Steps to Building Verbal Imitation in Toddlers, Parts 1-2

Steps to Building Verbal Imitation in Toddlers, Parts 1-2
Required Disclosure
Building Verbal Imitation Skills in Toddlers
Laura Mize, M.S., CCC‐SLP
KSHA 2016
• As owner of The Laura Mize Group, and, I receive a salary, compensation for speaking, and royalties from all product sales.
• I have no other financial or nonfinancial relationships with any of the other authors, publishers, or SLPs whose work I recommend in this course. @Laura Mize
Profiles of Late Talkers
Late Talkers are NOT a homogeneous group! @Laura Mize
Paul, Chawarska, Volkmar (2008)
1. Cognition ‐ Missing cognitive milestones – shows up in play more than anywhere else! Could mean autism… but could also mean general cognitive delay 2. Joint attention ‐ Self‐absorbed kids 3. Receptive Language Deficits NOT just a late talker if there are receptive language issues! Language comprehension scores are a SIGNIFICANT predictor of outcome 4. Gestures – No emerging gestures like pointing, waving, clapping by 12 months 5. Pretend Play Skills – NOT repetitive movements with toys 6. Repetitive movements – Stereotypic movements Key Purpose of Assessment for Any Late Talker
Separating children with only expressive delays
from those with larger developmental issues
@Laura Mize
Risk factors that tell us which ‘late talkers’ may not catch up… (
What if it does seem to be “just” late talking? Risk factors that tell us which children may not catch up to peers (
• quiet as an infant; little babbling • a history of ear infections • limited number of consonant sounds (p, b, m, t, d, n, y, k, g, etc.) • does not link pretend ideas and actions together while playing • does not imitate (copy) words • uses mostly nouns (names of people, places, things), and few verbs (action words) • difficulty playing with peers (social skills) • a family history of communication delay, learning or academic difficulties • a mild comprehension (understanding) delay for his or her age • uses few gestures to communicate 7. Unusual vocalizations – Atypical sound patterns @Laura Mize
@Laura Mize
Biggest Commonality Among Late Talkers
Break It Down…MOST RISK
Child isn’t talking!
Children with the final three factors: FAMILY HISTORY COMPREHENSION PROBLEMS LIMITED GESTURES are at greatest risk for continuing language delay. More importantly…
Child isn’t imitating! (
@Laura Mize
@Laura Mize
Lack of Imitation Means There ARE VERY LIKELY Delays In Other Areas
Imitation Matters!
The ability to “see and do” are HUGE developmental markers! A child who is imitating is:
Socially connected
Attention is usually developmentally appropriate
Cognitive skills moving along
Coordinated motor skills
Words – Child IS verbal
When we don’t see imitation in children, we suspect other delays too:
Sensory Processing
Cognition Motor Verbal
@Laura Mize
@Laura Mize
More Evidence
Why Does This Matter?
A child’s ability to imitate actions at 18 months old was a better predictor of his language skills at 36 months old than even gestures. (Child Development 2013)
@Laura Mize
If you’re not working on the right goals, you won’t see progress…. ESPECIALLY when there are multiple underlying reasons that the child is NOT talking!
@Laura Mize
Looking at a Child’s Imitation Skills
Levels come from…
get you on the right track for treatment for expressive communication delays/disorders!
Your focus will be on the reason there’s breakdown at a particular level. (social, cognitive, motor, language, speech)
Broken down into tiny steps
EASY for parents (and for us!)
@Laura Mize
@Laura Mize
Discuss for each level:
Why This Method Works
Prerequisites Most importantly… Where to begin treatment
Often times in our treatment plans with very young children with speech‐language delays, we jump straight to words. MANY children are NOT DEVELOPMENTALLY READY for this and then we don’t see progress for weeks or months because we started at a level that’s too high for them. @Laura Mize
@Laura Mize
Another benefit…
Overview of the Levels of Imitation
Success is important for EVERYONE!
• Child
• Parents
• You
@Laura Mize
• Level One: • Level Two:
• Level Three: Level Four: • Level Five: • Level Six: • Level Seven: • Level Eight:
Actions with Objects
Communicative Gestures
Nonverbal Actions with Face/Mouth Vocalizations in Play
Exclamatory Words
Automatic Speech ‐ Verbal Routines
Functional Words
Short Phrases
@Laura Mize
Building Imitation Through Play
How To Target Level One… PLAY! Level One: Imitating Actions with Objects
• The child learns to repeat an action that he sees another person perform with an object. • Motor imitation with an object comes first since is targeted first since this is one of the first kinds of imitation we observe in typical development. • Imitation with a familiar object will also be the easiest target for toddlers who aren’t already spontaneously or purposefully imitating actions, gestures, or words. Since we’re working with very young children, play‐based activities are the most developmentally appropriate ways to target new skills. @Laura Mize
Most children will already be able to physically accomplish those kinds of tasks on their own in daily routines, but the key skill is getting them to copy
what you’ve just shown them. @Laura Mize
“We cannot do anything with words until they are build on what was there before words existed.”
A. Charles Catania
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Toys and playing with a fun adult peak a child’s initial interest and keep the toddler engaged and participatory for longer periods of time.
