Kuhl Constructs: How Babies Form Foundations for Language

thumbsup_127461614Years ago, I was captivated by an adorable baby on the front cover of a book, “The Scientist in the Crib: What Early Learning Tells Us About the Mind,” written by a trio of research scientists including Alison Gopnik, Andrew Meltzoff and Patricia Kuhl.

At the time, I was simply interested in how babies learn about their worlds, how they conduct experiments, and how this learning could impact early brain development. I did not realize the extent to which interactions with family, caregivers, society and culture could shape the direction of a young child’s future.

Now, as a speech-language pathologist in early intervention in Massachusetts, more cognizant of the myriad of factors that shape a child’s cognitive, social-emotional, language, and literacy development, I have been absolutely delighted to discover more of the work of Kuhl, a distinguished speech-language pathologist at The University of Washington. So, last spring, when I read that she was going to present “Babies’ Language Skills” as one of a two-part seminar series sponsored by the Mind, Brain, and Behavior Annual Distinguished Lecture Series at Harvard University, I was thrilled to have the opportunity to attend. Below are some highlights from that experience and the questions it has since sparked for me.

Who is Patricia Kuhl and how has her work reshaped our knowledge about how babies learn language?

Kuhl, co-director of the University of Washington’s Institute for Learning and Brain Sciences, has been internationally recognized for her research on early language and brain development, and for her studies on how young children learn. In her most recent research experiments, she’s been using magnetoencephalography (MEG)—a relatively new neuroscience technology that measures magnetic fields generated by the activity of brain cells—to investigate how, where and with what frequency babies from around the world process speech sounds in the brain when they are listening to adults speak in their native and non-native languages.

Not only does Kuhl’s research point us in the direction of how babies learn to process phonemes, the sound units upon which many languages are built, but it is part of a larger body of studies looking at infants across languages and cultures that has revolutionized our understanding of language development over the last half of the 20th Century—leading to, as Kuhl puts it in a 2000 paper on language acquisition she wrote for the Proceedings of the National Academy of Sciences, “a new view of language acquisition, that accounts for both the initial state of linguistic knowledge in infants, and infants’ extraordinary ability to learn simply by listening to their native language.”

What is neuroplasticity and how does it underlie child development?

Babies are born with 100 billion neurons, about the same as the number of stars in the Milky Way. In “The Whole Brain Child,” Daniel Siegel and Tina Payne Bryson explain that when we undergo an experience, these brain cells respond through changes in patterns of electrical activity—in other words, they “fire” electrical signals called “action potentials.”

In a child’s first years of life, the brain exhibits extraordinary neuroplasticity, refining its circuits in response to environmental experiences. Synapses—the sites of communication between neurons—are built, strengthened, weakened and pruned away as needed. Two short videos from the Center on the Developing Child at Harvard, “Experiences Build Brain Architecture” and “Serve and Return Interaction Shapes Brain Circuitry,” nicely depict how some of this early brain development happens.

Since brain circuits organize and reorganize themselves in response to an infant’s interactions with his or her environment, exposing babies to a variety of positive experiences (such as talking, cuddling, reading, singing and playing in different environments) not only helps tune babies in to the language of their culture, but also builds a foundation for developing the attention, cognition, memory, social-emotional, language and literacy, and sensory and motor skills that will help them reach their potential later on.

When and how do babies become “language-bound” listeners?

In her 2011 TED talk, “The Linguistic Genius of Babies,” Kuhl discusses how babies under 8 months of age from different cultures can detect sounds in any language from around the world, but adults cannot do this:

So when exactly do babies go from being “citizens of the world,” as Kuhl puts it, to becoming “language-bound” listeners, specifically focused on the language of their culture?”

Between 8-10 months of age, when babies are trying to master the sounds used in their native language, they enter a critical period for sound development. Kuhl explains that in one set of experiments, she compared a group of babies in America learning to differentiate the sounds “/Ra/” and “/La/,” with a group of babies in Japan. Between 6-8 months, the babies in both cultures recognized these sounds with the same frequency. However, by 10-12 months, after multiple training sessions, the babies in Seattle, Washington, were much better at detecting the “/Ra/-/La/” shift than were the Japanese babies.

Kuhl explains these results by suggesting that babies “take statistics” on how frequently they hear sounds in their native and non-native languages. Because “/Ra/” and “/La/” occur more frequently in the English language, the American babies recognized these sounds far more frequently in their native language than the Japanese babies. Kuhl believes that the results in this study indicate a shift in brain development, during which babies from each culture are preparing for their own languages and becoming “language-bound” listeners.

In what ways are nurturing interactions with caregivers more valuable to babies’ early language development than interfacing with technology?

If parents, caregivers and other children can help mold babies’ language development simply by talking to them, it is tempting to ask whether young babies can learn language by listening to the radio, watching television, or playing on their parents’ mobile devices. I mean, what could be more engaging than the brightly-colored screens of the latest and greatest smart phones, iPads, iPods, and computers? They’re perfect for entertaining babies. In fact, some babies and toddlers can operate their parents’ devices before even having learned how to talk.

However, based on her research, Kuhl states that young babies cannot learn language from television and it is necessary for babies to have lots of face-to-face interaction to learn how to talk. In one interesting study, Kuhl’s team exposed 9 month old American babies to Mandarin in various forms—in person interactions with native Mandarin speakers vs. audiovisual or audio recordings of these speakers—and then looked at the impact of this exposure on the babies’ ability to make Mandarin phonetic contrasts (not found in English) at 10-12 months of age.

Strikingly, 12 laboratory visits featuring in-person interactions with the native Mandarin speakers were sufficient to teach the American babies how to distinguish the Mandarin sounds as well as Taiwanese babies of the same age. However, the same number of lab visits featuring the audiovisual or audio recordings made no impact. American babies exposed to Mandarin through these technologies performed the same as a control group of American babies exposed to native English speakers during their lab visits.

Kuhl believes that this is primarily because a baby’s interactions with others engages the social brain, a critical element for helping children learn to communicate in their native and non-native languages. In other words, learning language is not simply a technical skill that can be learned by listening to a recording or watching a show on a screen. Instead, it is a special gift that is handed down from one generation to the next.

