Therapy Tip: When is a Language Delay Something More?

Welcome to the Therapy Thursday on the blog! This is the day that I share a tip based upon my experiences as a pediatric speech-language pathologist and the mother of a child with special needs. Today's tip is:

When is a Language Delay a Sign of Something More? 

Last week, I wrote about factors that may contribute to a language delay. (If you missed it, click here.) From that, you know that there are many things that come into play that may contribute to a child having a language delay. As discussed, some children will make progress in therapy and eventually be discharged. Other children have underlying issues going on that will require intervention for years to come.

When your child is 2 years old and you're a worried parent, how do you know when a language delay is just late talking and when is it a sign of something else?

To answer this question, let's talk about red flags. Red flags in the therapy world are characteristics that may signal an underlying condition that has not yet been identified or diagnosed. When a child has red flags, it may indicate that something else is going on other than just a delay in language. There are many red flags I could discuss, but I'll go over just a few today. Here are some things I look for when working with toddlers in speech therapy that may indicate something more than just a language delay:

-Slow to no progress in therapy: Speech therapy is usually not a quick and magical fix for most kids. Change takes place slowly over time. If a child has been in speech therapy for 6 months, then I should see some progress. The progress will look different for every child because each toddler is starting out at a different point developmentally. However, at the six month mark, a child who has made little to no progress is a red flag for me. If we started out with one word, and still have one word six months later, then that's a huge red flag. Again, it's difficult to explain what constitutes as slow versus adequate progress in therapy because all children are starting with a different set of skills. A therapist who has been in her professional for a number of years will be able to make that judgment based upon experience. Don't be afraid to ask your child's therapist if their progress seems expected or slow. But slow-no progress is a red flag.

-Difficult to engage in therapy: There are some children who after just a week or two of therapy get excited to see me and want to see what activities we will do. They plopped down on the floor and are ready to start the session. This tells me that they are socially interested in me, have discovered our routine, and desire to play with toys. These are the responses I look for after I come for home visits for a month or two.

There are a few children who don't seem to acknowledge that I am there or notice my arrival despite our weekly sessions for months. There are some children that notice me but don't care. Little to no eye contact during activities may happen as well. All of these responses are atypical. On the flip side, a child who is excited about therapy but will only sit for a minute or two despite a few months of therapy is also atypical.

When I bring up concerns about poor engagement in therapy, parents are usually quick to remind me that their child is just 2. I understand that. I also have over 10 years experience with two year olds. I know when a 2 year old is acting like a 2 year old or having a bad day versus a child who is consistently showing poor engagement. If a child is never wanting to engage with me, that's a red flag. If I have to "work" to keep their attention, that's also atypical.

-Delayed gesture development: Poor use of gestures is another red flag. If a child is not talking, then I always want to know about what types of gestures and nonverbal communication the child uses. Pointing and waving are important early gestures that toddlers need to communicate a variety of functions. Nonverbal communication like leading an adult to a desired object or bringing a cup to an adult to indicate thirst show attempts that the child is trying communicate. The fewer the gestures and nonverbal communication, the more concerned I am that something else is going on besides just a language delay.

-Poor imitation: Poor imitation comes in many forms. There can be poor word imitation, which would be expected when speech therapy first starts. Eventually though, the child should start to imitate words. There can also be poor play imitation. If I show a child how to push a train around a track, then I expect the toddler to imitate it. If a child can't imitate actions that I do, motions to songs, or play movements, then this is a red flag. Again, this is something that I don't expect immediately when therapy starts but it should come fairly soon after some intervention starts.

If I have a child on my caseload who is having red flags, then generally I will make a referral to a developmental pediatrician or speak with the child's physician. They might diagnose a child with a developmental delay, autism, or run further medical tests. If I feel the language delay may be a specific speech disorder (i.e. childhood apraxia of speech), then I may decide the child needs more intensive tests performed by me.

The most important thing a parent can do if you see some of these red flags is to ask your child's therapist about them. Open communication is key in these situations. If you are getting no where with your child's speech therapist, then talk to your child's pediatrician or get a second opinion with a different speech-language pathologist.

Therapy Thursday is for educational purposes only and not intended as therapeutic advice.

I'm OK with My Child in Special Education

My sweet little girl with Down syndrome steps inside her classroom. Jaycee retrieves her folder from her backpack before hanging it up. Jaycee walks to her little basket containing basic toiletries to work on self-help skills. She brushes her teeth, brushes her hair, applies deodorant, and washes her face all on her own. She takes her seat in her desk ready to start her day at school.

In a typical day, Jaycee will have reading, spelling, writing, computers, social studies, and math. She has a full day, but it is a day tailored to her. The majority of her day is spent in a self-contained special education room specifically for children with (what I would consider) severe language and/or speech delays. Jaycee is now on her sixth year in this classroom that individualizes work on each child's level while trying to develop communication skills.

But, let's go back to the beginning. Jaycee started school the day she turned 3. Her first class was an early childhood classroom, which was a small class composed of children with developmental delays or diagnoses associated with delays/educational needs.

An Adorable Jaycee in Pre-school Stuck in a Classmate's Stander

It was not easy sending my very tiny and nonverbal three year old to school. The only comforting thing for me was her placement in the early childhood (EC) classroom. I liked the idea of a smaller classroom even if it meant that her classmates all had some sort of diagnosis.