@Laura Mize
This Level is CRITICAL for Children with Cognitive Delays Some experts recommend skipping this level if a child is already vocalizing, but if a toddler’s play skills are delayed, learning how to imitate actions with toys IS the first step to target. By teaching motor imitation in this way, you may be helping a child learn to really “play” with toys for the first time. Play is IMPORTANT for all children in order to help them master important cognitive skills to establish a foundation for language. @Laura Mize
Step is also CRITICAL for Suspected ASD
Imitation of functional actions with objects has been linked to the development of more mature play skills in children with autism. Over time this step decreases the stereotypic use of toys. By targeting imitation you’ll be teaching the child what to do with the toy or essentially how to play. @Laura Mize
Benefits for ASD
Brooke Ingersoll studies – improves JOINT ATTENTION
MANY adults are fooled by an echolalic child without much evidence of joint attention and true talking for communication. Even with those kids, you’ll start here for treatment! @Laura Mize
What if a kid isn’t there yet????
Prerequisites for Imitating Actions in Play
Motor and Social Proficiency at 6‐9 month Developmental Level
• Purposefully reach for or swat at an object • Hold a bottle or cup by themselves
• Explore a toy with their hands • A child must also be aware of another person in their environment and be able to attend to an activity for more than a few seconds. @Laura Mize
When kids are ready, begin by Modeling Actions in Play
(Remember…. Don’t jump straight to words!)
Level One Activities List
Address the underlying reason…
Begin with EXPECTED actions with objects 1. Motor Skills – OT and/or PT consult
2. Social Skills – Purposefully target interaction and engagement
3. Cognitive Skills – Direct instruction
Blocks, vehicles including cars, trucks, or trains, musical instruments like drums, bells, or toy pianos, dolls and accessories such as a bottle, brush and baby wipe, plastic dishes and utensils, pretend food, and other toys with tools such as a ball toy with a hammer TEST
@Laura Mize
@Laura Mize
Reminder for TYPICAL development
1 Eli – Early Imitation Objects
• Our perceptions can become skewed
• Imitation comes in EARLY for babies and toddlers
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1 Avery
Meet a Child Where He Is
Use toys he LOVES!
CAN use atypical interests: • Cabinet doors
• Feathers
• Sticks
• Train tracks or spinning the wheels on a toy train @Laura Mize
@Laura Mize
Teach Parents to use Everyday Objects to Target Imitation in Daily Routines
Guidelines for Level One Play • Brush his own hair while getting ready • Wash his own legs or the toy duck during bath time
• Cover his face with a blanket or wipe during diaper changes
• Hold a spoon in the air in imitation of an adult during meals • Pat his own shoes • Play with a child using toys he likes.
• Narrate your play using very simple language. • Imitate and respond to a child during play to encourage social interaction and joint attention. • Model familiar actions with toys first and move to new actions over time.
• Help a child imitate actions if he’s not doing it on his own.
@Laura Mize
@Laura Mize
Tips to Keep a Toddler’s Attention
More Advice about Attention…
Move on to new toys at least every 20 minutes or so to encourage renewed participation and decrease the risk of boredom for both of you!
Research confirms that a toddler’s attention span is variable at 3 to 6 minutes and will require full adult support to sustain longer than this amount of time. (Gaertner 2008).
@Laura Mize
(Ingersoll) @Laura Mize
My Best Strategies for Stretching a Toddler’s Attention Span
The “one more time” rule…
This can be…
• ONE more piece of the puzzle
• ONE more page of the book
• ONE more turn in play
• ONE more try with ANY goal
(You can also use this strategy the OTHER way to help a child transition from something he doesn’t want to leave.)
@Laura Mize
“Tell him, Show him, Help him.”
Perform an action 3 to 5 times and then provide physical assistance to help the child imitate your action if he doesn’t imitate on his own. @Laura Mize
Reciprocal Imitation or Imitating a Child’s Actions
Solving Problems with TOYS
Sometimes two identical sets of toys, one for the adult and one for the child, can be useful to elicit imitation of actions with objects during play. BUT it can backfire if the child then leaves you out of play!
• ONLY in small spaces
• ONLY WITH a child who is engaged with you
@Laura Mize
@Laura Mize
Troubleshooting with Actions with Objects
Once A Child Imitates
PRAISE and REINFORCE with child‐specific reinforcement: “Yay” with clapping
Quick squeeze if he’s a sensory seeker
Natural reinforcement – briefly play on his own Who REALLY gets to choose the reinforcement?
@Laura Mize
Be more fun!
Make the target easier.
Avoid power struggles.
Consider sensory needs.
Sing as you model actions. “Rock – rock –
rock the baby.” “Rolling. Rolling. Roll that ball!” 6. IF you can’t sing, CHANT.
@Laura Mize
Real life…
Jude Level One with Balls
The more significantly impaired a child is…
DIFFICULT…. Real life therapy
the longer this goal will take!
@Laura Mize
@Laura Mize
What happens when kids
After a child masters expected actions…
Move on to unexpected actions
What do we do???
This ensures that IMITATION is occurring – not just learning what to do with an object. Look at what he likes & expand attention & task participation FIRST
@Laura Mize
@Laura Mize
Twins – Unexpected Actions
More Troubleshooting
Make sure child is developmentally ready.
If he’s mouthing, throwing, exploring toys with no regard for you, target social & cognitive skills first. If a child is too “busy” get him regulated and calmer first, then present toys. @Laura Mize
@Laura Mize
Using Other Kids at Level One
Building Imitation with Gestures
• IF a child is struggling with YOU, an educated adult, he IS going to struggle with peers.
