Childhood Apraxia of Speech – What is it and How Can I Help My Child?

Childhood Apraxia of SpeechChildhood Apraxia of Speech (CAS) falls under the umbrella term “speech sound disorders.” Children with speech sound disorders have difficulty with motor production, perception, and/or phonological representation of sounds. Stress and prosody (speech intonation patterns) are also included in this definition. Childhood Apraxia of Speech (CAS) occurs in about 15% of three-year old children. The hallmark of CAS is inefficient speech praxis abilities, the ability to volitionally plan and program complex, sequenced muscular motor movements required for speech sound production (Campbell et al. 2003). By age 6, approximately 3.8% of children with CAS will continue to have impaired speech production skills (Shriberg et al. 1999).

Children with CAS often demonstrate limited consonant and vowel repertoire, use of simple syllable shapes, poor intelligibility, vowel distortions, prosodic errors (characterized by equal stress and/or segmentation), and difficulty moving from one articulatory configuration (word) to the next.

CAS can be hard to diagnose in children that cannot yet imitate clinician speech prompts. The speech of children with severe articulation deficits or phonological impairments can appear similar to the speech of children with CAS. However, it should be noted that children with articulation deficits or phonological impairments typically have good prosody and rate of speech.

The following excerpt describes a child I treated with CAS:

What I remember most about *Ryan’s speech sessions was the silence. When Ryan and I played with toys in the therapy room, no audible sound effects were heard. He did not babble; he did not ask questions; he did not ask for help; he did not relay information. The room was as silent as a first snow. Ryan was 5 years old.

Ryan had chocolate-brown hair perpetually slicked back by his mother, reminiscent of a 1950’s style. His twinkling, almond eyes matched his hair, and were often squinched up from his jovial smile. Although he could only articulate three consonant-vowel combinations: ma, no, and da, he was the happiest child I had ever treated. His mother had taught him an extensive number of ASL signs (American Sign Language); however, he often had difficulty recalling them, especially when put on the spot (which mother’s often do – myself included). His main mode of communication was miming accompanied by vocalizations.

His diagnosis… a severe motor speech disorder with possible Childhood Apraxia of Speech (CAS).

Ryan was cognitively bright and socially appropriate. He knew he could not speak, so he remained quiet. With intense modeling and tactical prompting, he could imitate about 5 consonants (t,p,w,b,g). His vowels were almost always distorted. His family wanted him to play for the Oregon Ducks. They shared this goal with me upon my suggestion of trialing a dynamic-display, augmentative communication device (AAC) for him to better communicate. This is a device that looks like an iPad that allows children to press buttons to speak for them.  Ryan’s parents told me they did not want him using a “talker”…EVER. Looking me deep in the eyes, his father whispered under his breath, “Football players don’t use talkers.”

So, you may be wondering why the parents were unnerved by the implementation of an AAC device. Fortunately, this was no surprise to me. As a speech therapist for over ten years, I know firsthand that AAC implementation can often be a difficult topic with parents. Before I explain that issue, I wish to discuss oral communication skills versus expressive language skills. This way, you can better understand how AAC can profoundly impact children severely effected by motor speech deficits in a positive way.

SLP’s divide oral communication into two arenas: speech and language.

1.) Speech Production (or) Motor Speech – getting articulators (lips, tongue, velum, teeth, palate, pharynx) to the right place at the right time with adequate strength to make the sounds of speech

2.) Expressive Language – organizing thoughts and ideas into coherent sentences using accurate grammar and age appropriate vocabulary

If a child has very poor speech production skills, it causes his expressive language skills to be delayed as well. This communicative delay in the presence of age appropriate cognition (thinking and understanding skills) often frustrates children because they cannot get their wants and needs met or their thoughts and ideas conveyed effectively and efficiently. Their motor speech skills do not match their language abilities. For this reason, many speech language pathologists will recommend an AAC device (augmentative alternative communication) to ease that frustration. Often, parents are concerned that an AAC device will cause their child to never speak orally again. Being a mother of two children, I completely understand this worry. And, now I will put it to bed.

