Augmentative and alternative communication (AAC) allows non-verbal children and adults the opportunity to learn how to communicate through a speech generating device (SGD). The device, similar in shape and size to a tablet, can be mounted to a wheelchair or desk, and tracks the movement of their eyes to choose preset pictures, words and phrases, depending on skill level.

Many children who are non-verbal experience frustration and behavioral issues due to the inability to express themselves to others. AAC focused therapy has the ability relieve the tremendous frustration that often accompanies lack of communication. Therapy sessions often include games to help patients learn how to utilize their full field of vision and learn how operate the device independently.

“If you’ve had any experience not being able to communicate, even for a short-term, it’s very frustrating when people don’t understand you,” Speech/Language Pathologist at Cook Children’s Rehab Center Carol Edley said. “We’re trying to get them to be independent, intentional communicators, and not be placed in the role of a responder.”

Eleven-year-old Willy struggled with speech his entire life until his mother, Carla Cowdrey, learned about AAC therapy, and knew Willy would thrive with the opportunity to finally speak.

“I really had a feeling Willy could communicate, and this was the way he was going to do it,” Carla said. “And it turns out, it worked.”

Willy has learned numerous words such as go, play, help, mom and recently said “she look”, referring to Carol on the computer monitor, during a telemedicine visit. His word choices are described as a one to two-step process, depending on his choice, and his mom is hopeful for longer phrases in the future.

More recently, Willy has begun using short phrases to ask questions.

“When you start having the child demonstrate what they are thinking, in a manner where they are understood, for lack of a better term, it just makes the family happy,” Carol said. “All of a sudden this child is something more than they thought he or she could be.”

For Marisa Sanchez, AAC therapy has allowed her to hear her daughter Isabella’s first words at six years old, including the word every mother wants to hear: mom.

“Going into this journey six years ago, and not being able to have your six-year-old communicate with you, it’s hard,” Marisa said. “Hearing Isabella say mom for the first time is something I’ll never forget.”

Isabella knew four words on her device in February 2020, and now has access to 28 words to grow her vocabulary.

“We’ve increased the number of buttons presented to give her more language to choose from,” Isabella’s speech language pathologist Theresa Jones said. “She’s recently started using words like “papa”, “go… home”, “go”, “put” and “stop”. This is in addition of her using [the word] mom. Dad got to see her use “papa” for the first time via FaceTime since we only allow one parent with a patient at a time due to COVID-19.”

Edley estimates 30% to 50% of the eye gaze therapy patients have moved to telemedicine in the wake of COVID-19. The change in therapy delivery has given families the opportunity to learn how to adapt when glitches and other life moments occur.

“For the kids, it can be difficult to shift eye gaze from their device to the computer screen that may have a book or some other language activity. But that is life and they would have had to learn to shift attention in busier environments to talk.”

Although COVID-19 has shifted routines and therapies, the Cook Children’s speech pathology team has still been able to work with the AAC SGD vendor to supply the devices for patients and families to continue working on speech at home.

“Excitedly, we gave out a rental device with eye gaze yesterday. She hasn’t had the chance to practice these last two to three months,” Carol said. “It was exciting to see the little girl's reaction. With her, her mother and I have found low tech ways to train her eye gaze. The real thing is so much better.”

AAC eye gaze therapy has given parents hope, and their children, like Isabella and Willy, a voice.

As a child, Rousey was diagnosed with Childhood Apraxia of Speech (CAS), a motor speech disorder. In recent interviews Rousey reports struggling with feeling of insecurity and inferiority following her diagnosis of CAS. During Rousey’s early years, there was question as to whether she would ever be able to use conversational speech. But with perseverance, intervention, and encouragement from her speech therapist and family, Rousey is now a well-spoken adult with a message to children with CAS: anything can be overcome with hard work no matter how insurmountable the odds seem.

Children with CAS have problems saying sounds, syllables and words in the absence of muscle weakness or paralysis. Basically, the brain has trouble telling the body parts necessary for speech how to move in order to form speech. Children diagnosed with CAS don’t follow normal speech sound development and won’t “catch up” to their peers without intervention.

