SLP Mommy of Apraxia

Tag: Childhood Apraxia of Speech

  • What exactly is CAS?

    What is Childhood Apraxia of Speech?

    Definition and characteristics

    Childhood Apraxia of Speech is a speech disorder that results from difficulty with programming, planning and sequencing the precise movements needed for clear speech.

    The American Speech/Language Hearing Association (ASHA), denotes three main characteristics that must be present for a diagnosis of CAS.

    • Inconsistent production on consonant and/or vowels in repeated productions of syllables and words.
      • An example of the word doggy for my daughter who has apraxia ended up being produced doddy, do-yee, daddy, da-yee.
    • Difficulty sequencing syllables and words of increasing complexity.
      • The child might be able to say “dada,” but when words or added like “my dada” the child might say ‘da-da-da.’
    • Errors with prosody
      • Prosody can include syllable stress, and kids with CAS might stress the first syllable in each word: BAnana instead of baNAna or may give equal stress to every syllable BA-NA-NA.
      • Can include difficulty with volume control.  This was definitely true with my daughter.  She could not be loud even when she tried in her younger toddler years.
      • May have prolonged sounds and prolonged pauses, possibly giving the child ad staccato sound to their voice

    Other soft signs that should be considered include:

    Speech

    • Vowel errors and/or reduced vowel inventory
      • May have a tendency to reduce vowels to the schwa (uh).  For example, buh-buh/bye bye.
    • Groping
      • The child’s mouth seems to make a lot of unnecessary movements while they “grope” for the correct placement
    • Loss of words or sounds that were previously produced
    • Consonant omissions in the initial position of words
    • May be more successful with automatic versus volitional speech
      • A child may say “mama” but then when asked to repeat “mah” may be unable to do so correctly
    • Limited babbling as a baby, or limited sound variation in their babbling
    • Typically comprehends much more than they can speak

     Non-speech

    • Oral apraxia (difficulty planning and executing non-speech oral motor movements
      • May have trouble blowing raspberries, puckering, sucking out of straw or blowing out a candle
    • General awkwardness or clumsiness
    • Limb apraxia
    • Low muscle tone

    Who diagnoses Childhood Apraxia of Speech?

    According to ASHA, a qualified Speech/Language Pathologist is the IDEAL professional to diagnose CAS.  However, diagnosis can be tricky, so you want to make sure you find an SLP who has experience and/or specializes in CAS.  Currently, CAS is both over-diagnosed and under-diagnosed, so don’t be afraid to ask questions to gauge your SLP’s experience and knowledge of it.  A good SLP will not mind being asked questions about their experience with CAS or answering questions related to it.

    The Childhood Apraxia of Speech Association of North America provides an advanced training for SLP’s who already have extensive experience in the disorder called the Childhood Apraxia of Speech Intensive Institute.   You can read more about my boot-camp experience here:

    What should therapy for CAS look like?

    There are many programs out there that say they are geared toward the treatment of CAS.  There is a growing body of evidence that the principles of motor learning affect the most change.  In short, you should be seeing:

    •    frequent repetitions of target sounds or words (mass practice)
    •    feedback that is specific.  The SLP should be giving them feedback such as “you’re lips were open, not closed,” rather than just “good job” “try again” or “that was great.”
    •    carefully chosen speech targets that take into account the child’s current phonetic repertoire and then practicing a variety of movement gestures (sound to sound, syllable to syllable, word to word) with these sounds.
    •    Cues – can be visual (SLP may pop her hand out for /p/) verbal (close your lips and use your humming sound), or tactile (SLP may use physical touch cues on the child like in PROMPT).

    For a great description on what parents should look for in CAS treatment, see my interview the executive director and founder of apraxia-kids.org Sharon Gretz.

     

    For a detailed description of DTTC, a therapy approach for apraxia, see my interview with Dr. Ruth Stoeckel from the Mayo Clinic.

     

    A note about the school-age population

    Since I have spent most of my 10 year career in the schools, I think it’s important to also address some symptoms SLP’s may see that vary slightly from toddler presentations.

