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Speech Therapy

A Primer

Published | By
Ellen Councill, M.Sc., CCC-SLP

Speech and Language Terms or “Speech Therapy 101”

As a rule, most people use the terms Speech and Language interchangeably. In fact, these two areas are very distinct categories, both developmentally and neurologically. “Speech” refers to the mechanics of talking and includes the movement of tongue, lip, cheek, throat, and upper body muscles to produce the sounds needed for talking. “Speech” also includes elements of breath used for talking as well as the mechanics of voice or vocal production. “Language,” on the other hand, refers to the higher cortical functions such as the words, the sentence length and construction, and the ideas which are both understood (“receptive language”) and expressed (“expressive language”).

In more detail, “receptive language” includes the words, directions, sentences, and sequences of ideas which a child is able to understand. “Auditory processing skills” describe the processes used to organize incoming (receptive) verbal or nonverbal auditory information: auditory discrimination between sounds, auditory memory, auditory perception, auditory synthesis, and auditory figure-ground. Difficulty with processing auditory information may be manifested by:

  • confusion in sounds/words heard
  • requesting frequent repetitions
  • inappropriate or lack of response to questions
  • hyper or hyposensitivity to extraneous or loud sounds

It may also include confusion in the sequence of sounds, words, and steps in a task when presented verbally. While it is true that young children at risk for auditory processing deficits are those who fail to develop language skills normally, or those children who have experienced repeated middle ear pathology during the language learning years, not all children with either of these profiles goes on to develop auditory processing difficulties.

“Expressive Language” is the linguistic information which a child is able to formulate or encode. It includes the vocabulary they use when they speak meaningful, relevant words, sequences of ideas, and syntax.

Early first gestures are extremely important in the development of expressive language and may include:

  • pointing
  • arms up
  • tugging
  • waving
  • all done
  • reaching
  • facial expressions

Receptive and expressive language skills also include a childs social use of language: do they ask developmentally appropriate questions, do they respond to questions, make requests, greet, protest? Do they interact well with peers? Do they take turns – both during game playing and conversational turns – appropriately for their age? This arena of language use is frequently referred to as “pragmatics.” Many children with apraxia demonstrate delays in this area of language development. These delays are sometimes, but not always, secondary to their speech delay (and resulting reduced opportunities for interacting with peers.)

How Important or Necessary is Language Therapy for Children with Motor Planning Issues?

Traditionally, apraxia has been considered a “speech,” not a “language” deficit. While it may be true that some children with apraxia have extensive language delays or disorders in addition to their apraxia, some children demonstrate delays in their language skills due to their limited opportunities to build their language through interaction. Whatever the reason a child may have a language delay or disorder, the ability to formulate (expressive) and to understand (receptive) language are inextricably related to motor planning skills. When children have limited language skills, and difficulties efficiently processing auditory, linguistic information or other sensory input, their pragmatic, or interactive/social skills, are effectively reduced.

Many children with delays in their language skills have splinter skills in the area of visual development, rhythm or musical development, perception of environmental detail, or memory for patterns (such as letters or number). [“Splinter” refers to skills which are much more developed than their delayed skills.] It is important to tease apart these strengths, use them during play and capitalize on them in order to optimize each child’s learning skills and perception of themselves as apt learners.

Language is symbolic. In order to achieve adequate symbolic thinking necessary for language development, it is important to make sure your child has opportunities for two primary activities: interaction and play. These activities act as catalysts for spontaneous language development. During play you are laying the foundational skills for more sophisticated, higher level use of language including sequencing, making predictions, expressing “why” something happened, reasoning and abstract thinking skills, making inferences, and problem solving.

