Archive for the ‘ Uncategorized ’ Category

Technology at TSHA Convention

Written by Sarah Van Dusen
March 9th, 2011

Every year, the Texas Speech-Language Hearing Association (TSHA) works very hard to put on a convention for speech-language pathologists across Texas. This year, there were more than 5,000 SLPs in attendance and more than 150 workshops relating to the various areas of our field. I love hearing about new research, new products, new technology, and new insights from my fellow therapists.

Growing up, my pastor used to say that you need to turn new information into action within 72 hours, or the chances are you'll never use it. I am determined to use the information I learned at convention. The most exciting topic for me was about technology. The brilliant Barbara Fernandes (known to her Twitter followers as @GeekSlp) is the founder of Smarty Ears. She has created 21 applications for SLPs to use on their iPhones, iPod Touches, iPads, and Androids to help children with various speech disorders. What kid doesn't want to play with your iPhone? She showed us the best ways to utilize the apps in therapy to hold the student's attention and to keep control of the session.

Ms. Fernandes also shared her knowledge about and experience with social media. She encouraged SLPs to get in the mix with Facebook, Twitter, iTunes, YouTube, blogging, etc. She inspired me to make time to blog again - to take the time to share information with families who are searching. There are many schools of thought regarding speech therapy, and parents should have all the facts. Therefore, I plan to do more blogging, spend more time on Facebook and Twitter, and use more technology in speech therapy. At next year's TSHA convention, perhaps I will have a story about how technology has changed the way I do speech therapy.

Whether you are a parent or an SLP, look up Smarty Ears and GeekSlp on Facebook, Twitter, iTunes, and

Full CAS and Prosody Article found on

Written by Sarah Van Dusen
November 9th, 2010

Improving Prosody in CAS

by, Sarah M. Gee, MS, CCC-SLP (as seen at

What is prosody?

When it comes to childhood apraxia of speech (CAS), many therapists are stumped. Even after helping a child find some words, there can be other problems including grammar delays and underdeveloped prosody. Prosody is loosely defined as the melody of speech. That melody is made up of several components: volume, rate, pitch, intonation, stress patterns, and general speech flow.

After months of drilling sounds and word shapes in apraxia therapy, children tend to be so focused on using all of the correct sounds in all of the correct places, that they lose (or never develop) any melody to their speech. They may sound robotic, choppy, or they may use incorrect intonation.

How does it sound?

Prosody can be just as important as the words themselves. For instance, I can easily tell if someone using an unfamiliar language is angry, happy, asking a question, or making a demand. A toddler whose speech is not yet intelligible uses prosody with his jargon to make his wants and needs known. Even when the parent does not know what he is saying, the child sounds like he is having a meaningful conversation. That is due, in large part, to prosody.

Here are some examples of prosody. If I say, “I can cut the grass,” stressing the “I”, it sounds as though I am comparing my ability to cut grass to someone else’s ability. If I say, “I can cut the grass,” stressing the “can”, it sounds as though I am trying to convince you of my ability. Or perhaps, (adding a whine) I am saying I can do it, but I would prefer not to. If I say, “I can cut the grass,” I may mean that I can cut it, but I need you to water it. This is how prosody relates to word stress in a sentence. Syllable stress can also be a factor (e.g., present versus present). An example of the importance of intonation is the difference between questions and statements. Questions often have rising intonation at the end whereas declarative or commanding statements are more likely to have falling intonation at the end. If the prosody in any of these situations is incorrect, the inferred meaning is also likely to be incorrect, causing a frustrating miscommunication.

What can I do?

There are many techniques for improving prosody (e.g., Melodic Intonation Therapy, PROMPT, music therapy, etc.). The problem is that all therapists are not trained in all of these therapies, and all families cannot afford multiple therapies per week. The question then becomes, “How can any speech-language pathologist working with a child who has CAS correct prosody problems, or even better, prevent prosody from becoming a problem in the first place?”

One of the most effective ways I have found to address prosody issues in children with CAS is to focus on their coarticulation skills. Any speech-language pathologist can use this technique without receiving additional training or certifications. Just as they do not learn speech on their own, most children with CAS do not learn to coarticulate on their own. Their speech is choppy and disconnected when they use all of their sounds. When their speech is fluid, they are often dropping off sounds, syllables, or even whole words (e.g., “I pu ca ere” for “I put a car here”). When I explain coarticulation to parents, I tell them that there are no spaces in speech. There are only spaces in writing. There are many types of coarticulation: vowel to vowel ("Iyam" versus "I…am"), consonant to vowel ("picka" versus "pick…a"), consonant to consonant ("horshoe" versus "horse…shoe"), etc. Coarticulation gives speech natural flow and aids the development of appropriate stress and intonation.