    By the time a child with CAS reaches Kindergarten, an SLP may run into three scenarios:

    • The child who has almost resolved due to intense and appropriate early intervention
    • The child who is still struggling significantly with motor planning, and is very unintelligible.
    • The child is still essentially non-verbal

    In scenario one, a child’s speech may be highly intelligible, with only residual articulation errors evident like a lisp, or an /r/ distortion of substitution.  It’s important to review the file closely and see what prompted the initial diagnosis of CAS.  This is important, because children may have additional issues after the CAS is resolved.  With one particular 4th grader, his speech only contained persistent errors with three speech sounds; however, his sentence formulation, grammar and syntax remained very problematic.  What is syntax?  One element is to correctly sequence the words in a sentence.  If a child had difficulty with the planning and sequencing of sounds, it ‘s not far off to think he/she may also have difficulty sequencing words correctly in a sentence.  I treated him differently and used the principles of motor learning to guide his treatment, unlike my other kids with an expressive language delay that never had an apraxia diagnosis.

    Other issues may include: pragmatics, narrative language, and persistent prosodic errors.

    In scenario two, a child may be speaking but is highly unintelligible.  By this age, they might actually have a vast repertoire of sounds, and actually be able to produce most sounds correctly in isolation.  One year I had a five year old walk through my school door.  One day he took out an alphabet BINGO and proceeded to name all the letters and letter sounds correctly in isolation.  However, this kid could not string two sounds together or consistently.

    In scenario three, the child may still be essentially nonverbal.  Until the child can commit to a motor speech exam, meaning he can or will at least attempt to imitate a variety of sounds and movement gestures, a definitive diagnosis cannot yet be made.  Aside from using Assistive Technology which can eventually facilitate speech, I would recommend starting with a functional core vocabulary book you two can make together that includes highly motivating syllables or words the child can work toward using sounds in his current repertoire.  With one five year old I had, he could only produce bilabials (b,p,m) and and /n/.  We started with word and word approximations to help him be more successful:  i.e. 1. no 2. bah/ball 3. mah-mah/mama etc.  Then we drilled them using the principles of motor learning that included massive amounts of repetition, involving visual and verbal cues, using specific feedback.

     

    CAS is a complicated disorder that is many times over-diagnosed and under-diagnosed.  In addition, the treatment approach varies from other traditional speech sound disorders.

    For resources I recommend the apraxia-kids.org webiste.  There is a wealth of information for parents and professionals.

    To find  CASANA certified SLP’s see the professional friends directory on the apraxia-kids webiste.

    Laura Smith is a speech/language pathologist in the Denver Metro Area specializing in Childhood Apraxia of Speech.  CASANA recognized for advanced training and expertise in Childhood Apraxia of Speech, she splits her time between the public schools and the private sector.  She is dedicated to spreading CAS awareness.  Her passion is fueled by all of her clients, but especially her own daughter who was diagnosed with Childhood Apraxia of Speech.  For more information visit SLPMommyofApraxia.com

    CAS

     

     

     

     

  • What exactly DO I want to hear at parent teacher conference?

    What exactly DO I want to hear at parent teacher conference?

    I had Ashlynn’s Fall parent-teacher conference for this, her last year of Pre-K.   The teacher gave me a HUGE packet for Pre-school standards for my review, and said she didn’t need to go through all of it.

    Um…okay.

     

    She showed me a picture Ashlynn had drawn the first day of school of a person with her name on the paper, and then another current picture of a person with her name on it.  There was improvement in both.  Okay…..cool.

    Then she said she had an idea to work on the morning routine.  Every morning the kids are to complete a series of 4 steps before the parents leave.  1.) Hang up Coat 2.) Wash Hands 3.) Check in 4.) Write name.

    Despite three months of doing the same thing, Ashlynn always comes in, gets distracted, and needs physical prompts to do each one.  She seems absolutely oblivious to verbal prompting.  It’s not ignoring either.  She is just so engrossed in what the other kids are doing, she loses focus.

    So,back to the teacher’s idea.  She wants me to physically take her to each station instead of verbally prompting her, to hopefully just get Ashlynn successfully completing the routine, and then we can add language.

    Ok….not a problem.

    She seemed relieved I agreed.  I mean, honestly, I’m not too wrapped up in the routine.  I need to know if my baby is making progress.  Is she going to be ready for Kindergarten?  What do I need to be doing at home?

    She really couldn’t pinpoint one thing.  Just kinda said Ashlynn is getting a lot of services to try and catch her up.

    She did say Ashlynn is engaging in collaborative (not just parallel) play, and is using her imagination to make up things.

