OT

Nate working on reading numbers during OT.  He is walking around the room reading numbers 0-30 out of order while another OT student is on a swing working on coordination.  I love how his OT is incorporating physical activity into his academic work.

Working Hard

Here are some short clips of Nate working on speaking and reading in complete sentences.  He still struggles with correct use of articles.  Since CAS is a motor planning disorder once his mouth gets going he starts to say things from rote memory (which you can see in this video) when he is creating a sentence about 5 shovels.  He has practiced saying "I see the" or "I see a" so much that when he needs to say something else, it's difficult.  The SLP here uses cards with words or sometimes just dots on a page to represent the individual words.  Since we are working on improving his reading and number identification skills he has been doing more work with print.

(These videos were done in October)

Estimated prevalances of five specific learning difficulties (data from Science, April 19, 2013)

NIH research funding for these SLDs in 2000-2009 varied widely


SLD                           Estimated prevalence (%)   NIH research funding in US $1000s
Dyslexia                                           4-8                                              27,283
Dyscalculia                                       3.5-6.5                                          1,574
ADD/ADHD                                    3-6                                            532,800
Autism spectrum disorder                  1                                               851,270
Specific language impairment            7                                                28,611



Of course co-occurence of these learning disabilities occurs more often than not, however the funding for research does seem somewhat one-sided for a very small population of children.

Alphabet Soup OT, PT, ENT

Nate had two specialist appointments today.  He saw a physical therapist (PT) and an Ear, Nose, Throat (ENT) physician.  Both appointments had positive results, so I was very pleased.  Finally, the physical therapist sees that Nate has coordination issues.  It can be so frustrating to have to wait until there is a gap when you can see the struggles all along.  She completed a survey with me where in one category, he scored at the 26th percentile which is slightly lower than they would like to see.  She then had him run up and down the hall.  This is where she could really see how awkward his running is.  He is a very active and physical boy but with his motor planning issues, he has developed an awkward run.  Arms and shoulders are pressed back, more like bird wings, chin juts out and mid-run one of his arms will pop out to the side to keep balance.  Even more telling was the next activity she had him do.  In the middle of the floor she placed a very short balance beam.  No more than 4 inches wide and 2 inches off the ground.  He had to stand with both feet on one side and move the foot closest to the beam to the other side with the next foot following and then repeat going back the same direction.  Initially he did not want to do it at all.  I have had evaluators interpret this as him just being difficult.  However I've noticed that when it's things that are hard for him to do, he will just not try it at all.  So after much coaxing and doing it with him, he tried.  It was quite hard for him to do as he would start with the foot that wasn't closest to the beam.  He will be going in again for further evaluation very soon.  I'm pleased that he is getting some help in this area.

Next stop was with the ENT.  Nate's always been a mouth breather (which I attribute to the apraxia), so we wanted to get his adenoids checked out and make sure everything was ok in there.  His adenoids tend to be enlarged although he hasn't had an excessive amount of infections.  The ENT numbed one of his nostrils and was able to send a tiny little camera into his nose.  She was able to see his breathing and that he has enough space for air to come through.  She and the nurse complimented him on his ability to sit and be patient while she was looking as most little kids can't handle it for that long.  In the end, Nate is right on the border for having them removed.  I told her that I would need to talk to my husband (and do some more research on it).

Next week we have an appointment with the occupational therapist (OT) and will be getting into to see the physical therapist again soon.

Frustration

I just wanted to share the horrible experience I had with Kaiser on Friday of last week with Nate's "evaluation".  It was so frustrating.

I brought along a copy of his triennial report to share with the SLP she didn't seem that interested in reading it.  She skimmed it.  She was very friendly but Nate can get quite shy in new situations with people he knows aren't going to understand him.  So while she was trying to ask him what he liked to do with his friends, he just sat with his fingers in his mouth (something he often does when he's nervous or anxious).  