It has been well documented that children, and adults, do what is easier and faster when communicating. If speech is more efficient than using a device, oral communication will dominate (and vise versa). Often AAC is used as a “bridge,” helping patients access expressive language as soon as possible, while they develop the skills required to verbally express their wants, needs, thoughts, and ideas independently.

What can we do to help children with CAS increase their speech skills? Research by Murray, McCabem & Ballard (2013) noted 3 treatment approaches that had evidenced positive effects:

1.Dynamic Temporal and tactile Cueing (younger children, 3-6 years)
2.Rapid Syllable Transition (7-10 years)
3.Integrated Phonological Awareness Intervention

Research also states that intensity is key to treatment success. This means that the preferred therapy delivery model is 20-30 minutes, for 3-4 days per week. Now, if you are a busy parent/caregiver, like we all are, this sounds daunting. And, if you are a speech therapist with a packed caseload or have a lot of clients with finicky insurance providers, this sounds daunting as well. But, in my honest opinion, I think this service delivery model is possible if we employ parents as facilitators. That involves parents observing speech sessions, getting training from the speech therapist, and employing a home practice daily. By practicing motor speech skills 10-15 minutes every day during activities of daily living (i.e. bath time, getting ready for school, homework time, cooking dinner), the practice will inherently be both frequent and intense. And, outcomes will be better. For some children, speech is similar to learning an instrument in that daily practice is needed to foster the muscle memory required for performance of the task.

Potential Symptom that your child may have CAS:
-Lack of babbling as a baby
-Inconsistent errors on consonants and vowels
-Lengthened and disrupted transitions between sounds and syllables- difficulty moving from one articulatory context to the next.
-Slow rate of speech
-Groping
-Increased difficulty with multisyllabic words
-Inappropriate prosody (intonation)
-Inconsistent voicing errors

If your child is displaying any of these signs, a formal speech language evaluation is warranted.


Aimee Brigham, MCD, CCC-SLP is an independent contractor and contributor to Chew Chew Mama with over ten years of experience.  See more of Aimee’s articles here, here and here.   Do you need help?  You can speak directly with Aimee Brigham about your child’s speech and language.

Book time for a coast-to-coast virtual consultation with Aimee here.


References:
1. Edeal, D. M., & Gildersleeve-Neumann, E. (2011). The importance of production frequency in therapy for childhood apraxia of speech. American Journal of Speech-Language Pathology, 20, 95-110.
2. Murray, E., McCabe, P., & Ballard, K.J. (2013). A systematic review of treatment outcomes for children with childhood apraxia of speech. American Journal of Speech-Language Pathology, 23, 286-504.
3. Namasivayam, A.K., Pukonen, M., Goshulak,D., Hard, J., Rudzicz, F., Rietveld, T., Maassen, B., Kroll, R., Lieshout, P. (2015). Treatment intensity and childhood apraxia of speech. Journal of Language and Communication Disorders, 0, 1-18.
4. Thomas, D. C., McCabe, P., & Ballard, K. J. (2014). Rapid syllable transitions (ReST) treatment for childhood apraxia of speech: the effect of lower dose-frequency. Journal of Communication Disorders, 51, 29-42.
5. Campbell, T. F. (2003). Childhood apraxia of speech: Clinical symptoms and speech characteristics. In L. D. Shriberg & T. F. Campbell (Eds.), Proceedings of the 2002 Childhood Apraxia of Speech Symposium, 37-40.

6. Shriberg et al (1999). Prevalence of speech delay in 6-year-old children and comorbidity with language impairment. Journal of Speech Language Hearing Research, 42(6):1461-1481.

* Ryan is an alias to protect the client; some details have also been altered.

