Q: What can I expect from speech therapy? My child doesn't say words or seem to understand what to do. It's so hard to keep his attention to teach him and he gets so frustrated.
A: There are several foundational skills important for learning language. It is important to understand that words are only a part of the picture in language development. Words alone are not functional without knowing how to use them appropriately and effectively. We use words to communicate our wants and desires, to talk about our surroundings and relate experiences, just to name a few. This is what we call communication. Communication, however, begins before a child learns to use verbal words or manual signs. It begins early in development through the use of eye gaze, social attention, vocalizations, gestures and other body language. There are also different reasons (functions) your child has for communicating and there are different ways (means/modes) to communicate.
It is important for caregivers to understand that your speech-language therapist may need to focus on pre-verbal communication, and early learning skills while facilitating functional communication development. Along with teaching functional communication skills, it may be necessary to also focus on skills that are essential for learning in general. Some children have significant challenges in self-regulation, attention, motor planning, imitation, and understanding social reciprocity. These skills are essential for most areas of learning and especially language and communication. Your speech-language therapist may need to determine if there is a need to focus treatment on building up these areas of learning at the beginning of your child's treatment journey.
It is equally important to understand that each child is different because of varying skill levels and learning styles. Keeping this in mind, therapy is a creative and dynamic process where clinical decisions are made dynamically throughout therapy for each individual child. Although many of the children need to work on the same skills, how these skills are taught will vary from child to child and the course of the therapy will differ as well. Additionally, if your child demonstrates strengths in the pre-verbal communication skills described above, their challenges may be explained by other reasons such as a motor planning challenges, language processing challenges, deaf or hard of hearing, or intellectual disabilities. It may take some time to determine underlying factors and treatment will take different forms depending on the outcome of further assessment. Your therapist should explain every step and provide education or appropriate referrals to provide the most thorough and appropriate treatment for your child. Family and caregivers are an integral part of the treatment team. Along with being part of decision making, you should receive hands-on training to facilitate the carryover of learned skills into every environment your child experiences. This is vital for progressive and sustained learning to occur.
Below is a list of important foundational skills which are essential for your child’s overall functional communication abilities. If your child demonstrates weaknesses in any of the following areas, treatment may focus on building those skills in the beginning of the treatment process:
Initiation – This is the internal motivation to get wants and needs met. As infants, a child's first form of communication is crying. Through exposure, observation, problem solving and a drive for social interaction they begin to understand that they can have an effect on others, especially to get their wants and needs met. It is so important for your child to be able to efficiently initiate communication (approaching, getting your attention, pulling you to what he/she wants, pointing, etc.) for a range of reasons, rather than just crying to which you might respond by scrambling to figure out what he/she needs before a full meltdown ensues. Once your child acquires more effective ways of communicating, he/she can experience less frustration and anxiety.
Persistence – This is when your child continues to try and communicate when his/her first attempt is not immediately acknowledged or understood or there was a breakdown in communication in any way. This is vital for overall learning and independent communication.
A lack of initiation and persistence significantly reduces opportunities for natural learning and makes it very challenging to create learning situations.
Attention to Activities/Social Interactions – Demonstrating the skill of sustained attention to a play activity or social interaction is paramount to early learning. A child may have challenges regulating his/her body as a result of difficulties in the body's ability to integrate environmental stimuli (sights, sounds, smells, touch). Or a child may experience breakdowns in internal processing (understanding where his/her boy is in space, motor planning deficits, etc.). The energy it takes this child to just regulate his/her body leaves little or no capacity to take in the ever-changing, dynamic information in learning language and navigating social interactions. Facilitating a child’s ability to regulate their body increases their ability to focus and attend to learning opportunities around them. If your child exhibits some of these challenges he/she may benefit from occupational therapy.
Anticipatory Excitement – This simply means increasing the level of anticipation for a play activity or social routine that is highly reinforcing to that child. Your child watches and waits in anticipation for what you will do next. Increasing your affect (facial expression, body posture, silly sound effects, etc.) heightens attention to you as the communication partner. In this emotional state your child’s attention is heightened facilitating better learning and social opportunities.
Reciprocal Interaction – This skill is foundational to the back-and-forth verbal interchanges of conversation, and it begins in early infancy. Some researchers have coined this skill “serve and return”. You can picture a volley back and forth. It encompasses such things as reciprocating an action (rolling a ball back and forth), or sharing a social exchange (back and forth cooing or a game of peek-a-boo) while sustaining the exchange for several turns.
Joint Attention – Joint attention is a pivotal skill in natural, incidental learning and is acquired solidly by 18 months of age. Children use this skill naturally to learn language. Joint attention is the sharing of an experience between a minimum of two people and an object or event (picture the three points of a triangle). For early learning, this would be your child and his/her caregivers. In its simplest form, joint attention is observed when a child experiences something and then looks back to his/her caregiver to share emotion (excitement over fireworks) or to gain understanding (learning the name of a novel object). This may look different for children on the autism spectrum as they can still be attending to you without overt eye contact, they may be attending through peripheral eye gaze, and proximity.
Nonverbal Imitation – Imitation of actions (e.g., you clap your hands, child claps hands) are a steppingstone to lay the foundation for later verbal imitation (you say “ball” while holding up a ball, your child imitates “ball”). Imitation is an underlying skill for reciprocity and is one of the ways children learn. This skill is also crucial for expanding functional play skills. Underlying motor planning challenges may call for additional supports.
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