Executive Function Disorders

“Difficulty with the process of coordinating, prioritizing, and/or managing information needed to perform tasks successfully may be indicative of a disorder of a child’s executive functioning abilities.”

A child with an executive function disorder may be highly intelligent, but they may also struggle to complete seemingly simple tasks, such as remembering to hand in their homework.

What are Executive Functioning Skills?

Executive functioning skills are cognitive based skills that help individuals plan, direct, and execute actions in their daily lives.

Lower-Level Executive Functioning Skills impact regulation of behaviors.

Higher-Level Executive Functioning Skills are meta-cognitive based.

Some executive functions include…

  • Planning and Prioritizing

This refers to the ability to “see and create” order, related to the individual’s life. Deficits in this area are evidenced by disorganization of materials and home/work spaces, as well as memory deficits.

  • Starting a Task (aka “initiation”)

This refers to the ability to begin actions in regards to activities or tasks. Deficits in this area are evidenced by difficulties “getting started” –even with help. Individuals who struggle in knowing where/when to “start” or those who cannot “get going” without extensive support from others could be experiencing an executive function disorder.

  • Controlling Impulses (aka “inhibition”)

Inhibition refers to the ability to control impulsivity and stop inappropriate actions and/or thoughts at the appropriate time. Delays in this area are evidenced by inappropriate comments and actions. Individuals who struggle with inhibition often “act before they think” or “lack a filter” for the things they say to others.

  • Shifting (aka “transitions”)

Deficits in this area may inhibit a child from switching focus between tasks fluidly or showing “flexibility” in thoughts, words, and actions. Individuals who struggle with transitions may become stuck on certain problems, topics, or activities. (See previous post “Trouble with Transitions”)

  • Controlling Emotions (aka “regulation”)

Deficits in this area are evidenced by mood swings and “dramatic” reactions to seemingly small problems. Individuals who struggle with regulation cannot change their reaction based on facts and may assume information or “jump to conclusions”, which supports their inappropriate reactions.

  • Using Working Memory

This refers to the ability to hold onto information while doing something with it. Deficits in this area are evidenced by difficulty in completing tasks. Individuals who struggle with working memory may start tasks but “lose-track” midway through.

  • Organizing Materials

This refers to the ability to plan and organize tasks related to projects. Individuals who struggle with this area may begin a task at a midway point rather than the beginning, start a task too late, or not have everything they need to complete a task upon starting.

  • Self-Monitoring

This refers to the ability to evaluate and monitor one’s own time and attention. Poor attention, poor timing, and an irregular pace at which to meet the demands of tasks/environment are common features associated with deficits in this area of executive function.

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Some children with executive functioning deficits may develop these skills later than their peers (delay) or experience ongoing weaknesses (deficit).

All of these skills develop differently and vary depending on a child’s age, degree of difficulties, and strengths in other areas.

Executive Function & The Brain:

“It is theorized that, although executive functions use multiple areas of the brain, these skills are based in the frontal lobe, acting as part of the executive system. It is a higher order process that involves connecting past experiences to present novel experiences to control and regulate one’s abilities and behaviors. This allows one to anticipate outcomes and adapt to changing situations in order to manage oneself and one’s resources to complete a task and/or achieve a goal.”

Executive Function Development:

  • Executive functions begin developing in infancy and continue to develop through adulthood.
  • In childhood, executive functioning delays are often seen in individuals with diagnoses such as ADHD, ASD, or other learning disabled.
  • Executive functioning skills may also be infiltrated by strokes, traumatic brain injuries, and the on-set of neurodegenerative disorders in older populations.

Assessment and Treatment:

An SLP’s intervention for executive functioning skills focuses primarily around the language aspects of the disorder. As previously mentioned, higher-level executive functioning skills involve meta-cognition, which is the process of “thinking about thinking”. These skills are language based because they involve self-talk and language processing in order to monitor, plan, and execute actions.

The assessment of executive functioning delays may be completed via formal assessments, informal testing, and observations.

REMEMBER…

“Formal assessments identify delays in an isolated and structured testing environment, while informal testing and observations take into consideration the impact of the delays across a person’s day in a variety of settings.”

THEREFORE…

A combination of assessment styles ensures the SLP or team of professionals working a case have full insight on the individual, and can create an effective and functional therapeutic intervention plan.