• Children with atypical development especially need adults! They’re NOT socially advanced enough to have moved beyond parallel play.
• Use other kids ONLY if it works for the child you’re teaching. If all of your time is spent managing behavior, then you’re not addressing your goals! In Level Two children begin to imitate actions that convey meaning to another person. Professionals refer to these actions as communicative gestures. Gestures precede words in typical development. It’s a HUGE red flag if gestures aren’t developing! We don’t see children with typically developing language skills who aren’t routinely using gestures. @Laura Mize
@Laura Mize
Gestures precede words in typical development. It’s a HUGE red flag if gestures aren’t developing! Capone says it’s a red flag for autism if no pointing at 18 to 24 months. We don’t see children with typically developing language skills who aren’t routinely using gestures. How early do gestures emerge in typical development?
First Gestures
In typical development motor imitation with gestures may first be seen with actions in early parent‐child social routines like Peek a Boo, Patty Cake, So Big, etc…
@Laura Mize
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2.0 Avery Social Games
Examples of Early Gestures
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2.1 Avery
In typical development, we see these more communicative gestures emerge pretty easily…
Waving & Pointing
May be so, so, so hard for little guys because of a variety of factors:
Social – Not enough meaning engagement or social referencing yet
Cognitive – Child is not symbolic.
Motor – Child can’t perform physical movements yet. • Because of these reasons, I don’t work on waving and pointing as first gestures when a child is really struggling. Try these first…
@Laura Mize
@Laura Mize
Early Gestures To Try
Word of Caution:
Introduce gestures when the child seems interested in performing the simplest of actions in imitation of another person: Clapping is HUGE!
Banging on a table or tray
Give Me Five
Knocking on a door
Kicking your legs while playing ball or bubbles
• If a child isn’t performing ANY Level One imitations, it’s highly unlikely he’s ready for Level Two with gestures. • Imitating actions with objects and interest in another person’s gestures are the prerequisites for Level Two
• Back Up and work on Level One as well as social, motor, and cognitive goals if a child isn’t there yet. @Laura Mize
@Laura Mize
Level Two Activities on Chart
Books with Actions to Copy
1. Begin with simple body actions or movements in play that aren’t necessarily communicative, but that the child can imitate
2. Move on to easy gestures in context during play and daily routines. 3. Move to more complex gestures/patterns
@Laura Mize
• Elmo Says…
• Barney Play Nose to Toes
• From Head To Toe – Eric Carle
CAUTION ABOUT BOOKS: If the child doesn’t let you participate, it’s not a great choice for teaching! @Laura Mize
Same RULES as Level One
1. Model gesture 3‐5 times then help child perform the gesture.
2. Use BIG gestures and heightened affect to attract and keep child’s attention.
3. PLAN your gestures and help parents plan too.
@Laura Mize
Moving on in Level Two… Introducing Signs
• ONLY when a child is imitating earlier Level 2 gestures! • Teach with REQUESTS first (not labels!)
Other Kids MAY Be Effective Here
Gross motor games are the first times we see evidence of social attention with peers and are particularly effective for toddlers and young preschoolers. GREAT therapy ideas for seeing kids at daycare. Gross motor games: • Running from Point A to Point B and back again
• Jumping • Swinging arms
• Marching
• Social games with peers – “Ring Around the Rosies”
@Laura Mize
WITH HUGE (and I mean HUGE) Motivators
–Movement Activity
Remember… who picks the motivators? THE CHILD, not you!
@Laura Mize
@Laura Mize
Signs List
The problem with this argument…
First Signs: more, eat, milk, all done, please, go, open, help, mine
Next Signs:
cookie, cracker, fish, chip, candy, juice, water, cup/drink, choo‐choo, bubbles, balloon, car/truck, plane, baby, play
Some controversy….. Some kids may overgeneralize and “get stuck.” @Laura Mize
Many babies (even typically developing toddlers!) overgeneralize as they’re learning language. It’s our job to help them learn specific words/signs and not get stuck!
@Laura Mize
Elijah Signs
• Elijah 2.3 – cranky, end of session first day
• Elijah 2.4 – mid 2nd day – happier – warmed up ‐ try signs with funny play routine
• Elijah 2.7 – mom goes home, frustrated…
• Regulated…. Fun …
• Why did this work? Troubleshooting for Level Two
1. Make gestures BIGGER and more FUN! 2. Introduce novelty
@Laura Mize
@Laura Mize
Signs are HARD for Some Kids
1. Kids on the spectrum have difficulty with social referencing. (EBP ‐ PECS is the way to go for communication! Frontiers in Integrative Neuroscience 2013)
2. For kids with cognitive and receptive language delays, symbolism is HARD and gestures are symbols.
3. Motor planning may also be difficult for a child to get his body to do what he wants it to do. Reward the effort, not accuracy. @Laura Mize
ANYTIME a child is not making progress, it’s because the goal is too difficult. PERIOD!
BACK UP, break your goal down, and work on smaller steps. For Level Two… (use chart!)
