Line Up: Pre-Writing Skills to Start at Home

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Help your child learn how to write with fun and easy activities

Children learn so many skills in early childhood, and like most things in life, the learning they do is incremental. Although we simplify the process when we discuss it, no one simply “learns to read” because reading is composed of understanding language, the alphabet, phonics, and other aspects that all come together to form the concept of reading.

Mastering a skill is like climbing stairs: There are many steps along the way, and the degree of difficulty is determined by where you are in your journey. Writing is no different, but it consists of early learning components not easily recognized as writing. These pre-writing skills are important to the process of learning to write, and encouraging your child to practice these skills will eventually help them master writing.

Marker milestones

You know those scribbles that appear in inconvenient places, like your freshly painted wall? Redirect your child’s artistic efforts to paper and appreciate those marks as pre-writing. Children have to learn how to make lines and strokes before they can learn to write the letters of the alphabet.

The ability to make these lines and strokes happens in a sequence. All children are different, but the typical developmental progress looks like this:

  • Age two: A child can imitate a vertical line and draw one proficiently by three.

  • Age two and a half: A child can imitate a horizontal line and circle and draw them by three.

  • Age three and a half: A child can imitate a cross shape and draw one by age four.

  • Age four: A child can draw a square.

  • Age four and a half: A child can draw a diagonal line in either direction

  • Age five: A child can draw an “X” shape and a triangle.

A helping hand

Certain physical development milestones must be met to develop pre-writing skills, as well. Writing involves the development of hand-eye coordination and a wide range of motor skills.

For example, children need solid core strength to sit up straight and strength in their neck, shoulders, and hands to watch and control the crayon.

They also need to be able to cross the midline of their body, which involves reaching across the center of the body to the opposite side. If a child has to switch hands in mid-reach or move their whole trunk towards the other side, they may be having difficulty crossing the midline.

Bilateral coordination is another necessity — kids must be able to use both arms or legs together to do something at the same time, such as holding the paper down while writing.

Practicing physical activities that help children develop strength is an unexpected but effective way to prepare them to learn how to write.

In the lines

One of the best ways to help children prepare involves something they likely enjoy anyway: coloring. Coloring seems like such a basic childhood activity, but it’s actually helpful in a wide variety of areas, including:

  • Development of hand-eye coordination

  • Practicing patience

  • Exhibiting creativity and self-expression

  • Helping with dexterity

  • Improving focus

  • Encouraging imagination

Children are avid learners and enjoy coloring, drawing, and creating. This simple act of entertaining themselves through art is an important step to the writing process.

Offer your child a range of coloring books, worksheets, and drawing implements such as crayons, pencils, and markers to encourage their scribbling. One day it will evolve into the written word.

Lumiere Children's Therapy is a full service, multidisciplinary pediatric therapy practice located in Chicago that serves the developmental needs of children from birth to 18 years of age. Learn more about how our team of clinicians can help improve your child develop writing and other essential life skills.

Food Fights: Fun Ways to Build Positive Eating Experiences for Children

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4 ways to make sure a child’s formative food memories lead to a healthy diet and self-esteem

Meals should be an opportunity to nourish the body and spend quality time together as a family. However, parents sometimes find themselves embroiled in a power struggle with their children instead. Whether it’s a boundary-testing toddler or a long-term picky eater, food refusal can be frustrating and cause concerns about nutrition and future habits.

Will a child develop properly on a diet that consists solely of macaroni and cheese served on a specific princess plate? Probably. But with patience and perseverance, his or her parents won’t have to find out. Create a healthy relationship between your child and food by finding ways to foster positive meal-time experiences.

1. Get kids involved

From meal planning to grocery shopping to food prep, kids will be more interested in experimenting with food if they’re included in the process from start to finish. Look at recipes together or find inspiration from a specific ingredient. Then make a grocery list, take a trip to the store, and let the child take charge of finding the items to prepare the meal.

Once you get home, deputize the child to wash, chop, stir, read the recipe, or help however possible. Not only does this experience emphasize good nutrition, but it also teaches important life skills. Helping your child learn to shop and cook from an early age is more likely to result in healthy eating habits later in life.

2. Make food an adventure

There are many opportunities to highlight the more interesting side of food, and pursuing those experiences will encourage a child to expand his or her palate. Visit a u-pick farm, take a cooking class together, explore different cultural cuisine, check out a farmer’s market, watch cooking competition shows, or start a garden in your own backyard.

Show your child that food can be fun by seeking out activities that provide unique perspectives on the act of eating.

3. Act as a good role model

Kids emulate the habits of the adults in their lives, for better or for worse. Make sure your child witnesses you eating a wide variety of foods, trying new things, and using nutrition as fuel for your body.

At the same time, keep negative talk about food out of the conversation. Speak about healthy food and how it helps your body instead of discussing weight loss, dieting, or labeling foods as “bad” — which may evoke feelings of guilt or shame.

4. Give kids some control

There are some battles you simply won’t win, but you must not give up entirely. If the child is intractable, don’t engage in a prolonged power struggle. Instead, find an acceptable middle ground. Try to establish the policy of taking a “no thank you” bite or two of each item served, even if he or she won’t eat a full serving.

You also may be able to make food more enticing by offering it on a special plate, fancy china, serving it breaded or fried, or by allowing your child to choose a dip, such as ketchup, ranch, Greek yogurt, honey mustard, or barbecue sauce.

The most important thing to remember is that your child probably won’t be eating a diet that exclusively consists of dinosaur-shaped chicken nuggets in college. Be patient, be persistent, be creative, and keep offering a variety of foods and dining options that emphasize the joy of eating and spending time together as a family.

Lumiere Children's Therapy is a full-service, multidisciplinary pediatric therapy practice located in Chicago that serves the developmental needs of children from birth to 18 years of age. Learn more about how our team of clinicians works to build healthy eating and social habits for children and their families.

See It and Say It: The Difference Between Phonics and Phonemic Awareness

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Learn how to teach your child to read and write by understanding the difference between phonics and phonemic awareness.

Phonics is one of the building blocks of learning to read and write and an essential part of early childhood literacy. Phonemic awareness may sound like the same thing — and they are both integral to learning language — but there are important distinctions between them. Emphasizing both phonics and phonemic awareness when teaching children words builds the strongest foundation for rich language skills.

Phonics vs. phonemics

For adults who’ve been reading since before they can remember, it’s hard to understand how difficult it can be to learn the basics of language. The process of learning words, how they’re built out of letters, how they fit together, and what they mean is literally what sets humans apart from animals. But even though our brains are wired to learn these things, they’re still a great leap in each child’s mental development. The intuitive process children use to bridge that gap relies on phonics and phonemic understanding.

Most adults are familiar with the basic concept of phonics, which involves the relationship between written letters, words, and their associated sounds. Phonics instruction helps students decode words by “sounding it out” based on the most common sound-spelling relationships. The ability to decipher unfamiliar words is crucial for learning to read.

Phonemic awareness is similar but not the same. Phonics focuses on how sounds look in writing, while phonemic awareness is understanding that each word is comprised of a series of sounds. Consequently, most phonics instruction is written, and most phonemic awareness lessons are oral.

Students must learn that words are made up of sounds before they can understand the sound-spelling relationships of written words. The two concepts are intertwined despite having different meanings.

Teaching phonics

Teaching kids to connect written letters with sounds is phonics instruction, a foundational element of early education. Learning the relationship between the symbols that make up the alphabet and the sounds they produce is one of the key building blocks of literacy.

The most effective way to learn phonetics is a structured and repetitive review of each letter and its associated sound. Using multiple senses helps to reach every type of learner. For example, you could have children write a letter in shaving cream using their fingers while repeating its sound. This leverages movement, touch, and smell to build the connection between the symbols and their pronunciations.

Once students learn each letter and its sound, they’re ready to move on to common letter blends — the sounds produced when letters such as “ch” or “sh” are used together.

Phonemic awareness

Segmenting and blending are two of the most important phonemic awareness skills to teach children. Segmenting is the act of breaking a word into individual sounds; blending is the ability to put those sounds together to say a word.

If children know enough phonics to recognize the sounds each word represents, they will be able to use phonemic awareness to sound out unfamiliar words and learn them. For example, deciphering the sounds in C-A-T and saying those out loud is segmenting. Recognizing those sounds as “cat” is blending. Knowing phonics is essential to having good phonemic awareness, and phonemic awareness is an important step of transferring that knowledge into the ability to read.

An easy way to remember the difference between phonics and phonemic awareness is that phonics is visual while phonemic awareness is auditory. Both are effective tools for helping children understand the symbols and sounds that create our alphabet and the words those letters build. Create good readers and writers from an early age by emphasizing both phonics and phonemic awareness.

Lumiere Children's Therapy is a full-service, multidisciplinary pediatric therapy practice located in Chicago that serves the developmental needs of children from birth to 18 years of age. Learn more about how our team of clinicians works to improve the lives of children and their families and discover our weekly reading group enrichment classes.

 

Growing Up: Position Your Baby to Develop Strength and Stability

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Physical positioning techniques can help your child develop the muscles to reach developmental milestones with ease.

Infants grow at an astonishing rate, and without any obvious outside intervention. As a parent, it can feel like your baby goes from practically immobile in a crib to performing circus feats in the blink of an eye. One day they’re lying there, easy to care for, the next they’re trying to roll off the changing table. And then they’re up and off — pulling themselves up on unstable objects, tottering into unfamiliar territory, and climbing for every out-of-reach zone they can see.

Your child’s physical growth is an amazing, surprising, and inspiring part of parenthood. As with every other stage of development, you want to make sure your baby gets the best possible start in their new adventure called life. You are the tour guide, security guard, navigator, chef, chauffeur, life coach, and teacher on their journey; supporting their physical growth is as important as the rest of those roles.

Help your baby develop the physical strength and coordination to grow through physical milestones by learning about appropriate positioning.

Heads up

Developing neck strength is one of the first — and most important — steps to physical growth. To look around and fully experience the world and its inhabitants, babies need to develop the muscles that lift their heads and hold them up independently.

At first, your baby’s head is precariously heavy to perch atop a floppy neck, and you must be careful to always support it. Help infants build upper body strength by positioning them close to your chest as you talk so they use those muscles to look up at you and track your voice.

When you lay your baby down in their crib to sleep, alternate the direction they’re facing. Babies must always sleep on their backs, but alternate positions so their feet are facing one end of the crib one day and the other the next. This encourages infants to turn their heads to see new sights.

Tummy time is another opportunity for physical development. Supervise babies as they play on the floor on their stomachs so they become accustomed to lifting and turning their heads, and eventually to pushing themselves up with their arms. Most babies can prop themselves up and control their head movements at around four months old.

On a roll

The importance of tummy time doesn’t diminish once babies have control over their heads and necks; it’s an essential exercise for developing the strength to roll over.

Now that babies sleep on their backs to help prevent SIDS, they often need additional encouragement to spend time on their bellies. Laying on their bellies helps babies learn coordination and muscle development. Place some interesting toys just out of reach so your infant will be motivated to stretch, wiggle, and eventually roll.

Children often begin to roll when you least expect it — so never leave babies unattended on a bed, couch, or changing table because they’ll inevitably decide to show off those new rolling skills in ways that fill you with parental guilt. Most babies can roll from their stomachs to their backs between four and seven months of age.

Take a seat

From a parenting perspective, life gets a little easier once the baby can sit unsupported. They can play with toys, look around, and just hang out happily without the need for special equipment.

Help your baby practice by positioning them so they’re sitting in front of you while you hold their hands as you would play a game of pat-a-cake. You can also prop your baby up with pillows and rolled-up towels to encourage short periods of unassisted sitting.

Babies begin to get a sense of balance by waving their arms and developing core strength as they wobble. Most babies are capable of unsupported sitting between six and eight months old.

Moving along

Babies usually let you know they want to crawl by getting up on all fours and rocking back and forth or pushing back on their hands and landing on their rears. These actions help babies establish balance and learn how to coordinate their bodies for eventual movement.

When your child reaches this phase, it is time to babyproof your living space. Once the environment is secured, encourage your baby’s movement experiments. Roll a ball so they’ll want to follow it, or place a few tempting toys within scooting distance.

Not all crawls look the same (some are more of a wiggle, others resemble dragging), but all are important for developing independence, motor skills, and coordination. Most babies will master this skill between seven and 10 months old.