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A speech-language pathologist plays a vital role in the identification, evaluation, and management of executive functioning delays and disorders, especially those involving higher-level metacognition and the language-based needs of the individual. A full assessment of the child/adult involves a dynamic assessment as well as observations to help ensure therapy is functional and generalizes across environments. While executive functioning skills impact every aspect of daily living, a solid treatment plan can immediately begin improving an individual’s quality of life.

 

Ashley DiGregorio M.A., CF-SLP, TSSLD

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SLP’s, We Need to Talk…

Six years of school equals more than just a bunch of letters after our names…

SLP-Interview

It is obvious that becoming a speech-language pathologist enriches our minds as much as it does our hearts.

BUT

It is important to remember that while we know what we’re talking about, many parents, teachers, and other healthcare professionals do not know our lingo!

While SLP’s have lots of big words and long answers to describe the ins and outs of our field, it is important to alter our language based on our audience.

The same way we simplify explanations on-the-spot for our kids, we can alter the way we explain things to parents, teachers, and other professionals involved in the treatment and care of our clients/patients/students. 


THINK ABOUT IT:  How can a parent help their child with carryover assignments if they, themselves, don’t even understand the goals or objectives? We cannot assume that every parent is proactive enough to ask questions when they’re unsure of what we mean (and we shouldn’t leave it up to Google to give them an answer!). We should be providing explanations or descriptions for everything we are doing. We should remember that these parents, teachers, and professionals don’t all have degrees in speech-language pathology.


The following is a “dictionary” for some of the lingo we frequently use

(and infrequently explain):

Articulation: Articulation is the physical ability to move the tongue, lips, jaw, and other oral motor musculature (known as the articulators) to produce individual speech sounds, which are also called phonemes.

Articulation Delay/Disorder:  An articulation delay/disorder is when a child has not mastered age-appropriate sounds in the typical time frame. This is characterized by the child substituting, omitting, adding, or distorting speech sounds.

Augmentative and Alternative Communication (AAC): Augmentative and Alternative Communication, also known as AAC, refers to “…all forms of communication (other than oral speech) that are used to express thoughts, needs, wants, and ideas. We all use AAC when we make facial expressions or gestures, use symbols or pictures, or write” (ASHA).

Babbling: Babbling refers to sounds and syllables an infant begins stringing together between 4-12 months of age. Babbling is referred to as a pre-linguistic skill: meaning it occurs prior to the development of speech/language.

Childhood Apraxia of Speech: CAS is a motor speech disorder. Children with CAS have difficulty producing sounds, syllables, and words due to difficulty with planning and executing the fine motor movements needed for speech. The child knows what he/she wants to say, but the brain is having difficulty coordinating the parts of the body that are used to produce these speech sounds (i.e., the vocal folds, lips, jaw, and tongue).

Choking: Choking occurs when food (or a foreign object) becomes lodged in the throat or windpipe, blocking the flow of air. Choking cuts off oxygen to the brain and consequently makes it difficult to breathe, resulting in the inability to cough and loss of consciousness.

Delay: a delay refers to development that is following the “typical or normal patterns” but is developing at a slower rate than age-matched peers.

Diastemas: Spacing between the teeth can cause difficulty producing certain speech sounds as it will allow for air to escape through the lateral portions of the oral cavity.

Dissociation: the separation of movement in two or more muscle groups based on adequate strength and stability.

Disorder: A disorder is classified as development that is NOT following the “typical or normal” patterns (i.e., abnormally).

Dysarthria: Dysarthria is a motor speech disorder resulting in weakness, paralysis, and/or incoordination in the muscles needed for producing speech (i.e., jaw, lips, tongue, palate, and respiratory system).

Dysfluency: speech with an irregular flow. Certain sounds may be improperly elongated, airflow may be interrupted, and sounds, words, or phrases may be improperly repeated.

Echolalia: a repetition of words that occur without meaning and in imitation. For example, a child might repeat a phrase they overheard. The imitation may occur immediately after the stimulus or long after.

Expansions: This is a strategy that can be used to help children learn language. Expansions are when you take the words your child says about what they see and do and repeat them while adding in missing words/grammar. By doing this, you are expanding your child’s language without directly “correcting” him/her.

