It is important to keep in mind that the parents are not the only ones experiencing frustration. In fact, we ought to have a lot of empathy for a toddler with an expressive language delay. An analogy may help to understand what is happening for a toddler in this situation: you’ve just spent hours writing a report for a class that begins in 45 minutes. You finally finish and send it to print—but the printer doesn’t cooperate! It won’t feed the paper, or just prints an endless sequence of random characters. The teacher for this class is the scariest in the whole school, and now you have to explain why you don’t have your work done.
You can imagine (or have experienced) how frustrating that would be. Children with an expressive language delay are often stuck in a similar bind. They have done all the advance work—they know what they want to say, the brain has sent the instructions to the articulators, but no output! Or, perhaps there is some output, but like the printer malfunction, it is just a sequence of random sounds that make no sense to anyone. And this is not just an occasional occurrence for these children, but happens every time they attempt to say something. Thus, there is considerable motivation on both sides to opening the channels of communication: for children, to be able to say what he or she needs and get it, with only minimal frustration involved; for adults, to know what the child needs without having a cup thrown at their head to indicate “more juice.�
The printer analogy points out an important distinction between two aspects of human communication: language (the program running on the computer) and speech (the printer). We form messages that we would like others to know, those messages get encoded into a set of words, and those words are placed in a particular order, before we start to produce sounds. These processes are collectively what we refer to as language. Language is then translated into motor commands that control the articulators, thereby creating speech. Speech refers to the actual process of making sounds, using such organs and structures as the lungs, vocal cords, mouth, tongue, teeth, etc. So, producing an utterance is really a two-stage process. Most of the process of forming an utterance is internal. While we can hear the sounds (and see the lips move), allowing us to directly observe the creation of speech, there is no direct way to observe what is happening in someone’s head when that person is encoding an idea into language.
The internal nature of language causes many people to think of language as being the same as speech. But language and speech are not the same. If you think about it, language is at least as important (if not more) than speech. An individual who had language but not speech could still write down his or her thoughts, read books, use sign language, and understand what another person was saying. But if someone didn’t have language, that person wouldn’t be able to do any of those things. Saying that language is important in no way implies that speech is not also important—speech is an amazing thing in itself. Speech requires the highly coordinated movement of a many different articulators. The point is just that since language often gets mistaken as being the same thing as speech, people often think that speech is all there is. You can hear this in the way that people talk about a child who is not communicating: “She has a speech delay.� He’s getting speech therapy.� The speech pathologist is waiting.� Etc.
One consequence of the hidden nature of language is that speech becomes the sole focus when a child has difficulty communicating. And since speech is a fundamentally a physical process, it is typically assumed that the best way to treat a communication delay is as a medical issue. Thus, the first action that many parents take when their young child isn’t talking is to seek a specialist who can help them determine if there is a problem. The first specialist that most families talk to is their pediatrician. The pediatrician makes a referral to a Speech-Language Pathologist (SLP), who evaluates the child, and gives the parents a sense of where their child is relative to typically developing peers. The big question is: What happens next?
In order to answer this question, it is necessary to take a quick look at how the medical model works. Medical issues, by definition, are about a single individual—the patient. In the medical model, the entire focus is on the identifying and managing a “disease� or “deficit.� Thus, the patient is “diagnosed� under a set of standard criteria. The patient undergoes chemical (pharmacological), physical (surgical) or behavioral (counseling) interventions that treat the illness or remediate the deficit. For example, someone with a disease (diabetes) takes a chemical (insulin) in order treat the illness. They may also engage in some recommended behavioral changes (diet, exercise) to help manage the problem. Unfortunately, the medical model isn’t really that successful, even when it comes to a seemingly straight-forward case like diabetes. With an issue like diabetes, the medical model is only about 60% successful. The reason the medical model isn’t very successful is that it is not designed to take a wider perspective on the problem; it doesn’t do enough to address the context of the person. The medical model stresses the physical aspects of the problem over the behavioral and social. Returning to our diabetes example, the best approach might be one that is focused on the peer group of the individual and what kinds of food the individual feels pressured to eat.
Now let’s look at how the medical model addresses a young child with communication delay: Assuming that the SLP recommends that the child receive speech therapy, the child will be brought to a clinic or hospital once a week for 30-50 minutes to undergo “treatment.� But communication, especially for a young child, is a delicate thing. Does it make sense to expect a toddler to want to communicate more with a stranger in a strange place? Also, toddlers are often just getting warmed up after 50 minutes, just when the session is over.