Language is learned through talking, singing, storytelling, reading and many other nurturing experiences shared between caregiver and child. Babies are naturally curious; they watch every movement and listen to every sound they hear around them. When parents talk, babies look up and watch their mouth movements with intense wonder. Parents respond in turn, speaking in “motherese,” a special variant of language designed to bathe babies in the sound patterns and speech sounds of their native language. Motherese helps babies hear the “edges” of sound, the very thing that is difficult for babies who exhibit symptoms of dyslexia and auditory processing issues later on.

Over time, by listening to and engaging with the speakers around them, babies build sound maps, which set the stage for them to be able to say words and learn to read later on. In fact, based on years of research, Kuhl has discovered that babies’ abilities to discriminate phonemes at 7 months old is a predictor of future reading skills for that child at age 5, as noted in a Harvard Crimson article on Kuhl’s Harvard lecture series.

I believe that educating families about brain development, nurturing interactions, and the benefits and limits of technology is absolutely critical to helping families focus on what is most important in developing their children’s communication skills. I also believe that Kuhl’s work is invaluable in this regard. Not only has it focused my attention on how babies form foundations for language, but it has illuminated my understanding of how caregiver-child interactions help set the stage for babies to become language-bound learners.

Sarah Andrews Roehrich, MS, CCC-SLP, works in early intervention at the ThomAnne Sullivan Early Intervention Center in Lowell, Mass.

Note: This post was adapted from an original version published by E/I Balance, a community blog on mental health research, set up by the Conte Center at Harvard University.

 

Best New Games for Speech Intervention

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I’m lucky to have enjoyed the unique opportunity to attend the International Toy Fair in New York City as a member of the press, viewing the exciting new products being introduced. After seeing hundreds of new games, toys and books, I shared my first impressions of what stood out, delivering language learning potential. Now that I have had a chance to catch my breath, the boxes are arriving with Ninja Turtle games and fuzzy chick puppets to review for my PAL Award (Play Advances Language). As speech language pathologists, we are a busy crew, spinning many plates at once–serving our clients, keeping data, attending meetings, planning therapy and keeping up with what’s new. Many of you have told me how much you appreciate my selection process and the products I recommend, saving you time, so here are my newest recommendations with descriptions on how I have found them to be helpful. As always, I love your comments on how YOU use them in new and creative ways too!

Animal Soup The Mixed-Up Animal Board Game! by The Haywire Group

Just setting up this game gets lots of giggles going as kids look at the pictured math showing the sum of a tiger plus a rhinoceros equals, of course, a “tigeroceros!” Preschoolers request that I read through each zany combination of animals before starting the game. Players make their way around the forest game board, which cleverly uses the box, as they land on different animals, collecting the corresponding picture card. Kids continually check the large reference chart of combined animals to see what they need to complete their “croctopus,” “birdle” or “squale”–(crocodile+octopus, bird+turtle, or squirrel+whale). Thankfully they have a “trade” option to land on so they can negotiate with a peer for the animal to complete their creature. Flip the two matching cards over, and you are rewarded with a hilarious animal soup combination. Two completed mixed-up animals wins the game. This game, based on the best selling book by Todd S. Doodler, can be used to further speech and language skills:

  • Articulation: repeat the goofy combined animal names, which I’ve found helpful in making preschoolers aware of moving their mouths and listening to include all the sounds in a word.
  • Practice negotiating skills as they realize cards needed for a trade and anticipate where their needed card is coming up on the board.
  • Follow directions.
  • Comparisons between the game and the book it is based on.

Suggested age: 3 and up. This is so popular with my preschoolers, they consistently request to play.

Teenage Mutant Ninja Turtles Clash Alley Strategy Board Game by Wonder Forge

Start your social language lesson as kids set up the 3-D game board, stacking boxes at different levels for the Teenage Mutant Ninja Turtles to traverse through the maze-like warehouse. A collaborative effort, players help each other to customize the board. An excellent introduction to strategy games, Clash Alley has many options to enhance the turtle’s success as they run, climb and leap to race to complete their mission, uncovering the card to rescue April, retrieve the AI chip, grab the Mutagen or even pick up a pizza! Earning and playing action cards are the key to successful travel across the board as your turtle can team up to battle villains–Kraag, powerful mutants and even Shredder–to collect spy cards to peak under a mission disk, swipe card to steal from another player, or Team Up, which allows two turtles to combine attack points to overcome a villain. The directions take a little time to understand but once kids got them, they couldn’t get enough of this game. Speech and language goals to address:

  • Description: I use this multi-leveled game of strategy in my group with higher-level kids on the autism spectrum and their typical peer play partner. I have my client explain the directions (which have many options for beating the villains) which can be challenging. The visual prompts of action cards and triple option dice help.
  • Social language: Learning to take turns and a group attack option to join forces with another player.
  • Academic language: Language of math as kids help each other add up attack points and have to determine what number is greater or less than another to win the battle.
  • Pretend play: Kids surprised me as they got into the game because even though they were competing against each other, there was a feeling of camaraderie against the villains.

Suggested age: The manufacturer says 6 years and up but I found the directions are more suited to 7 or 8 and up although you certainly can adapt this game to younger kids, since Teenage Ninja Turtles are so hot right now.

On the Farm Who’s In the Barnyard by Ravensburger

This farm set with characters, vehicles and animals is a puzzle, pretend play set and first game all in one. Open the barn like a book, identifying all the animals and objects from pigs, chicks and bunnies to tools and bales of hay. Talk through the illustrations on the outside of the barn with the fruit stand, conveyor with bales of hay and parked tractor. Kids love to snap out the windows and door as a puzzle experience so they can peer inside, or even play a game of peek-a-boo. Add the base and roof and you have a perfect house for your barnyard friends to practice your animal sounds as kids match and place your cut-out figures next to corresponding pictures on the barn. Take the play up a notch with a matching game as you switch game figures and others have to guess who moved! This set is so open-ended, I used it for several activities with 2 year-olds. Here are some speech and language skills to build:

  • Teach animal sounds, as you play with the corresponding figures.
  • Articulation. I had plenty of /p/ and /h/ words to model with this set.
  • Pretend play as the barn is built and animals can move in and out of the play scheme.
  • Verbs, and prepositions can be modeled as you play with this set.

Suggested age: 2 years and up. I’d say this is best for the toddler set. Excellent educational suggestions are included in the box so this is also a good product to suggest to parents who would like some assistance in how to encourage language learning with this toy.

