Late Talkers Are NOT A Homogeneous Group!: Building Verbal Imitation Skills in Toddlers

2/5/2016
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• I have no other financial or nonfinancial
Laura Mize, M.S., CCC‐SLP relationships with any of the other authors,
publishers, or SLPs whose work I recommend
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in this course.
@Laura Mize teachmetotalk.com
Key Purpose of Assessment
Profiles of Late Talkers
for Any Late Talker
Late Talkers are NOT Separating children with
only expressive delays
a homogeneous from
group! those with larger
developmental issues
@Laura Mize teachmetotalk.com @Laura Mize teachmetotalk.com
Risk factors that tell us which ‘late
Paul, Chawarska, Volkmar (2008) talkers’ may not catch up… (hanen.org)
1. Cognition ‐ Missing cognitive milestones – shows up in play more than anywhere
else! Could mean autism… but could also mean general cognitive delay What if it does seem to be “just” late talking? Risk factors that tell us
which children may not catch up to peers (hanen.org):
2. Joint attention ‐ Self‐absorbed kids • quiet as an infant; little babbling
• a history of ear infections
3. Receptive Language Deficits • limited number of consonant sounds (p, b, m, t, d, n, y, k, g, etc.)
NOT just a late talker if there are receptive language issues! • does not link pretend ideas and actions together while playing
Language comprehension scores are a SIGNIFICANT predictor of outcome • does not imitate (copy) words
• uses mostly nouns (names of people, places, things), and few verbs
4. Gestures – No emerging gestures like pointing, waving, clapping by 12 months (action words)
• difficulty playing with peers (social skills)
5. Pretend Play Skills – NOT repetitive movements with toys • a family history of communication delay, learning or academic
difficulties
6. Repetitive movements – Stereotypic movements • a mild comprehension (understanding) delay for his or her age
• uses few gestures to communicate
7. Unusual vocalizations – Atypical sound patterns
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Biggest Commonality Among
Break It Down…MOST RISK
Late Talkers
Children with the final three factors: Child isn’t talking!
FAMILY HISTORY
COMPREHENSION PROBLEMS
LIMITED GESTURES More importantly…
are at greatest risk for
continuing language delay. Child isn’t imitating!
(hanen.org)
Lack of Imitation Means There ARE
Imitation Matters!
VERY LIKELY Delays In Other Areas
The ability to “see and do” are When we don’t see imitation in children, we
HUGE developmental markers! suspect other delays too:
A child who is imitating is: • Social
Socially connected • Sensory Processing
Attention is usually developmentally appropriate • Cognition
Cognitive skills moving along
• Motor
Coordinated motor skills
• Verbal
Words – Child IS verbal
More Evidence Why Does This Matter?
A child’s ability to imitate If you’re not working on the right goals, you
won’t see progress….
actions at 18 months old was a
better predictor of his language ESPECIALLY
skills at 36 months old than when there are multiple underlying reasons that
even gestures. the child is NOT talking!
(Child Development 2013)
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Looking at a Child’s Imitation Skills Levels come from…
WILL TYPICAL DEVELOPMENTAL
get you on the right track for treatment for SEQUENCES
expressive communication delays/disorders!
(social, cognitive, motor, language, speech)
Your focus will be on the reason there’s
breakdown at a particular level. Broken down into tiny steps
EASY for parents (and for us!)
Discuss for each level: Why This Method Works
Prerequisites Often times in our treatment plans with very
young children with speech‐language delays, we
Most importantly… jump straight to words.
Where to begin MANY children are NOT DEVELOPMENTALLY
READY for this and then we don’t see progress
treatment for weeks or months because we started at a
level that’s too high for them.
Another benefit… Overview of the Levels of Imitation
• Level One: Actions with Objects
EARLY SUCCESS! • Level Two: Communicative Gestures
• Level Three: Nonverbal Actions with Face/Mouth
Success is important for EVERYONE! Level Four: Vocalizations in Play
• Child • Level Five: Exclamatory Words
• Parents • Level Six: Automatic Speech ‐ Verbal Routines
• You • Level Seven: Functional Words
• Level Eight: Short Phrases
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Building Imitation Through Play How To Target Level One… PLAY!
Level One: Imitating Actions with Objects Since we’re working with very young children,
• The child learns to repeat an action that he sees play‐based activities are the most
another person perform with an object. developmentally appropriate ways to target new
• Motor imitation with an object comes first since skills.
is targeted first since this is one of the first kinds
of imitation we observe in typical development.
• Imitation with a familiar object will also be the Toys and playing with a fun adult peak a child’s
easiest target for toddlers who aren’t already initial interest and keep the toddler engaged and
spontaneously or purposefully imitating actions, participatory for longer periods of time.
gestures, or words.
This Level is CRITICAL for Children
Most children will already be with Cognitive Delays
able to physically accomplish Some experts recommend skipping this level if a child is
already vocalizing, but if a toddler’s play skills are delayed,
those kinds of tasks on their learning how to imitate actions with toys IS the first step to
target.
own in daily routines, but the
By teaching motor imitation in this way, you may be helping
key skill is getting them to copy a child learn to really “play” with toys for the first time. Play
what you’ve just shown them. is IMPORTANT for all children in order to help them master
important cognitive skills to establish a foundation for
language.
Step is also CRITICAL for
Suspected ASD
“We cannot do anything Imitation of functional actions with objects has
with words until they are been linked to the development of more mature
play skills in children with autism.
build on what was there
before words existed.” Over time this step decreases the stereotypic
use of toys. By targeting imitation you’ll be
A. Charles Catania teaching the child what to do with the toy or
essentially how to play.
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Prerequisites for
Benefits for ASD
Imitating Actions in Play
Brooke Ingersoll studies – improves JOINT Motor and Social Proficiency at 6‐9 month
ATTENTION Developmental Level
• Purposefully reach for or swat at an object
MANY adults are fooled by an echolalic • Hold a bottle or cup by themselves
child without much evidence of joint • Explore a toy with their hands
attention and true talking for • A child must also be aware of another person
communication. Even with those kids, in their environment and be able to attend to
you’ll start here for treatment! an activity for more than a few seconds.
When kids are ready, begin by
What if a kid isn’t there yet????
Modeling Actions in Play
(Remember…. Don’t jump straight to words!) Level One Activities List
Address the underlying reason… Begin with EXPECTED actions with objects
1. Motor Skills – OT and/or PT consult Blocks, vehicles including cars, trucks, or trains,