Fluency: speech that flows smoothly and is clearly understood. Fluent speech is without irregularities like abnormal repetitions.

Frenum: a narrow fold of mucous membrane connecting a moveable part to a fixed part. Its purpose is to stabilize and check undue movement of that part. The lingual frenum is generally under the mid-portion of the tongue. It can help to stabilize the base of the tongue but does not interfere with tongue tip movement. With a short frenum, however, the lingual frenum may have anterior attachment near the tip of the tongue and may also be unusually short. This causes a virtual adhesion of the tongue tip to the floor of the mouth and can result in restricted tongue tip movement (Kummer, A., 2005).

Language: While speech involves the physical motor ability to talk, language is a symbolic, rule governed system used to convey a message. Language can be expressive (what we say) or receptive (what we understand).

Lisp: A lisp refers to an articulation disorder in which a child is having difficulty producing the phonemes /s/ and /z/. The most common are identified by interdental productions, or lateral air escape.

Morpheme: a morpheme is a meaningful part of language that cannot be broken down further. For example, “dog.” A bound morpheme is part of a larger word. For example, the “ing” on “singing.”

Motor Speech Disorders:  Motor speech disorders are a group of speech disorders characterized by difficulty with the motor aspects of speech. They can involve difficulty with the coordination and planning of movements needed for speech (Apraxia) or difficulties with the strength of the articulatory and respiratory system (Dysarthria).

Phonological Processes: the typical patterns of how a child simplifies his/her speech. For example, a young child will simplify the word “bottle” to something like “baba.” A young child may also say “goggie” for “doggie,” “sue” for “shoe,” or “nail” for “snail.” Phonological processes are the normal patterns of simplification all children use as they are learning to speak.

Phonological Delay/Disorder: A phonological delay refers to the prolonged use of phonological processes (sound simplifications) in a child’s speech.

Phonology: Phonology is the study of how speech sounds (phonemes) are organized and used in a language. This includes the study of the individual sounds of a language (phonemes), their patterns (processes), how they are learned (phonological development) and how they work and go together (phonation).

Pica: the persistent craving and compulsive eating of nonfood substances. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, classifies it as a feeding and eating disorder of childhood.

Pragmatic language: this is the social aspect of language that refers to the way an individual uses language to communicate. It may involve using language to communicate in different ways (like greeting others, requesting, protesting, asking questions to gain information, etc.), changing language according to the people or place it is being used (i.e., audience, setting, etc.), and following the rules for conversation (taking turns in conversation, staying on topic, using and understanding verbal and nonverbal cues, etc.).

Semantics: the meaning of words and language.

Syntax: the rules that govern how words and phrases fit together to create coherent sentences (grammar).

Speech: this refers to articulation/phonological skills, speech fluency, and voice. This looks at a child’s ability to physically produce the individual sounds and sound patterns of his/her language (articulation), produce speech with appropriate rhythm (suprasegmental features, inflection, prosody, timing, etc.), and produce fluid speech with an appropriate vocal quality.

Stuttering: a communication disorder that effects speech fluency. It is characterized by breaks in the flow of speech. Some dysfluencies are developmental (you outgrow them) but having too many can actually significantly affect one’s ability to communicate. Stuttering may include repetitions, prolongations, interjections, and blocks. Often stuttering is compounded by secondary behaviors such as tension in the neck, shoulders, face, jaw, chest, eye blinks, nose flaring, other odd facial movements, clenched fists, stomping of feet, jerking, and/or other unusual extraneous motor movements.

By creating a running document of common words, phrases, and areas of deficit, SLP’s can bridge the gap of misunderstanding, and help parents and children understand the nature of their deficits. With a greater understanding, we may achieve  better carryover of goals.

One Last Thing…

After every session try to review with your client/student/patient:

  1. Why do I come to speech?
  2. What did I learn today?
  3. How can I practice at home?

 

 

Ashley DiGregorio M.A., CF-SLP, TSSLD

How To: Manage Self-Stimulatory (“stimming”) Behaviors

Self-stimulatory behavior is commonly exhibited by children with Autism Spectrum Disorder (ASD), however, this population is not the only time that SLP’s and parents may encounter a behavior that a child has developed to stimulate or calm their senses.