WordARound by Thinkfun

I never knew reading in circles could be so much fun! Each round card has blue, red and black concentric circles, with a single word written in each ring. Players race to unravel the word and shout it out to win a card. Flip the card over and you will see what color ring to examine on the next round, searching for a word. With no beginning or end to the word, players look for patterns, prefixes and suffixes like “ant,” in “hesitant” and ” er,” in “finger.” I found myself looking for consonants to start a word, until other players beat me at “uneven” and “almost,” leading me to factor in initial vowels too. Some cards flipped over to present the word so I could read it easily like “porcupine,” which made for an easy turn. Starting anywhere on the ring and sounding out the string of sounds also brought results as players recognized parts of words like “typical.” WordARound is addictive, and watch out because little clients can beat you at this! I use it for:

  • Vocabulary: Discuss meanings and practice using new words.
  • Reading: Develop strategies to find words in the circle.
  • Articulation carryover for older kids.

Suggested age: 10 years and up

What’s It? by Peaceable Kingdom

What’s It? is a cooperative game where players interpret doodle cards and score points for thinking alike. Roll the dice with category options such as you love it, use it, wear it, don’t want it, or make up your own category. Flip over a doodle card, start the 30-second timer and play begins. Players record at least three guesses based on the drawing and category but try to think like their fellow players. This is where I was at a bit of a disadvantage, playing with 8 year-olds. They saw buttons when I saw a pearl necklace and they saw shark teeth when I saw a zipper! Players earn points when their answers match. I’ve used this game with higher functioning kids on the autism spectrum, encouraging more abstract thinking.

  • Calling up words in categories
  • Word-finding
  • Description

Suggested age: 8 and up

Qualities by SimplyFun

SimplyFun’s game, Qualities, is a natural language catalyst and a creative way to get to know and be known by friends. Up to seven players take turns identifying and rating certain qualities in themselves, while game-mates offer up their own perceptions. “Qualities” runs off of a Preference Board as players accumulate points as they match their assessment of player’s personalities to their own judgement. What gives you the most energy… going to the park, going to a museum or organizing? Lots of conversation follows as players defend their answers with examples of that behavior. Players rate the extent to which a player is “tolerant,” “cautious,””empathic” or “sympathetic,” to name a few. The trait and value cards were a vocabulary lesson in themselves.

  • Vocabulary
  • Language of persuasion
  • Explanation of how traits are manifested in a person’s actions or activities
  • Abstract thinking

Suggested age: 12 years and up. This game is great with adults too.

Disclosure: The above games were provided for review by their companies.

Sherry Y. Artemenko MA, CCC-SLP, has worked with children for more than 35 years to improve their speech and language, serving as a speech language pathologist in both the public and private school systems and private practice.

Tricks to Help Speech Lessons Carryover into Daily Life

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How can our clients better incorporate new skills into their speech in their daily lives? It seems that they are often limited by their social interactions with caregivers, parents or spouses, so that they can’t practice or complete speech homework between sessions.

Some of my adult clients will avoid practice sessions with their spouses altogether. How can we encourage use of newly acquired skills between visits? Wouldn’t the duration of therapy be reduced and functional communication improved? Research has supported more intensive therapy approaches to promote a more efficient, complete healing process. Because time and funding often limits therapy frequency, we send patients home with work for practice. Follow-through with homework generally rests on the motivation of the client or the client’s family. We need to find ways to make the therapy process efficient and functional.

In Pam Marshalla’s 2010 book “Carryover Techniques (in Articulation and Phonological Therapy),” she defines the term carryover are referring to “a client’s ability to take an individual speech skill learned in the therapy room and to apply it broadly in all speaking situations.”

Getting our students and clients to use their articulation and communication skills outside the therapy environment requires that we begin the process of carryover as soon as the skill is demonstrated in a variety of environments. For children, it might mean saying a fluent word or phrase during a game to get to the next square, or using the correct production of /r/ and /l/ during a short conversation about sports. For adults, the rules of learning after a stroke or traumatic brain injury still may require learning a new skill, like writing the first letter for phonemic placement or using cognitive-semantic linking to ask for coffee.

We need to get more creative to promote carryover across all our clients because of additional sensory, physical, psychological or cognitive difficulties that may impede the process. Charles Van Riper in 1947 wrote that while we cannot rush carryover, we must facilitate its progress.

Pam Marshalla listed some functional ways to promote carryover in children and adolescents, including use of:

  • Fill-in sentences or fill-in stories to stimulate spontaneity.
  • Idioms to stimulate spontaneity.
  • Negative practice to help break the incorrect speech habit.
  • Nonsense syllables and words to strengthen the carryover process.
  • Over practice to cause a hyper-awareness of the goals of therapy.
  • Rapid-fire questions and answers to promote naturalness.
  • Reading aloud as a step between word productions and conversational speech.
  • Rhyming to capture a client’s attention and encourage practice outside of therapy.
  • Riddles because they cause a client to combine practice material with creative thinking.
  • Shortening productions to encourage naturalness.
  • Singing to help children remember their speech work and to encourages effortless practice.
  • Spelling out errors to help the client think about what she is saying and how she is saying it.
  • Story-telling and re-telling to cause stimulate spontaneity and to cause a breakthrough in carryover.
  • Tongue twisters to teach children how to control their articulation.

More on promoting carryover in speech-language treatment can be found on Pam Marshalla’s website.

Many of these techniques are useful for adults as well as children. Here are some additional carryover ideas for adults:

  • Create a script to practice at a favorite restaurant.
  • Use the carryover phrases and substitute other items at a counter deli or a department store.
  • Make a to-do list (or grocery list) each day. Practice writing and reading.
  • Talk about the programs you will watch.
  • Use carryover phrases for conversation, such as, “Hi. How are______?” “What is____?”  “I’m _____.” “Who is____?”
  • Use a calendar and an 8 by 10 dry-erase board to practice drawing,writing and gesturing.
  • Use your smart pad, apps, whiteboard, AAC, text-to-speech, and speech-to-text to send emails and do alphabet board, speech tutor and naming practice.
  • Play your favorite brain games daily. They will help you with focus, learning, word-finding and memory.

If you encourage your clients to engage in games and functional activities daily, the overall quality of your clients’ understanding and speech production will improve because you are encouraging the growth of new neural connections. Your clients are naturally acquiring and using the new skills in their daily lives because they are using them. Becoming more functional can be the most motivating effect of carryover.