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Ready, Set, Read – Learn The Skills Required For Reading

Learn The Skills Required For ReadingWe make reading a ritual in our home.  To me, reading is… evening book clubs with friends, foggy mornings with a newspaper (albeit digitally) and a cup of joe, cold nights cozied up with my Kindle, and an entertaining, People magazine at the hair salon. But, for many, reading is not the above; it is not an enjoyable experience to cherish. According to the Department of Education, 32 million adults in the U.S. cannot read. That is 14 percent of the population. Initially, I was shell-shocked at that number. Then, I donned my speech language pathologist hat and recognized – with clarity- that becoming literate is a rigorous, laborious process. In this article, I will discuss the components of literacy, how literacy and language are connected, and how to foster literacy in your home.

Reading, the ability to translate print into meaning, results from two skill sets: decoding (sounding out letters) and comprehension (understanding text).3 Fluent decoding involves a mastery of phonemic awareness skills, such as sound blending (b–a–t = bat), sound manipulation (p-a-t can become t-a-p, by switching initial and final phonemes), sound segmenting (bash = b–a–sh), and rhyming (i.e. cat/mat).

In a perfect world, English would be an alphabetic language with a one-to-one correspondence between the phonemes (sounds) and the graphemes (letters). This would make decoding a breeze.  However, English contains 26 letters and approximately 40 sound units that connect to it. Ever wonder why the word “was” does not rhyme with the word “pass?” Because of English’s complexity, beginner readers must use both phonics and context for decoding accuracy. Decoding provides a bridge between word recognition and reading comprehension, but it is not the “end all, be all.”

Research notes that those who decode rapidly, accurately, and efficiently do not spend a ton of cognitive energy doing so. Because of this, they can focus readily on comprehension. Furthermore, individuals with efficient decoding skills are motivated to read widely; reading is seen as fun. This wide reading enhances their reading skills through practice.

Less fluent readers, however, must focus their attention on decoding, leaving little cognitive energy for comprehension. Reading is not deemed fun, rather more of a chore. These individuals become motivated to avoid reading. This avoidance, in turn, limits the development of their reading skills. As a result, the gap between achieving and non-achieving readers widens throughout school and into adulthood.

Tools To Expand Language Skills

Speech language pathologists view reading as a powerful tool to enhance and expand language skills. Reading exposes children to new words, which leads to increased vocabulary and refined grammatical skills. In therapy sessions, I often use books as pre-learning activities. For example, when facilitating the expression of the spatial term “around,” I first read the book, Whoosh around the Mulberry Bush with my client (receptive learning). Then, I act out the book with the child using props (gross motor). I follow up with a painting activity, having the child illustrate the concept on paper (fine motor). Lastly, I tempt the child into using the new spatial word in a prompted conversation (expression).

This type of activity is suitable for many concepts: color words (i.e. red, peach, aqua), number words (i.e. three, seven, fifty), positional words (i.e. first, third, last), and descriptive words (i.e. wet, dry, smooth). Research reiterates, that a child’s first encounter with an unfamiliar word only leads to partial word knowledge, but each additional encounter is an opportunity for a more complete understanding.

Reading Should Begin From Birth

When should you begin reading to your child? From birth, children benefit from hearing your voice, listening to sounds and rhymes in books, and bonding intimately with you. When reading with your child, the most important thing to do is follow his (or her) lead. Let your child pick the book. Observe him while you read. Is he looking at the book, or is he looking at the toy in the corner? If your child is not attending, change your delivery method.

You may decide to start pointing to the pictures in the book and talking about them instead or decide to make your voice sound silly. You could choose to read in the dark with a flashlight. Or, you might choose reading time is over. With shared reading, you are also teaching your child basic, book-knowledge: reading occurs from left to right, how to hold a book correctly, and that printed words correlate to spoken words. So much valuable learning, yet unintentional, occurs during shared reading time. Don’t give up if your child seems unmotivated by books.

For my son, only books with trains, cars, or construction vehicles sustained his attention (and, I mean for very, very, short intervals). He would literally throw any other books across the room. From 18 months of age to 24 months, I had to use visual prompts such as play dough stuck on the pictures for him to remove, a magnifying glass circling the pictures, or a flashlight pointing at the pictures to keep his attention. Books with flaps and sensory tabs also helped gain his attention. However, by age 3, he was on his way to loving all books, without all the visual prompts too.