musical instruments like drums, bells, or toy pianos,
2. Social Skills – Purposefully target dolls and accessories such as a bottle, brush and baby
interaction and engagement wipe, plastic dishes and utensils, pretend food, and
other toys with tools such as a ball toy with a
3. Cognitive Skills – Direct instruction hammer
TEST
Reminder for TYPICAL development 1 Eli – Early Imitation Objects
• Our perceptions can
become skewed
• Imitation comes in EARLY
for babies and toddlers
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1 Avery Meet a Child Where He Is
Use toys he LOVES!
CAN use atypical interests:
• Cabinet doors
• Feathers
• Sticks
• Train tracks or spinning the wheels on a toy train
Teach Parents to use Everyday Objects Guidelines for Level One Play
to Target Imitation in Daily Routines (Ingersoll)
• Brush his own hair while getting ready • Play with a child using toys he likes.

• Wash his own legs or the toy duck during bath • Narrate your play using very simple language.
time • Imitate and respond to a child during play to
• Cover his face with a blanket or wipe during encourage social interaction and joint
attention.
diaper changes
• Model familiar actions with toys first and
• Hold a spoon in the air in imitation of an adult move to new actions over time.
during meals • Help a child imitate actions if he’s not doing it
• Pat his own shoes on his own.
Tips to Keep a Toddler’s Attention More Advice about Attention…
Move on to new toys at least every 20 Research confirms that a toddler’s
minutes or so to encourage renewed attention span is variable at 3 to 6
participation and decrease the risk of minutes and will require full adult
boredom for both of you! support to sustain longer than this
amount of time.
(Gaertner 2008).
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My Best Strategies for Stretching a
“Tell him, Show him, Help him.”
Toddler’s Attention Span
The “one more time” rule…
This can be… Perform an action 3 to 5
• ONE more piece of the puzzle
• ONE more page of the book times and then provide
• ONE more turn in play
• ONE more try with ANY goal
physical assistance to help
the child imitate your action
(You can also use this strategy the OTHER way to
help a child transition from something he doesn’t
want to leave.)
if he doesn’t imitate on his
own. @Laura Mize teachmetotalk.com
Reciprocal Imitation or
Solving Problems with TOYS
Imitating a Child’s Actions
Sometimes two identical sets of toys, one FOLLOWING A CHILD’S LEAD
for the adult and one for the child, can be • ONLY in small spaces
useful to elicit imitation of actions with
objects during play.
• ONLY WITH a child who is
BUT it can backfire if the child then leaves
you out of play!
engaged with you
Troubleshooting with
Once A Child Imitates
Actions with Objects
PRAISE and REINFORCE with child‐specific 1. Be more fun!
reinforcement: 2. Make the target easier.
“Yay” with clapping 3. Avoid power struggles.
Quick squeeze if he’s a sensory seeker 4. Consider sensory needs.
Natural reinforcement – briefly play on his own 5. Sing as you model actions. “Rock – rock –
rock the baby.” “Rolling. Rolling. Roll that
ball!”
Who REALLY gets to choose the reinforcement?
6. IF you can’t sing, CHANT.
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Real life… Jude Level One with Balls
The more significantly impaired DIFFICULT…. Real life therapy
a child is…
the longer this goal will take!
After a child masters expected
What happens when kids
actions…
VERY LITTLE INTEREST IN TOYS Move on to unexpected actions
What do we do??? This ensures that IMITATION is
occurring – not just learning what
Look at what he likes & expand to do with an object.
attention & task participation FIRST
Twins – Unexpected Actions More Troubleshooting