So what causes CAS? Unfortunately, in most cases we don’t know. CAS is a motor speech disorder, meaning something is interfering with the brain’s ability to tell the mouth muscles how to make the right sounds. Possible causes include genetic syndromes, stroke, or brain injuries or abnormalities. While there is no cure, we know miraculous progress can be made given skilled intervention.

Not all children diagnosed with CAS will present the same way, but diagnostic signs or symptoms do exist. A child with CAS:

• May not babble or coo very consistently during infancy.
• Uses very few consonant and vowel sounds and has a hard time combining sounds to form words.
• Understands much more than he can tell us.
• May say a word clearly once or twice, but then doesn’t say it again.
• Struggles to imitate speech models. You may even be able to see him groping or struggling to coordinate his mouth when trying to talk.
• Has more difficulty saying long phrases and sentences than short ones.
• May have choppy speech with long pauses between sounds.
• Can be very difficult to understand, especially if you aren’t familiar with his speech patterns
• May have some difficulty eating

If this sounds like your child, an evaluation by a speech-language pathologist is imperative. A skilled therapist will help determine the best course of intervention. All children are so very unique, and therefore, treatment plans will be custom created based on several factors, including age, severity, and of course, your family’s schedule. However, research shows children diagnosed with CAS have a greater likelihood of success if they:

• Receive frequent and intensive intervention (think 2-4 sessions per week in a perfect world). It’s important to remember the age and tolerance of your little guy when scheduling therapy. Four sessions a week may be too much for him.
• Have the opportunity to work one on one with their therapist.
• Are exposed to a “multi-modality” approach to intervention. This is just a fancy way to say using many different cues and strategies to help them create the sounds, including touch (helping him move his lips to say “pa”), visual (looking in a mirror), and proprioceptive (pairing movement with sounds) cues. These kiddos need to learn and remember HOW to move their speech muscles so your therapist may encourage them to repeat a word or syllable many times.
• Practice, practice, practice at home! Even an intensive therapy program will give your child 3-5 hours a week AT MOST with his speech therapist, meaning he has 163-165 hours per week OUT of therapy room. Use those hours wisely and carve out time to practice everyday to see progress!

Resources for families:

Apraxia-kids.org

References:

ASHA.org - Childhood apraxia

*Photo from Ronda Rousey's Facebook page.

About the author

Amanda Fyfe is a speech-language pathologist at Cook Children's in Arlington and Mansfield. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. Click here to find the closest Cook Children's Rehabilition Services near you.

The obsessively clean freak with a dozen napkins at meals and the dust pan and broom standing by! I see the crumbs falling to the floor, the grape jelly graze the side of the chair, and the sticky fingers raking through the hair as my daughter enjoys her meal.

As a feeding therapist, I know as her skill in feeding develops so will the awareness of her fingers, hands, face and mouth. 

I MUST wait until she is finished before I attack with my arsenal of cleaning supplies. Sitting with her, eating with her, and having fun with her while she explores her dinner are the best things I can do as a parent.

Maybe you’re wondering, “Will my walls always be covered in food splatters?” or “Why does she continue to refuse foods I know she should be eating to have a well-rounded and varied diet?” “Does everyone’s baby require a bath after each and every meal?” “Is it normal for more food to be in her hair than in her mouth?”

Take comfort, mama. You are not alone in your exasperation when it comes to feeding your child while trying to maintain some semblance of tidiness in your kitchen.

Did you know that a baby’s mouth and hand have the highest number of sensory receptors per square inch than any other part of the human body?

That means the mouth and hands are the most sensitive parts of the body when it comes to what the brain can take in and learn.

So what does this all mean for your dinner table? Put away the fine china and good linens and get ready to embrace the mess. Researchers in the UK "found that playing with food may actually help kids overcome a fear of new flavors and eat a more varied diet, a small study suggests."