Reading is a learned skill

Reading is a skill that must be learned, like swimming. It is not innate; we must help our children develop mastery over time. We must be their best cheerleader. We must be their facilitator. That said I believe that reading, most importantly, is a time to bond with your child, a time to listen to your child, and a time to enjoy your child’s company. As we all know to well, time flies – soon enough our children will not need nor want our help. Currently, at our house, reading is a nightly ritual. One we all anticipate and enjoy. It marks the end of our day, winds us down from the stressors in our lives, and gives us time to snuggle and chat.

I encourage you to make reading a ritual in your home.

Aimee Brigham, MCD, CCC-SLP

References:
1. US Department of Education, Statistic Brain, August 22, 2016.
2. “Literate.” Merriam-Webster.com. Merriam-Webster, n.d. Web. 19 Aug. 2014.
3. Chard, D., Pikulski, J., Templeton, S., (2000). From Phonemic Awareness to Fluency: Effective Decoding Instruction in a research Based Reading Program. Houghton Mifflin Reading.
4. Harris, T.L., Hodges, R.E. (1995). The literacy dictionary: The vocabulary of reading and writing.
5. Anglin, J.M. (1993). Vocabulary development: A morphological analysis. Monographs of the Society for Research in Child Development. 58(10, Serial no. 238.).
6. Cunningham, A.E. & Stanovich, Kieth (1986). What reading does for the mind. American Educator, 22, 8-17.

Stuttering: When to seek out a Speech Language Pathologist

Stuttering

Aimee Brigham, MCD, CCC-SLP

The Hollywood blockbuster, The King’s Speech, illustrated – with acute accuracy – the impact of stuttering on self-worth, friendships, and daily activities. Individuals who stutter face speech challenges that fluent speakers take for granted. The boy who must cope after a caller hangs up on him because he cannot say hello; the woman who does not get a promotion because she cannot speak fluently to her team; the man who takes a factory job so he does not have to speak with others; the girl who orders vanilla ice cream because she knows she cannot say chocolate; the child who responds, “I don’t know,” to the teacher’s question because he cannot answer fluently. Stuttering interferes with school, work, and social interactions. In addition, some individuals who stutter report fear or anxiety about speaking and frustration about the time and effort required to speak.

What is stuttering?

Stuttering is defined as an abnormally high frequency and/or duration of stoppages in the forward flow of speech. On the opposite speech continuum, fluency is the rate, rhythm, and ease with which a person speaks. Please note that everyone experiences dysfluent speech at times. This is normal. Children -when tired- become dysfluent. Adults -when nervous or stressed- become dysfluent. In fact, after reading this article, you will notice dysfluencies in your speech. If the dysfluencies become commonplace, struggled, and/or avoided, a stuttering classification is possible.

As a parent and a speech therapist, I readily noticed dysfluencies in both of my children’s speech (more prominent with my son) during the preschool years. The dysfluencies started around the age of 2.5-3 years. And, interestingly, research states that the majority of stuttering begins between speech onset and puberty, most often between the ages of 2 and 5 years. You may be thinking, “I bet you were worried?” And, if you knew me, you would know that I have the ability worry about anything-literally. I fretted over my daughter’s name, Rayna, starting with an /r/ for years (it is a family name). The phoneme /r/ is a tricky phoneme to correct. Stuttering, however, I was not distressed about. This is why…

First off, the prevalence of stuttering (total number of stuttering cases at a specified time) is extremely low, 1% in pre-pubertal school children. The incidence of stuttering (the total number of people who have stuttered at some time in their lives) is 5%. The difference between the incidence and the prevalence indicates that most people recover from stuttering episodes.

Secondly, preschool children typically demonstrate some word and phrase repetitions, interjections, and revisions in their speech. In other words, dysfluency is the norm for young children acquiring language complexity. In order to express thoughts and ideas, one must process information relevant to the topic, organize thoughts into a grammatically correct form, and establish accurate semantics (vocabulary). Dysfluencies can “buy time” for the novice speaker.