I am a strong advocate of “pretend, interactive play” for the purpose of achieving these goals in young (ages 2-5) children. For children whose interaction is still at the gestural/preverbal stage, we have tremendous impact on their ability to think symbolically by playing with them. When a child is verbal (using words to communicate), the use of pretend, interactive play will readily address linguistic goals related to many other aspects of vocabulary and syntactic development, in addition to increasing their symbolic thinking and problem solving skills. Objects such as small people or action figures, animals, dollhouses and/or small furniture, pretend food, cars, trucks, roads, etc. facilitate pretend play.

When we nurture language and interactive skills, our children have a much better prognosis for progressing socially. At the same time, speech attempts become less “motor planned” and more automatic. For this reason, playing with your child, and arranging “play-dates” with age or developmentally matched peers, are essential parts of his therapy program. This important component of therapy is frequently understated in clinical recommendations.

Primary goals directed toward encompassing ALL of the needs of young children are necessary in order to realize gains in both speech and language skills. Goals directed toward rigorous systematic drill in order to directly address the motor planning component of speech production are important to insure isolated skill development. SLPs are trained extensively in behavioral methods, which facilitates the practice needed for rote production of difficult to access speech sounds and for sequencing those sounds into words. Frequently, this model is used to the exclusion of less formal interactive language goals. Less formal, interactive goals are particularly crucial for children under age 5. Usually around ages 4 – 7 children are more equipped to learn important language goals in more structured contexts using behavioral methods.

Goals which are directed toward enhancing expressive skills such as vocabulary development, word combining (syntax), and facilitating receptive skills such as understanding of various linguistic concepts, vocabulary, syntax, and following directions, are part of every plan to successfully achieve important language skills regardless of the method used.

In addition to addressing fundamental expressive and receptive language skills, it is important to include goals which relate to pragmatic issues, insuring that a child continues to increase his “dialogue” capabilities even though he may not be using words effectively. Or, when he is using words, dialogue skills will foster his development of higher level language skills. Increasing these skills insures maximizing the development of higher level language skills (problem solving, predicting outcomes, and making inferences).

When a child is able to complete only one or two circles of communication – with words or with gestures – then his ability to progress to the next interactive milestone is stifled.

Interactive Milestones

There are five interactive milestones which a child progresses through in order to achieve optimal problem solving skills*:

  1. Attention and Engagement – Usually in the first four months of life, the baby learns to look, listen, attend, and also to experience pleasure and comfort, dependency and warmth with the care giver. But it is important to look for this core process in two and three year old children as well. For instance, it is possible that for some children, difficulty sleeping or certain behavioral issues (not listening to directions or being aggressive) may relate to the difficulties in the proper negotiation of attention and engagement.
  2. Two Way Communication – Normally, between four and eight months, babies are learning how to go beyond a simple state of connectedness and shared attention into a state of cause-and-effect interaction. At this point there should be an emotional, social and intellectual dialogue going on, in addition to a motor dialogue and a sensory dialogue, between the “listener” or care giver and the baby. Is this dialogue now “cooking,” is there a two way communication? [This “dialogue” does not refer to spoken words; it can be gestures including pointing, requesting with facial expressions and sounds, giving and taking toys. This process is referred to as interaction even though true words may not be used.]
  3. Shared Meanings – The third core process involves the level of shared meanings, when, by 18 – 24 months, the baby is learning to use representations (symbols) to comprehend his or her world. At this level we see pretend play, phrases (“more juice”, “go bye-bye”). Whenever words convey intentionality or play involves representations or symbols that have emotional themes or content the child is into this third level of shared meanings. A child who does well at the early level of engagement and has two way gestural communication may have a problem at this higher level.
  4. Emotional Thinking – The fourth process is representational differentiation, or emotional thinking. From about ages two and a half or three to about four and a half to five hears of age, children learn to categorize shared meanings. They categorize units of thought or ideas into configurations. They see connections between images or representations or symbols. They can categorize dimensions of time – what is now, what is in the future, what is in the immediate past. This ability is critical for limit setting and impulse control. To be able to conceptualize a sense of space and distance and to define what is me and what is not-me what is inside me and what is outside me (a child’s basic boundary).