Think about it…

  • Babies are soothed when rocked.
  • Adults fan themselves to cool off.
  • People hug to give and receive comfort.

When an individual wants to increase or arouse their senses, they engage in an activity directly involving their senses such as:

  • Listening to music.
  • Eating food.
  • Watching a video or movie.
  • Scratching an itch/rubbing a bruise.

Think about it…

  • Most of these repetitive behaviors are seen as appropriate if carried out at the proper time and in the proper place.

What makes “stimming” different?

  • This phrase is one that portrays a more negative image.
  • The term refers to a repetitive body movement, such as hand flapping, that is hypothesized to stimulate one or more senses”.
  • In the world of ASD, this is known as any type of repetitive, stereotypical behavior engaged in to alleviate or increase sensory input.
  • Children will engage in this type of behavior to get a response, make someone interested, or achieve a more alert state of being.
  • “Stimming” is highlighted by patterns of self-regulatory behavior that are deemed unacceptable.
  • Depending what form the behavior takes and how often it occurs it could be seen as normal – a way to help a person function, or abnormal – a pattern of obsession.
  • Every child and adult, regardless diagnosis, will attempt to modulate his/ her sensory experience as they interact with their world.
  • In fact, only 10% of children with ASD actually engage in exaggerated self-stimulation, such as hand flapping, spinning, toe-walking, licking objects, tracking hand movements or sniffing foods, items, or people.

So you notice these behaviors, now what? 

  • There’s a fine line between behavior management (as a teacher, SLP, and even parent), and seeking professional help for a child’s sensory needs.
  • A qualified occupational therapist (OT) can create a customized sensory diet for every child, which can help reduce “stimming” behaviors.

Some other tips in assessing and managing these behaviors are as follows:

Conduct a Detailed Review: It is important to begin with a thorough assessment of the behaviors. Do the behaviors interfere with daily living, such as the ability to pay attention? Are there any behaviors that negatively impact socialization? Are any of the behaviors obsessive? Do they have a negative impact on the child?

Seek to Understand: What is the function of these behaviors? Most “stimming” behaviors occur involuntarily to some degree, especially in the beginning. However, once a child realizes the relief it brings to their sensory system it then becomes more intentional, and easily gets reinforced into a habit. If it is deemed appropriate it can become a functional way to self-regulate one’s sensory experience, but if it is seen as dysfunctional it can easily get out of control.

Gather Information: If the child is verbal it may prove beneficial to engage in conversation about the behaviors.

For example: If a child stares excessively at an object, consider asking them, “Are you trying to do something with your eyes? Tell me what you see.” If the child is able to verbalize an answer, you may gather extremely useful information to address the behavior with.

Make lists: Most “stimming” behaviors are functional; they serve a purpose for meeting a sensory need, but they may not necessarily be appropriate. Adults may make a list categorizing the behavior(s) as functional and appropriate vs. functional and inappropriate. This will help to determine which behaviors need to be addressed and in what order.

Regulate vs. Eradicate: Once a list is established, it is important to consider the impact that trying to ban the behavior will have on the person. Eradicating the behavior may not be realistic and may make things worse in the short term.  Sometimes regulating the behavior may be all we can do in some cases.

Be Positive: It is important to positively reinforce appropriate behaviors.

For example: “I like the way your hands are being quiet. It makes it easier for you to pay attention to what is going on around you.”

Keep Calm: Children often engage in these behaviors when they are stressed or as a means to manage emotions such as fear, anger and anxiety; therefore, maintaining an atmosphere that is as tranquil, predictable, and appeasing to the senses as possible will prevent many of these behaviors from surfacing.

 

Ashley DiGregorio M.A., CF-SLP, TSSLD

Play Therapy for Speech-Language Intervention

Play is a flexible, non-literal, episodic, and process-oriented form of therapy. During play, the child is actively engaged and intrinsically motivated. True play has no extrinsic goals, but we sacrifice some of that to ensure that target skills are being practiced during play-centered therapy.

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ATTENTION SLP’s:

Effective play therapy would include planning ahead to keep in mind specific goals being targeted.

Some common goals addressed via play therapy include but are not limited to:

  • Pragmatic Language (i.e., joint attention, eye contact, turn-taking).
  • Figurative Language (i.e., symbolism, non-literal language).
  • Expressive Language (i.e., models for increasing spontaneous productions through auditory bombardment).
  • Receptive Language (i.e., object ID, following directions).