If you can’t get signs, work on more gestures. If there aren’t any gestures, back up to Level One or use SIMPLER gestures with repeated practice. @Laura Mize
Building Imitation with Mouth Movements
In Level Three a child learns to imitate nonverbal actions with his face and mouth. This can also include learning to blow horns and whistles. Little controversial in our field at the moment!
SLP Experts who support an oral motor approach… (usually also feeding experts)
• Diane Bahr
• Lori Overland
• Sara Rosenfeld‐Johnson
• Pamela Marshalla
• Debra Beckman Oral Protocol
@Laura Mize
using any kind of nonspeech oral motor exercise in therapy as a way to improve speech intelligibility. Dr. Gregory Lof is a leading researcher in this area.
Dr. Caroline Bowen @Laura Mize
When An Oral Motor Approach IS Indicated
• Feeding skills are affected
• Muscle tone and/or sensory issues are prevalent or obvious
(Open mouth posture, excessive drooling after 2, little awareness of their mouths, strong aversions to toothbrushing, or excessive mouthing after 2)
• When you’ve seen little to no progress without it
@Laura Mize
Level Three Activities • Begin with exaggerated facial expressions and mouth movements. Show a child how to perform the action.
• Move on to more refined movements of the mouth like smiling, puckering, smacking, etc…
• Introduce a variety of mouth toys such as horns, whistles, kazoos, musical instruments, pinwheels, common household objects such as funnels, tubes, or even cotton balls (Goal is IMITATION or turn taking!) @Laura Mize
For a small percentage of late talkers…
We MUST help them learn that they have a little mouth and it’s under their control!
For many of them, everything they’ve done with their mouths up until now has been reflexive…(eating, drinking, breathing, yawning, crying)
ANY oral movement on command may be EXTREMELY difficult for them.
• Muscle tone differences • Motor planning difficulties
@Laura Mize
My BEST Use Of Level Three
• Use these activities diagnostically to see if there’s an issue
• Only a PART of a child’s therapy program IF it seems to help
• These things could be the “back up to” point in therapy if a child can’t move forward
• Use as a “treat” or diversion in sessions
• Use it as a way to satisfy strong oral cravings
• Teach activities to parents and turn it over as a part of a home program
@Laura Mize
Horns and Whistles Sets
• Formal programs: is one resource for you and for parents. (Get parents to buy them!) Caution… little EBP
• Informal methods:
Birthday party favors, Oriental Trading, and other toys like wooden train whistles
Debra Beckman Oral Motor Protocol seems to be at least a little more supported by research
@Laura Mize
Building Imitation with Early and Easy Vocalizations
Just for the record…
I’ve treated many, many, many children successfully without the use of a single horn or whistle or introducing any real oral motor imitation tasks. This is usually a very, very small part of our treatment plan for a small percentage of kids on my caseload.
In reality, I don’t care if a toddler still can’t blow a whistle if he’s already talking! In Level Four and Level Five a child learns to imitate mouth movements with sound during verbal play.
In typical development this phase is noted as babbling. Babbling also occurs in late talkers as they become more noisy before true words emerge. Who likes to work on babbling? @Laura Mize
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Experts Who Recommend Targeting These Sounds
Stanley Greenspan – Model Affect David Hammer – Apraxia Expert Dr. James MacDonald – Play To Talk Pamela Marshalla – TONS of great information
• Hanen – People Games
• Dr. Lynn Koegel – Pivotal Response Treatment – Overcoming Autism
Prerequisites for Introducing Play Sounds
Child is NOISIER during play. Vocalizations seem to be more purposeful.
Whining when upset (rather than a reflexive cry)
Scream or Squeal Purposeful Laughter
Purposeful Vocalizations with emotion “Da!” or even a grunt
@Laura Mize
@Laura Mize
What if this is NOT happening yet?
Activities to Promote More Sound
MODEL more sounds/vocalizations, but not as many real WORDS. Use those same kinds of noises and Play Sounds from Level Four and Exclamatory Words from Level Five during these next activities:
@Laura Mize
• Vocalizations during gross motor movement activities like swinging, jumping, running
• Gym activities like a trampoline or ball pit
• Large spaces that echo
• Vocal contagion (Pamela Marshalla) –
EVERYBODY talks, sings, or vocalizes Group games are very effective at this stage.
• Toys that amplify sound – microphone, funnel, paper towel roll, bucket @Laura Mize
Play Sounds
Level Four List – Sounds that are difficult to transcribe or “spell”
• Squeal or scream
• Fake cough or sneeze or cry
• Whine
• Raspberries
• Slurping with a drink
• Exhalation like ‘hhhhh’ after a child drinks
• ‘mmmm‐wah’ when blowing kisses
• Panting like a puppy
• Car noises – sirens, brakes squeaking, etc… @Laura Mize
Reminder about typical development…
• 4 Eli
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Probe for Early Level 4 Vocalizations
• 4.0 Elijah – first day – I’m playing while another therapist talks to mom
• 4.2 Elijah – second day – warmed up – I‘m saying, try panting…
Not with real words!!!