 

Betsy C. Schreiber, MMS, CCC-SLP, is a clinical supervisor at Ladge Speech and Hearing Clinic at LIU/Post on Long Island, and a partner at Hope 4 Speech Associates, P.C. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders, and 18, Telepractice.

 

On the Brink of Kindergarten: Placement of Bilingual Students

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As a preschool-based speech-language pathologist in New York City, I get a number of bilingual children on my caseload every year. Many of them are sequential bilingual learners, with English being their second language (L2). It is also not uncommon for these sequential bilinguals to first begin to acquire their L2 here at the preschool. Speech-language and overall cognitive functioning of these children varies greatly, often a function of how much exposure to English they had to prior to preschool. During the Turning Five meetings, these students’ overall speech-language progress becomes especially salient.

At these meetings, I find that for some of our bilingual students, particularly the sequential bilinguals, the kindergarten setting recommended by the evaluation team tends to be smaller (for example, a classroom size of 12). This type of educational environment is often recommended for children with severe delays and disorders such as autism spectrum disorders, learning disability and childhood apraxia of speech.

During one of these meetings, a graduating student I will call Andy was described as extremely slow to progress and retain information. All team members agreed he requires a lot of support to comprehend basic in-context commands in therapy sessions and the classroom, and presents with minimal use of words. However, we also know that he is from a home where the primary language is not English. In addition, the student only joined the program at the age of 4, not at 3, which would probably have made a big difference. The speech-language evaluation in the child’s file indicates a severe delay in English (I bet I would be severely delayed in a language to which I had minimal or no exposure) but no mention of the skills present in L1. Communication with the family has been limited due to a language barrier.

There are many bilingual children in the New York City school system that follow Andy’s path. Hence, it should always be alarming to us, the educators, when a bilingual student in whom L1 is not English but there are no known global delays transitions into a kindergarten setting of 12. Additionally, a kindergarten special education classroom includes students with a variety of diagnoses and behaviors, with the more severely impaired students not providing a model for appropriate social skills and verbal communication.

So why do these students continue to get placed into smaller, more restrictive educational settings? Most obviously because of concern that they will not be able to function in a larger setting. But what could we be doing instead? Each child’s case would need to be studied individually. Specifically, we would need to review all the relevant cultural and linguistic background information starting at birth, such as the amount of L1 and L2 exposure in and out of home, history of speech- language delays, and the level of education in the family, to name a few. Other variables to consider are: 1) the amount of time that the bilingual student has spent in an all-English formal academic setting, 2) the presence of “problem” behaviors that significantly maintain the overall delays and reduce time the student is actually learning, and 3) the lack of sufficient, if any, L1 support (Spanish/ Bengali/Arabic) received in the school setting, including from an assigned SLP.

The latter one is of particular interest to me, as I am a bilingually certified English/Russian speech-language pathologist. However, I have little practical language skill to offer to my Arabic-, Spanish-, Bengali- or Albanian-speaking students. In such cases we, for the lack of a better word, “exercise,” our nonverbal communication skills and teach English as a second language.

Sure, an ongoing collaboration and a close relationship with the child’s family can potentially shed light on the speech-language and cognitive skills of the student. However, my experience has been that, due to communication barriers, the family yields little information that can guide me. Therefore, in most cases, I cannot reliably pinpoint speech-language deficits present in languages other than English or Russian.

This is an ongoing issue of inappropriate services to and settings for our bilingual special education students. Research is full of examples of typically developing bilingual students taking longer to learn and acquire L2 skills. This is even more consequential for children with special needs, whose speech- language and/or cognition is already delayed. Subtractive bilingualism is the term Fred Genesee and colleagues use in their book “Dual Language Development and Disorders” (2004) to describe this language-learning dilemma and the danger of “switching” our culturally diverse students to English only. According to the literature, the problem with monolingual (English-only) placements is that many of our already delayed bilingual children can’t “catch up” to their monolingual peers. Therefore, the all-English classroom setting of 12 carries a rather pessimistic long-term implication for overall academic success.

But what if every bilingual child with special needs received enough L1 support? Would that change the outcome? What if we had enough bilingual certified SLPs representing a variety of cultures and languages to help our culturally diverse students? Would the bilingual children still be placed into restrictive settings with no L1 support and with communicative interactions that offer few appropriate models? I believe that if these students received speech-language services in both the L1 and L2, they would make significantly more progress and at a much higher rate.

It would certainly further expedite their progress and make the instruction more holistic and ethical. Of course, today, more than ever, we have major problems with budget cuts that affect the number and the size of special education classrooms available to us, as well as the amount and the type of services we can offer. In fact, in recent years it has become much more difficult to qualify a child for related services even in the presence of notable deficits. Greater still is the cost of not delivering appropriate and culturally/linguistically ethical services to our bilingual children. We might be in far greater need of special education services years down the line when trying to remediate difficulties that were further compromised due to lack of appropriate language support. Just something to think about!

Natalie Romanchukevich, MS, CCC-SLP, is a bilingual Russian speech-language pathologist at the Children’s Center for Early Learning in New York City. This post is adapted from a guest post Natalie Romanchukevich wrote for Tatyana Elleseff’s blog Smart Speech Therapy. Natalie can be reached at natalieslp@gmail.com.

Kid Confidential: “Join In on the Stim!”

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Autism Spectrum Disorders (ASD) is one of the great loves in my professional career. Persons with ASD are fascinating and wonderful and many times their behavior actually makes sense to me. I know what you are thinking, “This woman has got to be on the spectrum herself.” Well although I do believe that we all exhibit hyper- and/or hypo-sensitivities to various stimuli and that we all have what I like to call “a little autism in us,” it just may not be on the scale of persons who are diagnosed with ASD formally. It may not consume our entire interactions as it does for some students with ASD. So the question is, what do we do about it?

When I was in graduate school, the prevailing acceptable intervention was based on behavioral modification techniques. I was expected to spend time determining why that stimulatory behavior occurred (i.e. avoidance, stress, seeking sensory input, coping mechanism, sensory overload, etc.) and replace it with a more appropriate behavior. I still agree that this treatment strategy is appropriate in certain situations. For instance, if the student is seeking sensory input, let’s provide him/her with an appropriate sensory diet (under the supervision of an OT with the appropriate experience). If the student is exhibiting behaviors that are harmful to him or herself or others, they MUST be replaced by more appropriate safe behaviors. If the student is overloaded and attempting to escape/avoid a situation, let’s give him/her a break and/or modify the activity and expectations.