I never second guessed her placement. Jaycee had about 5 spoken words at that time but was a proficient signer. She didn't understand safety and would run off without warning. She was not potty trained and wouldn't be until age 5. Jaycee was extremely delayed in her fine and gross motor skills as well. As a speech-language pathologist, I had worked in this very school the two years prior to having Jaycee. I knew what was expected from each child in the classrooms. I knew that the best fit for Jaycee would be the EC room.

A few months after she was an EC student, I was chatting with another parent of a child with a disability that was in another school district. She was very surprised I had consented to Jaycee being in an EC classroom. When I told her that I didn't have a problem with the placement, the mom assured me Jaycee needed to be with typically developing peers. When I explained that Jaycee was very, very, very delayed compared to her peers, the mom responded that Jaycee could probably be in that regular classroom with an aide. I really didn't see the need to put a Jaycee in a classroom that was significantly above her abilities just to be with typically developing peers when there was a perfectly fine specialized and individualized classroom with a teacher trained to help a child like my own.

After that conversation, I realized my choice wouldn't be favored among some. I got that mom's perspective. I really did. But, I wished she would have stopped to listen to mine. Every child with a disability or diagnosis is different, and that's why there's education laws.

The Individuals with Disabilities Education Act (IDEA) here in America requires that children with disabilities receive the level of education they needed in the environment that is least restrictive, which is referred to as LRE. The principle behind LRE is that the child with the disability should spend as much time as appropriate with peers who do not receive special education.

The placement of a child is a case-by-case decision. A diagnosis does not mean that a child will be automatically placed into a special education room. School districts should not be placing all children with Down syndrome, for example, in a self-contained room on the basis of their diagnosis alone. Conversely, a child with a disability is not automatically assumed to need to be in the general education classroom. There are many factors to consider when deciding where a child should be placed and what level of support a child needs.

I'll be honest and say that Jaycee has always been in a very restrictive environment, but it's been the right one for her. She has always spent most of school day in a special education setting of some type. That being said, she has always had opportunities to be around peers during recess, physical education, lunch, class parties, music class, and library time. Everyone in her class knows her, and she has friends in the regular education room. Her time in a separate classroom has not isolated her from developing positive social relationships. More importantly, she has developed friendships with other students in her special education room.

Being in a special education classroom has not been detrimental to my child. Some parents I talk to fear that if their child is placed in a setting similar to Jaycee's that their child will not develop friendships, they will be isolated, they won't be challenged, they won't have good peer modeling, and that they will learn "bad" behaviors from the other students with disabilities. I get all of those concerns, but I have been more than happy with the attention and teaching my child has received in her special education classroom.

It's important to remember that there is no ONE single answer for placement for ALL children with disabilities. This has been the path and the decisions we have made for our child, and it seems to be working. That's why I'm ok with my child being in special education.

Therapy Tip: Alternatives to Sippy Cups

It's therapy Thursday! Hooray!
This is the day that I share a tip based upon my experiences as a pediatric speech-language pathologist and a parent of a child with a disability. Today's tip is:

Alternatives to Sippy Cups

After bottles, most parents offer their child sippy cups. Sippy cups are often a favored choice by parents for many reasons with the main one being that they avoid spills and leaks. But, they aren't favored by specialists like me.

But, hang on! I am a realist. I understand that sippy cups have their uses. For a child who is traveling or tends to throw things, a sippy cup is helpful. I'm not a total anti-sippy cup person, but there's something you need to know about these handy cups.

Sippy cups are not always the best for babies and toddlers who are already in speech therapy or have delays in development. When a baby is drinking from a bottle, the baby uses a suckle-swallow pattern to drink. The tongue is kept in a forward, low position to drink. A sippy cup essentially follows that same pattern. It encourages the tongue to stay in a low, forward position.

For children with low muscle tone or diagnoses such as Down syndrome, the sippy cup encourages the very thing (tongue forward position) that speech-language pathologist often are trying to discourage.

For these reasons, many therapists will offer alternatives to sippy cups. These alternatives do a few things. They encourage the toddler's tongue to retract and have more elevated movements.

A straw cup or an ordinary open cup are ideal alternatives to sippy cups that are easily found. Not every child has the motor abilities to drink from a straw or an open cup successfully. Therefore, I'm going to share some cups I have used with toddlers in my therapy practice. Below are cups that I have personally used. These cups are temporary tools to teach straw or open cup drinking. These are generally not needed long term because they are used simply to teach the drinking method to the small child. Some children work with one of these cups for a few weeks before moving on while others need more time to learn where their lips and tongue should go to drink successfully.

Reflo Cup
I found this cup this year and have started trialing it with some of the children I see in therapy. I really like this product! The cup basically has this special valve inserted inside their otherwise open cup. It slows the rate of which the water comes out of the cup. This is a great way to teach open cup drinking while the child learns how to tip a regular open cup and control the water flow rate. The top of the cup is just like an ordinary cup, which requires lip closure and tongue retraction in order to be successful.

The Honey Bear
The Honey Bear has become a staple item in my therapy practice. This is the cup I use to teach a child to drink from a straw when a child has absolutely no concept of straw drinking. I can gently squeeze this cup to assist in bringing the liquid up and in the child's mouth. You can achieve a similar effect using a standard juice box. However if a thin liquid comes out to quickly, I can put applesauce in the honey bear cup in order to teach the child to straw drink. I have used the Honey Bear multiple times to help children learn to straw drink.