Walk this way

Between 12 and 18 months, you officially have a toddler who’ll begin to master the important milestone of baby’s first step. Encourage them to learn to stand and find their center of gravity by providing safe, stable surfaces to pull themselves up to. Eventually, they’ll use that support to take a few experimental steps and, in no time, they’ll be making awkward little stumbles in your direction.

Don’t act too upset when babies fall down; they are most likely fine but will learn how they should react to these setbacks by how you respond. Act enthusiastic and light-hearted as you help the baby up and on its way again.

Your baby’s growth is a natural – and inevitable – process. Pave the way for those first forays into the physical world by positioning your baby for success.

Lumiere Children's Therapy is a full-service, multidisciplinary pediatric therapy practice located in Chicago that serves the developmental needs of children from birth to 18 years of age. Learn more about the importance of positioning in our movement enrichment classes.

Let’s Talk: How to Help Your Child Engage in Meaningful Conversations

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Teaching children good conversational skills helps build their confidence and relationships, and could even strengthen your bond with them.

Children raised in a language-rich environment generally experience more success in personal, academic, and professional situations throughout their lives. The ability to express thoughts, emotions, and ideas helps them create connections and build lasting confidence.

Teaching children good conversation skills doesn’t only benefit them. It also allows you a better view of their lives and experiences, which can help improve parenting skills and strengthen your relationship with them. Raising a good conversationalist can help you and your child lead better lives, together and apart.

Talk the talk

The ability to start, join, or engage in conversation is a skill many adults take for granted. Children may seem to learn social interactions organically through experience — and in some cases they do — but you can help improve their conversational proficiency by practicing at home.

Here are four ways to help children learn to start and maintain meaningful conversations.

1. Initiating conversation

Starting a conversation can be challenging even when you have life experience. As a child, initiating dialog can be truly intimidating. Give your child clues about social cues and suggestions on how to strike up a conversation with others.

Emphasize:

  • Body language and appropriate timing

  • Appropriate greetings and introductions

  • How to choose a topic or ask others about an interest

Model good skills by:

  • Introducing yourself to other adults in your child’s presence

  • Giving gentle and supportive feedback and suggestions

  • Encouraging your child to approach peers in social situations

2. Encourage exchanges

As adults, we’ve all experienced the awkward burden of having to carry the conversation. Teach your child about the reciprocal nature of conversations and that it makes people feel good to know the other party is interested in what they have to say.

Emphasize:

  • The importance of eye contact

  • Commenting on or otherwise acknowledging statements

  • Asking appropriate questions

Model good skills by:

  • Showing interest in what your child is saying

  • Taking turns communicating

  • Providing time for them to respond

3. Expanding conversations

Natural lulls in conversation or an obvious lack of interest from the other party mean it’s time to talk about a new topic. Help your child recognize these moments to move past the initial introductions and add depth to their dialog.

Emphasize:

  • Not monopolizing conversations with their own interests

  • How to take turns while talking

  • To listen for clues about topics the other party may be interested in

Model good skills by:

  • Asking your child open-ended questions about things they’ve said

  • Suggesting some general topics others may be interested in discussing

  • Practicing with sentence stem cards

4. Comfortable conclusions

Knowing how to end a conversation can be as difficult as understanding how to approach one. It’s important to recognize when the other party has to go, when the conversation has naturally come to an end, and how to extricate yourself gracefully.

Emphasize:

  • Body language and non-verbal cues of both the speaker and the listener

  • Transitional closing statements, such as, “Well, I have to get going.”

  • Making the other party feel good about the interaction: “It was nice meeting you!”

 

  • Model good skills by:

  • Point out nonverbal cues, like yawning, turning away, or checking the time

  • Teach your child phrases to politely end the conversation

  • Politely step in to remind your child it’s time to go if you see they need help

The best way to help your child master the art of conversation is to practice, practice, and practice. Ask them about their day, their friends, and their interests; encourage conversations with friends and family members. Exposing children to a broad range of people and situations can help them develop the self-confidence and social savvy to excel at talking to others.

Lumiere Children's Therapy is a full-service, multidisciplinary pediatric therapy practice located in Chicago that serves the developmental needs of children from birth to 18 years of age. Learn more about out social enrichment classes on how to initiate meaningful conversations.

How to Help an Anxious Child

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Learning to identify and manage the symptoms of anxiety in children.

One of the most difficult parts of parenting is watching your children struggle with things that and knowing you can’t step in and save them. It’s even more frustrating when the problem is something you may not fully understand, like anxiety.

Although it can be difficult to accept the validity or extent of an issue as intangible as anxiety, the feelings your child is experiencing are real. He or she is genuinely fearful, confused, and in need of your guidance.

Even if you can’t eliminate the source of the anxiety, you can help your child identify and manage its effects by educating yourself on the symptoms, triggers, and therapeutic tools for this condition.

Signs of childhood anxiety

Anxiety can be tricky to recognize because we all experience it to some extent — it’s a normal side effect of trying new things and dealing with the uncertainties of daily life. Children are surrounded by unfamiliar people and situations that may make them uncomfortable at first. How can you tell when your child is feeling nervous or reluctant to a normal degree versus experiencing anxiety?

It might be anxiety if your child shows a recurring pattern of the following symptoms:

  • Complains of headaches or stomach aches with no apparent medical reason.

  • Appears sensitive, cries, or seems restless, worried, or scared a lot.

  • Shakes, sweats, has an increased heart rate, or feels flushed in intimidating situations.

  • Has trouble falling asleep and staying asleep, or experiences nightmares.

  • Refuses to go to school or isolates themselves in social situations.

  • Experiences panic attacks due to an overactive fight or flight response.

If you suspect your child is suffering from anxiety, discuss it with their teacher or other caregivers to get a second perspective, then address the concerns with your pediatrician.

Helping children learn to manage their feelings

Unfortunately, you can’t just push a button and relieve your child’s anxiety or transfer that burden onto yourself. However, responding carefully and thoughtfully to your child’s concerns can help them learn to better manage the sensations associated with anxiety.

Telling your child that there is nothing to worry about, though it may be true, isn’t helpful. They don’t want to worry, but anxiety triggers a biological surge of chemicals and mental transitions that put the more logical part of the brain on hold while the automated part takes over. Children may even understand that the reaction is irrational, but that only compounds their fears that something is wrong.

Instead, try to acknowledge how the child is feeling. Ask them to pause and take some deep breaths with you. Encourage them to persevere and praise them for trying.

Learning to recognize and talk about these feelings can also help. Understanding the reasons behind their physical symptoms can dampen the fear of the unknown. From there, help your child brainstorm potential solutions — things they could do in the moment to relieve the stress they feel.

Most importantly, remain calm and be patient. Anxiety can be frustrating to deal with — and you’re not a bad parent for feeling that way — but keeping your composure will help your child feel safe, and that’s essential.

Working with a professional is the best path to long-term success, so don’t hesitate to get your child outside help for managing anxiety. Cognitive Behavioral Therapy (CBT) is a form of talk therapy that helps kids and parents learn coping skills to manage worry, fear, and anxiety. It teaches valuable tools that help children develop the confidence to face their fears throughout a lifetime.

Childhood anxiety can be stressful for parents as well as their children. But with the proper understanding and willingness to get professional advice, you can help your child learn to manage these emotions and react to difficult situations in ways that lead to a more peaceful and empowered life.

Lumiere Children's Therapy is a full-service, multidisciplinary pediatric therapy practice located in Chicago that serves the developmental needs of children from birth to 18 years of age. Learn more about how our team of clinicians works to improve the lives of children and their families.

 

Picture Exchange Communication System - Lumiere Children’s Therapy Chicago

Our previous post, Learning to Talk, outlined the typical development pattern for expressive language. Expressive language is the ability for one to communicate wants and needs, socialize, and interact with their environment through words, gestures, and nonverbal communication. For children with a language delay or an expressive language disorder secondary to an underlying diagnosis, a picture exchange system may assist in the development of expressive language. The picture exchange system can offer a bridge between communicating with gestures or signs to verbal communication. It may also help a child develop the necessary skills to operate a high tech Augmentative Alternative Communication Device (AAC).

Picture Exchange Communication System, often referred to as PECS, is a program of picture representations for common objects, actions, and thoughts. A person can initiate conversation using PECS to communicate their wants and needs without verbally speaking. It allows children to communicate with others even if they do not have the necessary verbal skills.



What is Picture Exchange Communication System?

Picture Exchange Communication System (PECS) was developed by Andy Bondy, PhD, and Lori Frost, MS, CCC-SLP in 1985 as a system used with preschool students diagnosed with autism. The goal of the program was to teach children how to self-initiate functional communication. Based on the success of the program, it is used with many learners with various communicative, cognitive, and physical difficulties of all ages. PECS is a six phase program that emerges from single word requests to building of sentence structures. There have been several studies that confirm that implementing PECS can help children develop verbal language, as well as decrease negative behaviors associated with language delays.



Who would be appropriate for PECS?

PECs is an approach used for nonverbal children. If your child consistently uses words, although limited, this system may not be the first choice in treatment. The following would indicate if your child would be a good candidate for a picture exchange system. 

  • Intentional communicator: In order to effectively use a communicate exchange, a child needs to want to communicate with others either through pointing, gestures, bringing caregivers to desired objects, or communicate through facial expression. 

    • Example: Jenny wants a chocolate chip cookies, so she directs dad into the kitchen and points to the cabinet with cookies. 

    • If a child does not involve the caregiver when trying to obtain an object, they may not be ready for a picture exchange program. The first step in this scenario would be to gain joint attention. Joint attention is when the child and caregiver are actively focused on the same object/activity. 

  • Preferences/motivation.  In order to understand the power of a picture exchange system, the child needs to be fully motivated for what they are receiving in return. When first teaching PECs, food, favorite toys, and motivating activities (slide, swing, etc) are most frequently used as motivation to communicate through pictures.

    • Example: Eric loves to build with legos. Parent will hold box of legos and give Eric one lego after every request. Eric is motivated to continue to use PECS to get more lego pieces. 

    • If a child has weak or no preferences, then PECs may not be appropriate. Preferences can be determined through trial and error of different foods, toys, and activities.

  • Discrimination of picture. Although picture discrimination is not a definite prerequisite of picture exchange system, it can enhance progress. As PECs continues to be implemented into daily routines, children will begin to learn which pictures correspond with the matching toys, food, activities, etc. If a child advances quickly with PECS, they may be more appropriate for an AAC high tech device. 



How is PECS implemented?

PECs is taught by a certified, trained speech language pathologist (SLP) but involves a caregiver or teacher as part of the team. The SLP becomes certified in PECS by attending a two day training. The SLP will be the primary PECS program coordinator for a child but it can be beneficial if caregivers attend the two-day training as well. Caregivers may include parents/family members, classroom teachers, and classroom assistants. Here is a list of training workshops available across states. PECS can be taught by the SLP in a therapy clinic, home setting with early intervention, and/or school or daycare. As the child and parent progresses in their knowledge and training of PECs, it should be used in all activities in their everyday activities. During phase stage, the goal is approximately 80 picture exchanges each day. 



Stages of PECS: 

In the early stages of PECs, there are three people in the training situation. The child, the person who receives the pictures (mom or teacher), and the facilitator who assists the child (speech therapist). Eventually, the facilitator is phased out of the training. 

  • PECS PHASE I: How to Communicate 

The first phase lays the foundation for exchanging single pictures for desired toys or activities. Receiver entices the child with the preferred object or food. As the child reaches for the desired object, the facilitator can assist the child to pick up the picture and hand to the receiver. The receiver does not say anything until receiving the picture. Once they receive the picture, they can say “ball, you want ball”.

  • PECS PHASE II: Distance and Persistence 

Phase II continues to target single pictures but in a variety of places, communication partners, and at greater distances from their field of view. It also teaches the child to become more persistent and consistent with communicating wants and needs. The facilitator is still present, and intervenes when necessary, but the child should be more independent in this stage.

  • PECS PHASE III: Picture Discrimination 

In this phase, two or more pictures are used at a time. The caregiver would present two or more pictures for a child to choose their desired object. The pictures are compiled into a communication book such as a ring binder for easy access by the child. 

