This post has been written primarily in response to a request that I received this week from a parent whose 2:6 year old had just received a diagnosis of Developmental Verbal Dyspraxia (DVD) from a speech and language therapist. She wanted to know a little more about the condition and how to help. About 6 weeks ago, I made a vlog/blog explaining how to spot DVD really early on in children. Now obviously, this needs to come with a warning that not all late talkers have DVD. I wrote my blog after attending a fascinating talk at the Clinical Excellence Network for Speech Sound Disorders at Strathclyde University. Yvonne Wren, a speech and language therapist and researcher with ALSPAC had identified early indicators of significant and persistent speech sound disorders. Of which DVD is only a tiny percentage. In fact, Developmental Verbal Dyspraxia is often over-diagnosed or mis-diagnosed, especially at such a young age. So, I'm going to give you some extra reading to do and then some proper hands-on strategies to implement which will help all late-talkers, but especially those who may have features of DVD.
First of all, if you would like a straight-forward handout on what Developmental Verbal Dyspraxia is here is one from ICAN the communication charity.
If you would like a really in-depth Policy Statement from the Royal College of Speech and Language Therapists (the UK's professional body) about Developmental Verbal Dyspraxia, then here it is - all 60 pages of glory
It is actually essential reading if you are an SLT, policy-maker or parent who regularly does more investigating on google than the FBI. But if you'd rather pull your teeth than trawl through 60 pages of policy, I've summarised some interesting snippets for you here:
- Firstly, no one can agree on whether DVD actually exists in its own right, as the characteristics of DVD overlap with other speech impairments (SIs) A child with DVD typically presents with a wide range of characteristics/deficits and so specialists in this area "suggest that clinicians should perhaps be looking for ‘apraxic/dyspraxic features’ rather than recognising whether a child has/does not have a condition." So, going back to my previous blog I mention here that most SLTs will describe a child as having dyspraxic features rather than saying "they have Developmental Verbal Dyspraxia."
- Secondly, because of the confusion mentioned above, over-identification may be a factor. "Several [research] papers, including Delaney & Kent (2004), show that clinicians identify a number of children as having suspected DVD features, who when assessed by researchers or clinical experts the potential diagnosis is rejected." So, your child might not actually have DVD anyway!! However....
- "RCSLT states that ‘(features of) DVD can manifest itself in early infancy with difficulty with feeding, sucking, chewing, followed by a delay in expressive language, difficulty in producing speech, reduced intelligibility of speech and inconsistent production of sounds in familiar words’" Something that was backed up by the research by Yvonne Wren down in Bristol, and on which my previous blog was based.
- "It can therefore be concluded, from the above studies, that the DVD symptom cluster is a rare presentation. However, its occurrence may be a warning sign of the likelihood of persisting speech difficulties, being identified in 0.2% of the referred population, i.e. 1 in every 500 children referred [to SLT.] ... Given that 1 in every 6 children are referred to SLT services (Law et al 2000), this estimate extrapolates to around 1 in 3,000 children presenting with the DVD symptom cluster in the general population."
Well, now that is clear (!) let's talk about how we can help the 2-3 year olds who are late in talking
Going back to the RCSLT's policy document, it says "It seems logical to suggest that such direct intervention on speech needs to take place when children are developmentally and cognitively ready to cope with motor planning drills and the like." Are 2-3 year olds going to be ready to sit down and cooperate with speech sound drills? Definitely not. And you'll only put them off therapy for life if you start too early. I agree wholeheartedly with the document which goes on to say: "In the earlier stages of intervention, SLT support may be more about establishing communication systems and helping the parents and other practitioners involved with the child begin to understand the nature and long term implications of the classification once its presence is confirmed....So, intervention should begin early, with one particular focus, but the focus will change as other skills emerge. For example, the focus may move from communication strategies, communication pre-cursors (e.g. attention & turn-taking) and vocalisation to motor planning drills, phonological awareness or literacy, as the child develops."
