in the Department of Audiology and Speech Sciences at Michigan State University. Her research has been in the field of childhood and adult speech production disorders; phonology, hearing impairment, dysarthria and apraxia. She founded the PROMPT Institute for the purposes of treatment, training and research in speech production disorders. Her current research efforts have been directed towards norming and publishing the VMPAC (Verbal Motor Production Assessment for Children), now available through The Psychological Corporation, and VMPAA (Verbal Motor Production Assessment for Adults) with colleague Dr. Paula Square. She is also a co-author of the EMCS (Early Motor Control Scales). Deborah has published extensively and has presented internationally at workshops and conferences both in United States, Canada, Australia, and Hong Kong. In addition, she is a member of Apraxia Kids’s Professional Advisory Board.]