The fact is, most young children don’t respond well to being brought to the hospital once a week to work on communication in a little therapy room. And, truth be told, the cause of communication delay for most children is usually not because there is something wrong with the physical process of forming speech sounds. That is, the delay in speech is not because anything is broken. More typically, there are other reasons why the child has not begun producing language. (The observable consequence of this, however, is: no speech. Hence, the tendency toward a medical intervention.)
One reason that children don’t talk is that they’ve experienced a rocky go if it so far with health complications, and they have gotten off track in the developmental sequence. What these children need is a good reason to start communicating. Other children, as noted above, have had chronic ear infections. These children often have given up on communicating and have become very independent. They also need a reason to communicate, as well as a lot of appropriate modeling of language in order to get them talking. For many children (including some of those just mentioned), their articulation system is just not yet up to the task of translating language into sound. What these children need is an alternative way to communicate until their nervous system matures enough to produce coordinated speech. In short, communication delay is usually not a “medical� issue in the traditional sense, and there are good reasons why a different approach might be more successful.
What does a different approach look like? The approach advocated in this book focuses on the whole environment, maximizing the resources of the family and others by providing caregivers with specific information that helps them to adjust the communication environment for the child where he or she is to be found: a naturalistic setting such as the home or community where the child is already comfortable. We can address communication issues by supporting a change in the relationship between the people who are communicating. And for young children, their important relationships are with a particular group of individuals—their families. The efficacy of naturalistic approaches is well documented, and, in my experience, getting communication moving again is easiest when it focuses the home environment. This is especially true for children who already have difficulty controlling their world due to a communication delay. Parents and consistent caregivers are the most important people in a child’s life, and they are the ones who will make the biggest impact on the child’s communication.
The goal of this handbook is to help families get their little girl or boy back on track with communication. I want to emphasize that the most important word in the previous sentence is families. Families are the key to the approach outlined in this book. Thus, the workbook is specifically designed to help adults learn how to talk to children in a way that will cause them to talk more. It is written in short chapters that can be read while the kids are in the bath, or during the 3 minutes in bed before tired parents fall asleep after a long day of chasing children around. The main activity (apart from reading the chapters) will be to keep a daily log of the sounds and words that your child is making. There are certain things that all children do while learning language, but there are a lot of individual differences as well. Especially with early sounds, each child may have his or her own way. For this reason, it is very important that you use the language log (included under the Toolbox section) to track the sounds and words that your child is producing. It is a good idea to put the language log somewhere you can easily access, e.g., on the fridge. When there is little time in the day to go find the book and write something in it, it is crucial that pages be taken out and put on the fridge, where there is a reasonable chance that they will be looked at and used.
In addition to the language log, each chapter is accompanied by a worksheet (attachment). The worksheets are important because they help make sense of the content of the chapters. Some of the worksheets depend on information that is collected on the language log. They transform information from the language log into usable strategies. They will help you decide what are the next steps (sounds, words, phrases) that your toddler is ready to take. You may choose to fill out the worksheets on your own, or you may choose to wait and do it with an educator or Speech Language Pathologist (SLP). In either case, they will help determine what is most appropriate to work on. Since some of the worksheets depend on information from the language log, it is all the more crucial that the child’s sounds and words be recorded. If your child is not yet producing much, read the early chapters (under the First Words and Behaviors sections) that focus on eliciting more expressive language. The techniques contained in those chapters will get the ball rolling, and give you something to record on the language log. The chapter titled: The Language of Communication contains a glossary of special terms that are helpful in talking about communication. If you are having difficulty understanding some of the words used in the chapters, look there for a description or definition.
Some parents will have tried to work with their child on language development and found that he is resistant to participating. These parents may have also noted the ease with which others may be able to work with the child, and have concluded that therapy in a clinic is really the only way that anyone will be able to connect with their toddler. Children with language delay can become so independent, especially at home, that half the work seems to be just in making contact, even before you can begin working on specific sounds and words. The suggestions in this book should allow you to make more progress with your child at home, where the child spends the most time, and where the most important relationships are.
For those toddlers that first need to learn that it is useful to communicate at all, it is sometimes productive to start with an alternative way to communicate. This might be the use of a few signs, such as “more� and “all done.� Another way is to use some pictures of familiar objects, so that the child can make choices about what he wants by pointing. Even just the use of a single sign or picture might entirely change the way the child thinks about communication (see Who’s Calling the Shots? for more about this topic). Neither of these systems, signs or pictures, is a long-term solution to the problem. But they serve a very important role: they get communication back on track, and in doing so, build the motivation in the child to also use words as a means of getting what he needs or wants. Signs and/or pictures are like the grease that gets the system moving again. If everything goes well, they won’t be needed after there is sufficient momentum for communication.
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