Infa Trainer Cup
This cup is similar to the Reflo cup but with some differences. It slows the liquid before it comes out so that it can more easily by managed by toddlers learning to drink. By simply twisting the lid, the flow rate can be changed to a higher or lower rate. There are three flow rates to choose from. This does have a spill resistant design, so that is a plus with this cup. The children I have worked with generally have more trouble learning open cup drinking with this cup because of the spouted opening, but I still think it's a good option for some.

Recessed Lid Cup
This cup has a very simple design. The lid of the cup is, as it's name suggests, recessed. Therefore, this cup can be used for open cup training, but it can also accommodate a straw too. I like this cup because the lid is recessed, which makes the lips close on the cup as if it were a regular open cup. The flow rate is reduced by the small holes in the lid. This cup also provides handles, which is more helpful for some children. This can be another great option for children who need the water to flow out of the cup more slowly to open cup drink.



There are many widely available alternatives to sippy cups. When a child just can't simply do a straw cup or an open cup, these are some great options for training. Determining which cup is more appropriate requires one to look at what is hindering the child's progress. Your child's therapist should be able to help guide you through this process if you have trouble deciding which one to try. One of these cups could be a key to your child's progress, so don't be afraid to give one a try.

Therapy Thursday is for educational purposes only and not intended as therapeutic advice. Please consult your child's speech-language pathologist if you want specifics on how to use these cups. 

Therapy Tip: To Sign or Not to Sign

Welcome to Therapy Thursday! This is the day I share a tip based upon my experience as a pediatric speech-language pathologist and a mother of a child with special needs.

Today's tip is:

To Use Sign Language or Not To Use Sign Language

Sign language is sometimes brought up in my work with toddlers with language delays. Parents seem to have different points of view on the subject.

Some parents are interested in learning sign language to help their toddler who is not yet speaking. They see sign language as a temporary tool that can help their child communicate. These parents seem to understand that sign language allows a child to learn to express a word in sign and use it meaningfully. This is opposed to a child who merely grunts and points at random to mean a variety of things. The message becomes clearer when the child can sign "eat" or "drink" or "cookie" or "milk." They can start to build an expressive vocabulary that is taking a sign form rather than a spoken form.

Then I have other parents who have serious reservations. Some believe that signing may prevent the child from wanting to use words. They worry that successful signing may lead to the child not wanting to speak instead. Other parents see signing as an inefficient use of therapy time. They don't want me "wasting" time in sessions teaching the child signs when I should be teaching spoken language instead. Some families find learning signs overwhelming and confusing. The family may have a very busy life, and learning sign language may be too much for them.

As a speech-language pathologist, I do consider the parent's preference on signing. However, I do share the positives about signing. Plus, there is plenty of research on this subject. There is no need to fear if signing is appropriate. The research is clear. (Signing Time has a list of many research links.) Sign language does NOT hinder the acquisition or use of spoken language. In fact, it sometimes helps a child understand words or concepts. Here's another great article on this subject.

As a speech-language pathologist, I'm pro-signing. However, I don't necessarily teach sign language to EVERY child I see in speech therapy. A child with a language delay doesn't always need to learn sign language. Sometimes, picture communication is another alternative form that is more appropriate. Other times, the toddler has a good spoken base vocabulary of 20-30 words and doesn't necessarily need to learn sign since they have a good foundational vocabulary.

There is one particular type of child in therapy that I am reluctant to teach signing to in sessions. This child is very quiet but uses many gestures and pointing to get their message to others. In this case, I am reluctant to start signing right away because this child likes to gesture and NOT try to speak. I, personally, have seen these children flourish with sign language but make no effort to use their voice in any way. Therefore, I choose not to do sign language with these children or at least in the beginning. My first objective in therapy would be to get the child to start vocalizing in any way in an effort to teach him to use his mouth first.

Still, there are many children with delays that benefit from using sign language. Adding sign language to speech therapy routines requires minimal changes to the session and takes relatively no time if incorporated naturally.

Here's some important things I try to remember when using sign language with toddlers with language delays:
-This should be obvious, but maybe it isn't. Whenever you are signing with your child, you will say the word you are signing. Doing both ensures the child will see the sign and hear the actual word. We always want to sign a word and say it as they are learning signs.

-If a child begins saying a word, then I don't care if the sign is used. Spoken words are the goal, so that is the driving force. Once in a while a parent will insist that the child do the sign for the word they are saying. Nope, nope, nope! If they drop the sign once they say a word, that's what we are hoping for.

-If you have a child with a diagnosis known to have language delays, sign language is a good communication to use in additional to verbal speech. Sometimes, pairing a word with a sign helps a child "see" the word and thus have a new way to comprehend it. Children with Down syndrome, for example, have been known to do well with sign language acquisition before they are able to verbally communicate. This was the case for my daughter.

-I don't care if a child imitates the sign perfectly. Some signs are challenging because they require finger dexterity that a toddler does not yet have. My daughter could not replicate signs exactly because of her Down syndrome as a toddler, but I recognized her sign approximations and didn't correct her attempts. As her fine motor skills improved, her signs naturally got more accurate.


Sign language is one tool that is used in speech therapy as a temporary method of communication for children with language delays. Like any therapeutic method, sign language has its pros and cons, but it may prove to be a positive way for children to begin communicating with their families. If you feel like sign language could help your child, talk to your child's speech-language pathologist.

Therapy Thursday is for educational purposes only and not intended as therapeutic advice. 

Therapy Tip: How Much is Enough at Home?

Here it is...Therapy Thursday! 

This is the day I share a tip based upon my experience as a pediatric speech-language pathologist and a mother of a child with special needs.

Today's tip is:

How much extra help is enough at home?

