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Question & Answer - Speech-Language Disorders and Treatment



I am concerned about a non-verbal 2 1/2 year old with age-appropriate receptive language skills and good hearing but no verbal imitative skills....

QUESTION FROM SUSANNE LILJEGREN, MA, CCC-SLP

August 2013



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COMPLETE QUESTION FROM SUSANNE LILJEGREN, MA, CCC-SLP

(GIG HARBOR, WASHINGTON)

 

I am concerned about a non-verbal 2 ½ year old with age-appropriate receptive language skills and good hearing but no verbal imitative skills. He vocalizes during active play, makes his wants and needs known via gesture and body language, socializes non-verbally at preschool, and has been heard to say “uh uh” for the word “no” and an approximation of the “p” sound. Signing and PECS (Picture Exchange Communication System) have reduced his frustration when requesting items; however, they have not facilitated speech. He was heard to say “mama” and “dada” at 1-year of age before his little brother was born. He also had a traumatic choking incident (i.e., swallowed a piece of plastic cup lid) requiring endoscopy under sedation around that same time. He reportedly had little “tummy time” as an infant and has had a history of reflux. On an occupational therapy sensory screening, he scored within normal limits except on the vestibular portion. I am wondering about possible childhood apraxia of speech (although I can’t begin to assess this, since he has little speech) and/or some emotional issues related to the choking incident and the birth of his brother.

 

ANSWER FROM DIANE BAHR, MS, CCC-SLP

 

This little boy’s problems are quite complex. Unfortunately, we are seeing many children with similar issues in treatment. Clinically, we wonder whether the lack of tummy time has something to do with gross and fine motor delays. Tummy time builds core strength and postural control needed for both gross and fine motor skill development. Speech is a form of fine motor function.

 

You are right. Childhood apraxia of speech (CAS) cannot be diagnosed without speech (ASHA, 2007). However, there are some characteristics (Bahr, n.d.) that may indicate a child is at risk for CAS (although CAS can occur without some of these):

 

  • Limited sound play as an infant (i.e., limited variety of speech sounds heard in babbling)
  • Difficulty imitating speech sounds and words
  • Atypical/Delayed gross and fine motor development
  • Sensory processing issues
  • Oral and/or limb dyspraxia
  • Eating and drinking skills that are more sophisticated than speaking abilities
  • History of speech and/or learning problems in family
  • Developmental disorders like autism spectrum disorder, Down syndrome, etc.

 

I also agree that there may be some emotional issues based on the events that occurred around 1-year of age. Some children seem to retain body memories of traumatic events. This may have been coupled with the birth of the second child and an inadvertant but natural change in the attention focused on the first child. However, it is also difficult to diagnose selective mutism (i.e.,  when a child does not speak for an emotional reason) in a child with little speech (ASHA n.d.).

 

I completely agree with the expansion of his augmentative communication system while you work through his communication concerns. He needs a way to communicate with others. Words often come along with signs and PECS unless the child is a selective mute (ASHA, n.d.).

 

In terms of speech work, I would consider the following (Bahr, 2010, pp. 270-274):

 

  • Introduce his family to concepts in the Hanen Program It Takes Two to Talk: A Practical Guide for Parents of Children with Language Delays (Pepper & Weitzman, 2004). This will help with overall communication, including the social-emotional aspects.

 

 

  • Help him become accustomed to hands-on facilitation such as PROMPT (Hayden, 2006) or motokinesthetics (Bahr, 2001, pp. 252-257) where you can manipulate his mouth and jaw to help him say targeted speech sounds and word-approximations.

 

  • Focus on vowels. These carry much of the content of speech. Play with vowel sounds. Begin with the sounds he produces during play. There are 11 English vowel sounds that can be facilitated with bite blocks, jaw closure tubes (or something similar), and other oral placement/phonetic positioning techniques during play (Hill, n.d., Marshalla, 2004; Rosenfeld-Johnson, 2009).

 

  • Listen carefully to what he vocalizes during play. Write down word-approximations and speech sounds that pop into his vocalizations. This will give you a starting place for a hierarchical speech program (Hammer, 2007). Continue to record his vocalizations, word-approximations, words, etc. over time, and it will help his parents see his progress.

 

  • Develop a hierarchical program for him (where he and his family find pictures of words containing the sounds he has been heard to make). Paste these into a notebook by sound for speech facilitation and practice (Hammer, 2007).