  • PECS PHASE IV: Sentence Structure

The child learns to construct simple sentences with a sentence strip using “I want” picture with desired picture following.

  • PECS PHASE V: Answering Questions 

At this point, the child can learn to use PECS to answer questions such as “What do you want to play?” or “What do you want to eat”. 

  • PECS PHASE VI: Commenting 

The final phase of PECS is using pictures to make comments or respond to questions in their environment. They learn to create sentences starting with functional phrase strips I see, I hear, I feel, It is a, etc. 



How does PECs help develop verbal language?

In the previous post, Learning to Talk, a list of seven prerequisites to verbal language were described with at-home strategies. Three of the prerequisites align with the foundation of a picture exchange system. 

  1. Adequate attention and joint attention. Joint attention is when a child is focused on the same item or activity as the communicator or parent.

    1. Joint attention is necessary for a child to understand the concept of PECs. PECs requires the child to establish joint attention between the communication partner and their desired object or action. 

  2. Understands words and commands. 

    1. Before a child can effectively use verbal language, they need adequate receptive language skills. Receptive language is the ability to understand and comprehend language. Receptive language involves the identification of pictures. PECs encourages children to identify an action or object with a corresponding picture. It increases the child’s recognition and labeling of common objects and actions, improving one’s receptive language skills. 

  3. Communicates wants and needs with gestures and/or pointing. Children learn to communicate and engage with caregivers before verbal language typically emerges. Children may smile when they get something they want, point towards desired objects, or carry toys to caregiver. These are all forms of expressive language. PECs helps facilitate non-verbal expressive language by giving the child resources to communicate wants and needs to caregivers. It teaches the concept that requesting for an object/action results in receiving desired item. PECS encourages the concept of cause and effect. 



As a child develops these necessary skills through a picture exchange system, they are reinforcing the development of communicating for wants and needs. The caregiver is modeling the verbal production of each picture exchange providing more opportunities for modeling. For example, if Noah brings a picture of a ball to his mom, mom will state “ball, want ball”. Noah is receiving verbal modeling of the word ball to picture multiple times. 

If you feel your child would be an appropriate candidate for a picture exchange system, contact Lumiere Children’s Therapy. At Lumiere Children’s Therapy, we have therapist certified in the program to help your child communicate their wants and needs across all environments.




References:

“Picture Exchange Communication System (PECS)® |.” Pyramid Educational Consultants, pecsusa.com/pecs/.

“The Picture Exchange Communication System (PECS).” The Picture Exchange Communication System (PECS), www.nationalautismresources.com/the-picture-exchange-communication-system-pecs/.

Vicker, B. (2002). What is the Picture Exchange communication System or PECS? The Reporter, 7(2), 1-4, 11.




Lumiere Children's Therapy Chicago: Mastering Gross Motor Milestones

Reaching and mastering gross motor skill milestones, is vital for proper child development. The following explains the five sequential milestones (tummy time, rolling, sitting, crawling and walking) and tips to help your child achieve them.

David Precious

David Precious

Tummy Time

Tummy time is important for your child to develop strength in his neck muscles. Neck muscle strength is important for your child to begin holding his head upright and in the middle, and contributes to his ability to roll over, sit, crawl and walk.

If your child seems fussy on their tummy, this is because it is a difficult position for your child. It is similar to an adult version of a plank— very difficult! Tummy time looks different each month of development, depending on your child’s age and level of strength, call Lumiere Children’s Therapy or attend one of our parent trainings to learn more about developmental positions and motor milestones.

Where can I do tummy time?

You can do tummy time on a blanket or foam mat on the floor, over your chest facing you while you are laying down, over your lap or carrying the child on his/her tummy across your forearms.

What should my baby look like in tummy time?

Tummy time looks different at each month of age. Initially in the first month, your baby will barely be able to lift his head off the surface to rest his cheek. Then, closer to 3-4 months you child will be able to lift his up further and further until it is at a right angle to his back. By 5-6 months, your child will start to push up on his hands with straight elbow. Then, it’s time to start pivoting and belly crawling.

Tummy Time Tips

  • Always supervise your child during tummy time. Get on the floor with your child so he/she is motivated to lift his/her head

  • Use a mirror, rattles, music-playing toys, or bubbles

  • Sing to your child during tummy time

  • Begin tummy time early on, as early as a week old!

  • Start in 2-5 minute increments and work your way up to total 60 minutes a day.

  • Perform exercises when your baby is the most energized and ready to play, such as after your baby has slept, eaten, and has a clean diaper, to ensure your baby is the best mood to “exercise”!

  • Note: some babies will need to wait an hour after eating before tummy time to minimize spitting up, especially babies with reflux. Ask your doctor about specifics if your baby has reflux.

  • Use a fun tummy time mat a comfortable tummy time mat will motivate your baby to stay on his tummy, engage in the toy, and be comfortable! Fisher-Price Deluxe Kick 'n Play Piano Gym or a water mat will also motivate your baby to perform tummy time! Hoovy Baby Inflatable Water Play Mat


Rolling

When should my baby be rolling?

Babies typically roll from back to belly around 4-6 months, and belly to back ~3-5 months. However, this is a range, and every child is different!

How can I help my baby roll?

There are a few fun activities that you can do with your baby to encourage rolling:

  • Reaching for feet: Rolling from back to belly requires quite a bit of core strength, so a great place to start is by encouraging your child to reach for his feet to really engage his core muscles.  You can do this by placing rings on your child’s feet to encourage him to reach up towards his feet to grab the rings. You may have to help him at first, but once he is able to do so let him do it more and more on his own until he does it on his own.

  • Reaching to one side: With your child on their back, use a toy to guide your child to look to one side and encourage him to reach for the toy by reaching across his body and rolling to his side. Sometimes you have to move the toy farther than you think to get him to reach!

  • Assisted rolling: Once your baby is reaching across his body for a toy, you can help your baby to his side by assisting at his hip. This helps teach him how to complete the motion with both his upper and lower body together. As he continues to gain strength, you can gradually decrease your support until he rolls on his own!  

  • Tummy time: The more comfortable and strong your baby is in tummy time, the more your baby will want to roll and tolerate floor time. Read above for tips on tummy time!

When and why would my baby need physical therapy to help with rolling?

Babies are all different and can develop at slightly different times, and that is okay! If your baby is showing any of the following “red flags” listed below, it might be a good idea to ask a physical therapist for an evaluation. (However, these are child specific. Call our and ask to speak with a physical therapist with any questions):

  • Not reaching with arms for toys at 6 months on back

  • Not able to lift head up in tummy time at 3 months

  • Not rolling back to belly by 8 or 9 months

  • Only reaching with one arm

  • Only rolling to one side

Additionally, your child may have another medical diagnosis that will make meeting motor milestones tougher, and a physical therapist can educate parents on treatment ideas and home exercises to teach your baby the motor plan to roll, as well as strengthen muscles!


Sitting

When should my baby be sitting?

Babies can begin prop-sitting while leaning on hands as early as 4 months, however while having a caregiver close by to assist with balance. Babies typically can sit on their own between 6-8 months. However, this is a range, and every child is different!


How can I help my baby sit?

There are a few fun activities that you can do with your baby to encourage sitting:

  • Prop-sitting: Hold your child around his trunk and help him lean forward onto his arms. At first, your child may only be able to do this for a few seconds at a time, but it builds arm strength! Work up to 30 seconds, then 1-2 minutes at a time, to your child’s tolerance. At first, your child will place his hands in front of his feet (around 4 months). As your child gets stronger, his arms will move closer to his knees (around 5 months), then hips, then he may place his hands on his own legs until he can sit without his arms (around 6-7 months). As your child gains strength, continue to sit close by and assist your child as needed.

  • Assisted sitting: Hold you child around his trunk and decrease your assist until your child can sit on his own. You can place toys directly in front of him to encourage him to sit up straight and lean his hands on a toy if needed.

Note: Babies do not gain the reflex to catch themselves on their arm from falling sideways until 6-7 months, and they do not gain the reflect to catch themselves on their arm from falling backwards until 10 months. Always be nearby and ready to catch your child from falling when practicing sitting exercises.

  • Tummy time: Similar to rolling, the more comfortable and strong your baby is in tummy time, the more your baby will have the core strength to sit. Read Part 1 for more tips on tummy time!



Toys for sitting

Cube activity Center: A vertical surface such as a large cube is great to provide some support for your child to place his hands on, and also encourage an upright trunk. Check it out here

Shape Sorter: A larger type toy is helpful to provide some support for your child to put his hands on as he learns to sit. Once he is sitting on his own, it encourages reaching and manipulating toys to further challenge balance in sitting. Check it out here


When and why would my baby need physical therapy to help with sitting?

Babies are all different and can develop at slightly different times, and that is okay! If your baby is showing any of the following “red flags” listed below, it might be a good idea to ask a physical therapist for an evaluation. (However, these are child specific. Call our and ask to speak with a physical therapist with any questions):

  • Not able to sit on his own by 8 months reach for toys on belly at 7 or 8 months

  • Not able to prop-sit while leaning on his hands by 7-8 months

  • Not able to sit upright when he sits (leaning to one side)

Additionally, your child may have another medical diagnosis that will make meeting motor milestones tougher, and a physical therapist can educate parents on treatment ideas and home exercises to teach your baby the balance to sit, as well as strengthen muscles!

Crawling

When should my baby be crawling?

Babies typically begin pivoting in a circle on their belly around 6-7 months, belly crawling forward on their belly between 7-9 months, and crawling forward on hands and knees around 8-10 months. However, this is a range, and every child is different!

How can I help my baby crawl?

There are a few fun activities that you can do with your baby to encourage crawling:

  • Sitting to belly: Once your child is able to sit on their own, its time to start introducing weight shifting to transition to his stomach. To do this,  start in sitting and you can lean your child to one side to lean on one arm while reaching towards a toy with his opposite arm. Then guide him up and over his leg and onto his belly.  Make sure to have him go over his side to protect his hips. This strengthens his arms and core and helps them learn how to shift his weight from side to side.

  • Kneeling at a surface: Next, help him kneel at a surface or a a low step to encourage weight-bearing on his knees in a modified crawling position. This a great place to practice lifting one arm to reach for a toy, to simulate reaching forward on all fours when crawling.

  • Rocking on all fours: You can also help him rock on all fours to help them slowly build strength in his core and arms. As he begins to get into all fours on his own (typically anywhere from 5-9 months) you can provide support at his trunk and legs to help him rock back and forth. Once he gets stronger, you can support his trunk and help him crawl forward as he moves his arms.

  • Tummy time: Similar to rolling and sitting, the more comfortable and strong your baby is in tummy time, the more your baby will want to pivot and crawl! Read Part 1 for more tips on tummy time!

When and why would my baby need physical therapy to help with crawling?

Babies are all different and can develop at slightly different times, and that is okay! If your baby is showing any of the following “red flags” listed below, it might be a good idea to ask a physical therapist for an evaluation. (However, these are child specific. Call our and ask to speak with a physical therapist with any questions):

  • Not able to reach for toys on belly at 7 or 8 months

  • Not trying to pivot on belly or move position on belly at 7-8 months

  • Not rolling back to belly by 8 or 9 months

  • Only reaching with one arm

  • Only rolling to one side

Additionally, your child may have another medical diagnosis that will make meeting motor milestones tougher, and a physical therapist can educate parents on treatment ideas and home exercises to teach your baby the motor plan to crawl, as well as strengthen muscles!


Walking

When should my baby be walking?

Babies can begin walking between 10-14 months. However, this is a range, every child is different, and this depends on their motor milestone acquisition thus far!

How can I help my baby walk?

There are a few fun activities that you can do with your baby to encourage walking. Always stand close by with your hands out during such exercises to catch your child from falling if necessary:

  • Assisted cruising: Once your child is able to pull to stand and stand at a support surface, you can start teaching him to move on his feet by stepping sideways to cruise along a table, coffee table, or ottoman. The surface can be about the height of your child’s chest. Once he has mastered cruising, you can encourage larger steps by having him cruise between two support surfaces at a 90 or 180 degree angle. Gradually, you can increase the distance between the surfaces to make it more challenging.