    Okay….that’s good.

    Oh, and then she said she usually has the kids change seats on the carpet, but she thinks it would be best to keep Ashlynn in the front so she’s not as distracted.

    Okay…sounds good.  She should be getting preferential seating per her IEP, so…. I mean….how is my baby really doing?

    Sigh.

    I don’t know what I want.  The whole thing was underwhelming.  No rave reviews, but then no suggestions on how to help her.

    Not at that meeting anyway.  I gleaned plenty when I finally had a chance to read through the skill sets.

    Let me just pick one out here:

    Early Literacy Skills Assessment:

    Out of 14 pre-literacy skills, Ashlynn has four boxes checked.  🙁

    Damnit.

    FOUR!!! out of FOURTEEN!!!

    It makes me want to cry.  Nevermind, I am crying now.  It’s not fair.

    So, I’m going to tackle those skills.  Comprehension, Phonological Awareness, Alphabetic Principle, and Concepts about Print.

    That’s just reading FYI

    Cody is going to tackle the math part….and that’s a whole other list of checks she doesn’t have that I just can’t bear to look at again.  Thank God my husband is amazing and helps lift some of the burden.

    Stupid Apraxia.  Stupid Apraxia.  I hate apraxia.  I hate this damn disorder.  I HATE IT.  I HATE IT.

    Okay, tantrum over.  Put on your big girl panties Laura.  You don’t see Ashlynn crying about all the work there is to do.  In fact, she’s looking at your right now with alphabet cards in hand ready to learn.

    Alright bug, bug.  We haven’t come this far to raise our white flag yet.  Like I said in my post at the beginning of the year, “Bring it on.  We’re going to give it everything we got.”

     

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  • “Oh my goodness!!” Ashlynn turns 5!

    “Oh my goodness!!” Ashlynn turns 5!

    The day started long before the AM. Preparations were in place to decorate the house after Ashlynn went to bed.

    This year was different though.  When I left to leave while Cody was putting her to bed, she asked me where I was going.

    “Mama?  Where you going?”

    Though I tried my best to cover, she asked,

    “You going for my birthday?”

    Freeze time.

    My daughter has ALWAYS been astute and observant, but we usually could play it off and nothing more was said.

    SAID.

    That’s the thing.  Nothing more was said, but Ashlynn has been watching all these years.  I think, wait, I KNOW she knew what was going on.

    We celebrated her birthday this morning.  My son has been getting up at 3 AM every morning for the past two weeks, so I was sleeping in a chair in his room when I heard noise outside.  I walked out and saw Ashlynn gasping for breath.  No, she wasn’t in trouble, she saw the balloons in the hallway!

    She’s seen these before, but today, she could EXPRESS that she really SAW them.  I had my phone on me and starting rolling the film.

    Me: Ashlynn, what do you see?

    Ashlynn: Oh…my….GOODness. (dancing through balloons looking at her decorations)

    Ashynn: Whose presents are these?

    Me: Those are YOUR presents!!

    Ashlynn: Who give them to me?

    Me: Mommy and Daddy!

    Ashlynn: Yeah?  Look!  It’s my jerjay Jace (dang assimilation…if you’re an SLP, you would find this fascinating, especially since she can say “birthday”

    Jace: It’s your birthday today?

    Ashlynn; Yes, it is!

    Me: How old are you Ashlynn?

    Ashlynn showing ten fingers: This many!!!

    Me: Say, “I’m five!”

    Ashlynn in excited fashion: “I’m five!!!

    A little later on,

    Ashlynn: Mama, where’s my cake?

    The last two years I made her a cake, but this year I decided to buy her a pretty Minnie ice cream cake that we hadn’t picked up yet.  I was surprised she asked where it was.

    Take that apraxia!

    As the morning rolled on, I was folding clothes when my husband came into the room, eyes red. Emotional. But before I explain why, it’s important to know the back story.

    A couple weeks ago we were discussing what to get Ashlynn for her birthday.  My husband always has it in his head to get our kids a BIG gift.  He remembers the BIG gifts from his childhood…and some he even remembers what age he was when he received them.

    I don’t remember my big gifts.  I remember gifts, usually practical.  I love gifts, but for example, on my list for Ashlynn’s gifts I had: long sleeve shirts, winter coat, robe, socks….(follow Cody’s “really?!?” face).