I think what was most frustrating was after she skimmed the copy of the report I gave her, she proceeded with 2 parts an assessment that his regular SLP had given him just two months before.(I believe they were part of the CELF-Clinical Evaluation of Language Fundamentals.  For one part he was read a story 2 times and had to pick pictures out of 4 choices that answered questions to the story and for the other, he was shown one or 2 drawings and she was say a sentence and he'd either have to finish it or same a similar sentence talking about the other picture.  I was very frustrated that the focus was so much on language and comprehension.  I brought up that he had just been tested using these measures and didn't that somehow invalidate the findings from this session due to him just having been tested with this instrument.  She said it would only validate what was already found.  I thought that was odd as if the findings weren't already valid.  

Whenever I talked about apraxia she would say that apraxia was highly controversial and that there are criteria that have to be met (which he does).  She brought up one of the criterion--groping, which he does but definitely not as much as he use to.  He still does more of this when he's really wanting to talk about something out of context or not in his regular overly-practiced speech/vocabulary patterns.  Additionally, she decided to do an articulation test, which seemed to be part of a Kaufman test.  But it was very basic with words like: duck, leaf, school, watch, teeth.  Of course he misarticulates the /th/ and she was concerned about this.  She even tried to get him to say it correctly and he wouldn't even look at her!  I tried to state that often those sounds (depending on th in the or th in teeth) don't come in developmentally until 7 or 8 and she seemed upset I mentioned this.  She stated that he had a phonological disorder which would be addressed by the school system.  When I brought up the groping again, she said that this wasn't the only characteristic of CAS, yet she never really assessed for that in any way.  

Additionally, during most of the "assessment" Nate would mumble or speak more quietly and she'd have to ask him to repeat what he said, which would cue him into self correcting (which is great and not great at the same time).  So she really wasn't getting accurate results either.  For an SLP I was surprised how much she didn't understand him.  At one point she asked to turn on her iphone to record him and of course that's all he was interested in for a while and not focused on the tests.

All of this is similar to what has happened before with Kaiser, but I know people with kids with Apraxia that are receiving services.  I either haven't found the right SLP or haven't found the right things to say!  So then I began doubting his diagnosis, and thinking maybe his problem is just a phonological disorder and then I read the following comparison and it confirmed for me that me and his other SLPs are right and that this person does not know apraxia.

Apraxia/Verbal Dyspraxia 

Apraxia is a neurological speech disorder that affects a child’s ability to plan, execute, and sequence the movements of the mouth necessary for intelligible speech.  Apraxia can also be referred to as developmental verbal apraxia, childhood apraxia of speech, or verbal dyspraxia.  Most SLPs use the terms interchangeably.  Characteristics of apraxia include:

• Limited babbling is present in infancy.  These are quiet babies.  
• Few or no words when other babies are talking by age 2
• Poor ability to imitate sounds and words
• Child substitutes and/or omits vowel and consonant sounds in words.  Errors with vowel sounds are not common with other speech disorders.
• His word attempts are “off-target” and may not be understood even by parents. 
• He may use a sound such as “da” for everything. 
• Often his errors are inconsistent, or he may be able to say a word once and then never again.  The child understands much more than he can say.   
• There is sometimes (but not always) a family history of communication difficulty.  (i.e.  “All the boys in our family talk late,”  or “My husband’s grandfather  still has trouble pronouncing some hard words.”)  

Phonological Disorders

A phonological disorder is difficulty with the “rules” or “patterns” for combining sounds intelligibly in speech in English.  For example, phonological processes patterns include prevocalic consonant deletion (leaving off consonant sounds that precede a vowel such as “at” for hat), syllable reduction (producing only one syllable in a multisyllabic word such as “bay” for baby), or reduplication (simplifying a multisyllabic word to a duplicated pattern such as saying “bubu” for bubble or even “dog dog” for doggie).  

There are many patterns for analyzing a child’s speech according to a phonological processes model.  All of these processes are common in typically developing children as well.  It becomes a problem when most children are maturing in their patterns of production, and a child is not.  For example, final consonant deletion (leaving off ending consonant sounds in words) typically disappears between 2 1/2 to 3 years of age.  If a child is not including final consonants by this age, it would be considered “disordered” or “atypical” since most of his same-age peers are now using a more mature pattern.  

