SLP Mommy of Apraxia

Tag: daughter with apraxia

  • 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

     

     

     

     

  • “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

  • You play dirt with me?

    You play dirt with me?

    We took our annual Fourth of July camping trip to Glendo State Reservoir in Wyoming.   It’s a family tradition, so I decided to document her progress each year.  Last year’s experience can be found here: Glendo 2013
    This was only a few short days after our near drowning incident at her pool during swimming lessons.

    Glendo is a HUGE reservoir, and a lot of our time involves the beach.  I was worried about Ashlynn’s safety, and also if she would be too scared to go in the water.  The first day she kept her distance from the shoreline; however, the second day she walked to the shoreline and was watching her dad who was floating in the water maybe 10 feet away. Sensing she wanted to come in, he held out his arms.  I didn’t see him at first and my sister motioned to me that it looked like she was going to go in.  I went running to her, but stopped just short behind her.

    I saw my husband with arms outstretched encouraging her to come to him, and then I saw her little shoulders rise up big as she took a deep breath, and she marched in the water.  She marched through the waves, keeping her balance, until she fell into his arms with a big smile upon her face.  He hoisted her up into a floaty with him to enjoy floating in the water under the warm sunshine.

    I looked on in awe.  She’s so brave.  Her character is quite astounding to me, and I’m her mother.  She faces challenges, fears, and obstacles head on.  She never gives up. She is determined and resilient.

    She also of course, rode our jet ski.  I wrote last year that she asked, “Ashlylnn play boats with daddy?” and this year, she announced proudly after riding, “I ride the je-si huh!”

    One of her favorite requests this year was, “you play dirt with me?”  imploring anyone who would listen to play in the sand with her.  No one had the heart to say no, so she made quite a few friends and suckered in quite a few family members!

    When it was time for fireworks, Ashlynn has historically stayed in the car.  However, this year, she again put on a brave face and ended up enjoying the show!  At times she would say, “that was too close!!!” but she never went back in the truck.

    I like documenting some of her milestones on the Fourth of July, Independence Day.  It’s so fitting since each year she becomes more and more independent.

  • Ashlynn summer speech therapy 3.9 years

    Ashlynn summer speech therapy 3.9 years

    Ashlynn received two grants to help with her speech and occupational therapy over the summer!  The United Health Care Foundation and the Lindsay Foundation made it possible!  I am so grateful.  Ashlynn will be back to getting intensive 1:1 speech and OT services.  

    As far as speech goes, Ashlynn communicates her wants and needs.  She has basic conversational skills and really does try to tell us what happened in her day.  Sometimes when she’s talking, I see my husband look at her with pride in his eye and I know what he’s thinking.   Even though we don’t always understand what she is saying, it is amazing to listen to her talk and try to tell us things.  She was silent for so long.  
    I love her speech therapist.  She was actually my mentor and is now one of my good friends.  She’s fun, but I also know she’ll push her.  However, I also know she’ll find the deficits and the continued deficits are hard to be faced with and make me sad.  I want to write it down though, because if I know anything about Ashlynn, I know she’ll overcome it.
    – She has significant word finding issues.  Sometimes, she needs so much wait time that eventually she even forgets what she wanted to say and moves onto something else.  
    – Her attention continues to negatively impact her progress
    – When something is hard, she changes the subject and tries to talk about something else
    – Auditory processing skills such as auditory discrimination between minimal pairs (sleep, seep) appear to be impacted.  
    – Grammar, including marking varying tenses and using s/v agreement along with pronoun usage are faulty
    – Syntax is jumbled, particularly for question forms
    – Still has a tendency to assimilate sounds she knows how to say (goggy/doggy), and continues to be inconsistent with her production of consonants in her repertoire (koys/toys). 
    – Needs continued work with /l/ and /r/
    – Continues to breakdown with novel multi-syllabic words
    – Receptive language skills continue to need monitoring
    That’s a long list, but I have to remind myself it used to be longer.  She’ll get there.  I know it.  There was a time I worried if she would ever make friends because she couldn’t talk to them.  Here she is at the splash park talking to perfect strangers and making friends.  One step at a time.
  • Summer speech with a little sidewalk chalk

    Summer speech with a little sidewalk chalk

    Looking for a fun way to incorporate some speech practice into your summer schedule?  All you need is some sidewalk chalk and your kid!

    I picked some sound combos Ashlynn is currently working on in speech and drew them in the boxes of a hopscotch grid.  We then would throw a rock and whatever the rock landed on, we would hop to that picture and say the picture.  She was so busy having fun, she didn’t really realize I was working on her /l/, /l/ blends, and /s/ blends!   Not sure if you can see here, but we have a firefly, spider, butterfly, ladybug, dragonfly, bumblebee, roly poly, star, and clouds in the sky.  

    As a bonus, since Ashlynn has global apraxia, the added jumping and keeping feet in the boxes would make any PT or OT happy too!

    Look at those good jumps!  My heart smiles at this picture because jumping did not come easy.  If you’re interested, you can read about here: Jumping on the bed

    Not to be outdone, her 24 month old brother was hopping right along too and practicing speech! Fun for everyone, and momma stays sane with kids entertained!

  • For once I went to school, and I heard only positives

    For once I went to school, and I heard only positives

    Let’s face it.  Being a parent is rough.  Whether you have a child with special needs or not, we all want for their happiness, that they will feel successful, that they will be confident, and that they will never hurt.  Of course we know that without trials they cannot fully appreciate the successes, without sadness they could never fully experience complete happiness, without hurt they simply wouldn’t be human. 

    School has been an absolute blessing for Ashlynn, my social butterfly.  She never let her limited speech hinder any of her relationships.  In fact, her first word was ‘hi’ and it was all she needed.  She could and still can engage anyone with that simple word and her beautiful smile, and they are hooked. 

    But

    That’s why it was so hard to go to IEP meetings, parent teacher conferences, and get reports from her teachers and therapists.  No matter how many positives were relayed, we always sit there waiting for the

    But.

    She is so happy and works so hard,

    But

    She is friendly, sociable, and loving

    But

    She is an absolute joy

    But

    I’m not gonna lie.  The “buts” hurt.  It really doesn’t matter if they are framed around 100 glowing adjectives, the “buts” can be overwhelming.  Especially when for one child she needs a

    speech therapist
    occupational therapist
    physical therapist
    special education teacher
    social worker

    They all come with their own set of “buts.” 

    Today though was different!!  Today, her last day of Pre-K, there were no “buts.”  Today, as I picked her up, I heard this:

    Teacher: “I have been blessed having Ashlynn is my class.”
    Social Worker: “Ashlynn is the sweetest, kindest child. She is friends with everyone, and everyone is friends with her.”
    Another parent: “My son told me this morning he was really going to miss Ashlynn. When I asked him what he would miss, he told me her laugh.”

    It just brings tears to my eyes. There’s no standard score or percentile for that….but if there were she would be way above average. 
      
    Ashlynn is my sweet, kind, loving, daughter who blesses those around her with her smile, her laugh, and her friendship.

    No buts about it.