  • Reaching in standing: Walking incorporates both balance and coordination, and a great way to target this is by practicing weight shifting while standing. You can start by having your child stand with his back against a couch or wall, and practice reaching forward or sideways. You can do this by having him reach for a toy or pop bubbles, whatever interests him. You can also have him hold onto the toy as you for another way to help him gain balance in standing with decreased assistance.

  • Walking practice: Practice taking steps by holding your child around his trunk and walking/kneeling behind them. This promotes proper alignment while walking.  When your child can stand on his own >20-30 seconds at at time, he is likely ready to start taking steps. Stand a few feet away from him to encourage him to walk to you. You can start by holding his hand, or holding the same toy, then fade assist as he gains strength and confidence!

  • Squatting: When your child can stand at a surface, hold objects at the height of his knee to encourage him to bend down and pick up an object, then return to standing. Both knees should bend, and this strengthens his muscles! As he gets stronger, you can hold the object lower and lower until the object is on the floor. Make sure to do this to both sides.

  • Tummy time: Similar to rolling, the more comfortable and strong your baby is in tummy time, the more your baby will have the core strength to sit. Read Part 1 for more tips on tummy time!

Walking tips

  • Start with your child barefoot so your child can feel the ground and use his toes for balance.

  • Use positive praise and get excited for your child so he stays positive!

  • Use bubbles or a fun toy to distract him!

  • Note: Some children may need some support in their shoes to add some stability to assist in standing and walking. A physical therapist can assess your child’s foot alignment to determine if an insert or brace is indicated.


When and why would my baby need physical therapy to help with walking?

Babies are all different and can develop at slightly different times, and that is okay! If your baby is showing any of the following “red flags” listed below, it might be a good idea to ask a physical therapist for an evaluation. (However, these are child specific. Call our and ask to speak with a physical therapist with any questions):

  • Not standing at a surface by 12-14 months

  • Not cruising along a surface at 16 months

  • Refusing to bear weight through legs at 10 months

  • Standing/cruising on tip-toes

Additionally, your child may have another medical diagnosis that will make meeting motor milestones tougher, and a physical therapist can educate parents on treatment ideas and home exercises to give your baby strength and confidence to walk!

Thank you for reading our motor milestone series! If this blog post has sparked any questions about your child’s development, feel free to call our office to speak to a physical therapist! We also offer two “mom and tot” classes about teaching your child to move, listed below. Call our office at 312.242.1665 to try a class!



PARENT/TOT CLASSES

BUDDING BABIES* (ages 4-10 months)

Your baby may not be crawling yet but there’s lots they’re learning – and you can help! Learn how to position your baby to build strength and develop stability. Explore the senses and support visual and auditory development with tummy time, rolling and other key exercises. This class includes parent discussion time to help learn about your child's development.

*Parent Involvement Required

WEE WALKERS* (ages 11-22 months)

As your baby becomes vertical, a whole new world of wonder is revealed. Play environments are vital to encourage discovery, problem solving, balance and coordination. Parents learn to understand how their infant interacts and communicates with them and others.

*Parent Involvement Required

www.lumierechild.com

Lumiere Physical Therapy: What is Plagiocephaly?

Plagiocephaly, or “flat head syndrome” is a condition in infants that is more common than you think. In a study done in 2013 and published in Pediatrics, the incidence of plagiocephaly in infants 7-12 weeks old was 46.6%¹. That means that this condition affects ~1 in every 2 infants. Read below to learn more about this common diagnosis, the causes, and which medical professionals can help.

What is Plagiocephaly (Flat Head Syndrome)?

Plagiocephaly, also known as “flat head syndrome”, means that your child’s head has flattened due to the fact that your child’s skull sutures have not yet closed. This may be caused by an infant spending too much time on his back, especially looking only to one side, resulting in a flat spot on one side of the head. This also may be due to Torticollis, which involves a child only looking to one side due to muscular tightness in the neck/trunk/pelvis. If this is the case, it is important to begin to work on opposite head rotation as well as positioning, to help get your child off his back. A physical therapist can help with this. (Check out our previous blog post on torticollis which helps with specific exercises/positions.)

Once a flat spot develops, it will be more difficult for your child to look the other way due to the flattening, which further exacerbates the issue, creating a type of ridge on the back of your child’s head. There also can be facial asymmetries associated with the flattening. On the same side as the flattening, your child’s eye and cheek may be slightly larger, with a slight forward bossing on the same side of the forehead, and the same side ear may also be pushed forward. Facial asymmetries are typically corrected when the skull is properly aligned, which will depend on the severity of the head flattening.


What is Brachycephaly?

Additionally, your child may develop a flat spot on the entire back of the head (not just only one side), which is called Brachycephaly. This is also caused by an infant spending too much time on his back, or in equipment such as car seats or bouncers². A shaping helmet may be indicated for both plagiocephaly and brachycephaly, depending on your child’s age and the severity of the flattening, described below.



Who can I see about my child’s flat head?

If you’re concerned about your child’s head shape, first talk with your pediatrician. Your pediatrician may refer him to a plastic surgeon or an orthotist. A specialist can measure your child’s head shape manually or using a scan. Depending on the results, they may recommend a shaping helmet, physical therapy, or both. It will depend on your child’s age and the severity of the flattening. The ideal window of time to receive a shaping helmet is around 6 months of age, however a child can receive and wear a shaping helmet up to 12 months old. After 12 months of age, there is minimal benefit to wearing a helmet.



A few places you can go in the Chicago area:

  • Scheck and Siress

  • Transcend Orthotics

  • Dr. Frank Vicari at Advocate

  • Head Shape Evaluation Program at Lurie Children’s Hospital

  • Cranial Technologies



How long will my child wear a shaping helmet?

This will again depend on your child’s age and severity of the flatness. Your orthotist or plastic surgeon will decide based on your child’s progress with subsequent scans. Helmets are typically to be worn 23 hours a day, with two 30-minute breaks permitted. A child may wear a helmet for as long as in indicated to correct the head shape, which can be anywhere from 4-6 weeks on.


Will it make my child’s head harder to lift?

The shaping helmets are pretty lightweight. A child will not receive a shaping helmet until he has enough head control. There may be an adjustment period while your child gets used to wearing it, however some infants do not tend to notice.

How can a physical therapist help?

A physical therapist can help with the underlying muscular factors such as muscular tightness that causes your child to look one way (torticollis), or low muscle tone that makes it more difficult for your child to move around and transition to different positions. A physical therapist can help with strengthening your child’s muscles during tummy time, as well as help your child with positioning and exercises to teach your child to roll and sit on his own and tolerate more time on his tummy.


If you have any additional questions about your child’s head shape or alignment, you can call our office at Lumiere Children’s Therapy and speak with a physical therapist.






References:

  1. Mawji A, Vollman AR, Hatfield J,McNeil DA, Sauvé R. The Incidence of Positional Plagiocephaly: A Cohort Study. Pediatrics. 132 (2). August 2013.

  2. https://www.cranialtech.com/my-babys-head-shape/


Lumiere Children’s Therapy: Autism and Physical Therapy

Happy Autism Spectrum Disorder (ASD) awareness month! Many recognize speech therapy as an important component of the overall treatment plan for ASD due to difficulty with spoken language, eye contact, facial expressions, and emotional recognition. Although language deficits are a core symptom of autism, children may also demonstrate difficulty with coordination, motor planning, and hand-eye coordination. Therefore, physical therapy can help facilitate gross motor development to increase participation in everyday activities and social activities such as gym class, sports, playing, etc.

Lecates - Flickr

Lecates - Flickr

What are the signs and symptoms of Autism Spectrum Disorder?


  • Social communication challenges

    • Difficulty with social interaction including initiating and maintaining topics during conversation

  • Pragmatic difficulties

    • Children with ASD may present with poor eye contact, difficulty gauging personal space, and decreased facial expressions

  • Difficulty identifying emotions

    • Difficulties may include recognizing one’s own emotions as well as the feelings of others. They experience trouble expressing their emotions during a variety of situations. Also, children may lack knowledge of when to seek emotional support or provide emotional comfort to others.

  • Repetitive behaviors

    • Repetitive behaviors present differently for each individual but some examples may include repetitive body movements (arm flapping, spinning), motions with objects (spinning wheels), staring at lights, and/or ritualistic behaviors (lining up toys in order)

What physical difficulties may a child with autism experience?

Children with ASD may present with the following physical challenges:


  • Developmental Delay:

    A developmental delay is when a child is lacking the age-appropriate skills in one or more of the developmental areas: cognitive, social-emotional, speech and language, fine and gross motor. If a child demonstrates a physical developmental delay, they may have difficulty rolling over, holding up their head, sitting up, crawling, and eventually walking and jumping.


  • Low muscle tone:

    Muscle tone is the amount of tension in muscles used to hold up our bodies while sitting or standing. Low muscle tone is when the muscles require more effort to move properly while doing an activity. They may have difficulty maintaining good posture when standing and sitting, and often affects their overall gross motor development.


  • Difficulty with motor planning.

    Motor planning is the ability to conceive, plan, and then execute the physical skill in the correct sequence. Motor planning assists children in attempting new tasks without the need to consciously learn the steps to each new task. Motor planning arises from organizing sensory input from the body, and having adequate body awareness and environmental perception. Children who have trouble with motor planning may experience difficulty carrying out new tasks, following physical commands when given verbal instructions, and appearing clumsy while executing new tasks.


  • Decreased body awareness.

    Children with ASD may lack awareness of where their bodies are in relation to their environment, causing children to become accident-prone or present clumsy.

Who is a Physical Therapist?

Physical therapists, often referred to as PTs, are professionals that help people gain strength, mobility and gross motor skills. They are experts in motor development, body function, strength, and movement. Pediatric physical therapists can help children with a variety of disorders gain functional physical skills so they can participate in everyday activities.

What does physical therapy target?

  • Basic skills. Physical therapists can help children develop the primary gross motor skills of sitting, rolling, standing and running if they are experiencing a developmental delay.

  • Coordination. Physical therapists focus on the necessary muscles and skills to improve balance and coordination in everyday activities.

  • Improve reciprocal-play skills. Help children use motor planning to coordination throwing and catching a ball, and other activities that involves interacting and reacting to another person.

  • Development of motor imitation skills. In order to learn new skills, a child must be efficient in imitation and following physical directions. PTs can offer strategies and practice of imitating movements.

  • Increasing stamina and fitness. For older children, physical therapy may focus on skills required to participate in play and sports such as kicking, throwing, catching, and running.

  • Parent education. PTs create home exercise programs so that family members can help facilitate building on strength, coordination, and development of specific goals into their natural environments and routines.


Why is physical activity important for children with ASD?

Physical therapy increases a child’s ability to participate in physical activities by improving strength and coordination. Once a child is able to functionally participate in physical activities, they are able to reap the many benefits of daily exercise.


  • Social skills. Gym class, playgrounds, and organized sports teams offer opportunities for children to develop friendships and social skills. For children with ASD, physical activity programs provide a fun, safe environment to develop and practice social interaction skills.

  • Improvement in behaviors. Physical activity may help decrease maladaptive behaviors and aggression. Children with ASD have difficulty expressing and understanding their feelings. Physical activity can aid in reducing stress and frustration in children, often helping them adjust in different activities without aggression.

  • Overall health improvements. Staying active and participating in daily physical activities can decrease the risk of general health problems in individuals with ASD, including obesity.

  • Increase quality of life. Daily activities such as climbing stairs, walking on the sidewalk, and going grocery shopping require the use of gross motor skills. Improving one’s strength and stamina can positively affect their participation in everyday chores and activities.


If your child has Autism Spectrum Disorder, and is experiencing difficulty with coordination, strength, and motor planning, physical therapy might be right for you. Our physical therapists at Lumiere Children’s Therapy can offer evaluations, customized treatment plans, and home exercise programs for carryover into the home.





References:

“Does Physical Activity Have Special Benefits for People with Autism?” Autism Speaks, www.autismspeaks.org/expert-opinion/does-physical-activity-have-special-benefits-people-autism.

Morin, Amanda. “What You Need to Know About Developmental Delays.” Understood.org, www.understood.org/en/learning-attention-issues/treatments-approaches/early-intervention/what-you-need-to-know-about-developmental-delays.

“Motor Planning.” North Shore Pediatric Therapy, nspt4kids.com/healthtopics-and-conditions-database/motor-planning/.