@Laura Mize
@Laura Mize
Exclamatory Words
THESE ‘WORDS’ COUNT! Level Five List – Words that are usually spoken with forcefulness and represent an onset of emotion that can be either positive or negative. Exclamatory words are those you seem to yell to exclaim your message. These kinds of words are probably prevalent in your conversations with young children. All adults who are great with kids instinctively say, “Uh oh,” “Yay!” “Whee,” “Wow!” and even phrases like, “Oh boy!” Sometimes adults don’t want to count these as real words, but they are made of the same phonemes (consonants and vowel sounds) and are a step toward talking for many, many late talking toddlers. @Laura Mize
@Laura Mize
Value for children is that they are fun, novel, easy, and more than anything else meaningful! You can use these words to increase the frequency and variety of vocalizations a child uses. 15
These ‘Words’ Work!
Many times late talkers already use some vocalizations like these in Level Four and Level Five, but their parents don’t credit them as “words.” We MUST meet kids where they are developmentally and this is where I often begin therapy with late talkers who already have a handful of words or sounds. @Laura Mize
• Bilabial Voiceless & Voiced – /p,b,m/ ‐ Car
• Tongue Tip Voiceless & Voiced – /t,d,n/ ‐ Plane
• Back of Tongue Voiceless & Voiced ‐ /k,g/ ‐ Crash
• Trachea Voiceless & Voiced – (Non‐English)
• Glottis Voiceless & Voiced – Growls ‐ Animals
• Nasal – Snort ‐ Pig
Work on these to teach kids PLACEMENT and provide strong input to oral mechanism. (Marshalla) @Laura Mize
Word of Caution…
The strategies we just discussed are NOT useful for a child who isn’t connecting with you socially OR who doesn’t understand LOTS of words. @Laura Mize
EASIER for NEW Speech Sounds
Level Four and Level Five ‘words’ may make it easier for a child to acquire to use a new sound or class of sounds rather than in a real word. @Laura Mize
One More EXCELLENT Resource The Big Book of Exclamations
Teri Kaminski‐Peterson
@Laura Mize
Troubleshooting for Play Sounds Be more fun! Many times increasing your own level of animation and playfulness is what helps a child begin to imitate Level Four and Level Five during play. Change yourself before abandoning this goal. Move, move, move! Balloons, bubbles, run, jump, swing, dance! @Laura Mize
More Troubleshooting
Change your volume: Whisper
Say it LOUDLY! Add gestures or hand movements: Pow!
Oh no!
Exaggerate the vowel sound… adds excitement/affect
@Laura Mize
Experts Who Recommend Verbal Routines
1. Dr. Rossetti
2. TEACCH Method 3. Giggle Time – Susan Aud Sonders (based on Greenspan)
4. Dr. Lynn Koegel – Pivotal Response Treatment (ABA meets Floortime) – Carrier Phrases
5. Hanen Building Imitation with Verbal Routines
In Level Six a child begins to use some real words during very familiar routines. Verbal routines can be completely original or well‐
established nursery rhymes, games, or songs. These words seem to become “automatic” meaning that a child says the word when very familiar and specific conditions occur. @Laura Mize
Why do verbal routines work? They are so appealing! The repetitiveness and predictability of your verbal routines will be particularly appealing to children who crave order including toddlers who may go on to be diagnosed with autism. Actually ALL young children can benefit from verbal routines. Effective preschool and kindergarten teachers have used these techniques for years as they sing the same songs to accompany routines in their day. Most loved children’s television and books are based on Verbal Routines. Adults crave verbal routines too!
@Laura Mize
@Laura Mize
Echolalic Kids
Common Verbal Routines
Learning STRENGTH is Verbal Routines
Establish verbal routines during play with easy ones listed. Remember that you’ll teach the verbal routine by saying the words over and over during play. Caution – Be sure you’re working on RECEPTIVE LANGUAGE with these kids! Just because they can say it, doesn’t mean they can understand it!
@Laura Mize
• “Ready – Set – Go”
• Counting by rote to begin a game with “1, 2, 3” • Say “Up, up, up” as you lift a child in your arms and then “Down!” as you drop her to the floor. @Laura Mize
Use Previous Preferred Activities Original Verbal Routines
Social games including Patty Cake, Peek‐a‐Boo, So Big, Give Me 5, Ride a Little Horsie, Row Your Boat, and Ring Around the Rosies When a child is making a toy climb a ladder or pushing a car up a ramp, I model, “Up up up” and then say, “Wheeeee!” as the object slides down the slide. Easy songs and fingerplays such as If You’re Happy and You Know It, Itsy Bitsy Spider, and Twinkle, Twinkle Little Star
If a child is hiding or obstructed from my view, I sing, “Where Oh Where?” or say, “______, where are you?” Zip!
Knock Knock Knock…. Open
Baby Doll Routines
@Laura Mize
6.2 Avery
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Key to Setting up Effective Verbal Routines