A child with only a phonological disorder exhibits typically developing language, meaning that his vocabulary and utterance length are the same as his peers, but he continues to exhibit patterns that are consistent with a younger child’s speech errors.   

Important Diagnostic Differences

1.  Vowel Sounds- Indicators for me always include a child’s vowel sounds.  Both children with apraxia and phonological disorders make errors with consonant sounds.  Children with apraxia also substitute, or in some cases omit, vowel sounds too.  For the most part, children with a phonological disorder use consistently accurate vowel sounds.  (Remember that vowels are A, E, I, O, U, and sometimes Y. Consonants are the other remaining letters of the alphabet.)

2.  Consistency in Errors - Children with phonological disorders are generally consistent with their errors.  This means that if they mess up a word, they usually mess it up all or most of the time, and usually in the same manner (until they start learning new pattern in therapy, and then they will likely revert between their “old” way of saying a word and their “new” way.)  

Children with apraxia are very inconsistent.  This means that they may say a word correctly once, and say it incorrectly a minute later.  Words  may be so “off-target” that the intended word is unrecognizable.  For minimally verbal apraxic children, they may say the word once, and then you may not hear it again for a long time.

Children with a phonological disorder exhibit patterns with errors.  For example, a child may omit final consonant sounds all of the time.  A child with apraxia may include a final consonant sound in one word, but not be able to produce the same final consonant sound in the same word or the same sound in another word. 

 3.  Language Skills- Children with apraxia almost always have delayed expressive language skills (especially before therapy starts.)  They do not have the same vocabulary size and utterance length as children their age.  

Children with a phonological disorder may have expressive language skills within or closer to the normal range.  They use lots of words and try to combine them into phrases like their same-age peers, but you may not be able to understand very much.  (This is different than jargon, or “baby talk.”  Children with a phonological disorder are saying real words, but they substitute or leave off so many consonant sounds that you don’t know what they are saying.)         

4.  Other Characteristics while Speaking- Children with apraxia often look like they are “groping” for words.  Things parents say to describe this include:

• “He sometimes opens his mouth to talk, but then it looks like he forgot what he was going to say.” 
• “She doesn’t know what to do with her tongue when she talks.”
• “I see him watching my mouth closely, and he tries to move his mouth in funny ways to copy mine, but he can’t.”

Children with phonological disorders do not have these issues.  For the most part, they can and do try to repeat what you’ve said to them without the hesitations.   

5.  Verbal Imitative Abilities-  Children with apraxia have major difficulties imitating or repeating what you’ve said (especially before therapy begins).  Children with a phonological disorder can repeat you, but the word may not be accurate.  

6.  Oral Imitative Abilities- Children with apraxia have difficulties with using their mouths to talk or to imitate or perform certain movements on request , but not in other activities like eating or if the activity is “automatic.” For example:    

• “He can stick his tongue out when he’s licking a sucker, but he can’t do it when I show him.”
• “She blew out her birthday candles last week.  I don’t understand why she won’t blow for you.”     

Children with phonological disorders are more consistent with what they can and can’t do with their mouths.

New Research

The Relationship Between Treatment Intensity & Treatment Outcomes for Children with Apraxia of Speech

from Apraxia-KIDS - Every Child Deserves a Voice by Apraxia-KIDS

by Aravind Namasivayam Ph.D. S-LP(C)

Childhood Apraxia of Speech (CAS) is in terms of diagnosis and treatment a very challenging and complicated speech disorder in children. Children with CAS find it difficult or impossible to accurately produce speech sounds and/or words despite having a good understanding of language. Although there are several treatment approaches for CAS, there are very few published studies examining their efficiency and effectiveness. For example, at present, we do not know the amount of change in speech intelligibility (the degree by which their speech can be understood by a listener) or their ability to communicate effectively in real world situations (i.e., functional communication) following treatment. We also do not know if more intense treatment (although promoted by most clinicians) is actually better for this population.  Thus, there is a strong need for well-designed research studies in this area to advance clinical practice.