These levels each require a progression of language development which, without, children are limited in their ability to motor plan longer and longer sound sequences, because their conceptual framework of interaction and communication is stuck. Language is sequential. We learn our first sequences by taking turns in communication. In the absence of this skill, learning to sequence sounds into words, string words together into sentences, and sentences into stories is very inefficient. The skill of sequencing is not available to the child to use spontaneously even though they have the motor plan in a drill.

Rather than focusing exclusively on the motor plan, it is important to also have goals which relate to the development of communication, interaction. By addressing “topics” of conversation during play which are at the level of interest to engage a child, then they will have the opportunity to develop more basic language skills (vocabulary, word combining) and more sophisticated language skills (pragmatics, problem solving, answering and asking questions). If we do not attend to their interests, then their attention to us will be limited to directives and confrontational prompting (“Johnny, say ‘I want juice’”). If we are going to use behavioral management strategies to teach speech sound production and words, we also need time to engage in interactive play activities. These activities need to be ones which are interesting to your child and, as often as possible, in a context which will help them to use their new speech skills and realize their automatic speech. Speech which a child initiates, that magical, spontaneous speech that we are always looking for as a target of our prompts and directives, is elicited in a play environment. More importantly, the groundwork for motivating interaction is being laid.

Behavioral programs and language learning are more efficient when they are balanced with play and interactive time together.

Definitions: Speech and Language

Following are definitions which are useful in understanding children with motor planning disorders.

TWO WAY COMMUNICATION
The process of opening and closing circles of communication. When the mother, father, or therapist takes an interest in the child the first circle of communication is opened. When the child responds, the child is closing the circle, and when the parent responds in turn, he or she is opening another circle. When the child responds again, he or she has closed a second circle. A circle of communication involves following the child’s lead with interest and responding in some way and the child then responds to the parental initiative. [Greenspan, Infancy and Early Childhood, International Universities Press, 1994]

A CIRCLE OF COMMUNICATION involves following the child’s lead with interest and responding in some way and the child then responds to the parental initiative. [Greenspan, Infancy and Early Childhood, International Universities Press, 1994]

SENSORY INFORMATION: information which comes in through the senses and includes:

  • Vestibular information (sense of gravity and sense of your body in motion)
  • Auditory information- (hearing)
  • Proprioceptive information – (muscle and joint)
  • Visual information – (seeing)
  • Tactile information – (touch)

SENSORY INTEGRATION is the way our brain organizes and synthesizes sensory information.

MOTOR ACTS (or the absence of motor acts) are a manifestation of how we process sensory information. For example, closing our eyes ( a motor act) results when visual stimulation (sensory input) is excessive. Turning away (a motor act) from a sound source (sensory input) is a “adaptive” response some children exhibit when they do not efficiently process auditory input.

MOTOR PLANNING is the highest and most complex form of function in children. It involves conscious attention and depends on complex sensory integration throughout the brain stem and cerebral hemispheres. Brain tells muscles what to do but the sensations from the body enable the brain to do the telling. (Jean Ayres; “Sensory Integration and the Young Child”)

A motor plan is a higher cortical function; this is going to be slower if the incoming information is disorganized. MOTOR PLANNING is the first step in learning skills. A child must have sensory integration skills in tact to motor plan efficiently.

Motor planned speech is speech which a child understands, but finds it difficult to motor plan when “confronted” with the task, as in a direct question. Motor planning-free speech: these same words may be easy to elicit in a play, interactive situation in which “automatic” or “spontaneous” speech is being elicited.

Important Concepts in Creating a Conceptual Framework for Motor Planning Disorders:

In order to have a “skill” (like tying a shoe, or typing or, for some children, use of words) you must motor plan it over and over again until your system has organized it in a way that makes it automatic.