Make sure child is developmentally ready.
If he’s mouthing, throwing, exploring toys
with no regard for you, target social & cognitive
skills first.
If a child is too “busy” get him regulated and
calmer first, then present toys.
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Using Other Kids at Level One Building Imitation with Gestures
• IF a child is struggling with YOU, an educated In Level Two children begin to imitate actions
adult, he IS going to struggle with peers. that convey meaning to another person.
• Children with atypical development especially Professionals refer to these actions as
need adults! They’re NOT socially advanced communicative gestures.
enough to have moved beyond parallel play. Gestures precede words in typical development.
• Use other kids ONLY if it works for the child It’s a HUGE red flag if gestures aren’t
you’re teaching. If all of your time is spent developing! We don’t see children with typically
managing behavior, then you’re not developing language skills who aren’t routinely
addressing your goals! using gestures.
Gestures precede words in typical
First Gestures
development.
It’s a HUGE red flag if gestures aren’t In typical development motor
developing! Capone says it’s a red flag for
imitation with gestures may first be
autism if no pointing at 18 to 24 months.
seen with actions in early parent‐child
We don’t see children with typically developing
social routines like Peek a Boo, Patty
language skills who aren’t routinely using Cake, So Big, etc…
gestures. How early do gestures emerge in
typical development?
2.0 Avery Social Games Examples of Early Gestures
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2.1 Avery Waving & Pointing
In typical development, we see these more May be so, so, so hard for little guys because of a
variety of factors:
communicative gestures emerge pretty easily…
Social – Not enough meaning engagement or social
referencing yet
Cognitive – Child is not symbolic.
Motor – Child can’t perform physical movements
yet.
• Because of these reasons, I don’t work on waving
and pointing as first gestures when a child is
really struggling. Try these first…
Early Gestures To Try Word of Caution:
Introduce gestures when the child seems interested • If a child isn’t performing ANY Level One
in performing the simplest of actions in imitation of imitations, it’s highly unlikely he’s ready for
another person:
Level Two with gestures.
Clapping is HUGE!
Banging on a table or tray • Imitating actions with objects and interest in
Dancing
another person’s gestures are the
prerequisites for Level Two
Give Me Five
Knocking on a door • Back Up and work on Level One as well as
Marching social, motor, and cognitive goals if a child
Kicking your legs while playing ball or bubbles isn’t there yet.
Level Two Activities on Chart Books with Actions to Copy
1. Begin with simple body actions or • Elmo Says…
movements in play that aren’t necessarily
communicative, but that the child can • Barney Play Nose to Toes
imitate
2. Move on to easy gestures in context • From Head To Toe – Eric Carle
during play and daily routines.
3. Move to more complex CAUTION ABOUT BOOKS: If the child doesn’t let you
gestures/patterns participate, it’s not a great choice for teaching!
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Same RULES as Level One Other Kids MAY Be Effective Here
Gross motor games are the first times we see evidence of
1. Model gesture 3‐5 times then help social attention with peers and are particularly effective for
child perform the gesture. toddlers and young preschoolers.
2. Use BIG gestures and heightened GREAT therapy ideas for seeing kids at daycare.
affect to attract and keep child’s Gross motor games:
attention. • Running from Point A to Point B and back again
• Jumping
3. PLAN your gestures and help • Swinging arms
parents plan too. • Marching
• Social games with peers – “Ring Around the Rosies”
Moving on in Level Two… WITH HUGE (and I mean HUGE)
Introducing Signs Motivators
• ONLY when a child is imitating earlier –Food
Level 2 gestures! –Toys
–Movement Activity
• Teach with REQUESTS first (not
labels!) Remember… who picks the motivators?
THE CHILD, not you!
Signs List The problem with this argument…
First Signs: Many babies
more, eat, milk, all done, please, go, open, help, mine (even typically developing toddlers!)
overgeneralize
Next Signs:
as they’re learning language.
cookie, cracker, fish, chip, candy, juice, water, cup/drink,
choo‐choo, bubbles, balloon, car/truck, plane, baby, play
It’s our job to help them learn specific
Some controversy….. words/signs and not get stuck!
Some kids may overgeneralize and “get stuck.”
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Elijah Signs Troubleshooting for Level Two
• Elijah 2.3 – cranky, end of session first day
• Elijah 2.4 – mid 2nd day – happier – warmed
1. Make gestures BIGGER
up ‐ try signs with funny play routine and more FUN!
• Elijah 2.7 – mom goes home, frustrated…
• Regulated…. Fun … 2. Introduce novelty
• Why did this work?
Signs are HARD for Some Kids Remember….
1. Kids on the spectrum have difficulty with social ANYTIME a child is not making progress, it’s
referencing. (EBP ‐ PECS is the way to go for because the goal is too difficult. PERIOD!
communication! Frontiers in Integrative Neuroscience 2013)
2. For kids with cognitive and receptive language BACK UP, break your goal down, and work on
delays, symbolism is HARD and gestures are smaller steps. For Level Two… (use chart!)
symbols.
If you can’t get signs, work on more gestures.
3. Motor planning may also be difficult for a child to If there aren’t any gestures, back up to Level
get his body to do what he wants it to do. Reward One or use SIMPLER gestures with repeated
the effort, not accuracy. practice.
Building Imitation with
Mouth Movements
In Level Three a child learns to imitate nonverbal SLP Experts who support an oral motor
actions with his face and mouth. This can also approach… (usually also feeding experts)
include learning to blow horns and whistles. • Diane Bahr
• Lori Overland
Little controversial in our field at the moment! • Sara Rosenfeld‐Johnson
• Pamela Marshalla
ORAL MOTOR CONUNDRUM! • Debra Beckman Oral Protocol
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TONS OF RESEARCH to negate For a small percentage of late talkers…