But are there times when we should actually encourage the stimulatory behavior? Are there times when we should not only support it, but “join in on the stim”? My answer to this is ABSOLUTELY! I know I just lost a few of you, but hear me out. The first time I read this idea, I was skeptical as well.

Jonathan Levy, author of “What You Can Do Right Now to Help Your Child with Autism,” challenges parents and therapists alike to do just this, join the child in his/her world by simultaneously imitating the stimulatory behavior. The idea is that for children who are profoundly affected by ASD and who spend all or most of their time exhibiting stimulatory behaviors actually need us to invade their world and physically pull them out of it by imitating them.

According to Levy, by joining your child/student in their stimulatory behavior you are telling them several things:

  • You understand their need to use this behavior.
  • You have something in common with them.
  • You want to interact with them and you are willing to enter their world.
  • They are safe to “be themselves” around you and you will not interrupt their need to stimulate themselves using these behaviors.

Does this actually work? According to Jonathan Levy, this is a technique Barry and Samahria Kaufmann, authors of the Son-Rise Program and founders of the Autism Treatment Center of America (ATCA), not only believe in, but have used successfully on their own child as well as numerous children nationally and internationally for more than 25 years. Anecdotally, I can tell you from my personal experience, I have done this and I have noted several positive changes with consistency:

  • Almost immediate increase in eye contact or facial referencing.
  • Students with ASD began to approach and/or gravitate to me whenever I entered their classrooms.
  • Students began to tolerate my touch or would take my hands and place them on their own bodies. For example, I had a female student once start pulling on my arms. I figured out very quickly she wanted me to do this to her. Although nonverbal, she made a request for the first time in her life! After I provided that sensory feedback, she was able to sit on the floor with her class during a large group lesson for the very first time.
  • And after a few weeks of joining in the stimulatory behaviors, I began to hear vocalizations. And for some of these children, it was the first time they ever vocalized!

Yes I was that therapist, jumping around in circles, flapping my hands, vocalizing various moans and groans along with my students. I was that therapist sitting at the lunch table filtering light through my fingers and screeching with my student as he attempted to eat. I was also the first person they made eye contact with; the first person, to which they handed a picture (i.e. PEC); the first person, with whom they exhibited joint attention; and the first person to whom they intentionally vocalized when making a request.

So does this technique work? I believe that it does if used properly for the appropriate students. This is not a technique that I believe every student with ASD requires or can benefit from, but it certainly appears to make significant changes in those who are so profoundly affected that they cannot find a way out of their own worlds without us stepping in and meeting them where they are.

Mr. Levy does leave us with a word of caution. Some children do not respond immediately to this technique as they are so far within their own worlds it could take them weeks to even notice your attempts to join the stimulatory behavior. But he ensures us, that this is not a reason to give up and believes that by giving the child adequate time, he will take note of your attempts to enter his world and you will break through the child’s barriers of stimulatory protection (Levy, 2007).

This has not been the case for me as I saw changes fairly immediately. However, I do believe that can be attributed to the fact that if the child is in a school setting, they are aware at some level that there are other people within the room, whether they seem to show it or not. I believe the school setting is unique in that just the setting itself forces the child with ASD to, even on a subconscious level, acknowledge there is a world bigger and different than what is found within themselves.

So the next time you have a student with ASD on your caseload that is profoundly affected and appears to spend all or most of his/her time exhibiting stimulatory behaviors, no longer ask yourself “What do I do with this child?”. Rather, make an attempt to enter their world and “join in the stim”. By doing this, you may just be the first person who has ever been able to connect with them.

Maria Del Duca, M.S. CCC-SLP, is a pediatric speech-language pathologist in southern, Arizona. She owns a private practice, Communication Station: Speech Therapy, PLLC, and has a speech and language blog under the same name. Maria received her master’s degree from Bloomsburg University of Pennsylvania. She has been practicing as an ASHA certified member since 2003 and is an affiliate of Special Interest Group 16, School-Based Issues. She has experience in various settings such as private practice, hospital and school environments and has practiced speech pathology in New Jersey, Maryland, Kansas and now Arizona. Maria has a passion for early childhood, autism spectrum disorders, rare syndromes, and childhood Apraxia of speech. For more information, visit her blog or find her on Facebook.

Toddler Talking Points

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Toddlers are some of my favorite people—they explore with abandon, imitate pirates and fairies, refuse with gusto, stack, dump and search, communicate with persistence, and give enthusiastic hugs with sloppy kisses. So why would we get in their way? One of the most common mistakes I see parents make with their toddlers is to ask too many questions, which actually inhibits their language.

I arrived at a home this week, to evaluate an 18-month-old boy, whose mom was concerned he was delayed in talking. As our play session progressed, it was apparent that he wasn’t far behind, using many words meaningfully in his little world, like “milk,” “ball,” and “car.” When I watched his mother interact with him, she was questioning him with, “What’s that?” or “Can you say ‘book’?” I gently suggested that when we ask too many questions, especially for the child to perform, it is not natural and many times the child clams up. They are smarter than you think and can feel the pressure.

Rather than questioning, model a word, phrase or sentence related to what your toddler is doing at the time. When we talk about what she is focusing on, she can take in more language since it relates to her experience. When she chooses a book, simply say, “Book. Let’s read our book. This book is about the beach.”

Joining your child’s play, following their lead and talking about what they are playing with can boost their language development. Selecting appropriate toys for learning at this stage engages the child and builds cognitive and language skills. Pretend play begins to emerge at around 1 year of age and progresses as a child imitates the adults around him. At one year of age, a teddy bear, cup, spoon, and blanket can encourage a little story, while a two year-old will enjoy pushing a fire truck into the station.

Look for toys that have a few related props for open-ended play that your child can direct. Playmobil’s 1.2.3 sets are geared for toddlers, providing simpler chunky figures that only take a twist to sit them down, or ride on an animal. The Playmobil 1.2.3. Large Zoo comes with fence sections to enclose the animals, a tractor and detachable trailer to deliver the food, and plenty of people, including mom and baby to chat on a park bench.

