Q: My male client is age 6. He has average intelligence, CP, and cleft palate. He was pre-mature and is non-verbal. He has been using an iPad with communication app “Words for Life” very successfully. He drools, can’t blow, barely moves his mouth, etc. He makes random vocalizations. Any ideas?

This child represents some of the most severe we see.  This is severe apraxia and dysarthria, with cleft palate thrown in just to make it interesting.

Let us state bluntly that there are no assurances anything will help him become verbal.  All we can do is try and he will show us what he can do over time.  He will move very slowly and gain little things here and there. The developmental sequence will not apply, and he will learn what he can as he goes along. You may find he learns difficult things more easily than easy things. You just never know.

The big step forward for him is not oral motor.  The big move for him is the simple expression of sound and word.  He needs to be encouraged to say any sound or word, any time, and any way.  It does not matter if what he says even sounds like anything specific.  He just has to say something.

Therefore, if he wants a banana, you say, “What do you want?”  And when he grunts, you say, “Oh! You are learning how to say banana! Excellent. Here’s your banana.”  He needs to be rewarded for anything and everything he says.

And then, once he is saying many sounds and/or words, we begin to shape them. Have you seen my book called “Becoming Verbal with Childhood Apraxia”?  That is the one for this type of client.  It is about how to get these kids to become more vocal, verbal, communicative, and imitative.

The idea is to stimulate his augmentative skills AND to stimulate his vocal/verbal skills simultaneously.  Don’t give up on his ability to talk.  It may take years for him to speak so that others can understand him, but it should come slowly and eventually.  Everyone around him must assume that he will talk.  Assume that his random vocalization are meaningful expressions for him and treat them as such.

Observe him in a variety of conditions and find out which ones stimulate him to be more vocal.  Then do more of that.

Oral-motor stimulation probably should come in the form of a good feeding program. You did not mention it, but I assume he is an oral feeder.  If so someone needs to be teaching him how to move his mouth better during the process of eating.  The skills he learns there then can be applied to oral speech movement.

Don’t worry about blowing–– He doesn’t need to learn to blow.  He needs to learn to INHALE more deeply.  Use a harmonica, siren, whistle straw, or inspiration spirometer.  The whistle straw is the best to start because it requires hardly any air movement to sound.  Focus on inhaling.  The more air he can bring in, the more air he will have to exhale for sound production.  If he can’t do the straw––because it is too skinny and his lips won’t close around it––use a harmonica. A harmonica is flat and long and may accommodate his loose lips better.

And finally, work with his team motor specialists to find out how to encourage better trunk stability and mobility.  That is the key to better inhalation and exhalation.