When do I start?

We begin teaching coarticulation at the same time we begin teaching two syllables. After the child is using CVC combinations to label objects (using nouns), the therapist should be adding “a” in front to increase difficulty and avoid the common problem among children with CAS of omitting articles. As soon as the child is ready to put two words together, try “hida…ball” instead of “hit…a…ball”. Many therapists make the mistake of leaving out the articles, so that the child is using more “meaning” words (e.g., “hit ball”). The problem with this technique is twofold. First, it is much more difficult to add articles at a later time than it is to teach the motor plan to include them from the beginning. Particularly in this disorder, it is vital that grammar be addressed as it comes in therapy rather than waiting for errors to occur. Secondly, it is much more difficult to say two consonants in a row than it is to say a consonant and vowel. Therefore, the “t” in “hit” is likely to be omitted creating the less intelligible phrase, “hi ball”.

What else?

You must also consider that in Standard American English, we write "water", but we say something more like "wader". A "t" between two vowels almost becomes a "d" sound. It is actually called a "flap t". Also, "a" and "the" are pronounced "uh" and "thuh" in connected speech. These are some of the unwritten rules of the English language in America that give our speech an attractive melody. In typical speech development, the unwritten rules are picked up automatically, but in CAS, we usually have to methodically teach the motor plans.

These seemingly tiny variations in speech can have a significant impact on the response of a listener to a speaker. Speech that is too perfect sounds awkward and forced. Correcting this can be the difference between the person behind the camera and the person in front of the camera. It can be the difference between the person who writes the speeches and the person who delivers them.

Parental Involvement

Written by Sarah Van Dusen
October 19th, 2010

Parents who have worked with me know that I am a stickler for parental involvement. Every child's parent/guardian is in the therapy room with me while I work with their child. The parent is taking careful notes, participating as a speech model, and being trained by me, so s/he can carry out the therapy at home.

I am concerned with the number of times I have heard, "My other SLPs wouldn't let me come back to see what they were doing." I understand that some children work better without their parent in the room - for a time. I teach children to work with their parents in the room, and I teach parents not to be a distraction to their child during therapy. This benefits them both much more in the long run.

For our children with childhood apraxia of speech, we often find that they have more trouble speaking with an audience. Having more than one person in the room gives them an opportunity to work on this skill. Most young children prefer having a parent nearby, but even if they don't, I need the parent to be handy.

Well-trained parents can provide speech therapy at home which takes pressure off the parents, ensures that they know the proper way to correct their child's speech, empowers the parent to help the child, shortens the length of time the child requires therapy, and gives the child the expectation that she is to use her "good speech" all the time. Why would we take this opportunity away from the family? I have never known a child to take more than 3 sessions to learn to work with the parent in the room. Usually, the children prefer it.

Parents can also be very helpful dealing with some discipline problems. They can offer the therapist more feedback regarding the child's speech performance outside the therapy room. They can even keep the therapist better informed about their concerns. The parent's presence can be encouraging to the SLP and the child. The parents are as important a part of the team as the SLP.

Parents, ask yourselves why an SLP would refuse to allow you to observe her sessions. I assure you, knowing a parent is going to attend means I cannot be underprepared. It also means I take careful notes after each session to be sure I can refer to them before preparing my next session with that child. It is accountability for the therapist. We see many students in a day. Our time is limited. We have piles of paperwork, research to read, conferences to attend, and sometimes, preparation is what can go out the window. It doesn't though, if there is someone observing every session. Hold your therapist accountable.

While we hate to doubt our fellow man, it is a good general rule for parents not to allow anyone to take your child behind closed doors and say you cannot see what is happening. Be a part of the solution for your child's speech development. Observe, ask questions, carry out therapy at home, and watch the magic happen.

Self-Monitoring for Skill Generalization

Written by Sarah Van Dusen
October 5th, 2010

When teaching children speech and language skills, one of the biggest questions seems to be how to get the skill out of the therapy room and into every other life context. Kids with simple articulation delays usually figure this out on their own, but those with phonological disorders, childhood apraxia of speech, auditory impairment, or articulation and concomitant disorders have a much more difficult time. The key is monitoring one's own speech - listening to oneself and making the necessary corrections.