Being a parent makes life busy. If you are a parent of a child with developmental delays and/or a disability, life is even busier. Therapy is a big part of a child and a parent's life when these delays are present.

When Jaycee was 2 months old, I started her in home early intervention therapies, specifically physical therapy or occupational therapy. Before she turned 3 years old, she had 4 different therapists addressing all areas of development because she was globally delayed.

These therapists were extremely helpful. Part of their job was to give me ideas to help Jaycee at home. If you have 4 people giving you ideas every week, then you might understand why I felt overwhelmed at times during those toddler years. While they did their job well, I felt I HAD to do home practice with Jaycee or else I was a bad mother. I also felt her progress or lack thereof was a direct result of what I was doing with her at home. I pressured myself to run her through exercises even when she clearly did not want to participate. It was extremely hard finding a balance between helping Jaycee with her developmental needs and not feeling crazed by the home activities that I felt needed to be done.

Now that Jaycee is 11, I have a better perspective. Our life does not center around therapy appointments and home intervention practices. I look back on those early years and regret many things I did. I let therapy take over. While my help at home most likely did help her achieve some skills, I hated doing home therapy most of the time. Looking back, I can see too that some things we were trying to work on were just too hard. She needed more brain maturation and time not more repetition and practice.

While I am past those critical early years with my daughter, my job as a pediatric speech-language pathologist means that I am still in a position of offering families ideas to build skills with their toddler at home. Many parents question me about how they can help their child.

Here are some things I tell these parents in our on-going discussions on helping at home:

-How much home intervention by parents is enough?
Every parent and family is different. Some parents like to focus on specific tasks throughout the day. For instance, they may focus on getting their child to say "drink" whenever the child is thirsty. Another example would be going over a few body parts at bath time during the week. Some parents like this idea of spreading out the home interventions throughout the day in natural routines. That is how the birth-three program is designed to help parents.

Still, other parents like to block off times to "work" with their child. This is what I always preferred with Jaycee. I set aside 20-30 minutes a day working on various tasks. I made a chart (I know I'm strange) marking what I would do for the 5 blocks of time a week. One day would be a sensory activity, another would be gross motor, another would be a signing/language activity, etc. It is not to say that I ignored Jaycee the rest of the day. I merely liked having our home therapy time together and then scratching it off our list of things to do. I did not like spreading things out all day. It didn't work for my brain.

Deciding what is enough is difficult. It really depends on your child. Speaking as a parent, if home intervention is causing lots of stress, then it's time to reconsider what you are doing.

-Can we have days off?
Yes!! Everyone needs a day off! Please take a day off from therapy and just enjoy your child. You are probably doing things to help them throughout the day that you aren't aware of. So, even on your days off I am sure there is something you are doing to help your child in a natural way.

Near the end of my daughter's birth-three program experience, she sometimes had two, 1 hour therapy sessions in a day. On these days, I did nothing specific to "work" with her. I imagined she had enough therapy already and didn't need me to do even more.

-You mentioned that I am helping my child naturally without really trying. What do you mean by this?
There are many ways parents build language naturally with a toddler. Many parents just instinctively do these things. Here are just a few examples:
-Peek-a-boo and patty cake are social games that we often play with toddlers. This encourages social interaction and imitation, which are important components of language development.
-Nursery songs are also commonly sang to babies and toddlers. Songs like "Wheels on the Bus" or "Itsy Bitsy Spider" are great for language because they are repetitive, encourage vocalization, and also encourage imitation as we look for the toddler to mimic the motions we do.
-Simply playing with your child is another good way to help them. When you play with them, you are modeling words and showing them how to play with toys. This encourages them to imitate what you are doing and saying.
-If you are talking to your child, you are modeling language. The main way a young toddler learns language is by hearing it from another person. If you are speaking to your child, then you are helping them understand new words and hopefully (and eventually) say those words.
-Giving your child directions is a way to target receptive language (the understanding of language). By telling your child to 'come here,' 'give it to me,' 'get your cup,' 'give me five,' 'give me a kiss,' you are checking your child's understanding of language via simple directions.
-Books are also things that parents often naturally do. Reading books encourages the child to look at pictures, build vocabulary, and attend to an activity that requires listening.


Finding a balance between therapy needs and home life can be difficult, especially if your child has more than 1 area of delay. It is important to find that balance to maintain healthy relationships among family members and to decrease stress that may arise. I hope that I have showed you that approaching therapy can look differently from one home to the next. If you are needing help finding this balance or for some better strategies to integrate activities into your daily routine, please ask your child's therapist.

Therapy Thursday is for educational purposes only and not intended as therapeutic advice.

Hard Things When Your Child has Apraxia of Speech

Did you know that yesterday was Apraxia Awareness day? There are many awareness days throughout the year now, but this one is important to me. Childhood apraxia of speech (CAS) is a diagnosis that can severely affect a child's ability to produce verbal speech. 

The Childhood Apraxia of Speech Association of North America defines CAS as:
a motor speech disorder that first becomes apparent as a young child is learning speech. For reasons not yet fully understood, children with apraxia of speech have great difficulty planning and producing the precise, highly refined and specific series of movements of the tongue, lips, jaw and palate that are necessary for intelligible speech.