The following list represents typical dysfluencies seen in preschool-aged children:
Repetitions – sound (h-h- hat), syllable (buh-buh- boy), or one-syllable words. (I-I-I was going).
Interjections- use of “fillers” (Let’s get – um- um – you know – pizza tonight for hmmm dinner).
Revisions – changing the sentence/phrase structure (I eat- I ate an apple).

Lastly, incipient stuttering has different characteristics than typical dysfluencies. It is characterized by more within-word dysfluencies, sound prolongations, and broken words. Charles Van Riper, a renowned speech therapist who also stuttered, stated, “It is the broken word that characterizes the majority of the stutterer’s difficulty.”

The following is a list of atypical dysfluencies:
Blocks/Broken words – stoppage of airflow or speech (Yesterday, I w—-ent to school.)
Prolongations – sustained articulation of a sound for lengthy amount of time (sssssssee ssssssssaw.)
Incomplete phrases – the thought and content of an utterance are not completed, and it is not an instance of phrase repetition (She was-and after she got there, he came)

Since most children who stutter, begin so around 2 ½ years of age, you may find yourself wondering what you can or should do as a parent if you notice your child’s speech becoming “bumpy.” Here is my professional advice.

If the dysfluencies fall mainly into the typical dysfluency examples and your child is not showing signs of struggle, I suggest you focus on indirect approaches to fluency. These include slowing your rate of speech down when speaking to your child, maintaining eye contact during dysfluencies, toning down excessive stimulation in the environment during communicative interactions, and allowing your child to finish his/her thoughts unassisted. Allow a few months to pass, as the pre-school years (2.5 years to 4 years) are usually a time of significant language growth. Reassess. If the dysfluencies get worse or continue long term, it may be time to see a speech therapist for a formal evaluation of speech fluency.

If the dysfluencies seem excessively frequent, struggled, and some atypical dysfluencies are noted, a formal evaluation may be warranted. Once the assessment is complete, fluency treatment approaches will be recommended based on the child’s needs and the family’s communication patterns. For preschool children who stutter, parent involvement in the treatment process is essential, as is a home treatment component.

Risk Factors:
Sex of child – boys are at higher risk for persistence of stuttering than girls.
Family history of persistent stuttering.
Time duration – stuttering lasting longer than 6 to 12 months, or minimal improvements over several months.
Age of onset-children who start stuttering at age 3½ or later.
A co-occurring speech and language impairment.


Do you have questions about stuttering?

Click here to empower your family with the support of a virtual speech language pathologist.


References:
Andrews, G (1983). Stuttering: A review of research finding=gs and theories circa 1982. Journal of Speech and Hearing Disorders, 48, 226-246.

Ezrati-Vinacour, R., Platzky, R., & Yairi, E. (2001). The young child’s awareness of stuttering-like disfluency. Journal of Speech, Language, and Hearing Research, 44(2), 368-380.

Kraft, S. J., & Yairi, E. (2011). Genetic bases of stuttering: The state of the art, 2011. Folia Phoniatrica et Logopaedica, 64, 34-47.

Mansson H. (2007). Complexity and diversity in early childhood stuttering. In J. Au-Yeung & M. Leahy (Eds.), Proceedings of the Fifth World Congress on Fluency Disorders (pp. 98-101). Dublin, Ireland: The International Fluency Association.

Mewherter, M. (1012). Cincinnati Children’s Hospital Medical Center: Best evidence statement: Evidence based practice for stuttering home programs in speech-language pathology.

Ntourou, K., Conture, E. G., & Lipsey, M. W. (2011). Language abilities of children who stutter: A meta-analytical review. American Journal of Speech-Language Pathology, 20(3), 163-179.

Peters, T.J., & Guitar, B. (1991). Stuttering: An integrated approach to its nature and treatment. Baltimore, MD: Williams & Wilkins.