“Physical Deficits.” Mental Help Physical Deficits Comments, www.mentalhelp.net/articles/physical-deficits/.

Rudy, Lisa Jo. “What Can a Physical Therapist Do for a Your Autistic Child?” Verywell Health, 24 July 2018, www.verywellhealth.com/physical-therapy-as-a-treatment-for-autism-260052.

Ries, Eric. “Physical Therapy for People With Autism.” Physical Therapy for People With Autism, www.apta.org/PTinMotion/2018/7/Feature/Autism/.

“What Are the Symptoms of Autism?” Autism Speaks, www.autismspeaks.org/what-are-symptoms-autism.






Autism: Recognizing & Managing Challenging Behaviors

Did you know that a big part of your child’s behavior, positive or challenging, is a reaction to something that is happening in their immediate environment?


Sometimes we inadvertently reinforce challenging behaviors but knowing the ABCs can help prevent inadvertent reinforcement. By recognizing the ABCs of behavior, you may be able to help prevent and better de-escalate challenging behaviors with your child. 

 A) Antecedent- This is what happens just before the behavior to provoke it.  

B)  Behavior-This is what you can see your child doing. 

C) Consequence-This is how you react the behavior.  The consequence will determine whether or not that behavior will reoccur. 

When thinking about how to intervene your child’s behavior, it is important to look at why the behavior is occurring, also known as identifying thefunction.  This is much more important than what the behavior looks like.  By recognizing which function the challenging behavior serves, you can begin to understand how to intervene.  The four main functions of behavior are:

 

Sensory - These behaviors are occurring because they feel good.  Stereotypy, or self-stimulatory behavior, is a common sensory behavior that children with autism often engage in. 

 

Escape - These are behaviors occur when your child wants to get out of doing something they don’t want to do.  This is often the root cause of difficulty with transitions, with which many children with autism have difficulty.

 

Attention - These behaviors occur to gain attention from somebody.  Attention-based behaviors can be easily inadvertently reinforced, so it is important to remember that negative attention is still attention!

 

Tangible - These are behaviors that your child engages in when they are told they can’t have something they want or if something they like is taken from them. By identifying common things that provoke behavior, we can arrange the environment to prevent behaviors in the first place.  By knowing why your child is engaging in a challenging behavior, you can begin to understand how to respond to your child. 

 

General Preventative Strategies

  • Give your child choices throughout the day.  This gives them a sense of control in their environment.  You can give them a “choice” when there may not actually be one.  An example of this is, “Which shoe do you want to put on first?” or “Do you want to go potty in 2 minutes or 4 minutes?”

  • If you would like for your child to do something, present it as a choice via instruction.  It is important that instructions are followed through. An example of this is, “Are you ready to put on your shoes?” vs. “It’s time to put your shoes on.” 

  • Prepare your child for transitions.  Instead of abruptly telling them that it is time to transition away from a preferred task, give them a visual or verbal countdown

  • Reward the positives!  Point out when you see your child making good choices.  Throw a party if they engage in a difficult and desirable behavior.  Some children with autism may not be motivated by social praise.  If this is the case, allow your child time with a favorite toy or sensory input (tickles, hugs, squeezes etc.)

  • Encourage flexibility!  Many children with autism can be rigid, so encouraging your child to play with different toys, try different foods, and pointing out when unexpected changes occur, can help prevent challenging behavior related to rigidity

  • Make sure your child has meaningful breaks throughout the day to engage in preferred activities

  • Teach appropriate behaviors when your child is calm and not engaging in challenging behavior 

 

General Consequence Strategies

 

 Sensory

  • Give your child something similar to do/have instead of the inappropriate behavior.  An example of this may be to offer your child a chewy snack instead of putting toys in their mouth

Escape

  • Be sure to follow through when an instruction is given

  • Validate your child’s frustration and let them know that you understand that they are upset, but they do need to complete whatever task is at hand

  • Try not to force your child to comply.  Have them complete the task at hand when they are calm and ready

  • Remember what the original instruction was and stick with it

  • Reward your child as soon as they complete the non-preferred task

Attention

  • Ignore attention-seeking behavior as much as possible.  Sometimes this is not 100% doable.  If you must provide your child with attention, minimize verbal attention and remain neutral

  • Do not show frustration or anger.  Children with autism sometimes think this is “funny” and may not have the social awareness to truly understand your frustration.  Emotions should be taught when your child is calm and regulated

 

Tangible

  • Not allowing the child to have access until they ask calmly or show that they are calm (if they do not have the language to ask)

  • If you are unable to provide your child access to the preferred item, acknowledge their emotion and their feelings

  • Do not go back on your word.  If you told your child that they cannot have an item, do not give your child that item, especially if they engage in challenging behavior

 

 

Tips provided by Lumiere therapist, Jacqueline M., M.A., BCBA, (Lead Board Certified Behavior Analyst)

 

 

Torticollis: What is Torticollis?

Devinf

Devinf

Torticollis means “wry neck” and refers to the position of your baby’s head and neck.  A common presentation is if your baby prefers to tilt his head to one side and/or look to the opposite side. Parents usually first notice that their baby only prefers to look one way and has difficulty or resists looking the other way. (Note: every baby with torticollis will present differently.)


How can I tell if my baby has torticollis?

Does your baby tilt his head to one side or prefer to look to one side more than the other? Does your baby only reach with one hand? Can your baby look all the way to each shoulder while on his back, belly, and sitting? If you notice some of these signs, you can ask your pediatrician for a physical therapy referral for an evaluation and assessment of your baby’s alignment, range of motion, and strength. An early referral is always best!

What causes Torticollis?

Torticollis can occur for a few reasons. It is commonly caused due to your baby’s position in utero. Some additional factors include a larger size baby, a larger size head, a smaller uterus, or a twin pregnancy. Additionally, if your infant gets accustomed to looking to one way, this can become a habit and cause some muscle tightness that will further compound the head position.

Due to his position in utero or post-birth, your baby can develop muscle restrictions in his neck, trunk or pelvis that cause him to develop a lateral head tilt and rotation preference to look one way. Subsequently, often his trunk and pelvis will also be asymmetrical.

Another factor that can exacerbate the torticollis is your baby’s head shape. If a baby spends too much time on his/her back, especially looking to one side, your baby can develop a flat spot on one side of the head which then will reinforce the head tilt/rotation. This is called plagiocephaly. Sometimes, a shaping helmet is required to address your baby’s plagiocephaly in addition to the torticollis. Your pediatrician can give insight on whether a shaping helmet is required for your baby and will work with an orthotist or plastic surgeon to decide. (Note: Helmets are only needed if a baby’s head shape is moderate or severely misshapen, and also depends on baby’s age. It’s important to note that not all babies with torticollis have plagiocephaly.)


How can physical therapy help Torticollis ?

Every baby with torticollis may present a little differently, and a physical therapist should evaluate your baby in each developmental position (on his back, tummy, sitting, on all fours, crawling, standing, walking) to determine specific positions, exercises and activities that are optimal for your baby to obtain symmetrical alignment and strength.

Physical therapy treatment sessions will incorporate positions, stretches, and exercises that are specific to your baby’s head and neck alignment. Treatment sessions will consist of passive or active stretches, strengthening exercises, and positioning to achieve postural symmetry with symmetrical muscle length and strength. A large part of physical therapy treatment will include parent education and a home exercise program so that the baby’s parents can be empowered to help the baby at home throughout the week to ensure good carryover from physical therapy sessions for optimal results.



Torticollis Treatment: The Traditional Way


My baby has torticollis. What can I do to help?

Torticollis exercises will be specific to your baby’s presentation, alignment, muscular restrictions, and head tilt. At a physical therapy evaluation, your therapist will determine a treatment plan, goals, and home exercises.

Note: all described exercises need to be prescribed and demonstrated by a physical therapist.


Torticollis exercises

Positioning

If you tend to lay your baby down on the crib and changing table the same way each time, try switching it up. Sometimes a child will look more to the right because there is a wall on the left of his crib, and it is more interesting to look to the right. Additionally, if a baby consistently is bottle or breastfed in the same orientation, try switching up the way you hold your baby for feeding to allow your baby a different orientation and place to look around. Your physical therapist can provide further details on this.


Active stretches

Depending on your baby’s muscle length/strength, active stretches can be indicated to gain muscle length and strength. For example, if your baby prefers to look to his left, you can place toys to his right to get him to look further to his right and hold his gaze. During such exercises, always follow your baby’s lead and allow the baby to perform the motion on his own. A physical therapist can help educate you on the best way to help your child to look the other way safely and comfortably. Sometimes passive stretches are indicated however, most babies do not tolerate passive stretching and should only be performed under supervision of a physical therapist and with the baby’s tolerance.



Strengthening

Depending on your baby’s muscle length/strength, strengthening exercises can be indicated to gain muscle strength to obtain symmetrical posture and development. Strengthening is important to make sure both sides of his body are equally strong in order to hold his head, neck, and trunk in the middle and use both arms and legs equally to play and move within his environment. Your physical therapist will educate you on gross motor milestones and will guide you to ensure your baby develops symmetrically, with assisted reaching, assisted rolling, tummy time, assisted sitting, etc., until your baby performs on his own.



Massage

Typically, your baby’s muscles will be tight on one side, so your physical therapist can help educate you on techniques to gently massage your child’s neck.



Home Exercise Program

Your physical therapist will demonstrate and teach prescribed exercises to the baby’s caregiver to ensure good carryover from physical therapy sessions for optimal results.



Torticollis Treatment: Total Motion Release Tots and Teens


What is Total Motion Release?

Total Motion Release (TMR) is a postural release technique founded by physical therapist Tom Dalonzo-Baker over 15 years ago1 to help his adult orthopedic patients with back pain, gain range of motion. These techniques release restrictions in muscle/fascia to encourage improved range of motion and symmetrical alignment in the pelvis/trunk, that leads to functional improvements in patients with pain, decreased range of motion, or atypical presentations. These techniques have been used on generations of orthopedic adult patients. 

Tom connected with a pediatric physical therapist Susan Blum in 2006 to modify these techniques to be utilized for the pediatric population, which is now called TMR Tots and Teens (TMR TNT).2 Susan now teaches TMR TNT courses for physical and occupational therapists in pediatrics all over the United States. You can reference the TMR website at www.tmrTots.com3 for more information!

Who is TMT TNT for?

TMR TNT is indicated for the many pediatric diagnoses including torticollis, Down Syndrome, cerebral palsy, hyptonia, motor control, scoliosis and more, however here, we will focus on using TMR to treat torticollis. It can be performed on babies and children of any age and it will be specific to your child!


Why is TMT TNT different?

While the traditional way to treat torticollis works, TMR TNT is a different way to treat torticollis. Using TMR TNT, therapists look for interconnected areas of limited range of motion elsewhere in the body which are associated with the torticollis. For example, TMR TNT therapists will focus on the entire body, not only the neck, when treating torticollis. Results can often be limited when only the neck is treated. From TMR TNT’s website2, it lists five features that make TMT TNT different than traditional therapy:


1. Focus: “Treatment is precise to get to the root problem and quickly fix it.”

2. Build on What They Know: This builds on your child’s strengths. “We reinforce the patient's successes with positive motor experiences, which aid in motor recruitment.”

3. Empowerment of Caregiver and Child: “Therapeutic activities are incorporated into daily routines at home, school and daycare.  Instead of 1 or 2 hours of therapy a week, treatment becomes 24/7 for even more accelerated results.”

4. No Tears - Parent Satisfaction: “The language of TMR is comfort!”

5. Results: “Many patients with incomplete correction of torticollis achieved full correction once TMR was used to identify and treat the associated restrictions"



What does TMR TNT treatment look like?

It involves placing the child in positions to their preferred/easy side to "unlock" the restriction to gain improved active range of motion, so it does not involve any stretching. It then allows your child to explore in his new range of motion and achieve symmetrical alignment, improved gross motor skills, gain motor control, and more! It is tears-free, feel-good therapy! 

The home exercises are simple and can be worked into the parent's day for two minutes at a time, so allows for easier carryover. For example, positions can occur while being bottle or breastfed, being held, while reading a book, and while playing! This empowers the caregiver!



Who can perform TMR TNT?