As a speech-language pathologist, I have treated some children with CAS over the years. But, my own child was diagnosed with severe CAS around age 5. Speaking does not come "naturally" for these children, and they require intensive speech therapy and home intervention strategies. When you watch your child struggle to make simple sounds and words, it can be difficult as a parent. Here's a few reasons why:

1. The repetitions needed to learn a word are exhausting.
Repetitions are critical when treating CAS. In order to help the child build a connection from the brain to the mouth (or more specifically the lips, tongue, jaw, or palate), repetitions are critical for the child to "learn" how to say a word and "remember" how to say it later. In other words, repetition builds memory. Getting the repetition needed in young children can be tiring. A mom trying to get multiple repetitions of "go" may line up 10 hot wheels cars and say "go" as she pushes 10 cars one at a time. Then the mom will try to get the child to do it. Then repeat, repeat, repeat until the child loses interest. Another repetition activity may be saying, "bug" as you point to all the bugs on the pages in the Ten Little Ladybugs book. It can also be a mom saying "neigh" as she puts 10 little horse figures one at a time in a wagon.

When as a parent you are working on repetitions, you can imagine how annoying the sound of your own voice can become. If your child is barely talking, you might be saying all of these word models with little repetition from your child. It can feel like you are getting no where. But, when the repetition does happen, it feels magical. Still, coming up with creative ways to get these repetitions can be exhausting.


2. The random spontaneous words are both good and frustrating.
Often with CAS, there are times when the child will blurt out a word randomly. However, that word is said so easily only for it to be gone. It can be a happy moment for the family because a new word is exciting, especially when the words are few. But, then the word disappears, which can be disappointing and frustrating. Random spontaneous words can occur because something clicks and comes together in the child's brain and mouth at that moment. The word was not said because there was a firm motor plan established, so the child is unable to say the word again on demand.

One day, the kids and I were getting ready to leave the house. Jaycee was ready to go and was getting frustrated that her brother didn't have his shoes on yet. She pointed to his flip-flops and said, "-ip -op." We looked at each other and said, "Jaycee just said flip-flops!" It was so neat, but then it was gone. We tried and tried in vain to get her to say it again, but it was not to be. She has recently started attempting flip-flops again consistently, but that first spontaneous attempt at it was at least 2 years ago!!

Jaycee signing "deer"

3. People's inability to understand CAS can lead to awkward situations.
CAS is not well-known, so many people don't understand common features of the diagnosis. With CAS, receptive language is much stronger than expressive language. In other words, the child understands much more than they can verbalize. With my own child, Jaycee was only able to say 3 words when she could identify all her colors and shapes. She could sign all her alphabet letters and knew hundreds of other signs. It might be easy for people to draw the conclusion that Jaycee should have been able to speak if she could sign so well. But signing bypasses the mouth. To me, it showed that Jaycee could communicate and understand language well, but the mouth couldn't form the words. But to others, it looked like she was simply choosing an alternative method of communication. Yes, people made a point to tell me that!

Another common feature that creates some awkward situations is those random spontaneous words. A person well versed on CAS knows that these random words like "flip-flop" can occur as a fluke connection, but it doesn't mean the child has the motor plan to replicate the word.

A by-stander may hear a word like that and say, "Did you hear that? She could talk if she wanted to." "She chooses not to talk." "Well, that word just proved no one must be making her talk at home because she just talked!" These were the moments when Jaycee was younger that I had to control my eye roll and my mouth.

CAS is a real and complex speech disorder. It is hard as a parent to watch your child struggle to talk when others develop speech so naturally. But, many children do make progress over time (the amount of time depends on the child and if other diagnoses are present). When those words do actually come out, it makes all the hard days worth it!

Therapy Tip: Can you Say...?

It's Therapy Thursday!! Wahoo!
This is the day that I share a tip based upon my experience as a speech-language pathologist and a mother of a child with special needs.

Today's tip is:

Can you say...

This is a very simple tip, but an important one. Are you ready?

As a speech-language pathologist, I rarely ever say to a child I am working with, "Can you say ..?" Working with toddlers who have little or no words, it may be surprising to you that I very rarely ask a child to say a word.

Here's the problem with "Can you say...?": The answer is yes or no. You are asking them if they can say something. You are not asking them to actually say it.

It may be semantics for some people, but these little things are important for speech-language pathologists!

When I want a child to say a word, I will say things like:
-"This is a car. Car. You say car."

-"Car. (Pointing to my mouth.)  Now it's your turn.  Car. (Point to their mouth.)"

-"Car! You try to say it. Car."

-"Car. Use your words. Say car."


See the difference? I'm telling them to say something not asking. This is a small difference that is very important! This isn't a magical strategy but one that's important to use when you have a child that is just beginning to say words.

If they don't say it, try again. You are just reminding them to speak and try every time you tell them to say a word. Don't ask them if they can say something, just tell them to try.

Therapy Thursday is for educational purposes only and not intended as therapeutic advice.

Guest Post: 5 Life Lessons I Learned During My Daughter's Therapy Sessions

This week my daughter is recovering from a hospital admission, so some wonderful bloggers are guest posting. Today's guest post is by Ali C. from the blog Crazy Cakes and Eskimo Kisses. I could relate to this piece so much when I first read it, and I hope you enjoy it too! ~Evana

My daughter began physical therapy when she was only four months old.  At the time, her hypotonia made it impossible for her to even lift her head, and her gross motor skills were extremely delayed.  I spent my days watching the therapist try to teach her how to roll over, and in the evenings, I did my best to imitate what I saw the therapist do. In whatever spare time I had left, I prayed that therapy would be the key to building up her strength and unlocking her potential.

And the days turned to months, and the months turned to years.  Rolling over turned into crawling, and crawling turned into walking.