using any kind of nonspeech oral motor exercise We MUST help them learn that they have a little mouth
and it’s under their control!
in therapy as a way to improve speech
intelligibility. For many of them, everything they’ve done with their
mouths up until now has been reflexive…(eating,
drinking, breathing, yawning, crying)
Dr. Gregory Lof is a leading researcher
in this area. ANY oral movement on command may be EXTREMELY
difficult for them.
• Muscle tone differences
Dr. Caroline Bowen • Motor planning difficulties
When An Oral Motor Approach
My BEST Use Of Level Three
IS Indicated
• Feeding skills are affected • Use these activities diagnostically to see if there’s
an issue
• Muscle tone and/or sensory issues are
• Only a PART of a child’s therapy program IF it
prevalent or obvious seems to help
(Open mouth posture, excessive drooling • These things could be the “back up to” point in
after 2, little awareness of their mouths, strong therapy if a child can’t move forward
aversions to toothbrushing, or excessive • Use as a “treat” or diversion in sessions
mouthing after 2) • Use it as a way to satisfy strong oral cravings
• When you’ve seen little to no progress • Teach activities to parents and turn it over as a
without it part of a home program
Level Three Activities Horns and Whistles Sets
• Begin with exaggerated facial expressions and • Formal programs:
mouth movements. Show a child how to perform talktools.com is one resource for you and for
the action. parents. (Get parents to buy them!) Caution… little EBP
• Move on to more refined movements of the
mouth like smiling, puckering, smacking, etc… • Informal methods:
• Introduce a variety of mouth toys such as horns, Birthday party favors, Oriental Trading, and other
whistles, kazoos, musical instruments, pinwheels, toys like wooden train whistles
common household objects such as funnels,
tubes, or even cotton balls (Goal is IMITATION or Debra Beckman Oral Motor Protocol seems to be at least
turn taking!) a little more supported by research
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Just for the record…
Early and Easy Vocalizations
I’ve treated many, many, many children In Level Four and Level Five a child learns to imitate
successfully without the use of a single mouth movements with sound during verbal play.
horn or whistle or introducing any real
oral motor imitation tasks. In typical development this phase is noted as
This is usually a very, very small part of babbling. Babbling also occurs in late talkers as they
our treatment plan for a small percentage become more noisy before true words emerge.
of kids on my caseload.
In reality, I don’t care if a toddler still can’t Who likes to work on babbling?
blow a whistle if he’s already talking!
Experts Who Recommend Targeting Prerequisites for Introducing
These Sounds Play Sounds
• Stanley Greenspan – Model Affect
• David Hammer – Apraxia Expert Child is NOISIER during play. Vocalizations seem to be
more purposeful.
• Dr. James MacDonald – Play To Talk
• Pamela Marshalla – TONS of great • Whining when upset (rather than a reflexive cry)
information
• Scream or Squeal
• Hanen – People Games • Purposeful Laughter
• Dr. Lynn Koegel – Pivotal Response • Purposeful Vocalizations with emotion “Da!” or even
Treatment – Overcoming Autism a grunt
What if this is NOT happening yet? Activities to Promote More Sound
MODEL more • Vocalizations during gross motor movement
activities like swinging, jumping, running
sounds/vocalizations, • Gym activities like a trampoline or ball pit
but not as many real WORDS. • Large spaces that echo
• Vocal contagion (Pamela Marshalla) –
EVERYBODY talks, sings, or vocalizes Group
Use those same kinds of noises and Play Sounds games are very effective at this stage.
from Level Four and Exclamatory Words from
• Toys that amplify sound – microphone, funnel,
Level Five during these next activities: paper towel roll, bucket
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Play Sounds Reminder about typical development…
Level Four List – Sounds that are difficult to transcribe or • 4 Eli
“spell”
• Squeal or scream
• Fake cough or sneeze or cry
• Whine
• Raspberries
• Slurping with a drink
• Exhalation like ‘hhhhh’ after a child drinks
• ‘mmmm‐wah’ when blowing kisses
• Panting like a puppy
• Car noises – sirens, brakes squeaking, etc…
Probe for Early Level 4 Vocalizations
THIS IS THE LEVEL WHERE I • 4.0 Elijah – first day – I’m playing while