A physical or occupational therapist who has taken a TMR TNT continuing education training course seminar can utilize the TMR evaluation tool and protocol to treat your baby or child. There are three levels of TMR TNT. Three physical therapists at Lumiere Children’s Therapy have taken TMR TNT Level 1!



Torticollis Tips, Tricks, and Toys


  • Utilize your pediatrician and physical therapist to help get you started! Don't let the internet or anyone else scare you. We will work with your family for an optimal treatment plan to help your baby.


  • Perform exercises when your baby is the most energized and ready to play, such as after your baby has slept, eaten, and has a clean diaper, to ensure your baby is the best mood to “exercise”!


  • Some babies will need to wait an hour after eating before tummy time to minimize spitting up, especially babies with reflux. Ask your doctor about specifics if your baby has reflux.


  • Utilize toys listed below to help your baby have the most fun during exercises!



Toys

  • Tummy time mat: a comfortable tummy time mat will motivate your baby to stay on his tummy, engage in the toy, and be comfortable!

  • Small rings: small rings are initially easier to grab, so it promotes your baby to reach. Your therapist can show you positions for your baby to reach on his back, belly, and in sitting!

    Bright Starts Lots of Links: https://www.amazon.com/Bright-Starts-Lots-of-Links

  • Music toys: toys that play music will distract your baby to look to one side and keep him focused on the toy, so he maintains his gaze. This toy is a parent favorite because of the soft music, and a baby favorite because of the size, colors, and sounds!: Baby Einstein Take Along Tunes Musical Toy

  • Cause and effect toys: Toys that encourage your child to reach in order to produce a song/sound/movement on a toy will encourage reaching and further gross motor development. Kids and therapists love this spin toy!: Leap Frog Spin and Sing Alphabet Zoo


Next Steps


If you have any questions or require an evaluation or therapy plan for your baby’s torticollis, please contact Lumiere Children’s Therapy.

Written by: Morgan, PT, DPT, a licensed physical therapist at Lumiere Children’s Therapy.

Lumiere Children’s Therapy: Learning to Talk

Mama, Dada, go, ball, and hi are all common first words you may hear your child say between 12-15 months old. Hearing your child say their first word is not only exciting, but helpful to be able to attend to your child’s wants and needs. Although each child develops language skills at different rates, delayed expressive language skills are usually first noticed by families.

Expressive language is the ability to communicate thoughts through words, gestures, and/or facial expressions. Expressive language allows one to communicate their wants and needs, socialize with others and interact in their environment. In order for a child to begin expressing themselves with words, there are a number of prerequisite skills that need to be mastered.

Prerequisites to talking

  • Exploration of the environment. Children should be constantly reacting to situations in their surroundings such as noises, lights, people, and activities. Reacting to others and new experiences are core features of communication.

    Strategies to try at home: Interact with your child in new ways to encourage exploration. Bang on pots and pans in the kitchen during meal prep, let your child ring the doorbell when walking in the house, or make a light show with flashlights. Be creative while incorporating music, sounds, visuals, and familiar faces!

  • Acknowledges others during play. Communication involves at least two people, so learning how to interact with another person is a necessary component. Children should want to be around others and react to interactions initiated by others.

    • Strategies to try at home: Get on the floor and play with your child! Initiate interactions by taking a turn on a puzzle, bumping your toy car into his, or stacking a block on his tower. Let your child acknowledge your interaction by imitating or responding in their own way. Continue to model interactive play with your child as often as possible.

  • Adequate attention and joint attention. Child should be able to remain on a single toy or activity for at least five minutes. Joint attention is when a child is focused on the same item or activity as the communicator or parent.

    • Strategies to try at home: To increase attention to asks, set a visual timer for two to three minutes on a chosen toy before they are able to pick a new activity. Instead of time increments, set a number of turns before moving to a new activity such as three puzzle pieces, three car races, or three items on Mr. Potato Head. In order to improve joint attention, be sure to sit at your child’s level and in their line of vision.Show your child that you are interacting with the same object by pointing, naming, and interacting with the same toy.

  • Demonstrates age-appropriate play skills. Language skills are most often learned through play in early development. Learning opportunities are frequent during pretend play, and while using interactive toys and early concept toys such as animals and play food. Playing with toys appropriately is required in order to use play to learn language. This may look like a child racing a car, pretending to stir a pot, or placing blocks on top of each other.

    • Strategies to try at home: Play with toys that require the child to interact, instead of watching it do something (i.e. light-up toys, ipads). Examples of good toys include puzzles, blocks, dolls, play kitchen and animal figurines. Model appropriate play with toys and encourage your child to imitate.

  • Understands words and commands. In order to use language to communicate, a child must understand language. This includes following simple requests such as “throw the ball” or “bring me book”, identifying pictures in books, or grabbing a named object in a group of three or more.

    • Strategies to try at home: If your child has difficulty following directions, give a verbal command first and then model the action. During routine activities such as getting dressed, brushing teeth, or leaving the house, give specific and consistent commands such as “put on your coat” or “open the door”.

  • Begins to imitate sounds, gestures, or facial expressions. Mimicking gestures teaches the concept of learning language through imitation without the pressure to use words. A child should learn to copy funny faces, clapping, waving, high-fiving, and other common gestures before being expected to imitate words.

    • Strategies to try at home: Sing nursery rhymes and do the gestures along with it such as Itsy Bitsy Spider, The Wheels on the Bus, and Pat-a-Cake. For facial expression, sit in front of the mirror and make funny faces such as sticking out your tongue. During social activities, encourage your child to wave to people they see and high-five family and friends.

  • Communicates wants and needs with gestures and/or pointing. Children will often learn to point to request objects before using words. Finding ways to express wants and needs by pointing, grabbing, or leading, is a way of nonverbal communication.

    • Strategies to try at home: If your child is wanting food or a toy, hold up two options and give the prompt, “what do you want?” Encourage your child to point by modeling the gesture. Teaching baby signs is a great way to facilitate non-verbal language as well. Start with teaching the signs for more, all done, and eat.

Once your child has developed the prerequisite skills for language develop, they will start to babble, imitate sounds, and use words for communicative purposes. The typical milestones for language develop are listed below. If your child is a late-talking, the months will vary but the hierarchy of skills will be relatively similar.



Typical Expressive Language Development


3-6 months

  • Makes pleasure sounds such as cooing and gooing

  • Smiles at familiar faces

  • Vocalizes to express anger

  • Initiates “talking” by playing with new sounds

  • Whines with manipulative purpose or cries for different needs

  • Laughs



4-6 months

  • Babbles with different sounds including p, b, and m

  • Vocalizes excitement and anger

  • Makes raspberries or gurgling sounds



6-9 months

  • Vocalizes four different syllables

  • Vocalizes two-syllable combination, example “uh oh”

  • Makes noises during play

  • Attempts to sings along with familiar song

  • Shouts or vocalizes to gain attention



9-12 months

  • Says mama or dada meaningfully

  • Repeats different consonant and vowel combinations

  • Imitates environment sounds such as car beep, animal sounds, or fire engine siren



12-15 months

  • Says or imitates between eight to 10 words independently

  • Imitates new words frequently

  • Says three animal sounds

  • Combines vocalizations and gestures when asking for an object (pointing and saying “milk”)

  • Babbles with adult-like intonation and occasional words



15-18 months

  • Child produces 15 words consistently

  • Uses words more than gestures

  • Begins to ask questions such as “what’s that?”

  • Child will name objects on request

  • Uses a variety of early consonant sounds like p, b, t, d, n, m, and h


18-21 months

  • Uses words frequently

  • Will imitate two-three word phrases such as “help me” or “want more please”

  • Child will occasionally produce two word phrases on their own


How to Encourage Language Development after First Words

After your child starts saying words, you may feel the progress of new vocabulary is slow. Modeling language, creating opportunities, and setting expectations are important to grow your child’s expressive language vocabulary. Below are a list of strategies to implement at home to improve your child’s use of words.


  • Narrate everything. During play, routines, and daily activities, narrate what you and your child are doing. Use simple, concrete nouns (dog, milk, cookie) and common verbs (go, eat, drink) in short phrases. If your child speaks in one word sentences, use two to three word sentences when narrating.

    • What does it look like? When getting dressed, mom says “Grace zips coat”. During mealtimes, dad says “I cut apple”.



  • Create language opportunities. Provide opportunities by holding toys back during play to encourage your child to request more of activities or specific items.

    • What does it looks like? Play with toys that have multiple parts such as legos, puzzles, blocks, sorting cube, and piggy bank. Parent holds the toy parts and hands each part after your child requests items with a word.  

Parent: “What do you want?”

Child: No response

Parent: “More”

Child: “More”

*Parent gives child one item*

If your child does not imitate word after two attempts, provide the toy so he or she does not become frustrated.


  • Wait. Parents know what their child wants without them having to verbally request with a word. Instead of automatically putting your child’s coat on or giving him the preferred toy, allow a period of wait time. Silently look at what your child wants, and wait for your child to request item. If your child does not say the item, give him a verbal model. If your child still doesn’t say the word after giving a prompt, give the item to your child.


    • What does it look like?

Parent: *silently looking at item”

Child: No response

Parent: “What do you want?”

Child: No response

Parent: “Ball”

Child: “Ball”

*Parent gives ball*



  • Give choices.  Providing two options to children forces them to communicate the object/activity they prefer. During meal times, hold up a preferred food (goldfish) and non-preferred food (carrot) then ask your child which one they want.  During play time, hold up two toys such as puzzle or ball.


    • What does it look like?

Parent: *Holds broccoli and goldfish*

Parent: “Which one do you want?”

Child: *Points to goldfish”

Parent: “Fish”

Child: “Fish”

*Parent gives fish*

  • Make it fun. Most importantly, make language development fun! The best way to do this is play with your child at their level. Teach them unique ways to play with your toys by making forts, pretend play, or setting up a picnic for all the stuffed animals. Children learn by imitating caregivers so continue to model phrases, play, and interaction with others.


Every child develops language at their own pace, but if you feel your child is significantly behind based on the typical milestone chart provided contact Lumiere Children’s Therapy for a language evaluation from one of our speech therapists.





References:

ChildTalk. “Child Talk.” How Many Words Should My Child Be Saying? A Quick Guide To Vocabulary Development, 1 Jan. 1970, www.talkingkids.org/2013/01/using-self-talk-and-parallel-talk-to.html.


Laura. “CHART 11 Skills Toddlers Master Before Words Emerge from Let's Talk About Talking.” Teachmetotalk.com, 28 May 2018, teachmetotalk.com/2018/04/18/chart-11-skills-toddlers-master-before-words-emerge-from-lets-talk-about-talking/.


Mattingly, Rhonda. “Typical Development .” Early Language Development . Early Language Development , 2016, Louisville, University of Louisville .


Mize, Laura. “11 Skils Toddlers Master Before Words Emerge.” Teach Me to Talk , Laura Mize, M.S., CCC-SLP, teachmetotalk.com/wp-content/uploads/2017/11/CHART-of-11-Skills-Toddlers-Master-Before-Words-Emerge-from-Laura-Mize-and-teachmetotalk.com_.pdf.

Rossetti, Louis. Rossetti Infant-Toddler Language Scale a Measure of Communication and Interaction. Pro-Ed, Distributor, 2006.

“The Effectiveness of Language Facilitation.” Leader Live - Happening Now in the Speech-Language-Hearing World, 29 May 2015, blog.asha.org/2014/05/22/the-effectiveness-of-language-facilitation/.


Lumiere Children’s Therapy: Asking and Answering Questions

“Hi, how are you doing?”

“I’m doing well, just got back from vacation”

“Where did you go?”

“Florida”

“Nice. Who did you go with?”

“My daughter”

“How did you get there”

“We drove.”


The above dialogue is an example of a typical conversation between two people discussing a recent vacation. The person asking the questions is showing interest and gaining more information by asking informative questions. The person answering questions is providing additional information about their trip by adequately answering the questions. Asking and answering questions appropriately is an important skill in order to participate in social conversation with others and build relationships.  It also aids in comprehension of spoken and/or written language by learning information through the form of questions and demonstrating understanding by answering comprehension questions.



What is Involved in Asking and Answering Questions?