I have no doubt that the early intervention my daughter received played an integral part in where she is today -- an age appropriate classroom, running, jumping, and dancing. But it wasn't until recently that I realized her therapy sessions taught me some valuable life lessons as well.

1. Measure life in inchstones; forget the milestones.  Technology makes it all too easy to quickly search developmental skills that your child should be reaching.  Social media makes it even worse. Often times, I was saturated in a sea of milestones -- reminders of what my child should be doing but was not.  While I was sincerely happy to see the accomplishments of my friends' children, I was also often left trying to shrug off feelings of envy and defeat.

Therapy taught me the beauty of an inchstone -- a small but powerful accomplishment. Sometimes in life, we become so focused on the mile, that we forget all the sweet inches that led up to it. Count what truly matters; ignore the rest.

2. It is OK to be afraid, but don't let your fears consume you.  Some days, it feels as if there is so much to fear -- medical procedures, surgeries and an endless slew of doctors around every corner. For the first two years of my daughter's life, I spent my nights worrying that she may never walk. I cried about the huge obstacles stacked against her. I cringed each time we were sent to see a new medical specialist.  And then, the other day, my daughter asked to take gymnastics.  I felt that old familiar fear immediately strike. What if she couldn't keep up?  What if she got injured?  I looked to her therapist for insight.  Her advice?  Don't let your fears stop your daughter from trying something new.

She was right. It is true that there are risks everywhere in life, but they are often accompanied by great rewards. Be bold. Don't let fears stop you from living.

3. Determination is key. Before my daughter started physical therapy, I gave up easily -- if something was too hard, or too time consuming, or if I was too tired. I gave up on diets. I gave up on projects. I was all too happy to be a self-proclaimed "quitter." Observing my daughter learn to walk uphill taught me the importance of a determined spirit.  I watched one day as her therapist helped her walk on the uneven ground sprawled out in front of them. My daughter's legs wobbled, the surface below her was soft under her feet, and more than once, she fell forward onto the unkind ground. But, she never gave up.  Fall after fall, she stood up more determined than the time before to master the hill.  Eventually, she did. 

Often times in life, we stand with unsteady legs on uneven ground. How many times we fall is not what makes us or breaks us.  How many times we pick ourselves up and start again is what defines us in the end. Falling is inevitable; picking yourself back up is a choice. Determination makes all the difference.

4. While determination is important, there is nothing wrong with taking a break.  There were moments during therapy sessions when my daughter would become tired or frustrated. I would watch as her therapist responded in various ways: She would give her a break.  She would redirect her.  She would remind her that if she finished the task at hand, they would do an activity of her choosing. And it worked. Every time. As an adult, I too experienced a daily helping of exhaustion and annoyance, but I rarely gave myself a break to recoup, relax and recover.   

When life throws difficult tasks or extreme stressors your way, do not hesitate to take a break. Read a book, go for a walk, listen to music. Allow yourself to recharge.  You are worth it. Frustration will not allow you to accomplish much, but a rested you with a fresh outlook is undefeatable.

5.  Hope is powerful.  With each fall, my daughter's therapist reminded me that we were a step closer to walking. In times of darkness and defeat, she recalled the many moments of light and triumph we experienced. When I focused on the obstacles and worries of today, she refocused me on the promises of tomorrow.

Therapy taught me this truth: In our lives, we will experience defeat and sadness.  There will be days when we are unsure of everything. There will be moments when giving up seems to be the easiest option.  We will compare and cry. We will feel extreme fear and bouts of envy.  But, at the end of each day, there will always be hope, and that is more than enough.

You can read the original post of this here!

Guest Post: A Hexagon, A Fat Cat, and A Rubber Chicken

My sweet little girl is home recovering from a recent hospital admission. To help me out, I have arranged some great guest posts by some writers I adore. First up is Tricia from Two Upside Down Turtles. Tricia is not only a blogger friend but a friend in my real life who I see at church. She has twin girls with Sensory-Processing Disorder and delays. I loved this story when I read it on her blog and hope you love it too! ~Evana


I allowed the words they spoke to keep me up at night.  They said the girls aren’t progressing. They’re not doing as well as they were several months ago.  It was one of those times when I wished I could put my fingers in my ears, hum a tune, and drown out what they were telling me.  I know what they said is true and fear began to grip my heart.  But then I began to truly look at our girls and I noticed that they are progressing in everyday life.

Hope crawled into my bed with her iPad and asked me to watch her play Monkey Math.  The game showed her 3 different shapes and she was supposed to press the oval.  Every time she pressed the oval it gave her 3 new shapes.  She was pressing ovals like crazy until she accidentally pressed the wrong shape.  She said “Oops…..that was a hexagon.  I need to poke the oval.”  What?  She knows what a hexagon is?  I had no idea she knew that.

We were working on auditory memory cards.   This is the story that I read individually to the girls.


These were the answers the girls gave me to the questions.
Who has a magic backpack?    
Hope: Zack        Mikayla: Jack (Oh….so close!)

Why is it magic?    
Hope: Because things won’t break     Mikayla:  Holds only things that aren’t heavy

If you look inside it, what will you see?    
Hope:  A rubber chicken    Mikayla:  A cat.  Zoe’s too big for the backpack.  (Zoe is our cat)

We worked on these same cards last year.  The girls could never remember the name of the person mentioned in the story.  Remembering names has always been hard for them.  But Hope got it right and Mikayla’s answer rhymed with the correct answer.  I couldn’t believe it.  That’s progress.