another therapist talks to mom
BEGIN THERAPY WITH MOST
‘SPEECH ONLY’ KIDS! • 4.2 Elijah – second day – warmed up – I‘m
saying, try panting…
Not with real words!!!
Exclamatory Words THESE ‘WORDS’ COUNT!
Level Five List – Words that are usually spoken with Sometimes adults don’t want to count these as real
forcefulness and represent an onset of emotion words, but they are made of the same phonemes
that can be either positive or negative. Exclamatory (consonants and vowel sounds) and are a step
words are those you seem to yell to exclaim your toward talking for many, many late talking toddlers.
message.
These kinds of words are probably prevalent in your Value for children is that they are fun, novel, easy,
conversations with young children. All adults who and more than anything else meaningful!
are great with kids instinctively say, “Uh oh,” “Yay!” You can use these words to increase the frequency
“Whee,” “Wow!” and even phrases like, “Oh boy!” and variety of vocalizations a child uses.
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These ‘Words’ Work! EASIER for NEW Speech Sounds
Many times late talkers already use some
vocalizations like these in Level Four and Level Level Four and Level Five
Five, but their parents don’t credit them as ‘words’ may make it easier for a
“words.”
child to acquire to use a new
We MUST meet kids where they are sound or class of sounds rather
developmentally and this is where I often begin
therapy with late talkers who already have a than in a real word.
handful of words or sounds.
Raspberries One More EXCELLENT Resource
• Bilabial Voiceless & Voiced – /p,b,m/ ‐ Car
• Tongue Tip Voiceless & Voiced – /t,d,n/ ‐ Plane
The Big Book of Exclamations
• Back of Tongue Voiceless & Voiced ‐ /k,g/ ‐ Crash
• Trachea Voiceless & Voiced – (Non‐English)
• Glottis Voiceless & Voiced – Growls ‐ Animals
thebigbookofexclamations.com
• Nasal – Snort ‐ Pig
Work on these to teach kids PLACEMENT and Teri Kaminski‐Peterson
provide strong input to oral mechanism. (Marshalla)
Word of Caution… Troubleshooting for Play Sounds
Be more fun! Many times increasing your own
level of animation and playfulness is what helps
The strategies we just discussed a child begin to imitate Level Four and Level Five
are NOT useful for a child who during play. Change yourself before abandoning
isn’t connecting with you socially this goal.
OR who doesn’t understand
Move, move, move!
LOTS of words. Balloons, bubbles, run, jump, swing, dance!
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More Troubleshooting
Verbal Routines
Change your volume: In Level Six a child begins to use some real words
Whisper during very familiar routines.
Say it LOUDLY!
Add gestures or hand movements: Verbal routines can be completely original or well‐
Pow! established nursery rhymes, games, or songs.
Oh no!
Shiver These words seem to become “automatic” meaning
that a child says the word when very familiar and
Exaggerate the vowel sound… adds excitement/affect specific conditions occur.
Experts Who Recommend Why do verbal routines work?
Verbal Routines They are so appealing!
1. Dr. Rossetti The repetitiveness and predictability of your verbal
routines will be particularly appealing to children who
2. TEACCH Method crave order including toddlers who may go on to be
3. Giggle Time – Susan Aud Sonders (based on diagnosed with autism.
Actually ALL young children can benefit from verbal
Greenspan) routines. Effective preschool and kindergarten teachers
4. Dr. Lynn Koegel – Pivotal Response Treatment have used these techniques for years as they sing the
(ABA meets Floortime) – Carrier Phrases same songs to accompany routines in their day.
Most loved children’s television and books are based on
5. Hanen Verbal Routines.
Adults crave verbal routines too!
Echolalic Kids Common Verbal Routines
Learning STRENGTH is Verbal Routines Establish verbal routines during play with easy ones
listed. Remember that you’ll teach the verbal
routine by saying the words over and over during
Caution – Be sure you’re working play.
on RECEPTIVE LANGUAGE with
• “Ready – Set – Go”
these kids! Just because they can
• Counting by rote to begin a game with “1, 2, 3”
say it, doesn’t mean they can • Say “Up, up, up” as you lift a child in your arms
understand it! and then “Down!” as you drop her to the floor.
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Use Previous Preferred Activities Original Verbal Routines
Social games including Patty Cake, Peek‐a‐Boo, When a child is making a toy climb a ladder or pushing
a car up a ramp, I model, “Up up up” and then say,
So Big, Give Me 5, Ride a Little Horsie, Row Your “Wheeeee!” as the object slides down the slide.
Boat, and Ring Around the Rosies
If a child is hiding or obstructed from my view, I sing,
Easy songs and fingerplays such as If You’re “Where Oh Where?” or say, “______, where are you?”
Happy and You Know It, Itsy Bitsy Spider, and
Zip!
Twinkle, Twinkle Little Star
Knock Knock Knock…. Open
Baby Doll Routines
Key to Setting up Effective Verbal
6.2 Avery
Routines
1. TIME!
Child has heard the routine often enough to
recognize it, to remember it, and he’s verbal
enough to be able to join in.
2. Cloze Method
3. Expectant Waiting…
TELL ME FACE
Build Verbal Routine Around a Toy Build Verbal Routine Around an Action
• 38 Garrett Phlat Ball • 6.3 Noah
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Make it up as you go! – Replace
Build Verbal Routine from a Game
MINDLESS NARRATION
• 44 Julia ‐ Night Night game If a child is digging in the sensory box and dumping beans
in a bowl, grab your own shovel or spoon to repeat his
actions. As you perform each step say, “Dig dig dig. In the
bucket. In the bucket. Dump!” Repeat the same sequence
of actions and words many times during play on the first
day and every subsequent time you play in the box.
As you push a child in a swing, say, “Push.” As he swings
say, “Whee!” After a set number of turns pushing and
swinging, catch him and say, “Stop!” Then begin your
routine again saying, “Push. Whee! Push. Whee! Push.
Whee! Stop!”
Verbal Routines are POWERFUL and you 6.9 Clayton
can build an entire session around verbal
routines.
EXCELLENT initial strategy for verbal kids
with autism who aren’t yet spontaneous or
who don’t request. You can use this
automatic speech to begin to direct what
happens next in play.
Building Imitation with Single Words Reminder of Typical Development
FINALLY…. WORDS! • 7 Caroline
Move to words when a child
has achieved a fairly high level
of mastery with the easier,
earlier levels.
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Prerequisites for Single Words as your
2. Cognition is moving along!
MAIN Focus for Therapy
1. Interaction is not a problem! Cognition is most easily assessed by looking at a
child’s play skills. When a child’s cognition
improves, play skills progress. You’ll see this as a
Social Skills are sufficient. Attention is pretty child understands how toys work, plays with a
variety of toys, and has mastered basic cognitive
good. Engagement is present. milestones such as object permanence, cause &
effect, and simple problem solving. You know he
imitates actions because he can watch you and play
If you’re struggling to keep a child engaged appropriate with even a new toy. If this isn’t
during fun activities and play, he’s usually not happening, the child isn’t ready to talk from a
cognitive perspective.
ready to talk yet from a social perspective.
3. Receptive Language is progressing! 4. Imitation is present!
Comprehension is improving. Words have Imitation skills are established with
become meaningful. The child more consistently easier skills. The child imitates actions,
follows simple directions related to his familiar gestures, and other kinds of
routines and during fun activities with you. If he
vocalizations. He has the ability to “see
does not yet understand words, he’s not ready
to talk from a receptive language perspective.
and do.” If there’s no evidence that a
child understands this process, it’s
unlikely you’ll be able to teach him to
repeat words.
Guidelines for First Word Selection Guidelines for First Word Selection
2. Choose words that are fairly easy to say.
1. Choose high frequency, familiar words.
Pick words a toddler hears often. These are Don’t begin with multisyllabic words or words
words a child should understand in order with difficult sound combinations. Early targets
would not include words like refrigerator,
to complete his daily routines and those he
basketball, or helicopter.
should learn to say in order to get his
needs met.
20
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Guidelines for First Word Selection Bryn Mawr List