In a nutshell, for children between the ages of 2 and 4, intervention is all about helping your child to feel happy and confident and to give them ways to communicate so that they feel less frustrated. Obviously, the ultimate aim is for them to communicate orally, but when they are tiny and frustrated, it might be useful to introduce other types of communication to support them. SLTs call these alternative or augmentative communication (AAC) systems and they might include:
- Signing systems such as makaton or signalong both of which use signs to support spoken language. Signing is never seen as something to use instead of speaking; it is to support speaking and it bridges the gap between no words and words.
- Symbol systems such as boardmaker or widgit which some people prefer if the child's fine motor skills are not accurate for signing. Just with speech, if only the parent can understand the child's sign, then that's not going to increase their communication or decrease their frustration. When you point to a symbol, there's usually no mistaking what the child is communicating.
Obviously, which one you use, is entirely up to you. I naturally used signing with my son when, at 2 years, he didn't have any words because, well, I naturally sign all the time. Most SLT departments offer signing courses. Using symbols requires more effort in the inital stages, in terms of preparation but a child is more likely to be able to communicate more by using symbols rather than signing. Here's a link to a blog to a parent (who is also an SLT) who uses PODD (it's a symbol system) to communicate with her daughter. I need to stress that symbols are usually used when the child is unlikely to speak due to a significant communication or developmental delay. Children with DVD will talk, but the clarity of their speech will take time to develop.
- As I've searched through the internet to bring the best advice to you, I was a little surprised to see that some websites who claim to be experts on dyspraxia recommend using oro-motor exercises (e.g. blowing, licking, moving tongue etc) to improve a child's speech. If you wanted to learn basketball, you wouldn't run around pretending to bounce a ball, as the flapping motion you made with your arms would bear no resemblance to the actual strength needed to bounce a ball. Likewise, practising sticking your tongue out helps you to stick your tongue out but doesn't help at all with any tongue movement required in speech because, well, you don't stick your tongue out when speaking. If you're in any doubt as to whether you should or shouldn't do oro-motor exercises for DVD, then read this. But I'll save you the effort and paraphrase "there is no evidence to show that this will help speech development." So, by all means, play blowing games and practise licking, but only because it's fun, not because it will help your child's speech.
So what will help my child's speech?
- Let's think about this from the child's perspective! What do they want to be able to say? It's obviously going to differ from child to child and family to family. So, it's useful to pick some vocabulary to target. Think about:
- Simple but effective words, such as "more" "bye" "ball" "baby" "open"
- You'll notice that I suggested words that have easier sounds, developmentally (you can refer to this chart if you want to see which sounds develop first) However, sometimes children with DVD don't follow the typical path of speech sounds development, so if "juice" is achievable, then so be it. Whichever sounds they are already using, or babbling with, choose more words with those sounds in them!
- Use the symbol or sign to go with them.
- Let them hear that word by itself (rather than in a sentence) lots of times. So, instead of saying "are you going to say bye to Grandma?" you'd say "bye bye." You'd also say "bye bye" when tidying toys away, putting dishes in the dishwasher, putting clothes in the washing machine. The aim is to let them hear it several times during the day in meaningful contexts.
- Pick ten functional words and then add in new words as they start to use the words functionally (not when they repeat it once!) You can use this pdf to keep a record.
- Encourage lots of symbolic noises in your play, so "wheee" as they go down the slide, "uh-oh" when you drop something, a sharp in take of breath to indicate something is hot, "oo-oo" for monkey. It's also important that your child starts to hear speech sounds by themselves, but in a fun way, not in a sit-down-and-say-this-sound-after-me type of way. So, when you are bouncing a ball you can say "b-b-b" or when you are drawing a snake in the sand, you can say "ssss" when you are popping bubbles, you can say "p-p-p" and so on. Don't expect them to repeat the sounds
- Don't forget all the usual advice for early language development. I touch on it in my blog "Extending words to Two Word Phrases" and you can watch the strategies in this video by ICAN It's for early years staff, but it goes without saying that the techniques are useful for parents too!
So, I hope this is useful - lots of links in one post, to save you having to trawl through the internet to get good (and not so good) advice. If you know of any more resources, let me know and I'll add them here.