1. TIME!
Child has heard the routine often enough to recognize it, to remember it, and he’s verbal enough to be able to join in. 2. Cloze Method
3. Expectant Waiting…
@Laura Mize
Build Verbal Routine Around a Toy
• 38 Garrett Phlat Ball
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@Laura Mize
Build Verbal Routine Around an Action
• 6.3 Noah
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Build Verbal Routine from a Game • 44 Julia ‐ Night Night game
Make it up as you go! – Replace MINDLESS NARRATION If a child is digging in the sensory box and dumping beans in a bowl, grab your own shovel or spoon to repeat his actions. As you perform each step say, “Dig dig dig. In the bucket. In the bucket. Dump!” Repeat the same sequence of actions and words many times during play on the first day and every subsequent time you play in the box. As you push a child in a swing, say, “Push.” As he swings say, “Whee!” After a set number of turns pushing and swinging, catch him and say, “Stop!” Then begin your routine again saying, “Push. Whee! Push. Whee! Push. Whee! Stop!” @Laura Mize
@Laura Mize
6.9 Clayton
Verbal Routines are POWERFUL and you can build an entire session around verbal routines. EXCELLENT initial strategy for verbal kids with autism who aren’t yet spontaneous or who don’t request. You can use this automatic speech to begin to direct what happens next in play. @Laura Mize
@Laura Mize
Building Imitation with Single Words
Reminder of Typical Development
• 7 Caroline
Move to words when a child has achieved a fairly high level of mastery with the easier, earlier levels. @Laura Mize
@Laura Mize
Prerequisites for Single Words as your MAIN Focus for Therapy
1. Interaction is not a problem! Social Skills are sufficient. Attention is pretty good. Engagement is present. If you’re struggling to keep a child engaged during fun activities and play, he’s usually not ready to talk yet from a social perspective.
@Laura Mize
2. Cognition is moving along!
Cognition is most easily assessed by looking at a child’s play skills. When a child’s cognition improves, play skills progress. You’ll see this as a child understands how toys work, plays with a variety of toys, and has mastered basic cognitive milestones such as object permanence, cause & effect, and simple problem solving. You know he imitates actions because he can watch you and play appropriate with even a new toy. If this isn’t happening, the child isn’t ready to talk from a cognitive perspective. @Laura Mize
3. Receptive Language is progressing!
4. Imitation is present! Comprehension is improving. Words have become meaningful. The child more consistently follows simple directions related to his familiar routines and during fun activities with you. If he does not yet understand words, he’s not ready to talk from a receptive language perspective. Imitation skills are established with easier skills. The child imitates actions, gestures, and other kinds of vocalizations. He has the ability to “see and do.” If there’s no evidence that a child understands this process, it’s unlikely you’ll be able to teach him to repeat words.
@Laura Mize
@Laura Mize
Guidelines for First Word Selection Guidelines for First Word Selection 2. Choose words that are fairly easy to say. 1. Choose high frequency, familiar words. Pick words a toddler hears often. These are words a child should understand in order to complete his daily routines and those he should learn to say in order to get his needs met. @Laura Mize
Don’t begin with multisyllabic words or words with difficult sound combinations. Early targets would not include words like refrigerator, basketball, or helicopter.
@Laura Mize
Guidelines for First Word Selection 3. Choose words with sounds and patterns a toddler already uses.
• Sounds – both consonants and vowels
• Introduce words with same sounds and in same class
/p, b, m/ /t, d, n/ /k, g/
• Syllable shapes – such as CV or reduplication This is ONLY a huge consideration if a child has such a limited repertoire of sounds. You’ll do this to get early success, but remember, you’ll have to hear new sounds sometime….
@Laura Mize
Words to Avoid for First Targets
Academic Words
Colors, Shapes, Numbers and Letters
Bryn Mawr List In 2011 researchers at the Child Study Institute at Bryn Mawr College identified the following 25 words every toddler should be using by age 2: all gone, baby, ball, banana, bath, bye bye, book, car, cat, cookie, Daddy, dog, eye, hat, hi/hello, hot, juice, milk, Mommy, more, no, nose, shoe, thank you, yes
@Laura Mize
Teach REQUESTS Even though the majority of early words in a typically developing child’s vocabulary are labels, STILL teach those words as requests so that you establish Why??? NOT FUNCTIONAL for NEW Talkers
Save for AFTER a child has established a functional vocabulary (50 words and short phrases)
@Laura Mize
RED FLAG for High Functioning Autism in Toddlers
• Talking but not communicating • Child knows HUNDREDS of labels and that’s the extent of his/her vocabulary
• MUST learn to ask for things, respond to questions, etc…
• This is why so many higher functioning kids are missed before ages 3 to 4
@Laura Mize
Communicative Intent
I have to DO Something to GET Something!
@Laura Mize
MATERIALS for Teaching Single Words
Toddlers learn best by doing! TOYS and Daily Routines
@Laura Mize
Strategies to Enhance Imitation of Single Words
• Use motivating materials a child likes! Play!!!
• Find a balance being both fun and demanding!
• Do everything you can to achieve early success! As a professional, you must Master WITHHOLDING!
Model the word 3‐5 times fully expecting a child’s best efforts, but then give a child the item he wants regardless of his response. Pleasant persistence and direct cues work best for many children as you say things like, “Tell me ____,” and “Say ____.” (Unless child is echolalic and repeats your prompt!) @Laura Mize
@Laura Mize
Other Strategies • Lean forward and wait expectantly as if to cue… ‘It’s your turn to talk!’
Elsa • 7.0 Elsa – Potato Heads – Vocal Contagion
• 7.1 Elsa
• Sing Song Vocal Prosody – motherese
• Vocal Contagion – EVERYBODY models! @Laura Mize
@Laura Mize
Mass Practice Repetition at this level is critical! Multiple opportunities for a child to say and hear the same word over and over again!