 

  • Familiarize him receptively and begin facilitating words using the Kaufman Speech Praxis Treatment Kit: Basic Level (1997) or another bottom-up speech approach. The Kaufman shapes word-approximations toward target words via systematic cueing techniques. You can also do listening discrimination work with the Kaufman (e.g., show me “two,” vs. show me “do”).

 

  • Use the Rosenbek (1973) sequence (similar to Edythe Strands’s Dynamic Temporal and Tactile Cueing  approach, 2006) where you begin by saying sounds/word-approximations in unison and work systematically toward functional speech.

 

  • Introduce visual cues at the place of articulation (i.e., your mouth) and pacing boards (combinations of dots and lines that represent speech) as you play with speech.

 

Unfortunately, we don’t have the time or space in a Q & A to elaborate on each of these approaches. However, the references listed below expand on the ideas covered here. For example, the 3-part series (Bahr, 2012, May, June, July) covers the definition, differentiation, and treatment of CAS. Many of the same techniques listed above are discussed (in greater detail) in Part III of that series. Pam Marshalla's book Apraxia Uncovered: Seven Stages of Phoneme Development is another wonderful resource on this topic.

 

Thank you so much for sharing this case with us. I know that many others will benefit by your question.

 

References

 

American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical Report]. Available from http://www.asha.org/policy/PS2007-00277.htm. doi:10.1044/policy.TR2007-00278.

 

American Speech-Language-Hearing Association. (n.d.). Selective mutism, its assessment and treatment, and its occurrences. Retrieved July 22, 2013 from http://www.asha.org/public/speech/disorders/SelectiveMutism/

 

Bahr, D. C. (2001). Oral motor assessment and treatment: Ages and stages. Needham Heights, MA: Allyn & Bacon.

 

Bahr, D. (n.d.). Ages and stages oral sensory-motor assessment. Unpublished literature-based checklist. Las Vegas, NV: Ages and Stages®, LLC.

 

Bahr, D. (2012, May). My child has CAS part I: What on earth is CAS, and who has it? Special-ism.com
 

Bahr, D (2012, June). My child has CAS part II: What makes CAS different from other speech problems? Special-ism.com
 

Bahr, D. (2012, July). My child has CAS part III: What’s a parent to do? Special-ism.com

 

Bahr, D. (2010). Nobody ever told me (or my mother) that! Everything from bottles and breathing to healthy speech development. Arlington, TX: Sensory World.

 

Hammer, D. W. (2007). Childhood apraxia of speech: New perspectives on assessment and treatment. Las Vegas, NV: The Childhood Apraxia of Speech Association. (workshop)

 

Hayden, D. A. (2006). The PROMPT model: Use and application for children with mixed phonological-motor impairment. Advances in Speech-Language Pathology, 8(3), 265-281.

 

Hill, R. R. (n.d.) Apraxia program. Charleston, SC: Talk Tools.

 

Kaufman, N. R. (1997). Kaufman speech praxis treatment kit for children: Basic level. Gaylord, MI: Northern Speech Services.

 

Lindsay, L. (2012). Speaking of apraxia: A parents' guide to childhood apraxia of speech. Bethesda, MD: Woodbine House.

 

Marshalla, P. (2004). Oral-Motor techniques in articulation & phonological therapy. Mill Creek, WA: Marshalla Speech and Language.

 

Marshalla, P. (2005). Apraxia uncovered: Seven stages of phoneme development. Kirkland, WA: Marshalla Speech and Language.

 

Pepper, J., & Weitzman, E. (2004). It takes two to talk: A practical guide for parents of children with language delays.(2nd ed.). Toronto, ON, Canada: Hanen Centre.

 

Rosenbek, J., Lemme, M., Ahern, M., Harris, E., & Wertz, T. (1973). A treatment for apraxia of speech in adults. Journal of Speech and Hearing Disorders, 38, 462-472.

 

Rosenfeld-Johnson, S. (2009). Oral placement therapy for speech clarity and feeding. Charleston, SC: Talk Tools.

 

Strand, E., Stoeckel, R., & Baas, B. (2006). Treatment of severe childhood apraxia of speech: A treatment efficacy study. Journal of Medical Speech Pathology, 14, 297-307.