The therapist providing treatment may act as the perfect model to elicit language.

  • A common teaching strategy is providing children with a binary choice so that the child must attempt to approximate a word, not simply give a yes or no answer. (i.e., “Do you want blue or red?”, “Does puppy say moo or woof?”)

Play Scales

For play therapy to be appropriate it is important to refer to normed scales of the stages of play and language.

Bloom and Lahey

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  • This framework identifies the normal developmental sequence of utterances that a child learning English expresses (i.e., says, signs, or cues.)
  • In most children, comprehension develops before expression, meaning that most children are likely to comprehend utterances much more complex than the utterances they are able to spontaneously express at the same time.
  • Input by a person fluent in English should be abundant throughout the language acquisition process and is absolutely necessary for both comprehension and expression to develop.

Westby Play Scale

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  • This framework connects language use in children with the development of their symbolic play skills.
  • Research shows that language skill development coincides with a child’s emergence of play schemes.

Mother and daughter drawing together

The Bottom Line

  • It has been evidenced that children who present with language delay respond well to these treatment methods.
  • Following parental education, play therapy may be easily duplicated in many settings.
  • There is a positive correlation between play and language.
  • With one toy, multiple tasks may be addressed.
  • In order for language to develop, appropriate play skills must be intact.

 

Ashley DiGregorio M.A., CF-SLP, TSSLD

The Trouble with Transitions

Many children experience difficulty transitioning between activities, places, and objects of attention. When a child is asked to stop one thing and begin another, it is not uncommon for problematic behavior to surface, especially for kids who have emotional or developmental challenges.

SLP’s, teachers, and parents can learn to understand, manage, and eliminate these “tantrums” by getting to the root of the problem.

“Transitions are hard for everybody,” says Dr. David Anderson, senior director of the ADHD and Behavior Disorders Center at the Child Mind Institute. “One of the reasons why transitions may be hard is that we’re often transitioning from a preferred activity – something we like doing – to something that we need to do.”

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What does trouble with transitions look like?

Trouble with transitions can manifest in a variety of ways based upon each child and their setting. Some kids exhibit resistance, avoidance behavior, distraction, negotiation, and often a full-blown meltdown.

Children may react this way for two reasons:

  1. They are overwhelmed by their emotions.
  2. They have learned what works to successfully delay or avoid a transition.

Example:  A child who is told that it’s time to put away toys and begin a speech task might throw a tantrum initially because he/she cannot properly manage feelings of anger or frustration, but further because he/she found that it has worked to delay beginning the speech task in the past.

Children may master the art of whining, distracting, or negotiating with the adults in their life. It is up to the adults to respond accordingly, rather than enable the progression of their transitional difficulties.

Why is transitioning so hard for children?

It is fair to say that parents, teachers, and SLP’s have all dealt with some less-than-eager responses or resistance from children when asked to perform non-preferred activities, but for children with emotional and developmental issues it is particularly difficult.

Children may exhibit similar behaviors when faced with a transition, but it is important to understand that the reasoning behind each child’s breakdown is probably very different.

Transitional Difficulties By Diagnosis:

ADHD: Children with ADHD have difficulty regulating attention; therefore, turning their attention to something they are expected to do, rather than something that they find rewarding can be a challenge. Children with ADHD also have a tougher time managing their emotions than other kids.

Autism Spectrum Disorder (ASD): Many children with ASD have an adaptive need for predictability. For these children, changing activities is upsetting, because it is a deviation from the routine they know and are comfortable with. ASD also presents children with some level of cognitive inflexibility, which lends itself to the hyper-focused interests and tendency to fixate on sameness in this population.

Sensory Processing Challenges: For kids who are easily over stimulated, routine and order allow them to feel regulated, which helps them feel calm and in control. Additionally, children with sensory issues are sometimes prone to emotional tantrums that they cannot control when they are overwhelmed by unexpected changes.

Anxiety: Children who suffer from anxiety may have trouble with transitions due to fear of the unknown, or fear of what’s going to happen when they’re put in a new situation.