Doll play encourages dialogue and imagination as children care for and take their friend out on activities. Corolle‘s premier dolls, geared for age appropriate play from infant and up, has just introduced a new doll that loves the water,

Bébé Bath & Accessories.” Pack up for a snorkeling adventure in the tub, complete with floaties, flippers and a snorkel mask!

Thinkfun’s “Hello Sunshine” joins their first toddler game, “Roll ‘n Play” which was popular with toddlers and their moms last year. I am more frequently asked for toy suggestions by parents of toddlers than any other age, which might explain why these simple starter games provide more structure for parents and caregivers who appreciate some guidance on where to start their play. Hide the plush Sunshine ball according to picture cards depicting positions such as in a box or on top of your head!

Flexible, multi-use toys are my favorites as HABA’s Arranging Game My Animal Friends can be a flat puzzle of 17 interlocking, brightly colored wooden pieces or a three-dimensional story making houses, bridges, or towers while stars, a fence, bridge and grass provide the backdrop for a cat, dog, mouse, frog, ladybug, and bee to carry on with the storytelling.

WOW Fire Rescue Rory is a parent’ s dream because it has only four pieces but so much potential for creative play. The helicopter is powered by kids, pulling the trigger, activating the friction motors to fly to the rescue. A casted figure slips into the stretcher to be scooped up by Rory thanks to a magnet system. Kids love to transport the injured person and release him to a doctor’s care. The story is totally up to the child as they add on doctors, hospitals and helpers.
Finally, an excellent resource for parents is “My Toddler Talks, Strategies and Activities to Promote Your Child’s Language Development” by Kimberly Scanlon, MA, CCC-SLP.

So come along side your toddlers and enter into her play, following her lead as she builds a town for her ladybug and bee, feeds the zoo animals, goes for a swim, searches for an injured friend, or delights in finding a little sunshine.
The opinions expressed are solely those of the author. The above products were provided by their companies for review.

Sherry Y. Artemenko MA, CCC-SLP, has worked with children for more than 35 years to improve their speech and language, serving as a speech language pathologist in both the public and private school systems and private practice.

Helping Clients With Aphasia Retrieve Words—On Their Own

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Eric Broder Van Dyke / Shutterstock.com

“I can’t hear it!” This was said by Mrs. A, a 67-year-old woman with aphasia, who actually hears fine. What she meant to say is that she can’t recall the sequence of sounds to express a particular word or idea. When we have that tip-of-the-tongue loss of a name, how do we try to remember it? What strategies are we using to get to that word that we can’t remember?

Our success depends on our ability to hunt and gather—and on the number of neural connections we can tap into to access the information. These skills are cognitive, not simply learned operantly.

In my last blog post, I talked about establishing cueing hierarchies and functional activities for our adult clients. This post looks at using the cueing hierarchy to stimulate the rewiring process. Sometimes I think that I am a sort of electrician rather than an SLP. I work on finding the connections based on observed behavior from evaluations or activities (like writing, gesturing or drawing) that require least intervention.

How do we develop these skills? How can we teach strategies for short and long-term functional success?

Sometimes, we spend the therapy session working on the most disabled aspects of the communication disorder: comprehension, word retrieval, writing and reading. But if we don’t tap clients’ best abilities to foster some success, and if we don’t address whether they are continuing to practice these skills outside the therapy room, how will compensatory skills, adaptive skills and new connections work for them?

Let’s look at Mrs. A, who said, “I can’t hear it.” She was telling me about the very connection that she lacks due to her aphasia: re-auditorization. She can’t hear the words or the phonemes that make up the words in what I call “her mind’s ear.” If given the first phoneme, or a carrier phrase, she almost always names the word. She is able to write the word about 75 percent of the time but can only read it aloud about 30 percent of the time. She will often be able to speak complex multisyllabic words or a short phrase when discussing a topic. Auditory and reading comprehension is 75 percent for paragraphs. She is very intact cognitively, but her affect varies emotionally from congenially engaged to depressed and angry.

She is about two years post-stroke and has an all-in-one AAC that she doesn’t use. Our goals must address her frustration by establishing immediate successful compensatory strategies for communication. Then we need to build skills that will help in the rewiring, so that she begins to cue herself. The rewiring will be difficult here because she doesn’t link the phoneme to the letters she is able to write. But if she can write the word and then read it aloud more often, she can develop a clear strategy for verbalization that will reduce her frustration.

We will begin by simply reviewing phonetic placement in monosyllabic words. I like to use real words—which have semantic value—rather than nonsense syllables. Consonant-vowels alone don’t work as well as consonant-vowel-consonants that mean something. Mrs. A started relearning that a /b/ means that the lips come together when starting a whole word like “beer.” We chose beer for the visceral, emotional connection it has for many people. We talked about when she might drink beer, such as at a baseball game, which lends itself to picture assistance to boost cognitive links. We initially used a mirror to model the placement while sitting next to her. We highlighted the first letter and said it with her. She saw the picture, then wrote the word.

Mrs. A can now produce the whole word “beer” after seeing a picture of it. Looking at the Cueing Hierarchy, we have moved from most clinician involvement to independent self-cueing for this phoneme. She is moving on to more phonemes rapidly so that we may not need to review every letter after a period of time. Mrs. A. is beginning to generalize the link to other sounds. New neuro-behavioral links and relinks are helping her associate the orthographic letter with a physical movement and the sound that is produced. New cognitive links and self-cueing has begun!

Next, she will need to use the strategy in controlled conversation and small groups to increase her comfort level and functional use outside of treatment. This is a big hurdle. Families and caregivers are crucial players and need to be instructed how to encourage communication without frustration. When possible, teach the caregivers and families how the strategy works. They will use it more readily at home and will see how it can work in a variety of situations, such as in restaurants.

Another client, Mrs. C, had a similar functional ability to write but not verbalize. With time, she was able to trace the first letter in the air to cue herself to say a word.

In both cases, skills that had been present were improved, then used to create a compensatory strategy for functional communication. We must teach our clients strategies for improving the scope of their communication without our cues, using their own strategies, thereby making them more independently functional. While available strategies are unique to each client, they usually take the form of low tech gesturing, drawing, writing, even circumlocution.

We want our clients to be learning and improving communication dynamically. If we always fill in all of the sentences or speak for them, they cannot make their own connections. When allowed to use strategies independently, they then blossom, not only communicatively but socially.