Children need the chance to explore new foods and textures with all five senses. In a perfect sensory world, your little one should have the opportunity to touch, smell, and taste new foods unabashedly. So, set the paper towels aside and join in the fun!

Your child will “learn” both good and bad habits depending on the mealtime experiences they are afforded.

For instance, if your child is given peanuts and experience an allergic reaction, he will most likely begin to refuse peanuts!

Alternatively, if broccoli and green beans are offered during a family meal in a way that is fun and supportive, you might find your little guy eating them with gusto! But, don’t be disheartened if he turns his nose up at beets the first time you present them.

Research has shown children may instinctively refuse new foods to survive simply because they are new. In addition, it can take up to 15 presentations before a food is deemed worthy in your child’s eyes. However, with good exposure, no illness or bad consequences, and repetition, children will learn many foods are safe to eat!

What can you do to help your child become a magnificently messy and healthy eater?

1. Make meal times a routine at the table, in their chairs, with NO distractions.
2. Allow your child to explore the foods that you’ve given him with the opportunity to say, “I don’t like this” without consequences.
3. Don’t set your sights on the spoon: allow him to eat with his hands!
4. Let him PLAY! Think finger painting with yogurt or building a tater tot tower.
5. Relax while he digs in and gets his hands dirty. He is learning about the different properties of the foods we eat when he touches, smells, tastes, and looks at the foods that are on his plate.
6. Keep offering the foods you desire him to eat. Remember, experts have found it may take your child 15 times of trying a food to decide how they really feel about it.
7. Lead by example! Tuck into the meal with your child. It is important for our littles to see us eating the same things we are asking them to eat.
8. Try to have as much fun at the table as possible while still enforcing the rules of “manners”. Talk about your day, talk about your food, smile, laugh, and make faces in your cheese. 

Your child may not have developed the oral motor or sensory skills to support a healthy, well-rounded, adult-like diet. Be on the lookout for the following feeding “red flags”:

• Drowsiness or sleepiness at every feeding.
• Poor oral tolerance (spits food out, shuddering, gagging, vomiting)
• Able to chew but prefers liquids
• Frequent gagging
• Coughing and/or choking

If one or more of these signs describes your child, consider talking with your pediatrician about your concerns and a possible feeding evaluation.

Satter, E. (1987). How To Get Your Kid To Eat…But Not Too Much. Boulder, CO: Bull Publishing Company

About the author

Melanie Van Noy is a speech pathologist at Cook Children's.Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury.

You may be thinking, “Am I the only parent in town dealing with dinner drama every night?”

The answer is no. It is reported 25 to 45 percent of typically developing children experience feeding and swallowing problems, while a staggering 30 to 80 percent of children with developmental delays struggle with mealtime (Arvedson, 2008).

Now for the million dollar question: what causes feeding problems? There are several factors that can impede a child’s ability to develop a happy, healthy relationship with food, including: sensory processing disorders, gastrointestional complications, prematurity, and dysphagia.

Food should be fun. And for most of us, it is just that. But children may not see eye to eye with us when it comes to mealtime, causing this to become a stressful time for the whole family. Little ones can be incredibly stubborn when it comes to food choices.

Most parents have described their children as picky eaters at least once or twice. However, it is important for parents to know the difference between “picky eaters” and true problem feeders and when to seek assistance.

Picky eating can be a typical stage in normal development. Ready for the skinny on picky eating?

A picky eater will typically:

• Accept approximately 30 foods. That may sound like a lot, but it’s really not.
• Tolerate a new food on his or her plate and may even taste it once or twice. This new food may become a new favorite. But then again, it might get tossed on the floor. This truly depends on the child’s sensory reaction to the food in question.
• Eat meals with his or her family, but requires different preferred foods.
• Eat only one food from each food texture category (puree, crunchy, solids,etc).
• Consume one preferred food consistently, and then suffers “burn out” and refuses to eat this food for a period of time (picky eaters will usually begin to accept this food again after a brief break).
• Eat new foods after frequent exposure.