A skill is a task we initially had to motor plan but now we can do spontaneously (remember learning to ride a bike?); children with interactive difficulties miss out on the interaction and thus, opportunities to motor plan are reduced and skills which require a lot of rehearsal to become automatic do not occur. Conversations which other children easily experience are not easy for children with apraxia because they are working, first, to organize routine sensory input in order to engage in routine interaction. What do we do, then? Facilitating nonverbal “topics” your child wants to talk about is a first step. Talking in this context does not necessary mean the use of words. A dialogue, or conversation can be about anything a child is willing to take turns doing. [“Anything” as long as it doesn’t hurt them or the listener.] Initially, we are not looking for socially appropriate play. Socially appropriate play is taught subsequent to engaging the attention of a mutually shared game (pushing a truck back and forth, chasing games, etc.)

In order to motor plan a skill: The best motor planning happens when senses are integrating efficiently; when children with sensory integration difficulties are fully engaged with another person, in an activity of their choice, they skip the motor-planning component and move right into the skill use of their language. Their spontaneity increases significantly.

Spontaneous Language – Language which is used by internally driven motivation and shared interest. Words which are generated when the system is more fully integrated, and the learner is choosing rather than being compelled to speak achieves two primary goals:

  1. In our normal day-to-day interactions with our children, we use words for many reasons. One of the ways that we relate to our children includes all of the “maintenance” messages we give to them : “time to go,” “time to get your shoes and socks on,” “drink juice,” “time for bed,” “don’t do that,” “please give it to me,” etc., etc. Another way that we use words to communicate is to have fun, interact because it is wonderful to be with our children, play, describe, etc. Words which are used to communicate in this way encourage children to grow in a very different way that the cues we give them in a Stimulus – Response paradigm (for example, when we say to a child, “Say ‘more juice’ ” or “Say ‘I want cookie’”) . When children use words to communicate during a playful interaction, they are achieving milestones important for their continued development of interactive skills.
  2. This also sets a child up to enjoy interacting: “Wow. Somebody likes what I like. Someone is experiencing what I experience.” This limbic connection allows us to move forward and try more things, enjoy other people, discover what has, before, been uncomfortable because it was too new. If we skip the steps of being integrated and using emotionally based decisions to communicate, then the language a child uses will need to be learned entirely by rote, and, for some children, this language will do little to foster motivation to communicate except on command.
  3. When the prompts are absent, words used are primarily symbolic with the intent to share common meaning through interaction. Incidentally, we do not need “words” to interact! Communication can happen through sound making, taking turns building with Duplos, chasing games, etc.

Goals and Short Term Objectives

Goal areas and short term objectives which will be updated periodically and which may be considered relevant in addition to systematic drill which addresses oral motor movement and sound production are included below. Specific information about development levels will be determined individually by your SLP.

      1. Goal: To increase circles of communication during play
        Short term objectives may include:

        • Moving from gestural to verbal interaction
        • Increasing the frequency of interaction
        • Increasing the duration of the interaction
        • Increasing the variety (“topic”)/content of the interaction
      2. Goal: To increase expressive language skills
        Short term objectives may include:

        • Increasing use of labels, word combining skills/syntax,
        • prepositions, action words, use of “WH” questions
      3. Goal: To increase receptive language skills
        Short term objectives may be related to:

        • Increasing vocabulary (including labels, actions, location or preposition words) that a child understands, appropriate response to questions, following directions appropriately
      4. Goal: To increase pragmatic skills
        Short term objectives may be directed toward:

        • Increasing turn taking abilities, establishing the skill of “greeting” (Hi!, Bye-Bye!), establishing a framework for “planning” ways of responding to frustration with peers.

About the Author:
Ellen L. Councill, M.Sc., CCC-SLP
Speech/Language Pathologist
Piedmont Speech Services
1111 Rose Hill Drive Suite 5
Charlottesville, VA 22903
e-mail: edufun@comclin.net

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (CASANA)
www.apraxia-kids.org