Betsy C. Schreiber, MMS, CCC-SLP, is a clinical supervisor at Ladge Speech and Hearing Clinic at LIU/Post on Long Island, and a partner at Hope 4 Speech Associates, P.C. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders, and 18, Telepractice.

My Baby Can Play: How Productive Play Promotes Literacy

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My Baby Can Read…Play: How Productive Play Promotes Literacy

If you pay attention to the current toys, television shows, and materials for children like Your Baby Can Read! you should notice a cultural shift to the promotion of literacy, especially early literacy skills.  From older shows such as Sesame Street and Between the Lions to newer shows such as WordGirl, WordWorld, and Super Why! we see the push for phonological awareness skills and reading skills, which encompass rhyming, letter/sound naming and identification, sound segmenting and blending, and so on.

The available research clearly shows the importance of promoting literacy skills early, and the overall consensus is that oral language provides the building blocks for literacy.  So if oral language is the foundation, and if we achieve language through quality language input, how is that input provided for infants and toddlers?  Through play!

Besides daily care-taking routines that parents and children engage in (feeding, grooming, sleeping), the next most important activity they engage in (where crucial language input is provided) is play.

So, if appropriate play skills predict appropriate language skills, and if strong language skills predict literacy skills, then I see a clear link between play and reading.

I’m not suggesting reading to infants and toddlers is not valid and necessary; I am suggesting that perhaps there should be a greater, or at least equal, push for promoting quality play.  My meaning of play, however, is where the play partner of the child is engaging the child and providing quality language input naturally but purposefully.

In a nutshell, let’s not bypass the building block of play because we’re so concerned that children be able to read.

As a personal example, both of my toddlers love books.  From the time my four-year-old daughter was one, she would quietly sit on the floor going through baskets I had set around the house full of little books, and she would flip through the pages “reading” one book after another.  I often find my two-year-old son sitting in a rocking chair in his room surrounded by books “reading.”  He spontaneously points out characters and talks about the pictures.  His big sister also helps him out, making up stories for him based on the pictures as though she is reading…and he believes every word!

As parents, my husband and I have read to them consistently, have made sure books are readily available and accessible to them, and have encouraged them to talk about the pictures and relate what they’re seeing to experiences they’ve had, but I firmly believe their enjoyment of books would not have been fostered without purposeful play in our home.

Purposeful play is crucial in order to develop what I call the 4 C’s: Concentration (attention), Curiosity, Creativity (imagination), and family Connection (through a shared activity).  These four components are extremely important for promoting reading ability.

So as professionals, educators, and parents, let’s evaluate where we’re investing our time and resources and make sure the push for early literacy doesn’t overshadow or do away with the need for consistent and quality play, not through the latest electronics or gadgets, but using good ol’ blocks, dolls, cars, toy farms, puzzles, toy kitchens, playdough…and the list goes on and on.

For purposeful play suggestions, check out free tip sheets (known as P.O.P. sheets) entitled Purposeful Ongoing Play: Enhancing Language Skills Through Play.

(This post originally appeared on The Speech Stop)

Ana Paula G. Mumy, MS, CCC-SLP, is a multilingual speech-language pathologist and the author of various continuing education courses, leveled storybooks, and instructional therapy materials for speech/language intervention.  She has provided school-based services, home health care, and private services for more than 12 years and thoroughly enjoys providing resources for SLPs, educators, and parents on her website The Speech Stop.

Speech Therapy and Aging: Brain Plasticity and Cueing Hierarchies

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Given our knowledge of the plasticity of the brain, are we as clinicians or caregivers, able to help to develop new links with a behavioral model, by using gradated cueing hierarchies?  Could this low-tech and pharmaceutical-free form of treatment  have neurologically based implications for rehabilitation and adaptation in communicatively challenging settings?

Perhaps more testing with fMRI scans may be necessary to really prove the theory. Therapy approaches using cueing models have been well documented in the literature in speech therapy treatment for aphasia.  However, the way we use clinician originated cues can help create new links and expedite a broad area of cognitive and linguistic improvement, or maintain the functional status quo, unless we analyze the kinds of cues we are using and the amount of independence we are carefully eliciting from the client.

By looking at each task and cue needed on a continuum from simple to complex, concrete to abstract, you can construct a grid of where on the continuum the client functions and how you can provide a cue or help them provide their own cues for success.

The idea that the damaged axons and dendrites in the brain are looking for connections and stay active when the brain is activated, prompted me to want to create a cueing continuum (see http://carmichaellab.neurology.ucla.edu/integrated-view-neural-repair-after-stroke.) On the theory that the client can develop new pathways , if we always fill in the missing word or provide the first phoneme, then the client will never have to learn where to get it, via their own written word, for example.  But how do we get from writing the word for the client to having the client write the word in the air and say it? It all depends on the residual abilities, but the concept can be applied to everyone.

We have a 60 year old gentleman with TBI who is learning how to semantically cue himself to find a word. Initially, he had severe speech and cognitive impairments. Now, in conversation, he often uses circumlocution to get his point across. However, sometimes specific words are warranted, and this is difficult for him. He can sometimes spell the word aloud even though he cannot speak it. We had him do this several times with great success. Our next task was to remind him that he could do this to help himself.  Later we only asked him what he would like to do.  We are helping him build those dendritic links ( and learn to use a skill) by carefully reducing the amount of clinician prompting or cueing during the sessions and writing down the strategies for him to practice at home. Although there are many approaches to cueing, none of them seem to describe cueing in a continuum from most invasive to most independent. Many clinicians describe the cues as semantic or phonemic.  I found that there were nuances in cueing that I had learned over the years to allow the client to gradually become independent. When I had difficulty transmitting these ideas to my students, I created a loose continuum to mark where our clients fell given specific objectives, and how we could get their neurons to get closer together behaviorally if not actually by breaking the cues down.

Along with the goals we establish for our clients, no matter their abilities, we must always be evaluating their behavior and trying new materials and varied activities to facilitate language.

As we converse with others, we derive cues from the environment and from the people with whom we are speaking (that is part of the reason why conversation amongst the adult neurologically language-impaired looks better than when we test them by looking for specific words and longer utterances).

Our goal with cueing is to develop self-cues and elicit more language. A self-cue can be as basic as a gesture or a drawing, but if the client is doing it and communicating to me what he did for the weekend, then he has been successful. Often when the stress is lower or the focus is away from speaking, the words and incidental phrases flow more freely. The best reward is to see the expression on our client’s face when he says a few words effortlessly because he was engaged in the activity. But this is not we what we are trying to do. We are trying to give him real tools for those times he cannot utter a word.