Shapiro, David (1999). Stuttering Intervention: A collaborative journey to fluency freedom. Austin, TX: PRO-ED.

Van Riper, C. (1982). The Nature of Stuttering (2nd ed). Englewood Cliffs, NJ: Prentice-Hall.

Yairi, E., & Ambrose, N. (2005). Early childhood stuttering for clinicians by clinicians. Austin, TX: PRO-ED.

Yaruss, J. S., LaSalle, L. R., & Conture, E. G. (1998). Evaluating stuttering in young children: Diagnostic data. American Journal of Speech-Language Pathology, 7(4), 62-76.

Yaruss, J. S., & Quesal, R. W. (2004). Stuttering and the International Classification of Functioning, Disability, and Health (ICF): An update. Journal of Communication Disorders, 37(1), 35-52.

Play with your children to build language

Play with your kids to build language

Aimee Brigham, MCD, CCC-SLP

Did you know that playing with your children builds language?

When parents observe therapy sessions, they often remark, “What fun! Playing all day.” They are absolutely right. Pediatric, speech-language pathologists love to play. What sometimes goes unrecognized is that this type of play can be hard work for both the client and the clinician. Speech therapists often use goal oriented play in their sessions, whether it is aimed at teaching a child to articulate /s/ accurately, or modeling the use of irregular past tense markers, or increasing comprehension of 2-step directions, or engaging a child in a turn-taking activity. In fact, most pediatric goals are initiated and practiced during playful interactions because “play offers an opportunity to organize intervention episodes that engage children and facilitate practice (Adler 2012).”

Throughout my practice, I have witnessed many children who need to learn how to play. For them, playing did not come innately or by watching others play. Playing is the way friendships are woven in youth. And, every parent wants his or her child to play with other children. Some children do not demonstrate the ability to stack blocks, to talk on a make-believe phone, to feed a baby doll, or to take turns with a peer. Intervention targeting play foundations is an important speech and language goal for these children. Leslie Adler adds, “Playing is one of the primary occupations of children, and when they are playing they are participating in life (Adler, 2012).” Stating the position of the American Academy of Pediatrics, Kenneth Ginsburg says, “Play is essential to development because it contributes to the cognitive, physical, social, and emotional well-being of children and youth (Ginsburg, 2007).” As one can see, the common phrase, “Let’s play!” is quite complex when underway.

What is Play?

Play is a process – the outcome is not as important as the process itself.
Play is child-initiated. Activities are created for no other reason than experimentation.
In play, everything and anything can happen: a sheet over a table becomes a castle and the little girl inside the princess. Functions of objects are transformed.
Play becomes an arena for testing rules, both logical and illogical. Rules freely appear and disappear in play.
Play is an activity of the mind. Children may become deeply engrossed in play and find it difficult to stop. (S.C.Hurwitz, 2003)

Free play, play that is child-driven, rambunctious, and unstructured, is the most important kind of play (S.C. Hurwtiz 2003). During free play, children learn new vocabulary and increase auditory comprehension skills. They practice cognitive skills including, problem solving, creativity, and self-regulation. Social skills are demonstrated during play when a child initiates, interacts, and compromises with his or her communicative partner. In addition, strategies to cope with feelings of excitement, fear, anger, and frustration are vented during play. Children are constantly learning and growing during play. “Having control over the course of one’s own learning, as in free play, promotes desire, motivation, and mastery (Erikson, 1985).”
Now let’s talk about being successful when playing, as success is very important. Without a feeling of success, participation and engagement decrease. Some children may revert to atypical types of play, such as repetitive play and self-stimulating play. For play to remain organic and fun, scaffolding, giving support, is necessary. Scaffolding can take many forms, from altering the environment to encourage play or decreasing distractions to encourage focused attention. Using visual aids to assist in play sequences and modeling language needed for games and playful interactions are also considered scaffolds.