Steps to adequately answer questions include:

  1. Hearing the question correctly

  2. Thinking about the meaning by deciphering the difference between who, what, where, when, why, and how

  3. Understanding the meaning or context

  4. Forming a suitable answer

  5. Articulate the answer in a grammatically correct sentence


Steps to adequately asking questions include:

  1. Determining the information you would like to receive

  2. Formulating a cohesive, grammatically correct question in your head

  3. Articulating the question to another person using adequate social skills

There is a hierarchy for answering and asking questions during development. “What” questions are the easiest to learn, use, and answer in language development. “Where” questions are next, followed by “who” questions. Lastly, the hardest questions to answer are “when” and “why”. When teaching children how to answer questions, start with “What” and “where” questions until fully mastered.


Milestones for Asking and Answering Questions

1-2 years old:

Answering:

  • Answers simple “what” questions like “what’s that?” while pointing at common objects

  • Answers simple “where” questions by pointing to objects or pictures in a book, such as “where are your shoes?”

  • Responds to yes/no questions with a nod or word

Asking:

  • Starts to add rising intonation to the end of phrases to indicate questions. For instance, “cookie?” may stand for, “Can I have a cookie?”

  • May start to ask “what’s that?” to unknown objects



2-3 years old:


Answering

  • Point to objects when described in questions such as “where do you sleep?” or “What do you wear on your feet?”

  • Answers simple wh-questions (what, where, who) logically

  • Follows directions when asked “Can you..” such as, “Can you give me the brush?”

Asking

  • Asks basic “where”, “what”, and “what are you doing”.. questions independently, “Where daddy?”



3-4 years old:

Answering

  • Appropriately answers more complex /wh/ questions such as “who”, “what”, “where”, “when”, and “how”

  • Answers questions about objects function such as “what do we do with a towel?”

  • Answers hypothetical questions. For instance, “If your sick, where do you go?”

Asking

  • Uses correct syntax while phrasing questions such as “where is sister going?” instead of “sister going where?”

  • Starts to ask “why” questions about everyday life

  • Asks the following types of questions using correct grammar:

    • Early infinitive “Do you want to go to the zoo?”

    • Future “Are we going to school?”

    • Modal can/may “Can I use the bathroom?”



4 years old:

Answering

  • At this age, children should appropriately answer all wh-questions including “when” questions. For instance, “when do you brush your teeth?”

Asking

  • Asks questions using age-appropriate structure including “ Can I…”, “Do you want to…”, and “Are we going…”


Activities to Try at Home:

  • For 1-2 year olds, asking questions should remain at the basic level. Line up favorite toys or household items and ask the child to name each by asking “What’s that?” Play with animal figurines and ask your children, “What sound does a pig make?” and so on. Books are great to use so that children can point to the answers for “What’s that” questions. First 100 Words by Roger Priddy is a favorite book of speech therapists.

  • In order to work on yes/no questions, ask preferential questions in that format. For instance, “Do you want yogurt? Yes or no?”. Nod your head accordingly while saying yes versus no so that your child fully understands.

  • Car rides provide ample time to address “wh” questions revolving daily activities. If headed to the grocery store, questions may include “Where do we go to buy food?”, “What should we buy for breakfast”, or “Where do they keep the milk?”. After school, ask more specific questions about the day, “What did you eat for lunch?”, “Who did you sit next to in class?”, or “Where did you play during recess?”.

  • Make a wh- poster board. Split the poster into thirds (what, where, who) or fourths (what, where, who, when) depending on your child’s age. Look through old magazines and cut out pictures to glue into the corresponding spots. “What” pictures may include clothing, food, or toys. “Where” pictures would include indoor or outdoor places. “Who” pictures would be people. “When” pictures can feature seasons, holidays, or time of day.

  • Create your own story books. First, decide what the story is going to be about (vacation, dance class, school, shopping, getting a pet, etc). Next, ask your child questions about the story in order to write a plot, such as “Who is the story about”, “Where are they going?”, “What are they doing there?”, “When does it take place?”, and “How does it end”. Have your child draw a picture on each page to go along with the text.

  • For older children, games can be used to encourage asking questions. The following games encourage the development of asking and answering questions.

Reading Comprehension Milestones

As children enter school-age, asking and answering question skills are applied to reading comprehension. Children begin to understand what they are reading through determining the elements of a story (character, setting, plot, main idea, rising action, and resolution). Below outlines a typical development of reading comprehension skills, and strategies to aid in development to try at home.

Kindergarten (5 years old)

  • Kindergarteners can start to retell details of a story read out loud by stating the who, what, when, where, and why of the plot

  • Children can retell the main idea of simple stories

  • Children can arrange story events in sequential order

  • They are able to answer simple “what” questions about the story read to them

First and Second Grade (6-7 years old)

  • Children are able to read simple, familiar stories themselves

  • Answer questions about a story that requires them to think about what they have read

  • Demonstrate understanding of a story through drawings

  • Children can create their own stories by organizing thoughts in a logical sequence of beginning, middle, and end

Second and Third Grade (7-8 year old)

  • Children are able to read longer books independently

  • Able to identify unfamiliar words through context and pictures

  • Apply reading skills to writing skills by forming complete paragraphs


Fourth through Eighth Grade (9-13)

  • Able to read and explore variety of texts including narratives, poetry, fiction, and biographies

  • Identify the elements of the story such as time, setting, characters, plot, problem and resolution

  • Analyze texts for meanings, use inferencing skills, and make predictions.

Strategy for Home

Make reading a part of your daily routine, whether it is a book in the morning, after school, or before bed. Stop periodically throughout the book to check for comprehension by asking “What is happening?”, “Who is this about?”, and “What do you think will happen next?”. For younger children, fold paper into three creases and have the child draw three pictures to represent the story.

If your child demonstrates difficulty answering or asking questions or seems behind on the language development milestones, Lumiere Children’s Therapy can provide the appropriate intervention to improve language skills.

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References:

“Asking and Answering Questions.” Speech And Language Kids, www.speechandlanguagekids.com/questions-resource-page/.

Lanza, Janet R, and Lynn K Flashive. “Question Answering and Asking Milestones.” Parent Resources Blog, LinguiSystems, Inc., 2008, parentresourcesblog.files.wordpress.com/2013/05/questions-development.pdf.

Morin, Amanda. “Reading Skills: What to Expect at Different Ages.” Understood.org, \www.understood.org/en/learning-attention-issues/signs-symptoms/age-by-age-learning-skills/reading-skills-what-to-expect-at-different-ages.

“Reading Milestones (for Parents).” Edited by Cynthia M. Zettler-Greeley, KidsHealth, The Nemours Foundation, June 2018, kidshealth.org/en/parents/milestones.html.

Spivey, Becky L. “How to Help Your Child Understand and Produce ‘WH’ Questions.” Super Duper Handy Handouts, 2006 Super Duper Publications, 2006, www.superduperinc.com/handouts/pdf/110_wh_questions.pdf.

“Teaching Your Toddler to Answer Questions - Receptive and Expressive Language Delay Issues.” Teachmetotalk.com, 13 Sept. 2017, teachmetotalk.com/2008/02/26/techniques-to-work-on-answering-questions-with-language-delayed-toddlers/.

“Why Is Asking and Answering Questions Important?” ABC Pediatric Therapy, 11 Mar. 2018, www.abcpediatrictherapy.com/why-is-asking-and-answering-questions-important/.


Lumiere Children’s Therapy: Breathing Difficulties in Children

Examine your breathing for a minute. Are you breathing through your nose or mouth? Is your mouth open or closed? Is your tongue on the bottom or roof of your mouth? Optimal breathing should be effortless and quiet through the nostrils with the tongue suctioned to the roof of the mouth behind the front teeth and the lips should be gently closed. Nasal breathing positively affects swallowing patterns, chewing, speaking, voicing and body posture. If nasal breathing is compromised for any reason, orofacial myofunctional disorders and/or airway function disorders may arise. This article focuses on descriptions of airway function disorders, including pediatric obstructive sleep apnea, and treatment options.

Airway Function Disorders (AFD)

AFD occur when the airway function is obstructed at any level of the airway, affecting a range of human functions. Sleep disorder breathing such as pediatric obstructive sleep apnea, is a collapse at any level of the upper airway resulting in abnormal breathing during sleep. Pediatric sleep apnea will be discussed further in this article. Sleep disordered breathing is initially impacted by daytime breathing specifically in children who mouth breath.

Signs of mouth breathing include the following:

  • Open lips

  • Low or forward tongue posture

  • Short upper lip

  • Forward head posture (protruding from neck)

  • Frequently dry lips

  • Misaligned teeth requiring orthodontics

  • Dry mouth

  • Hyponasal speech (speech that sounds nasal like they have a cold)

  • Drooling

  • Nasal congestion or constant runny nose


Impact of AFD

Airway function disorders may impact a variety of functions in a child’s life. It may interfere with language development, learning and academics, memory, attention, socialization, and self-regulation. Children with AFD may exhibit primary behavior characteristics of excessive fidgeting, hyperactivity, decreased attention and emotional outburst.

airway

AFD may also impact a child’s speech and swallow function. Some children with AFD present with an interdentalized (tongue between teeth) on the following sounds /s, z, t, d, n, l/ as those sounds are produced with tongue elevation.  Children may also experience abnormal swallowing patterns such as tongue-thrust swallows or impaired chewing.


Risk factors of AFD

The following is a list of risk factors associated with AFD:

  • Enlarged tonsils and/or adenoids

  • Mouth breathing

  • Nasal abnormalities such as a deviated septum (Deviated septum is when the thin wall between nasal passages is displaced causing one nasal passage to be smaller)

  • Frequent nasal congestion or allergies

  • Chronic rhinitis: set of symptoms including running nose, itchy nose, post-nasal drip, congestion, and sneezing that persist for months to a year

  • Higher Body Mass Index

  • Gastroesophageal reflux disease (GERD): when stomach acid flows back up irritating the lining of the esophagus

  • Low muscle tone

  • Craniofacial syndromes or growth alteration

  • Prematurity

  • Traumatic birth

  • Gender (Males are two times more likely to have SBD)

  • Ethnicity (African Americans are at a higher risk)

Pediatric Obstructive Sleep Apnea (OSA)

Reflect on your quality of sleep the past few nights. Did you sleep soundly through the night without any disturbances and wake up rejuvenated, or did you toss and turn all night feeling distracted and lethargic in the morning? The quality and effectiveness of a good night’s sleep impacts your mood and productivity the following day. The same holds true for children; if a child experiences disturbances throughout the night, they may demonstrate difficulties in behavior and attention during the school day. Studies have suggested that as many as 25% of children diagnosed with attention-deficit hyperactivity disorder may have symptoms of obstructive sleep apnea.

What is OSA?

OSA is an airway function disorder that is observed during sleep. OSA is when a person has repeated episodes of partial or complete upper-airway obstruction during sleep

How prevalent is OSA in children?

Studies have shown that up to 5% of children are diagnosed with OSA, with a correction between pediatric obesity and OSA.

What are the symptoms of OSA?

The most prevalent symptom of OSA is snoring. Although some children may only demonstrate habitual snoring which consists of vibration of airway tissue with no airway obstruction, studies have found a ratio between 3:1 and 5:1 between symptomatic habitual snoring and obstructive sleep apnea (OSA).

Other symptoms include the following:

  • Agitated sleep

  • Nightmares

  • Mouth breathing or open mouth posture

  • Bedwetting

  • Pauses in breathing or gasping for air during sleep

  • Audible breathing

  • Grinding teeth

  • Sweating

Treatment for Airway Disorders

  1. The first step to treatment of airway disorders is to determine the function of the nasal airway. Determining structural or physiological barriers to nasal breathing is necessary to determine plan of care. An evaluation by an allergist and otolaryngologist (ENT) is necessary to determine if medications such as antihistamines, allergy medicine or surgery is required to be able to safely breath out of the mouth.

  2. Elimination of non-nutritive sucking is important for adequate growth and formation of dental structures. Non-nutritive sucking (e.g. pacifier, finger, and object sucking) is a risk factor for future dental occlusion abnormalities. Orofacial myofunctional therapist can provide strategies to eliminate the use of nonnutritive sucking.

  3. Establishing adequate oral rest posture would be the next step of therapy. Orofacial myofunctional therapy focuses on retraining the muscles to stabilize a normal rest posture between the tongue, lips, teeth and jaw. Orofacial myofunctional therapy uses oral tactile stimulation and resistance activities to help disassociate the tongue from the jaw, improve lip closure and strengthen tongue elevation.

