Acknowledgments: Supported in part by research grant 1 K08 DC 00102-01A1 from the National Institute on Deafness and Other Communication Disorders, National Institutes of Health.

Will my child talk?

• Talking isn't an either/or question, and labeling a child as "nonspeaking" does not indicate that they cannot use speech for any type of communication.

• Children who are having difficulty controlling the muscles involved in the speech/respiratory process, or who have other neurological or cognitive limitations that affect speech and language, are at risk for developing speech that is intelligible to all listeners.

• Children's motor systems are still developing in ways that cannot be predicted, and early intervention is too early to give up on further improvement in speech skills.  Almost all children who can produce a voice will use sounds in some ways that are interpretable to listeners.

• When children continue to learn new sounds or new variations on the sounds they are producing, that is a positive sign for their continued vocal development.

• Even children with limited sound repertoires can often use sounds for specific purposes such as attention, emotional signals, or emphasis
   
• Improving vocal strategies does not necessarily imply drill and practice - formal teaching strategies are not appropriate for young children
   
• Evidence suggests that successful improvement in vocal use by young children can be facilitated through focused partner feedback and prompting in the context of functional and language-based activities
   
• Children with physical and/or cognitive impairments may have interaction patterns that affect their learning and use of vocal strategies
   
• Children with poor kinesthetic feedback may have a limited sense of which movements produce different sounds
   
• Children with physical impairments may be less likely than expected to imitate sounds and movements (Cress, Reynolds, & Andrews, 1998)

• Three children under 2 years old with physical impairments

• All children were participating in a longitudinal study addressing language and communication development in children relying on AAC

• Vocal strategies were included as part of trial therapy in the longitudinal study (2-4 hours per visit, every 3 months)

• Strategies included:  modeling, trial therapy, recommendations, parent coaching and support, and providing materials reinforcing goals

• positioning for trunk and head control
  
• breath support (e.g. blowing, towel rolls)
   
• reducing other distractions or discomforts
   
• desensitization and stimulation of oral structures e.g. "toothettes" to brush mouth, vibrating toys

• 22 month old boy with cerebral palsy
• Sits without support, pulls to stand, grabs and holds objects
  
  Battelle Developmental Inventory Subscores (age equivalence):
•  Fine/Gross Motor:  7 months
•  Cognition & Receptive Language:  15 months
•  Expressive Language:  12 months
  
  Sounds: 
  2-3 vowels, 4-5 combinations, infrequent babble, little sound combination (CV's), parent report difficulty vocalizing & eliciting sounds
  
  Goals: Increase frequency of vocalization during activities
  
   1.  Produce sounds more often within activities

• pair vocalizing with child in motion, esp. sensory integration activities (rolling, etc.)
• provide lots of modeling at or just above child's sound ability
• give tactile responses when children vocalize
• give children a variety of ways to participate in activities if they can't vocalize right away

Results:  ZC

• Introduced new vocal routines and modeled with family, e.g. roll, toy play, or splash with modeled sounds
• Modeled and coached turntaking routines with sounds, including imitation with pauses for ZC's sounds
• After 6 months:

• increase in promptness of vocalization within routines
• added one new sound to vocal repertoire
• more spontaneous babbling and coordinating of vocalization with  activity

• 21 month old boy (corrected age) with cerebral palsy
• needs supported sitting, weak palmar grasp with both hands

Battelle Developmental Inventory Subtests (age equivalence):

•  Fine/Gross Motor:  5 months
•  Cognition & Receptive Language:  10 months
•  Expressive Language:  12 months

Sounds: 
3-4 distinct vowel sounds & 7-8 consonants that he combines with open vowels.  Frequent emphasis on vocal imitation with parent

Goals: 
Use familiar vocal play to increase diversity of vocalizations within activities

 2.  Increase variability of children's sounds

• imitate child's sounds after they make them
• look for continuation of sound and turntaking by child, often in the context of activities
• gradually introduce variation of sound, often paired with different motion or activity
• give lots of feedback to child when they use different sounds, try to repeat circumstances

• Imitation games began by imitating OA's spontaneous sounds
• Parent modeled new sounds in full-face contact with minimal distraction
• OA was tactilely and socially reinforced for sounds and response to modeling
• After 3 months, OA:

• attended closely to parent models
• began to orally posture new sounds

After 6 months, OA attempted to change his vocalization in response to parent model  

Case Description 3:  MB

• 20 month old girl with hydrocephalus and spina bifida with Arnold Chiari malformation
• sits alone, no standing without support, slow pincer grasp
  

• fine motor, social, receptive communication:  20 mo (at age level)
• cognitive and expressive language:  14 months

Sounds: 
most vowels, 4-5 consonants, frequent babble during play using vowels with intonation contours, little use of consonants in babble, frequent use of sounds for communicative requests or attention

Goals: 
using vocalizations to represent meanings within a variety of activities  3.  Associate vocalizations with meanings

• pair achievable sounds with activity, but place low stress on child production at first
• provide tactile, social cues for sound (e.g. phone, microphone/tape, social routines)
• include activities where sounds are natural (songs, books with repeated lines, rhymes)
• provide functional feedback within activity related to children's vocalizations

• Modeled and coached parents in adding sounds to gesture routines
• Presented simple sound patterns (Cvs) for parents to model in specific frequently used requests or comments
• Adapted songs and routines so that MB had an achievable sound role in routine at a predictable time
• After 6 months:
• MB used at least 15 CV words for referents
• MB also began to use her 15 word spoken vocabulary in 2-word sentences such as "bye-bye mama"