Stages of play:

Exploratory Play (around 6-8 months) – At this stage, children are becoming familiar with objects through observation and exploration. This play is not goal oriented. Children are motivated to understand more about the objects in play. Fingering, mouthing, banging, and listening are witnessed at this stage.
Constructive Play (around 12 months) – Here, children manipulate their environment to build things. Toys are used for their intended purpose (building with blocks, drawing with markers, digging in sand, brushing a doll’s hair). Constructive play develops imagination, problem-solving skills, fine motor skills, and self esteem(R. Owens 2011).
Symbolic Play (around 18 months)–Children use objects to represent other objects in play. They may use a block as a train or a plastic banana as a telephone.
Rules and Games (school aged) – Children impose rules and roles during play at this stage. Self-regulation, cooperation, and flexibility are needed (Frost 2004). Here, children are seen role-playing life scenarios, making rules to pretend games, and playing games with set rules.

In today’s world of after-school schedules and modern technology, children seem to be playing less and less. Technology, screen time, has replaced time spent playing alone, with a friend, or with a sibling. In addition, free play in school is sneakily being redefined as choice time or center time in an effort to keep classrooms calm with engaged students. School districts are reducing recess time and creative arts time to focus on mathematics and reading (Dillon, 2006). Pediatricians want children playing more; they want children interacting with peers and increasing their fun, rambunctious, free-play (Ginsburg 2007). Right now, you may be asking, “How can I increase free play in the home?”
Here’s how…Be silly, get creative, and have fun with your kids. Schedule times in the day where children are expected to play alone for short intervals, younger children may require scaffolding and very short intervals to be successful at independent play. It is OK for children to state they are “bored.” Sometimes when children are “bored” they are really thinking, problem solving, and reflecting on life events. And mostly, play should not be work. The point of play is that is has no point.

Play Temptations by Stage:

Exploratory play – Schedule times in the day where you can sit, eye-level and face to face, with your child and explore toys. Seek out objects that make noise, have cause and effect, and are brightly colored. Model language and exploration during play.

Constructive play – Sensory bins (i.e. sand, water, rice) are great for this level of play. Model pouring, shoveling, burying, and stirring. Watch your child to see what interests her/him, model language and expand on his/her verbalizations.

Symbolic play – Promote pretend play activities by setting up an environment of play, such as a barber-shop, a doctor’s clinic, or a pizza parlor. Help your child make symbolic items to be used in play. For example, a pizza oven can be made from an used gift box; play dough can pizza dough.

Rules and Games – Research shows that visual aids help children create imaginary play and promote language (Adler 2012). Make imaginary play bins: bins filled with scarves, eyeglasses, and silly slippers. Place a large mirror in the play space, children love watch themselves acting silly. Have a box of old-school board games available: chutes and ladders, operation, connect four, Hi-Ho Cherrio, etc.

Resources
Adler, L. “Linking Play to Function: Utilizing NDT and SI Strategies to Facilitate Functional Skills Through Play.” Education Resources. 2012 p.1-10.
Dillon S. Schools cut back subjects to push reading and math. New York Times. March 26, 2006;1:1.
Erickson, R. J. (1985). Play contributes to the full emotional development of the child. Education, 105(3), 261-263.
Frost, Joe L., Pei-San Brown, John A. Sutterby, Candra D. Thornton. The Developmental Benefits of Playgrounds. Olney, MD: Association for Childhood Education International, 2004. p. 25.

Ginsburg, Kenneth. The Importance of Play in Promoting Healthy Childhood Development and Maintaining Strong Parent-Child Bonds, Pediatrics.2007, 199:182-191.
Hurwitz Sally C. To be successful: let them play! Child Educ. 2002/ 2003;79:101–102.
Metrocom International (Producer) for Michigan Television. (2007). Where do the children play? [DVD]. Ann Arbor: Regents of the University of Michigan.
Owens, Robert. Language Development: An Introduction. Allyn and Bacon, 2001. Print.
*Why Do Children Play?” Mesa Community College. The Developmental Psychology Student NetLetter. http://www.mesacc.edu/dept/d46/psy/dev/Spring98/earchild/index.html > 27 Aug. 2010.