Question
I have been working with a child for approximately 2 months who makes no open mouth vocalizations except when crying and laughing. He does make a closed mouth, humming noise to get someone's attention. He is 23 months old, and by parent report did not bab
Answer
The possibility of some type of oral motor deficit is an important question to consider for this child. With the exceptions of the r-colored vowels, vowel sounds are acquired very early by typically developing children. Even among children with articulation and phonological delays, errors on vowel sounds occur infrequently. A young child with significant difficulty producing any open sounds (i.e., vowels) is presenting an atypical pattern. This child is described as willing to imitate various oral motor movements, suggesting the clinician has been able to explore oral motor function for nonspeech tasks. Additional information could be obtained from the child's parents and from observation of oral movement during functional tasks such as eating. The parents would know if the child had any feeding difficulties during infancy in addition to the limited occurrence of vocal play and babbling. Observation of the child while drinking and eating provides information about oral motor abilities. Watch for movements such as vertical jaw motion while chewing, lip seal while drinking, and tongue movement to manipulate food in the mouth and/or lick food off the lips (Strand & McCauley, 1999). The presence of oral motor difficulties indicates a need to consider special motor speech treatment approaches (e.g., Hayden & Square, 1994; Strand & Skinder, 1999) or to incorporate techniques addressing oral motor and/or oral sensory deficits into the treatment plan (Velleman, 2003).
Vertical movement of the jaw with sound production is considered the earliest developing articulatory movement. Thus, the goal of open mouth vocalizations is certainly appropriate. Currently the child phonates, i.e., makes a humming noise, with a closed mouth. If one of the oral motor movements the child imitates is opening the mouth, then the goal is to coordinate phonation with this open mouth gesture. Because direct imitation has not been effective, one suggestion is try simultaneous production as used in integral stimulation treatment (Strand & Debertine, 2000; Strand & Skinder, 1999). Rather than ask the child to vocalize following a model, ask the child to vocalize at the same time as you - while you are opening your mouth and vocalizing a simple vowel such as "ah." If you are not able to elicit vocalization with an open mouth gesture, you might need to start with something less demanding such as airflow. For example, you could model an open mouth gesture and production of a sustained "H," eventually adding voicing to this sustained airflow. Finally, you could try tactile cues to encourage mouth opening. This cue could be something such as downward pressure on the child's chin or stroking downward on the sides of the face. Velleman (2003) includes a review of treatment approaches using tactile cues in her book.
The child's current humming vocalization occurs for a functional purpose, "to get someone's attention." This suggests that finding ways to make any new vocalizations functional is important. For example, vowels such as "oo" or long "o" could be functional in noticing a new toy or indicating a fun action. Even the sustained "H" might be used in an activity such as "huffing" to blow a house down as you retell the story of the "Three Little Pigs." Finally, once you are successful in eliciting vowel sounds, it is important to move quickly to facilitating consonant-vowel sequences. An early starting point for CV syllables is pairing /m/ or /b/ with a vowel sound (Hayden & Square, 1994).
References
Hayden, D. A., & Square, P. A. (1994). Motor speech treatment hierarchy: A systems approach. Clinics in Communication Disorders, 4 (3), 162-174.
Strand, E. A., & Debertine, P. (2000). The efficacy of integral stimulation intervention with developmental apraxia of speech. Journal of Medical Speech-Language Pathology, 8 (4), 295-300.
Strand, E. A., & McCauley, R. J. (1999). Assessment procedures for treatment planning in children with phonologic and motor speech disorders. In A. J. Caruso & E. A. Strands (Eds.), Clinical management of motor speech disorders in children (pp. 73-107). New York: Thieme Medical Publishers, Inc.
Strand & Skinder, (1999). Treatment of developmental apraxia of speech: Integral stimulation methods. In A. J. Caruso & E. A. Strands (Eds.), Clinical management of motor speech disorders in children (pp. 109-148). New York: Thieme Medical Publishers, Inc.
Velleman, S. (2003). Childhood apraxia of speech resource guide. Clifton Park, NY: Thomson Delmar Learning.
Dr. Lauren K. Nelson began her career as a speech-language pathologist in 1978. She has been on the faculty at the University of Northern Iowa in Cedar Falls, Iowa since 1990. Dr. Nelson can be reached at lauren.nelson@uni.edu.