    Ashlynn just isn’t into BIG gifts.  For some reason, she loves cards.  Any cards.  Trading cards, flash cards, alphabet cards, playing cards….cards.

    I told Cody, if he wanted to get her a BIG gift, he should get her cards.  Buy her a binder she could decorate and put in pocket protectors.  He did…begrudgingly.  But it’s true. It’s what she wants.  We took her to the toy store THREE times, and she just wasn’t crazy about anything.

    Okay, so back to his red eyed confession.

    Cody: Ashlynn just said “thank you daddy” unprompted.

    Me: Really?  For what?

    Cody: Buying her cards. She’s never said thank you unprompted before.

    Take that apraxia!!

    As the guests arrived, her Grandma and  Grandpa  were two of the first people in the door.  She excitedly ushered her grandpa to her swing where she got him to push her.  I remember a time my dad came to visit and she wasn’t really talking.  She said ‘hi’ but that was about it.  He left that day and told my mom he wasn’t sure Ashlynn knew he was.  You can read about that story here.

    The thing is, Ashlynn always knew who he was.  She knew he’s the guy who plays ball and boats with her. She knew, but because she couldn’t say, he left feeling the way he did.

    All those are distant memories now.  She asked him “you push me on the swing?”  and they were gone.

    As she was opening gifts, she was telling everyone “thank you” in a big loud voice.  She opened up a box that had a hoodie in it that she saw in the store shopping with me and told me it was pretty.  This was her face opening it up.  I think she liked it 😉

    Another shirt she opened had the word Princess written on it.  I asked her who calls her princess.  As she looked up and scanned the crowd, her eyes stopped on her other grandpa that was there. She smiled and pointed at him, saying his name.  He later reported what a cool moment that was.  Verbal confirmation that Ashlynn has always known all along just what has been going on.
    This year, singing Happy Birthday and blowing out candles all came easy.  That milestone was met last year.  
    The best came at bedtime.  I read her a bedtime story, prayed, and then kissed her goodnight.  She was holding the card book Cody gave her.  She told me, “Mommy!  These are my decorations.”  (She was pointing out her room decorations that have been on her wall since basically she was born).  Yes, honey, those are you room decorations. “Yep, just like my decorations for my birthday.”  
    She is starting to retain, recall, and generalize higher vocabulary.  I smiled.  Then she pointed to her card book.  
    Ashlynn: Daddy gave this to me
    Me: Yes, he did
    Ashlynn: That was nice of him.  You get him so I say thank you?
    Me: You bet Ashlynn.
    And that’s how we are kicking apraxia’s butt!
    Happy 5th Birthday Ashlynn!  May you continue to find your voice and voice your thoughts, hopes, and dreams.
    Love,
    Mommy

  • Kids say the darndest things….unless of course they don’t because they have apraxia.

    Kids say the darndest things….unless of course they don’t because they have apraxia.

    What was it that Bill Cosby always said?  Kids say the darndest things or something like that.  Unless of course, you know, they don’t because they have apraxia of speech and can’t even say the most basic things.  Or this that I just ran across:

    Unless of course, they don’t because they have Apraxia 

    When Ashlynn was born, I wondered what her personality would be, the funny things she would do and say.  I just expected it to happen.  She would be so witty.  She has two smart parents, and one in particular who is quite funny (I won’t name names but it’s not the SLP).

    As time marched on, I did see her personality, and she did do funny things, but it was all so limited. It’s pretty hard to say or do basic things, much less funny things when you have motor planning issues affect your entire body.

    Seeing other kids her age or younger on social media or worse in person, usually broke my heart.  It got to the point I didn’t want to take her around other kids her age and I had to hide friends on social media because I couldn’t bear another kids say the darndest things” moment, or really any moment that a typical developing child would have:

    Scenario:
    My crazy kid is doing back flips off our couch
    What I saw:
    Ashlynn can’t even jump yet

    Scenario:
    Look at our precious baby wearing her mom’s high heels.  We’re in trouble!
    What I saw:
    My precious baby still falls wearing her own sturdy tennis shoes

    Scenario:
    My son just imagined this carrot looked like an alien
    What I saw:
    Can my daughter even say carrot, and does she even know what an alien is?

    Scenario:
    Look at our big boy riding his two wheeler!
    What I saw:
    My big girl still can’t pedal a big wheel.