Why questions are the hardest questions for our girls to answer.  I didn’t expect them to answer the “Why is it magic?” question.  But they gave me answers. They weren’t the correct answers but I thought they were good answers.

When Hope blurted out rubber chicken I laughed and she grinned.   When Mikayla said Zoe’s too big for the backpack it showed that she’s developing critical thinking skills.  Our cat is huge and she wouldn’t fit in a backpack.  That’s the truth.

As I was putting the cards back in the case I was thinking about how I answer questions.  If I don’t know the answer I will say “I don’t know.”  It’s safe to respond that way.  I’m certainly not going to blurt out an answer and possibly be wrong.  That would be embarrassing and risky.  But our girls aren’t afraid to risk.  If I ask them a question they’re going to give me an answer.  If it’s the wrong answer they don’t care.  They just go on with life.  If they don’t know the answer then they’re going to make something up.  And let’s be honest.  Isn’t a backpack with a rubber chicken and a cat in it more fun than a sock, a rock, and a clock?  Oh how I need to be more like our girls.  They live life and they don’t worry about what anyone thinks.

Progress doesn’t always show up in a 45 minute therapy session.  But it shows up in the moments that we’re just living life.  It shows up when a little girl recognizes a hexagon.   It shows up when a fat cat can’t fit in a backpack.  Progress is important.  But I’m learning to not worry so much when progress doesn’t show up on a piece of paper.  Worrying takes away the joy of living life.   And sometimes I just need to stop, laugh at a rubber chicken in a backpack, and savor the grins on the faces of little girls who make my world a better place.


Click here to read the original post on Tricia's blog.

Therapy Tip: I'm Worried About My Toddler's Language

Welcome to Therapy Thursday! Today is the day I share a tip based upon my experience as a mother of a child with special needs and a pediatric speech-language pathologist.

Today's tip is:

I'm Worried About My Toddler's Language. Now what?

For the past 10 years in my career, I have worked primarily in my state's early intervention program. This means the majority of my work has focused on providing speech-language intervention to children under age 3. Most of these children are two when I evaluate them as part of a team that decides if delays are present and/or warrant therapy. By the time I am coming to the home to talk to the parents and evaluate the child's language, most parents have had concerns for some time.

So when DO you know it's time to get your child evaluated? When do you wait and see if they will start talking on their own?

Today, I hope to help you answer these questions.

Consult Developmental Information
First, there are many, many websites that can give you information on typical speech and language development for babies and toddlers. It is important to know what is typical to decide if your child is behind. Sometimes, parents will see another child their child's age who is saying and doing more. Just because one child has more skills, doesn't mean your child is "behind." That's why the developmental norms are so important.

Here are two websites with some of this information:
ASHA's Speech-Language Development Information

Developmental Information from the Child Development Institute

Information presented in these websites are good reference points for concerned parents. These are just some of the things that a speech-language pathologist will look at when determining whether a child has a language delay or not. Parents are usually surprised by the number of questions or skills I look for even in a young 18 month old child. The number of words the child has is just 1 factor in assessing their overall language development.

If your child is not meeting some of the skills listed on developmental checklists that you have looked at, then consider a full evaluation from a speech-language pathologist.

Medical/Developmental Information to Consider
Maybe you looked at the developmental information, and you are left confused. You can read so many websites that you may be getting mixed opinions about your child. So, let's move on. If you are concerned about your child's language development but aren't sure if you should have an evaluation now or wait, then consider the factors below.

-Does your child already have a diagnosis that would put them at risk for a language delay?
-Does your child have a history of multiple ear infections or fluid in the ears? Has your child received ear tubes or being considered for tubes?
-Is there a family history of educational, speech-language, hearing, or developmental issues? This may included siblings or parents that needed special services.
-Is your child behind in meeting other milestones? Did your child sit up or crawl late, for example?

If you answer yes to any of these and have concerns with your child's language, then consider getting an evaluation.

More Specific Red Flags to Consider
Besides the developmental and medical history, I often look for these red flags when I am first evaluating a toddler. Each of these would be considered a red flag that would constitute a full evaluation from a speech-language pathologist.

-Was your child quiet as a baby with little to no babbling?
-Has your toddler ever had consistent words or skills that he/she no longer does?
-Has your child's eating ever caused you stress due to gagging or texture aversions?
-Does your child seem to ignore you when you call their name almost every time?
-Are gestures absent? (No waving, no pointing)
-Does your child play with toys in an usual manner? (I.E. spinning car wheels only on cars or simply holding small objects instead of playing with them)
-Does your child seem to ignore other people or children?

If you answered "yes" to any question above, then have your child's language evaluated by a professional. This does not mean that your child is definitely having a delay, this just means that I would not recommend a wait and see approach with these children.

Who should "wait and see" what happens?
If the above information did not alert you to anything new, then I am fine with some parents using a wait and see approach. However, give yourself a timeline to make a decision. For example, if no improvements have been made in __ amount of time, then I will call someone or talk to my child's doctor.

I do want to stress that getting your child evaluated is important if you have ANY concerns. It will decrease your stress, give you answers, and allow your child to get proper treatment if appropriate. Even if your child is tested and a delay is found, you may or may not want to start speech therapy right away. But, hopefully the professionals will empower you to make the best choice for your child.

I have evaluated children who follow directions very well, use many different gestures (even making up their own), communicate well non-verbally, seem to understand everything they are told, but just aren't saying many words. Sometimes, these parents choose to give their child time to improve without any intervention. I usually support the parents but give them a time limit (3 months) to see if their child can improve with just some parent training and parent led intervention at home.