In July 2011, the Childhood Apraxia of Speech Association of North America (CASANA) awarded a competitive clinical treatment research grant to Dr. Aravind Namasivayam of the Speech and Stuttering Institute in Toronto, Ontario, Canada. His team consisted of experts in the areas of CAS research (Dr. Ben Maassen, University of Groningen in the Netherlands), speech science (Dr. Pascal van Lieshout, University of Toronto in Canada) and speech disorders treatment (Ms. Margit Pukonen from the Speech and Stuttering Institute, Toronto, Canada). The CASANA funding was used in support of the research project titled “Exploring the Relationship Between Treatment Intensity and Treatment Outcomes for Children with Apraxia of Speech”. 

Using the funds from the CASANA grant a specialized screening tool was developed to identify a subpopulation of two to five-year-old children, who demonstrated characteristics of CAS, from a larger database of 102 preschool age children with motor speech issues. All children received a specialized motor speech treatment program delivered by qualified speech-language pathologists in one of two possible treatment formats: high-intensity (2 times a week for 10 weeks) or low-intensity (1 time a week for 10 weeks).  Each speech therapy session lasted for 45 minutes. The speech-language pathologists providing the treatment were randomly assigned to either of these treatment formats. A child’s ability to correctly produce speech sounds in words, speech intelligibility and functional communication were evaluated both before and after treatment. Speech intelligibility was assessed at the word-level (percentage of words correctly identified by a listener) and at the sentence-level (percentage of words correctly understood in imitated sentences by a listener). 

Overall, the results of the study demonstrated that the outcomes of the high-intensity treatment were superior to those of the low-intensity treatment. Specifically, high-intensity treatment resulted in a significant change in a child’s speech production abilities, word-level intelligibility and functional communication when compared to low-intensity treatment. Furthermore, high-intensity treatment produced almost twice the amount of positive changes and had fewer children failing in treatment (i.e. not showing any real progress- especially for speech production) relative to the low-intensity treatment.  However, neither high- nor low-intensity treatment improved sentence-level speech intelligibility in children with CAS.

This CASANA funded study represents the largest data set available to-date relating the amount of therapy induced change and treatment dose and its effects on speech intelligibility and functional communication outcomes in children with CAS. The results from the study could be used to set appropriate levels of clinician and parental expectations prior to treatment and could potentially guide clinical practice (e.g. amount and possibly type of treatment required for this population). 

Importantly, even though positive changes were found for speech production and functional communication in CAS children with 20 sessions (2 times a week / 10 weeks) there was only minimal improvement in sentence-level speech intelligibility following treatment. Thus, the CAS children may benefit from more than 20 sessions of therapy and from a treatment program that systematically builds in practice of speech production targets in longer utterances (i.e. phrases, sentences, connected speech). At present additional analyses are being carried out to identify factors contributing to positive outcomes in children with CAS. For example, we ask which of the following factors affect a child’s treatment outcomes: child’s participation in the therapy process, amount of home practice and/or quality of parent-child interaction? With further analysis, we will be able to identify key factors that contribute to positive treatment outcomes in children with CAS and thus make a significant contribution to future clinical practice in this area.

[CASANA funded research dollars are raised through the Walk for Children with Apraxia]

Basketball, Butterfly & A Lizard

Nate's been busy--between school and therapy sessions.  I think because of his great disposition, he's able to handle his schedule in stride!  Here are a couple of short clips from a therapy session this week.

In this first clip he is working on multi-syllabic words.  In order to get him to slow down an annunciate, his therapist uses colored chips to represent each syllable.  Here he's saying the word "watermelon".

Here's "basketball" and "butterfly".  Notice how he zooms through butterfly and says "bu-ter-fy".

In this last clip, he is using the colored chips to represent individual words in the sentence "The lizard is looking for food."  He is still working on verb tenses, so you'll hear him leave of -ing in looking.