Mass Practice
• 10 Elijah Dr. Caroline Bowen’s recommendation:
• 12‐18 models of your target word
@Laura Mize
@Laura Mize
Elsa – Muffin Pan
• 7.2
• 7.3
Making Sets for Muffin Pan Therapy
Any Little Objects: Balls, Bugs, Bows, Army Men – Man, Guy, Horses, Cows, Dogs, Socks, Moons, Cars, Cats, Forks, Spoons, Turtles, Boys, Girls, Fish
Stickers – Erasers –
Pictures (maybe…) – Toddlers like REAL stuff! @Laura Mize
@Laura Mize
By Now….
If not…
If you’ve done a good job by being fun and with word selection based on what a kid likes and sounds you know he can say….
You should be getting an attempt almost every time you cue a word. The child is not developmentally ready for words OR he would be imitating you! Back up!
@Laura Mize
@Laura Mize
Moving Along…
When a child is imitating several different words well in a session, offer CHOICES! Not just one choices, DOZENS of choices in a sessions and HUNDREDS of choices in a day. Choices turn a child into a full‐time imitator of single words. @Laura Mize
• Choices can “trick” a toddler who won’t normally imitate on command into imitating.
• Keep it fun! • Keep your choices motivating. If a kid doesn’t like what you have, what’s the point??? @Laura Mize
Rory Vocabulary Development
Pay CLOSE attention to expanding a child’s vocabulary at the single word level BEFORE moving to phrases.
Some experts disagree with this, but I’ve found… when we build a child’s vocabulary at the single word level, everything else falls into place and phrase production is easier! @Laura Mize
Don’t Forget to Teach…
New Nouns
Descriptive Words
• AAC Learning Lab Chart – reference – link in manual
@Laura Mize
Help a Child Move Toward Spontaneous Single Words Environmental Sabotage –Communication Temptations • Place favorite items out or reach
• Use toys that promote requesting – bubbles • Eat a child’s favorite snack in front of him, but don’t give him a piece until he verbally requests the food. • Set out a more difficult toy that a child must get assistance from you. (wind up toys, Hot Wheels Motorcycle set, a balloon pump, rocket launcher)
• Give only 1 PIECE of an activity that requires many parts (paper but no markers, race track with no cars…)
@Laura Mize
@Laura Mize
Building Imitation with Phrases
ALWAYS start sessions with what a child can already say. During Level Eight a child begins to imitate short phrases. If all else fails, cue a child’s default words or signs. As noted in the previous phases, imitation precedes spontaneous use, and it’s no different here at Level Eight with phrases. Learning to imitate two and three word phrases is a critical step in helping a child develop spontaneous phrases and become conversational. BACK UP!
@Laura Mize
@Laura Mize
Difficulty With Phrases
EASY Patterns First
Move to phrases too soon Spontaneous single word vocabulary (35‐50 words minimum)
Not enough variety with his words
Around 18 Month Developmental Level
@Laura Mize
My + Favorite object More + Noun child says frequently Noun + Please More Please
Bye bye + Name/noun child says Hi + Name/noun child says Night night + Name child says @Laura Mize
8 Kellie Phrases ‐ “My ____”
Holistic Phrases No way! Aw man! Oh no! Oh boy! I got it! Right there/Right here See ya’ C’mon (for come on) 147
8.1 Kellie
@Laura Mize
Selecting Phrase Targets • Don’t start with carrier phrases! (I want ___, I see ____, Give me ____ ) • Holistic Phrases with Heightened Affect
Save these patterns for AFTER other phrase patterns are well established at the spontaneous level! 149
@Laura Mize
More Advice for Phrases
Treating Sequencing Issues
• Pair words from a child’s existing vocabulary, since these are words you know a child can already say. • Try high frequency word combinations a child he hears in every day routines such as, “Bye bye
Dada!” • Use combinations from your well‐established Verbal Routines. If you’ve played baby dolls and have sung or said, “Rock baby” or “Night night
If a child only says one word of the phrase, he needs more sequencing practice. Work on the same word in a sequence
Up up up – down down down
Dog Dog Dog
Me me me!
Sing! Even the same word or syllable “Row Row Row Row Row…”
@Laura Mize
@Laura Mize
Miles Singing Single Word
Treating Sequencing Issues
• If child repeats same word, use backward chaining. (“more more” for “more milk”)
Sometimes this is due to a motor planning problem, but sometimes it’s cognition!
