A little girl in my class who just turned 4 has limited speech. She uses mostly single words, and it is difficult to understand her. But she does listen and respond appropriately to what I would consider to be complex language. How should I be working with her?
It's important to start as you did — by assessing the child's ability to focus and attend to social signals. It's also important to consider her ability to use gesturing, her use of imagination in pretend play, and her ability to understand complex commands and abstract concepts. I'm glad that you assessed her understanding and relating and found her to be functioning well in those areas.
Understanding the Causes
There seem to be two components to this child's problem. The first is an oral-motor component. This addresses her ability to make specific sounds. The second component involves stringing together many ideas in a row. This can be related to something called word-retrieval challenges, in which it's hard to find the words for the things you want to say. Or it may have to do with what we call planning and sequencing — the ability to sequence ideas in a row. There are other reasons, not all clearly understood, why some children have a difficult time articulating what's on their minds. It's important to have a qualified speech pathologist do an evaluation to see if there are specific areas to be worked on in speech therapy as well as in the classroom.
Measuring Motor and Sensory Abilities
Since this child has articulation difficulties, her motor and sensory systems should be considered. Can she carry out multiple-step motor tasks, such as copying shapes, writing letters, throwing or catching a ball, kicking a ball, or getting through an obstacle course? You'll want to observe both fine- and gross-motor abilities, not just in a short sequence, but also in a 5- or 10-step sequence, such as in playing musical chairs or copying a number of shapes in a row.
Also observe her sensory system by looking at each sensory pathway. This includes touch, sound, sight, and movement. See if they're over- or under-reactive. Again, sometimes a problem in one area, such as the oral-motor, is associated with challenges in other areas. So the same child who has oral-motor trouble may be over- or under-reactive to touch or sound. And many children who have oral-motor problems are also finicky eaters because they are very sensitive to tastes. They may be sensitive to other children's brushing up against them or to some kinds of clothing or to loud noises. These are all things for you and the child's parents to consider. If it turns out that there is any question about motor or sensory functioning, it's a very good idea to have an occupational therapist do an evaluation of the child.
Preparing a Program
At the same time that the proper professional evaluations are being done and parent-teacher discussions are under way, it's important to organize a program at school and to help parents design one at home that will help the child with her articulation and expressive-language challenges. Here are two places to start:
- Try to engage the child in as long a conversation as you can each time there is an opportunity to converse. The talk can center around pretend play, such as a situation in which the child is taking a dolly for a ride in a truck to visit Grandma. Stretch conversations as far as you can. If the child says, "We're going to Grandma's," ask what she'll do there. If she says she'll play, ask what kinds of things she'll play at Grandma's house.
- Involve the child in floor-time activities. This involves getting down on the floor, engaging the child in imaginative play, and extending the circles of communication with lots of back and forth conversation.
Suggestions for Teachers
In school, you can create opportunities for the child to have long conversations with other children. Be very patient if she answers in one word-and be satisfied with that. Then ask for elaboration, and you're likely to bring on longer phrases or sentences.
At group time, call on the child to answer questions, always following up with more back and forth extensions of the conversations. At the same time, you will be helping the articulation problem by encouraging the child to listen and talk a great deal, practicing sounds.
You and the child's parents should each work with the speech pathologist, playing little sound games that offer the child practice with sounds that are hard for her. Start out with sounds that are easy for her to make, then move into more challenging ones, all incorporated in such games as Simon Says.
It also helps a child who struggles to make a sound to look at how your lips and tongue move when you make the sound. So model for the child, saying, "Watch." Then the two of you can look in the mirror and try it together. The key is to be very patient.
Suggestions for Parents
Parents should seize opportunities to extend conversations at home. For example, suppose the child is dressing a doll as she plays. The parent can dress another and say in the doll's voice, "I don't like that dress; I want a different one." The child has to say, "Which one do you want?" and the parent says, "I don't know. You have to help me decide." And so the conversation keeps on going.
Parents can also help by gently touching the part of the child's lip that has to move. Under the guidance of a good speech pathologist or occupational therapist, parents can provide some sensory support. This might include gentle massage in the soft palate or around the lips. This helps the child experience more sensation in the mouth, or more balanced sensation, while it also helps with motor control.
The most important role of the teacher and parents is to facilitate lots of chitchat back and forth with adults and with other children, in all sorts of situations. Be sure to make it fun and a natural outgrowth of play, not something that evokes anxiety by demanding performance.
The Child With Special Needs by Stanley I. Greenspan, M.D., and Serena Wieder, Ph.D.
The Affect-Based Language Curriculum (ABLC): An Intensive Program for Families, Therapists, and Teachers by Stanley I. Greenspan, M.D., and Diane Lewis, MA, CCC/SLP