When the client leaves the therapy room, we want him or her to be able to use their own skills, rather than rely on others. Since they may not be able to develop their own means of self-cueing, we include self-cue skill development as part of the therapy plan.  The client may or may not have the ability to provide his or her own cues, yet. But throughout the therapy and rehabilitation process, we work toward the skills of self-cuing no matter the level, such as writing, gesturing, drawing pictures, and talking about the item or activity with words that are available.

The Cueing Hierarchy Continuum is by no means linear, but will generally go from simple and most dependent to complex and independent. They follow the behavioral branches that may be used in clinic therapy logs. They are separated on my behavior grid in 3 categories: Clinician Assisted Cues, Clinician prompting (or reminding the client to use a strategy) and Self Correcting. This approach requires that the client learn about his strengths and how to implement them to improve what we would consider weaknesses. By identifying which cues are more dependent, we can be cognizant of allowing the client to work at a documented realistic level achieve the objective.

It is well documented that there is enough plasticity in almost any brain to stimulate, heal and renew brain function after a stroke or TBI. For cognitive loss during normal aging, the dementias and the progressive dementias, there is less clear documentation for which approaches are the most effective and pragmatic for our clients. However, similar principles can be used to establish functional objectives along with the family and caregivers.

How to develop skills? How to develop strategies for short and long-term functional success?  Sometimes, we spend the therapy session working on comprehension, word finding, writing and reading using a variety of materials.  But, if we don’t address what they are learning outside the therapy room, which they may visit one or two times a week, how will compensatory skills, adaptive skills and  new connections be utilized?   That will be the topic for next month’s post.

Betsy C. Schreiber, MMS, CCC-SLP, received a BA in Psychology and MMS Master of Medical Science in Speech Pathology from Emory University in Atlanta, Georgia. Her CCC was earned during the 3 years she worked at Hitchcock Rehabilitation Center in Aiken, South Carolina where she had the opportunity to learn about NDT and Sensory Integration with the original, Jane Ayres, working with LD and CP children and neurologically impaired adults. She is currently a clinical supervisor at Ladge Speech and Hearing Clinic at LIU/Post on Long Island, and a partner at Hope 4 Speech Associates, P.C. She has also served as an ASHA Mentor and hopes to participate in ASHA’s  Political Action Committee in the coming year. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders, and 18, Telepractice.

Crafty Apps for Language-Based Therapy

It is no secret; I have never been a crafty person. During my days in graduate school I struggled a lot with the fact that many of my peers were able to spend hours creating these amazing therapy activities with glue and various types of paper. Yes, I did question my ability to become a speech therapist when I saw one of my colleagues bring the cupcakes she had baked at home along with all these amazing cupcakes decorations for the session. I clearly was not capable of such a thing!  Oh, and of course there are the scrap-booking SLPs! Clearly, I had no idea that SLPs had to dedicate hours preparing meals, buying scrap-booking materials and other tools for various “crafty therapy sessions”. In graduate school, I appealed to my technophile side to create my sessions around my computer. I know what you are thinking…  “What about the iPad?”. I didn’t even own an iPhone while in graduate school (and the iPad was still years from being invented). Today’s post is dedicated to all my fellow speech therapists and teachers who lack “craftiness” and want to be crafty on the iPad! Blessed be the iPad!

Here are some of my favorite apps for fun, creative, and open language based therapy sessions:

1. Art Maker by ABC’s Play School ( $0.99) – Prepositions, vocabulary and more.

This application allows you to create scenes by selecting from various background options and pieces of craft that go with the theme.  You can also pick from your own photos and add various pieces of provided objects and crafting materials to your photo (see how non-crafty I am based on the photo below). The images are added to your photos. For those of you feeling a little adventurous you can even make a movie as you move the items around the screen. You can use this app for promoting language skills and vocabulary. Prepositions (put the star on her shirt, put the tree next to the dog, etc.) is also a great target to use this app for.

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2. Martha Stewart Craft Studio ($4.99) – Story re-telling and sequencing in one place.

This app is worth every penny I spent on it, I just wish I had it 6 years ago! The Martha Stewart app is very easy to use and offers so many possibilities. It allowed a non-crafty person like me to create a scrapbook page! The app comes loaded with possibilities. You can take photos of the students during the session or send a letter to the parents to send some family photos with the kids for the upcoming session. It is an amazing way for working on retelling a story and it is perfect for those sessions with adults! After you create each page you can print and send it home with the child. This is by far a much more cost efficient way to do a crafting session.

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3. ScrapPad- Scrapbook for iPad ( Free + buy in app) – Vocabulary &  following directions at no cost.

This app is very similar to the Martha Stewart application. It has several background, stickers, borders and embellishments you can add to each page you create. Using this app can be great for vocabulary as well as for following directions. Just like the previous app, you can also save the final work onto your photos and print them when you are done.

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4. Hello Cupcakes (Free + buy in app) – Great app for following directions with amazing visual support.

This fourth app is truly a helping hand for those who want to do a real life cupcake but are not as talented as most of my former co-workers. The app comes with a baking tray which gives you information on which materials you will need to create the cupcakes. This app is just phenomenal; it includes step by step photos you can use for creating each cupcake. The cupcakes can be quite elaborate but this app has so many amazing visuals and it will guide you and your students to create quite the cupcake project. This is the perfect app to guide students, especially students who can benefit from visual support, for working on following directions. The app has amazing visual details. The buy in app options offer a variety of themed cupcake options too.

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It turns out that not only I can be crafty, but I love being crafty on the iPad! Should I call myself technocrafty?

Barbara Fernandes, M.S; CCC-SLP is a trilingual Speech- Language pathologist, a geek  and an app developer. She is the founder and CEO of Smarty Ears Apps , a company that creates apps for speech therapy. Barbara is also the face behind GeekSLP TV, a blog and video podcast focusing on the use of technology in speech therapy. Barbara has also been a practicing speech therapist both in Brazil and in the United States. She is an affiliate of ASHA Special Interest Groups 16, School-Based Issues, 12, Augmentative and Alternative Communication, and 1, Language Learning and Education. Barbara has created over 21 applications for the mobile devices for speech therapists. Find her at GeekSLP.com or on Twitter at @geekslp.