• Practice last word first several times then add the first word. @Laura Mize
Backward Chaining
Helps to get BOTH words if a child is repeating a word for a phrase
“More more” for more milk, practice “milk, milk, milk” then “more milk”
Also works for multisyllabic words like Elmo, puzzle, cookie, cracker, goldfish, Daddy, bubble @Laura Mize
@Laura Mize
Use One Word as an Anchor for Phrases
Apraxia‐ – several articles with great references for this ‐ helps with motor planning
If several nouns and the word “go” are well established and the child seems to need the same word to “get started,” try:
Go car, go truck, go choo choo, go boat, go plane
Or change first word and use a well‐rehearsed second word such as “please” OR a very familiar “almost default” word…
No Mommy, up Mommy, help Mommy
More bubble, blow bubble, up bubble, down bubble, pop bubble
@Laura Mize
Spontaneous Phrases & Conversations
• QUESTIONS may shut a child down. • STILL do lots of commenting and modeling. (1 to 4 ratio)
• Playing TOGETHER is what makes this more natural and less like a “firing squad” for a kid. @Laura Mize
CHART • Use the chart as a CHEAT SHEET during sessions
• Move up and down • When a child seems stuck, figure out where he’s successful and EXPAND that level
• Remember, if there’s no progress, the goal is TOO HARD. BACK UP! @Laura Mize
QUESTIONS? Email me:
[email protected]
@Laura Mize
Building Verbal Imitation in Toddlers
Level One
Level Two
*Level Three
Actions with Communicative
Actions with
Your Face
and Mouth
Expected Actions:
Shake a rattle
Bang two blocks
Pat hands on table
Remove a blanket
Dump out toys
Put objects in box
Knock over tower
Stack blocks
Push a car
Roll a ball
Hit a balloon
Pat a drum
Push button on toy
Knock on a door
Stir with a spoon
Hold phone to ear
Pat, hug & kiss doll
Put hat on
Brush a doll’s hair
Feed a doll
Wash a doll
Hammer ball/pegs
Simple Big Body
Actions such as:
Pantomime actions
Bang hands on lap
Animal movements
Knock under table
Hide hands
Place toy on head
Roll car down leg
Sit on a hat
Hand Motions for
Songs & Fingerplays
Easy Communicative
Reach to be lifted
Blow kisses
Give Me 5
Shake head yes/no
Open/close mouth
Widen eyes
Raise eyebrows
Puff out cheeks
Round your lips
Chatter teeth
Grimace or snarl
Pucker lips to kiss
Smack lips
Lick lips
Close lips tightly
Stick out tongue
Pull tongue back in
Wiggle tongue
Click tongue
Pretend to lick
*Not necessary
for most late
Simple Sign
Cotton balls
Musical toys like a
flute or kazoo
©Laura Mize, M. S., CCC-SLP
Level Four
in Play
Level Five
Say “ah” in bucket
Pant like a dog
Audible inhalation
Squeal or scream
Grunt with effort
Fake cough
Fake sneeze
Car/Truck noises
Siren noise
Fake laugh
Fake cry
Snort like a pig
Slurp with drinking
Exhale after drink
Indian noise
Sh! for quiet
Mmm, mmm, mmm
Yum or yummy
Yuck or yucky
Ick or icky
Ouch, owie
Boo boo
Uh oh
Oops or whoops
Woo hoo
Aw Man
Oh no
Oh yeah
Oh boy
No way
Blow Raspberries
Animal Sounds
Vehicle noises like
beep, vroom, woowoo, boom, crash
Level Six
Speech in
Pause to let child
fill in words with:
Ready, Set, Go
1, 2, 3
Social Games
Patty Cake
Give Me 5
Ride Little Horsie
Row Your Boat
Ring Around The
Early Songs
Twinkle Twinkle
Itsy, Bitsy Spider
If You’re Happy…
Wheels on the Bus
Old MacDonald
Develop your own
Verbal Routines
during play with
the same words
each time.
Games from
Teach Me To Play
Level Seven
All done/all gone
Choo choo
Thank you
Early Verbs
Early Prepositions
Early Pronouns
Early Descriptives
Level Eight
My __________
More ________
_______ please
More please
Bye bye ______
Hi __________
Night night ____
Combine words
from a child’s
Holistic Phrases:
I got it
I did it
I do it
See ya’
Come on
Right there
What’s that?
Where it go?
Where are you?
Carrier Phrases:
I want _______
More _____please
I see ______
I like ______
Works Cited/ EBP References
AAC Language Lab. (2009). AAC language lab stages chart. Retrieved from
Ellis, E. & Thal, D. (2008). Early Language Delay and Risk for Language Impairment.
Perspectives on Language Learning and Education, 15: 93-100.
Ellis, E. & Weismer S. (2007). Typical talkers, late talkers, and children with specific language
impairment: A language endowment spectrum? In: Paul R, editor. The influence of
developmental perspectives on research and practice in communication disorders: A Festschrift
for Robin S. Chapman. Mahwah, NJ: Erlbaum; pp. 83–102.
McCleery, J., Elliott, N., Sampanis, D., & Stefanidou, C. (2013). Motor development and motor
resonance difficulties in autism: relevance to early intervention for language and communication
skills. Frontiers in Integrative Neuroscience, Retrieved from
Olswang, L.B., Rodriguez, B. & Timler, G. (1998). Recommending Intervention for Toddlers
With Specific Language Learning Difficulties: We May Not Have All the Answers, But We
Know a Lot. American Journal of Speech Language Pathology, 7, 23 - 32.
Rice, M. L., Taylor, C. L., & Zubrick, S.R. (2008). Language outcomes of 7-year-old children
with or without a history of late language emergence at 24 months. Journal of Speech, Language,
and Hearing Research, 51, 394-407.
Telethon Institute for Child Health Research (2008). Mixed Results For Late-talking Toddlers.
ScienceDaily. 16 May 2008. Web. 10 Jun. 2011.
Thal D, Tobias S, Morrison D. (1991). Language and gesture in late talkers: A one year followup. Journal of Speech and Hearing Disorders. 1991;34:604–612.[PubMed]
Tsiouri, Ioanna, Rhea Paul, Elizabeth Schoen. Simmons, and Moira Lewis.Rapid Motor
Imitation Antecedent (RMIA) Training Manual: Teaching Preverbal Children with ASD to Talk.
Baltimore: Paul H. Brookes Pub., 2012. Print.
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