3. Choose words with sounds and patterns a toddler In 2011 researchers at the Child Study Institute
already uses.
• Sounds – both consonants and vowels at Bryn Mawr College identified the following 25
• Introduce words with same sounds and in same class words every toddler should be using by age 2:
/p, b, m/ /t, d, n/ /k, g/
• Syllable shapes – such as CV or reduplication
all gone, baby, ball, banana, bath, bye bye,
This is ONLY a huge consideration if a child has such a book, car, cat, cookie, Daddy, dog, eye, hat,
limited repertoire of sounds. You’ll do this to get early hi/hello, hot, juice, milk, Mommy, more, no,
success, but remember, you’ll have to hear new sounds
sometime…. nose, shoe, thank you, yes
Words to Avoid for First Targets Teach REQUESTS
Academic Words Even though the majority of early words in a
typically developing child’s vocabulary are
Colors, Shapes, Numbers and Letters labels, STILL teach those words as requests so
that you establish
Why??? NOT FUNCTIONAL for NEW Talkers
Communicative Intent
Save for AFTER a child has established a functional I have to DO Something to GET Something!
vocabulary (50 words and short phrases)
RED FLAG for High Functioning Autism
MATERIALS for Teaching Single Words
in Toddlers
• Talking but not communicating Toddlers learn best by doing!
• Child knows HUNDREDS of labels and
that’s the extent of his/her vocabulary TOYS and Daily Routines
• MUST learn to ask for things, respond to
questions, etc… NOT Flashcards, Apps, or Electronic
• This is why so many higher functioning Toys
ESPECIALLY FOR OUR YOUNGEST KIDS
kids are missed before ages 3 to 4 ON THE SPECTRUM
21
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Strategies to Enhance Imitation As a professional, you must
of Single Words Master WITHHOLDING!
• Use motivating materials a Model the word 3‐5 times fully expecting a
child’s best efforts, but then give a child the
child likes! Play!!! item he wants regardless of his response.
• Find a balance being both fun
Pleasant persistence and direct cues work best
and demanding! for many children as you say things like, “Tell
• Do everything you can to me ____,” and “Say ____.” (Unless child is
echolalic and repeats your prompt!)
achieve early success!
Other Strategies Elsa
• Lean forward and wait expectantly as if to • 7.0 Elsa – Potato Heads – Vocal Contagion
cue… ‘It’s your turn to talk!’ • 7.1 Elsa
• Sing Song Vocal Prosody – motherese
• Vocal Contagion – EVERYBODY models!
Mass Practice Mass Practice
Repetition at this level is critical! • 10 Elijah
Multiple opportunities for a child to
say and hear the same word over and
over again!
Dr. Caroline Bowen’s recommendation:
• 12‐18 models of your target word
22
2/5/2016
Elsa – Muffin Pan Making Sets for Muffin Pan Therapy