Self-monitoring is not a new concept. As adults, we do it all the time to incorporate new skills into our everyday life or even to eliminate habits/behaviors when necessary. To directly teach someone how to monitor herself is a difficult task. In my practice, I use three main techniques: a bean system, a traffic light, and appropriate praise. None of my techniques are original, fancy, or awe-inspiring, but a combination of the three works 95% of the time.

The bean system consists of 100 yellow beans, 10 green beans, 5 red beans, and a glass cup or bowl. It works like a traffic signal where red means stop the current behavior, yellow means take your time and focus, and green means continue what you're doing - I love it! A child gets a yellow bean in the cup for every good verbal response. The goal is to get 70 to 100 responses in a 30 minute session. The number of responses at the end of a session tells the child how hard he worked. It also helps the therapist. If there are few beans at the end of a session, she may realize she is talking too much and reducing the number of opportunities the child has to practice the target. She may determine the child did not get enough correct responses because the task was too difficult and therefore, reduce the difficulty for the next session. The glass cup offers an auditory reinforcer for the child as well. Every time the bean dings in the cup, the child can feel proud of a job well done. (It is important to note that a "correct" response can mean something different for each task. If your target is to elicit any vocalization, babbling may result in a bean. If the target is to elicit a perfect /s/ sound in words, only a perfect /s/ within a word will result in a yellow bean.)

Red beans are usually used to eliminate unwanted behaviors (e.g., using a sing-song voice, repeatedly getting out of the chair, telling the therapist "no", etc.). At the generalization stage, they may be used each time the child misses the target sound during a session. In my practice, three red beans results in losing the previously determined reward for a good therapy session.

Green beans are earned when the student corrects his own error of the target sound, when the student spontaneously uses a target sound correctly that is in the generalization stage, and occasionally, to reinforce good behavior. Five green beans during a session results in an additional reward at the end of the session.

The traffic signal I use is a reinforcer for rate of speech. Often used in fluency therapy, I have adapted it for use with my students who speak too quickly to use all of their acquired skills. It is a rectangle with three blank circles on cardstock. I have a red, yellow, and green construction paper circle to indicate which speed is appropriate. I use the red circle when I need the student to be quiet and listen to instructions. For students with echolalia, I use the red circle to give them a visual reminder for whose turn it is to talk. The yellow circle is for slow, gentle speech. When I place the yellow circle on the traffic signal, both the child and I use a slightly slower rate (with typical prosody) that allows time for thinking about what is to come, motor-planning the words, and listening for/correcting mistakes. The green circle is for practicing target sounds at a typical speech rate. If the child misses the target sound at his normal rate, I replace the green circle with the yellow one to help him slow down and work in all of his sounds.

I also carefully choose the way I praise a child. I try not to use general words such as "Good job!" If a child made a good effort at the target but was not exact, I may say, "I like your good trying!" If a child self-corrects or attempts a self-correction, I may say, "Thank you for listening to yourself and trying to say your sounds correctly!" If the child is continuing to have a good attitude during a difficult task, I may say, "You are working so hard! I like your sweet attitude!" If the child remembered to use the target sound in a new context, instead of only "Good job," I may say, "Great job remembering to use your sounds!" This type of specific praise tells the child exactly what she does that is positive so that she can attempt it again for further praise. Now, the child is practicing listening to and correcting herself which is a direct path to generalization.

I am sure other speech-language pathologists use other means to help a child self-monitor. Please share your ideas with me at I am always looking for new techniques.

Pediastaff: Improving Prosody in Children with CAS

Written by Sarah Van Dusen
September 21st, 2010

Pediastaff has published one of my articles on "Improving Prosody in Childhood Apraxia of Speech". Follow the link below to access the full article.

Companion Pet Services

Written by Sarah Van Dusen
September 21st, 2010

Thank you, Companion Pet Services for advertising the Dallas Walk for Apraxia coming this Saturday! These families greatly appreciate your support! Take a look: They will take great care of your pet while you are walking with us on Saturday or any time!

Sign Language and CAS

Written by Sarah Van Dusen
August 20th, 2010

Sign language was one of my first loves. I began my career working with children who have auditory impairments. Some of them signed and others did not. Some of my students (when they reached an appropriate age to make the decision for themselves) chose to use sign language and refused oral is their right. Others were oral communicators and were not going to use sign as their primary means of communication no matter what their parents and teachers tried to force on them. What I found was that manual communication served as a language booster for many of my oral communicators. They did not begin to rely solely on sign language, but having some signs as children, helped them learn concepts and put words to those concepts.

I have also seen it with many children who do not have a hearing impairment or even a speech delay. Give them a motor plan for their hands before their mouth is ready, and suddenly, they are communicating their wants and needs. You have given them power and independence.