  4. Once the resting posture has been achieved, orthodontics may be recommended for dental stability if the child presents with a malocclusion of crossbite, overjet, or underbite; this might include braces, retainer, or rapid palatal expansion depending on the occlusion.

Pediatric Obstructive Sleep Apnea Treatment

In cases of pediatric sleep apnea, the first treatment step is typically the removal of the adenoids and tonsils. As reported by American Sleep Apnea Association, the removal of the adenoids and tonsils results in complete elimination of pediatric OSA symptoms in 70-90% of uncomplicated cases. As previously mentioned, a dental evaluation should be performed to check for hard palate development to accommodate the child's tongue. If necessary a rapid palatal expander (a non-invasive fixed and/or removable dental device) can be worn for six months to one year, to expand the transverse diameter of the hard palate.The next treatment option to consider is positive airway pressure, or PAP, which is typically used as a palliative treatment for adults with sleep apnea. A PAP machine blows pressurized air into the child’s mouth to counteract the closing of the throat during sleep. The amount of pressure is determined through an overnight sleep study.

If you feel your child exhibits any of the symptoms listed above for an airway function disorder, speak with your primary care physician for adequate referrals to airway specialists. At Lumiere Children’s Therapy, our speech-language pathologist can treat speech sound disorders, swallowing disorders, and oral motor deficits associated with AFD.

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References:

Archambault, N. (n.d.). Healthy Breathing, 'Round the Clock. Retrieved from https://leader.pubs.asha.org/doi/full/10.1044/leader.FTR1.23022018.48


Capdevila, O. S., Kheirandish-Gozal, L., Dayyat, E., & Gozal, D. (2008). Pediatric obstructive sleep apnea: complications, management, and long-term outcomes. Proceedings of the American Thoracic Society, 5(2), 274-82.

Children's Sleep Apnea. (2017, February 13). Retrieved from https://www.sleepapnea.org/treat/childrens-sleep-apnea/

Deviated septum. (2018, March 03). Retrieved from https://www.mayoclinic.org/diseases-conditions/deviated-septum/symptoms-causes/syc-20351710

Gastroesophageal reflux disease (GERD). (2018, March 09). Retrieved from https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940

Hayes, K. (n.d.). Coping With Chronic Rhinitis. Retrieved from https://www.verywellhealth.com/coping-with-chronic-rhinitis-4160487

Orofacial Myofunctional Disorders: Treatment. (n.d.). Retrieved from https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589943975§ion=Treatment

Positive Airway Pressure Therapy for Sleep Apnea. (2017, February 03). Retrieved from https://www.sleepapnea.org/treat/sleep-apnea-treatment-options/positive-airway-pressure-therapy/


Lumiere Children’s Therapy: Feeding Tubes

For children who are at risk for complications when eating by mouth, feeding tubes can provide necessary nutrition in a safe manner. Problems with swallowing may occur in one of the four stages of the swallow as described in a previous post,  Swallowing Difficulties in Children. There are six types of feeding tubes available to children with swallowing problems. Below explains the advantages and disadvantages of each type of feeding tube, as well as treatment for children with a feeding tube.

Nasal Feeding Tubes

Nasal feeding tubes are tubes that are entered through the nose down the esophagus. There are three types of nasal feeding tubes: nasogastric, nasoduodenal, and nasojejunal. Deciding between the three types depends on whether your child can tolerate feedings into the stomach. Nasoduodenal and/or nasojejunal tubes are recommended if a child demonstrates chronic vomiting, inhaling or aspirating stomach contents into airway, and/or does not empty feedings well since those tubes bypass the stomach.

Nasogastric Tubes (NG)

NG tube enters through the nose feeding into the stomach through the esophagus (connects the throat to the stomach).

  • Advantages

    • No anesthesia is required for insertion of tube

    • Tubes may be replaced at home

    • Feedings are usually quick

    • NG are used for shorter duration cases, usually 1-6 months

    • Stomach provides a larger capacity for feedings

  • Disadvantages

    • NG tube is visible on face

    • NG tube can be irritating so younger children may pull it out

    • Increased risk of aspiration (food or liquid entering airway) from reflux

    • Increased nasal congestion

    • Possibility to cause oral aversions and/or increase amount of reflux

Nasoduodenal Tubes (ND)

ND tubes enter through the nose and extend into the beginning of the small intestine called the duodenum. The small intestine is the location of the majority of digestion in a person’s body, therefore bypassing the stomach.

  • Advantages

    • No anesthesia is required for insertion of tube

    • Can reduce reflux. Reflux is when stomach bile irritates the food pipe by coming back up the esophagus

    • Reduced risk of aspiration (food or liquid entering airway) from reflux

    • ND are used for short term use, usually 1-6 months

  • Disadvantages

    • Feedings are given slowly over 18-24 hours

    • Child may be self-conscious with visible tube coming from nose

    • Tube may be irritating with younger children possibly pulling it out

    • Potential intolerance to feedings entering small intestine causing bloating, cramping, and/or diarrhea

Nasojejunal (NJ)

NJ tubes are similar to ND as they enter through the nose extending into the small intense. NJ tubes extend further into the small intestine called the jejunal. The tube is designed for children who demonstrate difficulty with feedings into their stomach.

  • Advantages

    • No anesthesia is required for insertion of tube

    • Reduces risk of reflux

    • Reduced risk of aspiration (food or liquid entering airway) from reflux

    • Tubes are primarily recommended for short term use (1-6 months)

  • Disadvantages

    • Feedings are given slowly over time

    • Tube is visual, so may be irritating and/or children may feel self-conscious

    • There are potential intolerances to feedings such as bloating, cramping, or diarrhea

Stomach Feeding Tubes

Feeding tubes are entered directly into the stomach instead of through the esophagus. There are three types of stomach feeding tubes: gastrostomy, gastrojejunal, and jejunostomy. The following are common conditions that may require the use of a stomach tube.

  • Problems of the mouth, esophagus, stomach or intestines presented at birth

  • Prematurity, brain injury, developmental delay, and neuromuscular conditions causing sucking and swallowing disorders

  • Failure to thrive, which is when a child is unable to gain adequate weight to grow appropriately

Gastrostomy Tube (G)

The G-tube is inserted through the abdomen directly into the stomach, completely bypassing the throat. If a child requires tube feeding for over 3 months and/or having difficulties with nasal tubes, gastrostomy tubes are usually recommended.

  • Placement of tubes: There are three types of methods for inserting G-tubes: percutaneous endoscopic gastrostomy (PEG), laparoscopic, and open surgical procedure. All procedures take about 30-45 minutes to administer.

    • PEG: most common technique for first placement of G-tube as it does not require surgery. The doctor is able to use a thin, flexible tube with a camera to insert the tube through the mouth and into the stomach

    • Laparoscopic technique: performed by making small incisions into the abdomen and inserting a tiny telescope to help with placement

    • Open surgery: Alternative for cases where a PEG placement is not appropriate

  • Advantages

    • PEG placement does not require surgery

    • Decreased clogging of tube since diameter is larger

    • Larger reservoir in stomach compared to small intestine

    • Child may feel less self-conscious since tube is not visible

    • Decreased chance of tube being pulled out

  • Disadvantages

    • Risk of aspiration due to reflux

    • Family is required to provide extra care to cleaning of tube

    • Surgery may be required depending on placement.

    • Possible skin irritation from leakag

Gastrojejunal (GJ)

A GJ tube is similar to a G-tube as the tube is placed through the skin into the stomach. The difference is a GJ tube has two feeding ports on one tube so that the food enters into the stomach and then down into the small intestine (jejunum portion). G-tubes may be converted into GJ tubes if the child is not tolerating stomach feedings.

  • Advantages

    • Reduced risk of aspiration

    • May reduce reflux

    • Less costly than J-tube placement

    • Tube is hidden, so child may be less self-conscious

  • Disadvantages

    • Potential intolerance of tube

    • Extra care required

    • Potential skin irritation

    • Tube may clog more easily due to smaller diameter

Jejunostomy (J)

A J-tube is placed directly into your child’s small intestine through the skin. This type is not as common for children.

  • Advantages

    • Reduced risk of aspiration and reflux

    • Tube is hidden

  • Disadvantages

    • Potential intolerance to placement of tube

    • Extra care required

    • Potential skin irritation from leakage

    • Tube is small and more likely to clog

    • Surgery is required for placement of jejunostomy

    • Feedings are slow


Treatment of Children with Tube Feedings

Depending on the type of tube and duration of tube feeding, children with tube feedings are at risk for developing oral aversion to food through the mouth. Oral aversion is when a child experiences a fear of eating or drinking and avoids sensation around or in the mouth. Children who are tube-fed often, develop oral aversions because many have learned that food hurts based on a history of medical issues involved with eating (reflux, aspiration, food allergies, and/or motility). In some cases, feeding tubes are used to supplement adequate nutrition but children may be able to eat orally with some limitations on foods, consistencies, textures, and liquids. If your child has been approved to eat some food orally, it is highly encouraged. In order to reduce the risk of developing oral aversion, the following is recommended by speech therapists:

  • Oral sensation. Children with oral aversions will try to avoid sensation around and in the mouth. Children with feeding tubes should continue to experience the same oral sensation in normal routines as children who eat orally, especially oral care. Adequate oral care such as teeth brushing is not only important to reduce aspiration (food getting into the airway) from reflux, but also continues to provide oral sensation. Consider getting a child-proof vibrating toothbrush for extra sensation. During nightly routines, apply lotion to the face while massaging the cheeks, place chapstick on the lips, and make funny faces in the mirror to encourage facial muscle movement.

  • Participate in mealtimes. Children with feeding tubes often miss out on the social, exploratory, playful aspect of eating. Allow your child to continue to experience the fun of eating by helping prep for dinner, setting the table, sitting with the family, and even playing with the food on the table! If your child is able to eat pre-approved food, be sure to have appropriate food available. Most children with oral aversion would prefer not to participate in the act of eating, but continues to benefit from the social aspect of mealtimes.

  • Playing with food. In many feeding therapy approaches, the first step to consuming food orally is accepting food using the other senses: touching, smelling, and licking. Create artwork using edible food by painting with pureed food, making edible play dough, and building structures with variety of food. Show children that food can be fun and non-threatening.

If your child currently has a feeding tube or is planning to receive one, feeding therapy is highly recommended to ensure your child is receiving adequate nutrition and quantity from oral feedings. Speech therapists can provide systematic feeding approaches, including but not limited to mealtime focus, S.O.S. (Sequential Oral Sensory), ABA (Applied Behavior Analysis), baby or child-led weaning, and hunger-based cues. Lumiere Children’s Therapy can provide feeding therapy for your child as well as a home exercise program to assist with carryover into the home environment.

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References

“Addressing Oral Aversions.” Feeding Tube Awareness Foundation, www.feedingtubeawareness.org/navigating-life/oral-eating/feeding-therapy-oral-aversions/.



“ARK's Y-Chew® Oral Motor Chew.” ARK Therapeutic, www.arktherapeutic.com/arks-y-chew-oral-motor-chew/.



“Enteral Tube Program | Home Care Instructions after Placement of a Gastro-Jejunal (G-J) Tube | Boston Children's Hospital.” Boston Childrens Hospital, www.childrenshospital.org/centers-and-services/programs/a-_-e/enteral-tube-program/family-education/giving.



“Feeding Therapy.” Feeding Tube Awareness Foundation, www.feedingtubeawareness.org/navigating-life/oral-eating/feeding-therapy-oral-aversions-2/.



“Gastrostomy Tube (G-Tube).” Edited by Steven Dowshen, KidsHealth, The Nemours Foundation, Jan. 2018, kidshealth.org/en/parents/g-tube.html.


Mattingly , Rhonda. “Management of Pediatric Feeding Disorders.” U of L Pediatric Feeding. U of L Pediatric Feeding, 2017, Louisville , University of Louisville .


“Tube Types.” Feeding Tube Awareness Foundation, www.feedingtubeawareness.org/tube-feeding-basics/tubetypes/.


VanDahm, Kelly. “Chapter 9: The Nutritional Foundation.” Pediatric Feeding Disorders Evaluation and Treatment, Therapro, Inc, 2012, pp. 227–227.