• 7.2 Any Little Objects:
• 7.3 Balls, Bugs, Bows, Army Men – Man, Guy,
Horses, Cows, Dogs, Socks, Moons, Cars, Cats,
Forks, Spoons, Turtles, Boys, Girls, Fish
Stickers – Erasers –
Pictures (maybe…) – Toddlers like REAL stuff!
By Now…. If not…
If you’ve done a good job by being fun and with
word selection based on what a kid likes and
sounds you know he can say…. The child is not developmentally
ready for words
OR he would be imitating you!
You should be getting an attempt
almost every time you cue a word.
Back up!
Moving Along… Choices
When a child is imitating several different words • Choices can “trick” a toddler who won’t
well in a session, offer CHOICES! normally imitate on command into imitating.
Not just one choices, DOZENS of choices in a • Keep it fun!
sessions and HUNDREDS of choices in a day.
• Keep your choices motivating. If a kid doesn’t
Choices turn a child into a full‐time imitator of like what you have, what’s the point???
single words.
23
2/5/2016
Rory Vocabulary Development
Pay CLOSE attention to expanding a child’s
vocabulary at the single word level BEFORE
moving to phrases.
Some experts disagree with this, but I’ve found…
when we build a child’s vocabulary at the single
word level, everything else falls into place and
phrase production is easier!
Help a Child Move Toward
Don’t Forget to Teach…
Spontaneous Single Words
• New Nouns Environmental Sabotage –Communication Temptations
• Verbs • Place favorite items out or reach
• Use toys that promote requesting – bubbles
• Prepositions
• Eat a child’s favorite snack in front of him, but don’t
• Pronouns give him a piece until he verbally requests the food.
• Descriptive Words • Set out a more difficult toy that a child must get
assistance from you. (wind up toys, Hot Wheels
Motorcycle set, a balloon pump, rocket launcher)
• AAC Learning Lab Chart – reference – link in • Give only 1 PIECE of an activity that requires many
manual parts (paper but no markers, race track with no cars…)
Troubleshooting Building Imitation with Phrases
ALWAYS start sessions with what a During Level Eight a child begins to imitate short
child can already say. phrases.
As noted in the previous phases, imitation
If all else fails, cue a child’s default precedes spontaneous use, and it’s no different
words or signs. here at Level Eight with phrases. Learning to
imitate two and three word phrases is a critical
step in helping a child develop spontaneous
BACK UP! phrases and become conversational.
24
2/5/2016
Difficulty With Phrases EASY Patterns First
Move to phrases too soon • My + Favorite object
• More + Noun child says frequently
Spontaneous single word vocabulary • Noun + Please
(35‐50 words minimum) • More Please
• Bye bye + Name/noun child says
Not enough variety with his words • Hi + Name/noun child says
• Night night + Name child says
Around 18 Month Developmental Level
8 Kellie Phrases ‐ “My ____” Holistic Phrases