This is a wonderful way to bridge the gap between silence and speech for most children, but as always seems to be the case, childhood apraxia of speech (CAS) is in its own category. Please do not misunderstand me. Many children with CAS benefit greatly from the use of sign language. It is the way we use the signs that should differ from children with other speech delays/disorders.

Let's consider CAS. It is a neurological, motor-planning disorder. Saying the word "more" requires motor-planning for speech. Signing the word "more" requires motor-planning for your arms, hands, and fingers. Doing these two things at the same time requires two motor plans. Can you pat your head and rub your belly? I know I spent many afternoons as a child practicing this motion with my siblings. It almost never started easily, but with enough practice, I could get the hang of it. There are people who are unable to do it at all. They cannot create the motor plans for both activities simultaneously. Doing one activity at a time is much easier. How much more so for our children with apraxia!

When I teach signs to children with CAS, I teach the sign, then I allow the child to use the sign, but I do not allow the sign to be enough to communicate. After she uses the sign, she must attempt a verbal approximation of the word commensurate with her speech ability. If a child has no sounds, I observe her sign for "more", and I repeat the sign and the word before granting her request. I may even sign "more", say "more", then say, "The first part of that word is 'mmm'." (I will only do this for a few sessions which is all it should take for the child to have some sound to use here.) When the child has a small repertoire of sounds, I observe her sign for "more", then I sign it, say it, and request one appropriate sound from her (e.g., "mmm" or "ooo") while she is not signing before I grant her request. The purpose  is to acknowledge the child's communication attempt, give the child the opportunity to create the motor plans for sign and speech at separate times, and still give the expectation for speech.

Even in playing with my speech toys, I almost always have the child say the words before manipulating the toy. For most children with CAS, when they attempt both activities at the same time, their speech deteriorates. In fact, when the child has almost mastered a goal, I will add a gross or fine motor movement to increase the difficulty. For example, the child may be able to say "hit a ball" long before he can say it while actually moving his arms to hit the ball. Every time parents or therapists put a speech demand on a child with CAS, we must note any other motor planning that may be taking place, and adjust the demand accordingly.

This is a particularly important consideration in children who have CAS and low or high muscle tone - or children who have CAS and limb or global apraxia. It is advisable to do a "test run" when determining whether sign language is useful for improving the speech of your child with apraxia. I sometimes tell parents that we will try to add some signs over three weeks of treatment. If the child does not appear interested in using the signs or seems unusually frustrated by the attempt to sign and speak, we will cease the focus on signing.

Sign language can be a wonderful communication tool used to fill the gap before speech is developed and for some kids, to improve their verbal output, but in my experience, it is only effective with children who have CAS when the motor plan demands are taken into account. We know that parents and speech-language pathologists only want what is best for the child. In my opinion, all avenues to speech should be explored, yet we should not continue on any path that is showing no evidence of progress. Therefore, if signs are not helping your child, explore other avenues. If they are helping, the child with CAS finally caught a break!

Thank You, Bully Promotions, Inc.

Written by Sarah Van Dusen
July 21st, 2010

Bully Promotions, Inc is sponsoring the Dallas Childhood Apraxia of Speech Walk on September 25th! A quality company getting behind a quality event. Please look at their website to learn more about what they do and how they may be able to help you achieve your advertising goals.


The Advertising Specialty you're looking for!

The online tool Bully Promotions has developed makes it easy to get promotional items such as our t-shirts, bags, and special CAS bracelets!

Houston CAS Walk

Written by Sarah Van Dusen
July 21st, 2010

Houston is getting on board with their own walk to benefit programs and research for childhood apraxia of speech (CAS). If you are going to be near Houston (Tom Bass Park) on October 23, 2010, please join them.

The Houston walk website is

Help Houston raise awareness for their children with CAS!

A Mom’s Point of View

Written by Sarah Van Dusen
July 2nd, 2010

I wanted to share this poem from a mother's heart. (Discovered at


by Michelle Genser-Jones

The expressions in your face
Show the words you can not say
Not a fault, of yours nor I,
But of Apraxia,

Unknown to most….
It is not heard, nor seen,
But a Voice it takes

Scared parents…cry…worry
While surrounded by others…
Who just can’t understand

The fate, the destiny of their loved child
Seem unfounded through the endless wait…
With ears constantly ready for that first word
Joyful tears pour out when it’s finally heard

Words…movements… Sounds, may be found
Only to be lost once more,
And re-found at a later date
Dreams only to remain are those shared

Between child and parent
A bond always remains