Obsessive-Compulsive Disorder (OCD): Children with OCD may feel an intense need to do things perfectly. If a child with OCD is interrupted before they are able to do something exactly the right way, they may get very upset.

How can we help?

Helping a child learn how to transition without trouble is a fundamental skill that can make the difference between a traumatic experience and a successful day conducive for learning.

SLP’s, Teachers, and Parents are encouraged to:

  • Create Routines: If a child does not want to transition because he/she likes consistency, routine, and structure, then start by building these factors into the transition process.
  • Preview/Count Down: Before each transition, the adult in the room can give a timeframe and description of what will happen along with countdowns (“in 30 minutes xyz, then 15, then 5, etc.). This allows a child to “emotionally” prepare for an event.
  • Give it a sound track: Songs can be especially effective tools to help implement routines and ease transitions.
  • Visual Cues: Most children benefit from visual cues. Being able to point to a chart with photos about what is expected from a particular transition or the steps involved can help decrease the fear of the unknown. This is also easy to adapt for a variety of settings.
  • Use rewards: Rewards, such as stickers, snacks, or a point system that leads to a tangible prize, can be an effective way to habituate a child to the transitional process. Across settings, adults can implement reward systems, and once the child gets into the habit of effortlessly transitioning this can often be decreased or eliminated.
  • Implement appropriate consequences: If a transition is not going well, an adult may choose to pay less attention to it rather than worsening the situation. An adult may also choose to ignore the behaviors as long as the child is making an effort to make the transition. However, if a child is misbehaving or putting themselves or others at risk, then an adult may use an appropriate consequence for that behavior that makes the child understand that the behavior is off limits. 
  • Praise good transitioning: It is essential to recognize when things go well. As a parent, teacher, and SLP it is important to be really enthusiastic and acknowledge that the transition went well. The adult should provide specific feedback, and follow up with a reward when appropriate.

Screen Shot 2017-03-01 at 12.22.04 AM.pngWith the right support, children can learn to transition without trouble.

Ashley DiGregorio M.A., CF-SLP, TSSLD

Parents’ Guide to Getting Started with an AAC Device

 

Your child was just given a new AAC device, now what? One of the hardest parts about beginning to use an AAC device with children, is knowing what to do with it once you have it.  An alternative and augmentative communication (AAC) device is any device that allows a child to use language to communicate other than spoken speech.

It can be tricky to figure out how to incorporate the device into your child’s everyday life, either at school or at home. However, it is important to teach your child to use their AAC device in the same way you would teach them to speak.

Here are some ideas for how you can implement using the device at home or at school:

1) Have a Speech Pathologist Find a Good Fit

First, your child needs to get evaluated for an AAC device.  This is something that should be done by a good AAC evaluation team. These teams are usually made up of a speech-language pathologist who specializes in AAC as well as an occupational therapist who can give input about the motor components of using AAC devices.  There are many ways for children to activate AAC devices and they will know which one is right for the child.

2) Become Familiar with your Child’s AAC Device

Your child should have gone through speech therapy and an evaluation to determine what means of communication is best for him and his family.  Regardless of what method was chosen (sign language, picture communication, picture board, speech output device), the adults who are going to be communicating with the child need to be comfortable using it.  Take some time to get familiar with the AAC device or system.

3) Model Using the AAC Around the Child

Children need to see their AAC device being used around them.  If they never see anyone communicating with it, why would they be motivated to use it themselves?

Just as children with typical speech need to hear language modeled constantly before they are able to begin using it, your child needs to see his AAC device being used as well.  Use the system when you are talking to the child, talking to other adults, talking to other children, etc.  Just make sure that you are leaving the AAC device or system near the child (not taking it away) so that he or she can use it as well.

4) Encourage The Child’s Attempts to Use the AAC Device

At first your child will probably not be using his AAC device meaningfully.  He may just push buttons randomly to hear what they sound like.  But whatever you do, do not take it away.  This is all a part of the learning process. If your child pushes a button, even if it’s accidental, you can still respond as though it was meaningful.  If he pushes “potato” when you’re playing in the bedroom, you can say “Potato?  We don’t have any potatoes in here.  There may be some in the kitchen though.”  This may seem silly, but it helps the child understand that the words he is creating using his AAC device have real meaning.

 

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-Mallory Varrone MA CF- SLP, TSSLD