No way!
Aw man!
Oh no!
Oh boy!
I got it!
Right there/Right here
See ya’
C’mon (for come on)
147 @Laura Mize teachmetotalk.com
8.1 Kellie
Selecting Phrase Targets
• Holistic Phrases with Heightened Affect • Don’t start with carrier phrases!
(I want ___, I see ____, Give me ____ )
Save these patterns for AFTER
other phrase patterns are well
established at the spontaneous
level!
149 @Laura Mize teachmetotalk.com
25
2/5/2016
More Advice for Phrases Treating Sequencing Issues
• Pair words from a child’s existing vocabulary, If a child only says one word of the phrase, he
since these are words you know a child can needs more sequencing practice. Work on the same
already say. word in a sequence
• Try high frequency word combinations a child he
hears in every day routines such as, “Bye bye Up up up – down down down
Dada!” Dog Dog Dog
• Use combinations from your well‐established Me me me!
Verbal Routines. If you’ve played baby dolls and
have sung or said, “Rock baby” or “Night night Sing! Even the same word or syllable
baby” “Row Row Row Row Row…”
Miles Singing Single Word Treating Sequencing Issues
• If child repeats same word, use backward
chaining. (“more more” for “more milk”)
Sometimes this is due to a motor planning
problem, but sometimes it’s cognition!
• Practice last word first several times then add
the first word.
Use One Word as an Anchor
Backward Chaining
for Phrases
Helps to get BOTH words if a child is repeating a Apraxia‐kids.org – several articles with great references for
this ‐ helps with motor planning
word for a phrase
If several nouns and the word “go” are well established and
the child seems to need the same word to “get started,” try:
“More more” for more milk, practice “milk, milk, Go car, go truck, go choo choo, go boat, go plane
milk” then “more milk”
Or change first word and use a well‐rehearsed second word
such as “please” OR a very familiar “almost default” word…
No Mommy, up Mommy, help Mommy
Also works for multisyllabic words like Elmo, More bubble, blow bubble, up bubble, down bubble, pop
puzzle, cookie, cracker, goldfish, Daddy, bubble bubble
26
2/5/2016
Spontaneous Phrases & Conversations CHART
• QUESTIONS may shut a child down. • Use the chart as a CHEAT SHEET during
sessions
• STILL do lots of commenting and modeling. • Move up and down
(1 to 4 ratio) • When a child seems stuck, figure out where
he’s successful and EXPAND that level
• Playing TOGETHER is what makes this more • Remember, if there’s no progress, the goal is
natural and less like a “firing squad” for a kid. TOO HARD. BACK UP!
QUESTIONS?
Email me:
Laura@teachmetotalk.com
27
Building Verbal Imitation in Toddlers ©Laura Mize, M. S., CCC-SLP teachmetotalk.com
Level One Level Two *Level Three Level Four Level Five Level Six Level Seven Level Eight
Actions with Communicative Nonverbal Vocalizations Exclamatory Automatic Functional Short
Objects Gestures Actions with in Play Words Speech in Words Phrases
Your Face Verbal
and Mouth Routines
Expected Actions: Simple Big Body Open/close mouth Say “ah” in bucket Mmm, mmm, mmm Pause to let child All done/all gone My __________
Shake a rattle Actions such as: Widen eyes Pant like a dog Yum or yummy fill in words with: Baby More ________
Bang two blocks Pantomime actions Raise eyebrows Audible inhalation Yuck or yucky Ready, Set, Go Ball _______ please
Pat hands on table Bang hands on lap Puff out cheeks Squeal or scream Ick or icky 1, 2, 3 Banana More please
Remove a blanket Stomp Round your lips Grunt with effort Yay Bath Bye bye ______
Dump out toys Kick Chatter teeth Yawn Ouch, owie Social Games Bye-bye Hi __________
Put objects in box March Smile Fake cough Boo Peek-a-boo Book Night night ____
Knock over tower Dance Pout Fake sneeze Boo boo Patty Cake Car
Stack blocks Animal movements Blow Car/Truck noises Uh oh Give Me 5 Cat
Push a car Grimace or snarl Siren noise Oops or whoops Ride Little Horsie Choo choo
Combine words
Roll a ball Easy Communicative Pucker lips to kiss Fake laugh Oh Row Your Boat Cookie
from a child’s
Hit a balloon Gestures: Smack lips Fake cry Ew Ring Around The Cracker
established
Pat a drum Reach to be lifted Lick lips Whine Eek Rosies Dada/Daddy
vocabulary
Push button on toy Wave Close lips tightly Snore Whee Dog
Knock on a door Clap Stick out tongue Snort like a pig Wow Early Songs Eye
Holistic Phrases:
Stir with a spoon Blow kisses Pull tongue back in Slurp with drinking Whoa Twinkle Twinkle Hi/hello
I got it
Hold phone to ear Give Me 5 Wiggle tongue Exhale after drink Woo hoo Itsy, Bitsy Spider Hot
I did it
Pat, hug & kiss doll Shake head yes/no Click tongue Shiver Pow If You’re Happy… Juice
I do it
Put hat on Pointing Pretend to lick Indian noise Hooray Wheels on the Bus Milk
See ya’
Brush a doll’s hair Sh! for quiet Aw Man Old MacDonald Mama/Mommy
Come on
Feed a doll *Not necessary Growl Oh no More
Right there
Wash a doll for most late Oh yeah Develop your own No
What’s that?
Hammer ball/pegs talkers! Oh boy Verbal Routines Nose
Where it go?
No way during play with Shoe
Where are you?
the same words Please
each time. Thank you
Unexpected: Hand Motions for Horns Blow Raspberries Animal Sounds Games from Early Verbs Carrier Phrases:
Knock under table Songs & Fingerplays Whistles Teach Me To Play Early Prepositions I want _______
Hide hands Pinwheels Vehicle noises like WITH You Early Pronouns More _____please
Place toy on head Simple Sign Cotton balls beep, vroom, woo- Early Descriptives I see ______
Roll car down leg Language Musical toys like a woo, boom, crash I like ______
Sit on a hat flute or kazoo
Works Cited/ EBP References
AAC Language Lab. (2009). AAC language lab stages chart. Retrieved from
http://www.aaclanguagelab.com/materials/AACPartsOfSpeech.pdf.
Ellis, E. & Thal, D. (2008). Early Language Delay and Risk for Language Impairment.
Perspectives on Language Learning and Education, 15: 93-100.
Ellis, E. & Weismer S. (2007). Typical talkers, late talkers, and children with specific language
impairment: A language endowment spectrum? In: Paul R, editor. The influence of
developmental perspectives on research and practice in communication disorders: A Festschrift
for Robin S. Chapman. Mahwah, NJ: Erlbaum; pp. 83–102.
McCleery, J., Elliott, N., Sampanis, D., & Stefanidou, C. (2013). Motor development and motor
resonance difficulties in autism: relevance to early intervention for language and communication
skills. Frontiers in Integrative Neuroscience, Retrieved from
http://www.frontiersin.org/Integrative_Neuroscience/10.3389/fnint.2013.00030/full
Olswang, L.B., Rodriguez, B. & Timler, G. (1998). Recommending Intervention for Toddlers
With Specific Language Learning Difficulties: We May Not Have All the Answers, But We
Know a Lot. American Journal of Speech Language Pathology, 7, 23 - 32.
Rice, M. L., Taylor, C. L., & Zubrick, S.R. (2008). Language outcomes of 7-year-old children
with or without a history of late language emergence at 24 months. Journal of Speech, Language,
and Hearing Research, 51, 394-407.
Telethon Institute for Child Health Research (2008). Mixed Results For Late-talking Toddlers.
ScienceDaily. 16 May 2008. Web. 10 Jun. 2011.
Thal D, Tobias S, Morrison D. (1991). Language and gesture in late talkers: A one year follow-
up. Journal of Speech and Hearing Disorders. 1991;34:604–612.[PubMed]
Tsiouri, Ioanna, Rhea Paul, Elizabeth Schoen. Simmons, and Moira Lewis.Rapid Motor
Imitation Antecedent (RMIA) Training Manual: Teaching Preverbal Children with ASD to Talk.
Baltimore: Paul H. Brookes Pub., 2012. Print.

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What are some risk factors that can indicate a child may have continuing language delays?

Why is assessing a child's imitation skills important?

2/5/2016

1. Motor Skills – OT and/or PT consult Blocks, vehicles including cars, trucks, or trains,

Reminder for TYPICAL development 1 Eli – Early Imitation Objects

• Brush his own hair while getting ready • Play with a child using toys he likes.

Twins – Unexpected Actions More Troubleshooting

TONS OF RESEARCH to negate For a small percentage of late talkers…

THIS IS THE LEVEL WHERE I • 4.0 Elijah – first day – I’m playing while

Guidelines for First Word Selection Bryn Mawr List

Elsa – Muffin Pan Making Sets for Muffin Pan Therapy

8 Kellie Phrases ‐ “My ____” Holistic Phrases

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