So, how can you nudge your picky eater toward the leafy greens and save your sanity? Here are a few simple suggestions for success at the dinner table regardless of whether you’re serving pizza or brussel sprouts.

1.Develop a routine and stick to it. Offer meals and snacks at about the same time each day

2.Don’t force feed or bribe your child to eat. This will likely increase refusal behaviors or even worse, bring on a power struggle.

3.Offer a variety of foods, including 1 to2 of your picky pumpkin’s favorite items, at the family meal.

4.Persistence is key! Remember not to shy away when he shudders at his first taste of peas. You may need to offer those peas up to 20-25 times before he will tolerate them.

5.Explore food with your child. Talk about the way it looks, smells and feels. Invite her into the kitchen to help you prepare the foods. Bring her along to the grocery store or farmer’s market to choose a new fruit or vegetable. Star fruit? Why not?! Eggplant? Coming right up!

6.Make it fun! Serve fruits and veggies with dips. Use cookie cutters to make a Shamrock Sandwich for St. Patrick’s Day or Santa for Christmas. Eat dinner by candlelight. Serve breakfast for dinner. Better yet, have everyone put on their coziest jammies for a pancakes and PJ’s party. Get creative!

7.Practice what you preach! This means you, parents. If you want your little ones to eat salad for dinner, you will need to dive into that bowl of greens yourself and forgo the drive-thru on your way home. Our children are always watching and learning from our actions and habits.

8.Don’t become a short-order cook. If your child refuses the family meal, it can be tempting to head back to the kitchen to whip up the macaroni and cheese he is coveting. Resist! This may promote picky eating.

Now, let’s get down to business. While picky eating can be frustrating, it is a typical stage in normal development. However, problem feeding is a true disorder that requires specialized assessment and/or intervention and is downright disheartening for parents. A child that does not eat well can evoke feelings of anxiety, fear, and helplessness, leaving caregivers struggling for a solution.

A problem feeder may:

• Eat fewer than 20 foods.
• Refuse the bottle/breast or drink a small amount and then refuse during infancy.
• Refuse an entire texture category (for example, a problem feeder may refuse to eat all pureed foods).
• Not accept new foods on his plate and may cry, scream or tantrum at the sight of a new food. Problem feeders may even gag or vomit at the sight of an offensive foods.
• Be unwilling to try new foods, despite multiple exposures.
• Eat the same food over and over, but once he experiences “burn out,” he will most likely not go back to eating that food. This will cause him to slowly, but surely, shrink his group of tolerable foods.

If your child is showing symptoms of problem feeding, talk to your child’s pediatrician regarding a feeding evaluation by an occupational therapist or speech-language pathologist. A thorough evaluation is necessary to determine the best course of individualized treatment for your child.

Hang in there, parents. There IS hope! Our feeding therapists are trained to help your child with a wide array of feeding difficulties.

References:

http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934965§ion=Incidence_and_Prevalence

http://www.sosapproach-conferences.com/articles/picky-eaters-vs-problem-feeders

Resources for Parents:

www.feedingmatters.org

www.yourkidstable.com

About the author

Amanda Fyfe is a speech-language pathologist at Cook Children's in Arlington and Mansfield. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. Click here to find the closest Cook Children's Rehabilition Services near you.

That question makes me cringe. Not because of the question itself. I understand it. As parents, we all want what’s best for our children. I’m not afraid of the question or looking to evade it. It’s just who is making the choice on what’s “normal.” I use the opportunity to talk to parents. To reframe what may be thought of as normal, go over their concerns and provide perspective.

Here are some basic guidelines that I give to parents on how a child should be developmentally from 1 to 6 years old. Every child is different and this is only a starting point. If you have you concerns, please talk with your pediatrician for a referral to a speech/language pathologist.