    Scenario:
    Little girl just said she wants to be a princess for Halloween.  She sure is daddy’s little princess!
    What I saw:
    My little princess has yet to say her name.

    The list goes on. Not that I wasn’t proud of all of these other kids, I was.  I was also happy for the parents, and maybe a little jealous.  How easy everything came.  All these cute little milestones taken for granted.

    Worse yet, the posts about their child’s annoying incessant talking.  If only there was some peace and quiet.

    Really?

    The quiet is our own little hell.  You can’t even to begin to understand how painful that is to hear as a mother who has a nonverbal child, when every quiet moment is spent praying that they will talk.

    That’s why my last post was so special I guess about Ashlynn confusing “coworkers” with “construction workers.”  She always comes along, just in her own time,

    and your kids will too.

  • Working our way out of the apraxia tunnel

    Working our way out of the apraxia tunnel

    Ashlynn has been saying things lately that are really showing higher level thinking. You’d think this would be glaringly apparent to me, but it really IS crazy how much language gives us an idea of what is going on in their brain.

    She’s been VERY interested in her schedule, and where she is going the next day.  I still haven’t made our visual schedule, but it’s on my to do list.  She usually asks me though while she’s laying in bed to go to sleep,
    “Mama, what are we doing today?”
    “you mean tomorrow?
    “yes”
    “Tell me that.  What are we doing tomorrow?”
    “What are we doing, tomahyo?”
    And then we talk about it.  She loves it when her grandma drops her off at school and I get to take her to her class.  This happens on Tuesday and Wednesdays.  She used to just keep asking 
    “you takin me to school?”
    I would reply, “Grandma will take you to school and I’ll take you to class.”

    I’ve been telling her that since she started school.  This week she finally said, 
    “What are we doing today mama?”
    “you mean tomorrow?”
    “yes”
    “Say that, What are we doing tomorrow?”
    Instead of repeating it back to me, she asked, “Grandma take me to school and you take me to class?”  
    This may seem small, but I was sooo proud!
    She also asks me who I work with almost everyday and I usually tell her my coworkers or colleagues.
    Well the other night, she said, “who you go to work with, mama?  Construction workers?” 
    LOL  
    I love it.  It makes my heart smile, and in those moments, I know everything is going to be okay.
    My last update has to do with school.  This is her third year of preschool.
    The first year she came home singing (with 1-2 sounds) the melody to the baby bumblebee song.  By the end of that year, she was also telling me who her friends were in school.
    The second year, she would tell me who she played with for that day, but that was usually the extent of her school reporting.
    This year, her third year, she’s identifying the letters of her name all over the place.  She also told me the other day when we were talking about arctic animals and that polar bears live there, 
    “I live in Colorado.”  
    Me: “Did you just say you live in Colorado?”
    Ashlynn: “Yes, my teacher tell me that.”  
    I sat their in awe.  This is the first time she’s ever told me something she’s learned at the school.  Heck, this was the first time she said something that she hadn’t learned from me or that I hadn’t heard her say before. 
    I see the light at the end of this tunnel that is apraxia.  To be honest, I’ve seen it for some time now, but I feel we’re getting closer to making it completely out.
  • What to do when you can’t say “Trick or Treat”

    What to do when you can’t say “Trick or Treat”

    Ashlynn said her first “trick or treat” on command at the age of four.  At three…she had an approximation, but then she froze when we went trick or treating.

    Many people were polite and kind, not demanding she say something for her candy.  Others though, sat indignantly at the door waiting for “the magic words.”  Because Ashlynn’s strengths lie in social skills, she was always able to charmingly muster up the word “hi” instead, and most of them would give her the candy.

    However, many of my clients report anxiety around this time of year for them and for their child with apraxia.  I’ve heard of some creative ways around this.

    One client I had said she took her daughter with older cousins who all went in a group and spoke for her, if you will.

    Another client had a sign that said “Trick or Treat”

    A mom I’ve met through the fb group, made these cute and wonderful cards that not only say “trick or treat” for the child, but also spread awareness!!  I asked if I could share and she was happy to pass them along.

    So here they are!!  Thanks Shelley for your generosity!

    If you are finding these hard to print, feel free to email me at lauraslpmommy@gmail.com and I will be happy to send you along the PDF.