The Bottom Line
If you are worried, just make that call for an evaluation, talk to your doctor, or give yourself a time frame to make a decision. An evaluation should give you the information you need to help your child and answer any questions you have. Getting an evaluation will not "label" your child for life. Speech-language pathologists are here to help you and your family!

Therapy Thursday is for educational purposes only and not intended as therapeutic advice. 

Therapy Tip- The Problem with "OK"

Today is Therapy Thursday! It's the day I share a tip based upon my experience as a mother of a child with special needs and a pediatric speech-language pathologist.

Today's tip is:

The Problem with "OK"

When I was a graduate student, I spent a semester working in my university's Center for Autism as a speech-language pathologist (SLP) in training. At that time, the SLPs worked along side of those training in the field of Applied Behavior Analysis (ABA).

If there is one thing I remember most in our group sessions, it was Dr. Anthony Cuvo, a professor and clinical supervisor of the ABA clinicians and autism program, and his hatred of the word "OK." If anyone said the word OK to a child when we were giving them a direction, we would surely hear about it from him later.

I tried not to say "OK" when I was in group sessions treating children with autism, but it came out so naturally! After he educated us on the problems with saying "OK" when giving directives to a child, it all made sense. Though I found it hard to do!

Here in America we often say "OK" at the end of a direction. For example: "You need to go clean your room. OK?" "Put it in the box. OK?"  "Let's all get ready to have a bathroom break. OK?"

When we put an OK at the end of the sentence, we usually add it in to mean, "Did you hear me?"

Dr. Cuvo stressed to us that adding "OK" at the end of a directive was actually a way to give the child an out. It is as if we are asking the child if they want to complete the direction. When we add "OK," we are allowing the child to answer yes/no.

If they say no, then what are we going to do? We essentially asked them if they were OK with our direction. If they say no, we were the ones who foolishly offered them an out. Their refusal to comply is in part our fault.

Maybe in your part of the world, OK is not said very much. But, here where I live, OK is added in more than people realize. I had to really pay attention to what I was saying to the children I was treating. I had to make an effort to say things with no gray areas that also made a firmer stance. I had to remind myself that the direction I want them to follow should be firm, simple, and give no options for refusal.

All these years later, this principle has stuck with me, so now I pass it to you.

The direction should be the direction and nothing more. It should definitely not contain "OK" in it!

You may be reading this thinking this is a very small word to take an issue with, but sometimes the small things have a big impact.

Your challenge this week: Watch how often you say "OK" when giving your child a direction. Make an effort to give the direction and nothing more.

Think you can do it?
OK! Give it a try!

Therapy Thursday is for educational purposes only and not intended as therapeutic advice.

Therapy Tip: Pace Cards for Phrase Development

It's therapy Thursday! This is the day that I share a therapy tip based upon my job as a pediatric speech-language pathologist and a mom of a child with special needs.

Today, my therapy tip is:

Pace Cards for Promoting Phrases

What is a pace card? Great question!

A pace card is a visual representation of a phrase or sentence. Since I work with toddlers, my pace cards are made for two and three word phrases. Here are two examples. The pace card on the left is a visual for a two word phrase and the right is a three word phrase. Pace cards are very simple, easy to make, and can be a great technique for some children.

I first read about pace cards in a book titled, Early Communication Skills for Children with Down syndrome.  This book is written by Libby Kumin, a speech-language pathologist who is well known within the Down syndrome community. I was able to listen to her speak at a Down syndrome conference once and learned so much from her.

When I read about pace cards in Libby's book, it was new information to me. I thought it was a great idea. Many children with Down syndrome are visual learners, so the pace card is a great tool for children who learn best visually.

After I read about this technique in her book, I started using it in my speech therapy sessions with a variety of children none of whom had Down syndrome who were struggling to talk in phrases. That was almost 10 years ago! Since then, I have used pace cards many times. Sometimes, the child will connect with it on the first exposure to it. Other children seem confused by the pace card. I have had a variety of responses. It isn't a magic fix. Like any technique used in speech therapy, not everything works for everyone.

How do you use a pace card?

Here's how I introduce a pace card with a toddler:

1. First, I model some two word phrases using the pace card. I point to each dot as I model each word. ("My turn.") Usually, I follow that with, "Did you see that?" Then I repeat the pointing at each dot and the words. Depending on the child, I may do this for a complete session before moving on to the next step. Other children move to step two on the same day.

2. The next step is to try to get the child to repeat both words of the phrase using the pace card with a pause between the words. After I use the modeling as described in step one, I then say, "Your turn. Say my (pause for child to say), turn. Great! My turn!" Again, I point to the dot that corresponds to each word as I am saying it. Some children will get stuck here for quite awhile as they will not combine words without the short pause.

3. Finally, the child will progress into repeating the phrase with no pause while I continue to model the phrase while pointing to each dot.

4. When I start to hear some spontaneous phrases, I usually discontinue the pace card. Some children use the pace card several weeks and some just need it a session or two.

Who should you try it with?
I have tried the pace card with a variety of children. I tend to try the pace card for children when I am not getting phrases from the usual methods. Again, some children click with it right away while others do not. I give it a few sessions before deciding if it's a method worth continuing with.

My recommendation would be to try pace cards if you are unsuccessfully trying to get phrases or longer sentences with a child.  

Therapy Thursday is for educational purposes and not intended as therapeutic advice.