• 12 months old - Children usually can say 1-21 words on their own, actively listen, wave bye-bye, look around when asked, "Where is __?" and use real and toy objects to act out common actions, e.g., feeding, cleaning, etc.
• 24 months old - Speak 145-150 words, combine 2-3 words, produce plural - s and - ing words, enjoy nursery rhymes, finger play and songs and put 2-3 actions in symbolic play.
• 30 months old - Say 360-600 words, speak in simple sentences, have his or her speech understood by family members, listen to real stories and start role playing in life experiences, such as going to the doctor.
• 36 months old - Say so many words you can't count them, have his or her speech understood by more than half the people your child meets, use "I, me, my and you" correctly. Answer what, where, when and who questions and retell familiar stories. At this age, children should be asking questions, not learning to read yet, but enjoying books and making friends. 
• 4 years old - Your child should start playing with words and making up stories. Most children at this age will be playing with friends and pretending to be a superhero, a cowboy, a parent or an animal. Children may begin using voices as characters and creating their own costumes and props.
• 5 years old - Most children at this age have started school. They can sit and listen for a whole story. They will start using words such as "know, understand and think." They will talk to ask questions, to explain things and to imagine.
• 6 years old - At this age, most children begin to speak more like grownups, especially at school. They can be polite when talking and know when adults don't understand what they have said. Often times, children will be able to change what they originally said to be better understood. Children at this age should be able to use all of their speech sounds and begin reading.

You know your child better than anyone and of course there will be times when your child just won't pay attention or doesn't feel like reading. But these general guidelines should be taken into account as an overall view of your child's development. I hope this helps give a better understanding of what we observe as speech patholigsts at Cook Children's.

*The vocabulary ranges used in this blog are based on MacArthur-Bates CDI.

About the author

Carol Edley, M.S., CCC-SLP, is a speech/language pathologist at Cook Children's. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury.

That question makes me cringe. Not because of the question itself. I understand it. As parents, we all want what’s best for our children. I’m not afraid of the question or looking to evade it. It’s just who is making the choice on what’s “normal.” I use the opportunity to talk to parents. To reframe what may be thought of as normal, go over their concerns and provide perspective.

Here are some basic guidelines that I give to parents on how a child should be developmentally from 1 to 6 years old. Every child is different and this is only a starting point. If you have you concerns, please talk with your pediatrician  for a referral to a speech/language pathologist.

• 12 months old - Children usually can say 1-21 words on their own, actively listen, wave bye-bye, look around when asked, "Where is __?" and use real and toy objects to act out common actions, e.g., feeding, cleaning, etc.
• 24 months old - Speak 145-150 words, combine 2-3 words, produce plural - s and - ing words, enjoy nursery rhymes, finger play and songs and put 2-3 actions in symbolic play.
• 30 months old - Say 360-600 words, speak in simple sentences, have his or her speech understood by family members, listen to real stories and start role playing in life experiences, such as going to the doctor.
• 36 months old - Say so many words you can't count them, have his or her speech understood by more than half the people your child meets, use "I, me, my and you" correctly. Answer what, where, when and who questions and retell familiar stories. At this age, children should be asking questions, not learning to read yet, but enjoying books and making friends.
• 4 years old - Your child should start playing with words and making up stories. Most children at this age will be playing with friends and pretending to be a superhero, a cowboy, a parent or an animal. Children may begin using voices as characters and creating their own costumes and props.
• 5 years old - Most children at this age have started school. They can sit and listen for a whole story. They will start using words such as "know, understand and think." They will talk to ask questions, to explain things and to imagine.
• 6 years old - At this age, most children begin to speak more like grownups, especially at school. They can be polite when talking and know when adults don't understand what they have said. Often times, children will be able to change what they originally said to be better understood. Children at this age should be able to use all of their speech sounds and begin reading.

You know your child better than anyone and of course there will be times when your child just won't pay attention or doesn't feel like reading. But these general guidelines should be taken into account as an overall view of your child's development. I hope this helps give a better understanding of what we observe as speech patholigsts at Cook Children's.

*The vocabulary ranges used in this blog are based on MacArthur-Bates CDI.

About the author

Carol Edley, M.S., CCC-SLP, is a speech/language pathologist at Cook Children's. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury.