Childhood Apraxia of Speech

Apraxia is a neurological disorder that results from poor motor planning.  Physical therapy, occupational therapy, or speech therapy can help kids with Apraxia.  Developmental Apraxia of speech interferes with the child's ability to produce different sounds needed for intelligible communication. 
 The child may know what he/she wants to say, but the area of the brain cannot "motor plan" appropriately to make the muscles of the jaw and mouth move appropriately to make the sounds.    Even when trying to correct them, the child cannot figure out how to make the correct syllables and sounds.  Some signs of apraxia include children who have very limited sounds they can make, intelligible speech that doesn't "clear up" with time, inconsistent speech errors, frustration with speech correction attempts, ability to say short words but can't string a series of words together, drops ending off of words, can imitate sounds better than plan them on their own, etc.

The information below is taken directly from www.aprakia-kids.org.

What is Childhood Apraxia of Speech?

Childhood Apraxia of Speech is a motor speech disorder. For reasons not yet fully understood, children with apraxia of speech have great difficulty planning and producing the precise, highly refined and specific series of movements of the tongue, lips, jaw and palate that are necessary for intelligible speech. Apraxia of speech is sometimes called verbal apraxia, developmental apraxia of speech, or verbal dyspraxia. No matter what name is used, the most important concept is the root word "praxis." Praxis means planned movement. To some degree or another, a child with the diagnosis of apraxia of speech has difficulty programming and planning speech movements. Apraxia of speech is a specific speech disorder.
The act of speech begins with an intention to communicate.  Next, an idea forms, outlining what the speaker wants to say.  The words for the desired message are put in the correct order, using the correct grammar.  Each of the words are comprised of a specific sequence of sounds (also called phonemes)and syllables that must be ordered together.  All of this information is translated from an idea and information about order of sounds into a series of highly coordinated motor movements of the lips, tongue, jaw, and soft palate. 
The brain must tell the muscles of these “articulators” the exact order and timing of movements so that the words in the message are properly articulated. Finally, the muscles must work properly with enough strength and muscle tone to perform the movements needed for speech.
In typically developing speech, children make word attempts and get feedback from others and from their own internal systems regarding how “well” the words they produced matched the ones that they wanted to produce.  Children use this information the next time they attempt the words and essentially are able to “learn from experience.”  Usually once syllables and words are spoken repeatedly, the speech motor act becomes automatic.  Speech motor plans and programs are stored in the brain and can be accessed effortlessly when they are needed.  Children with apraxia of speech have difficulty in this aspect of speech.  It is believed that children with CAS may not be able to form or access speech motor plans and programs or that these plans and programs are faulty for some reason.

How Is CAS Different Than A Speech Delay?

A true developmental delay of speech is when the child is following the "typical" path of childhood speech  development, although at a rate slower than normal. Usually this rate is in pace  with the child’s cognitive skills. In typical speech/language development, the child's receptive and expressive skills increase together to a large extent. What is often seen in a child with apraxia of speech is a wide gap between their receptive language abilities and expressive abilities. In other words, the child's ability to understand language (receptive ability) is broadly within normal limits, but his or her expressive speech is seriously deficient, absent, or severely unclear. This is an important factor and one indicator that the child may be experiencing more than "delayed" speech.  In the case of such a mismatch in skills, the child should be evaluated for the presence of a specific speech disorder such as apraxia. However, certain language disorders may also cause a similar pattern in a child. A gap between a child's expressive and receptive language ability is insufficient to diagnose apraxia.

John's Services Updated

I have lots of news today and it may take more than one topic to cover all the news on John. I'll start with the IEP.

Today, we had John's IEP (Individualized Educational Plan) with the school district. It was a bittersweet moment as we learned that John no longer will qualify for services. This is a very good thing because it means that the progress John has made since May has been so overwhelming that he does not need Special Education. The school district determined through their assessments that, although John has showed developmental delays in the past, his scores in all areas of development fall within the average range. He doesn't show a need for continued service, whether it be special ed pre-school, speech, or occupational therapy.

Hopefully, the early intervention will serve as a deep enough foundation for John to integrate into regular pre-school and naturally develop alongside other children/peers. I am disappointed that occupational therapy and speech could not be continued. I learned today that to qualify for occupational therapy, he would have had to meet the requirement for special education. Then, it would be determined if it was necessary for OT. However, speech is a little bit different. It is a standalone service, meaning that if he meets certain criteria, he could qualify for speech, even if he did not for special education preschool.

Hopefully, John will continue to develop his attention so he can engage in a classroom setting without too much re-direction. As far as skill levels, he has caught up in every catergory, which I will get into in the next blog topic with regards to his latest Casa Colina evaluation. His largest problem area that his current educators see is his willingness to participate, along with his attention and engagement with little re-direction.

Starbucks Cake Makes Me Happy!

You may see me eating at Starbucks a little more often than I already do. This is because John has verbalized to me (without prompting) that Starbucks cake makes him happy! His class ended early and we had some time to waste between that and another appointment, so we stopped by Starbucks and I got him a Cinnamon Swirl Coffee Cake. He kept saying "starbucks cake makes" and then something that I couldn't understand. When I told him I didn't get it, he did the sign language for happy and touched his cheeks and smiled. I've told so many people (in front of him) that he did this, so now he uses it a lot! :)

I've asked him what else makes him happy (he still can't say the hard "e" sound, so it comes out "happ-n"). So far, elevators make him "happ-n" and city buses make him "happ-n".

Driving in the car is a 'talkative' experience for John now. He points out gas stations, the post office, every city bus that drives by (which if you pay attention is A LOT), school buses (which are different from city buses and John is proud -- "skool bus --dellow (yellow)"), as well as green lights and red lights, "big guck" (big truck), car (with a Boston accent), and don't forget all of the important places like Target and McDonalds. ("McDonals other way")

I can't tell you how "happ-n" it makes me to see John express himself through language. In March of this year, I would have thought it impossible to improve this much, not only his vocabulary, but his cognitive speech. His understanding that green and red lights have different meanings ("go, go, go" and "tops" -- he puts the s at the end instead of the beginning), that city buses and different from school buses, and that Starbucks cake makes him happy are just a few examples on how far we've come in such a little time.

I asked the kids where they wanted to go for lunch the other day and John said Carls Jr. (which he just learned recently was different from McDonalds) I told him "later", which right now works really good to get him to move on from something. So, today, I asked the kids where we should go to lunch and John said "Carls Jr., Des." "Des" is Yes. So, I told him we could do that today. He smiled, "carls jr. des".

Again, to anyone that is considering early intervention, or to those that know something is wrong, but are having a hard time admitting it, let me tell you that the gains are so worth it!

To look at John's face and see him not only use language to fulfill immediate needs or label an object, but to see him express feelings is worth all the hard work. Looking back to March of this year, when John could only say 2 words that were clear, and testing at a 17 month cognitive level (when he was 30 months old), I am SO grateful for the services we are receiving. The 'formula' of services that John is getting is working and I'm so grateful that "starbucks cake makes him happy"!

Documenting John's week

The last week was a big week for John. Although the flu went around the family (except for me), and we had some "over stimulated" evenings and mealtimes out, John has progressed visibly this last week.

First of all, his language has really come a long way.
3 speech milestones for John:

1. He said "I want granola bar" with no prompting -

• "I want" has been a speech therapy goal
• He went into the kitchen while playing and called me; then saying "I want granola bar"
• Now, "Granola" was a mouthful and "bar" was more like "ba", but I understood it.
  

2. He is answering questions with "Yes" and "No"

• I started playing a game with him to help him understand "Yes and No" because he never would use it so we weren't sure if he had the concept or not
• I would ask him in the parking lot "Is this mommy's car?" I would point to different cars and say "no" and then finally to mine, saying "yes". For about 1-2 weeks he's been playing along with me, saying it.
• A few days ago, I asked him if he wanted play-dough and he said "yes" --- first time he really used "yes" in answer to a question; I used to get grunts, squeals, happy screams of delight, and grabbing, but no language for "yes", so this was a big deal!
  

3. He wanted an "apple bah" for breakfast, which is an apple juice box, but I was out and told him I had to buy more at the store. We then went to school, lunch, napped, back to school for speech, and then a neurofeedback session. I called Bill on the way home and told him I was stopping at the grocery store to buy something for dinner. When I got off the phone John said "sto. Buy apple bah". I was excited that he was able to relate 'store' to buying the apple juice boxes, as well remembering from that morning!

John also has "pooped" in the "potty seat" all week long! He has discovered that he enjoys "passing gas" while sitting on the toilet, and he gets a sticker if he actually poops in the toilet, so he spent the week collecting his stickers. I am very very close to saying that he is fully potty trained. Although, going to the bathroom and "wash ands" is becoming an obsession, I am pretty excited to have gotten through this milestone with such little problems.

Today, something else happened -- twice. I was reading about sensory children who need their muscles 'squeezed' or crave bear hugs. One mother talked about her experiences of squeezing her child's muscles before going to sleep. The book also talked about using pillows to 'sandwich' the child who likes to be bear hugged, etc.

I needed John to take his nap between speech and the in-home teacher arriving. He was so wound-up that I wasn't sure he was going to settle down in time to get an hour nap in. I remembered what I read. So, I started with his hands. I squeezed them. He closed his eyes and smiled. I moved up his arms, squeezing firmly. He rolled onto his stomach on his own, so I started at his feet and began firmly squeezing his muscles. He moaned slightly, but seemed to relax. I grabbed a pillow and placed it on his back. I pressed down on the pillow, starting at his legs. By the time I got to his lower back, he was asleep. It took a matter of 2-3 minutes!
I tried it again at bedtime, and WOW---same thing.

I'd say in a week, John's language grew, he became potty trained, and bedtime has just got easier! Let's see if this can continue....

EDIT: I wanted to add a few more things now that I have some more time.
John has had 5 neurofeedback sessions since last week. We brought his favorite movies to watch and they incorporate it into the brain training. He sits still for them and enjoys his time there and the process still intrigues me. He has 4 more left of the initial 10 free sessions we received.

At pre-school on Monday, John was able to string 6 beads and attend very well to the tasks he was asked to do. He was not interested in riding the tricycle or practicing jumping at school, but once he got home, he bounced in the bounce house, showing me he can jump.

Yesterday, he worked with Marilyn in speech and she is working on his eye contact. She played peek-a-boo on his lead and she makes sure he looks at her when he says "go" before she allows him to jump in the ball pit, play with cars, etc. (get any of his speech rewards). She uses tokens to show him how many words he needs to say before he gets his 'reward'. He picks his 'reward' from a picture. Yesterday, he picked the ball pit. He loves to hang from the trapeze bar and swing before falling in the pit of balls.

Today, he worked with Tonyia in speech and she is helping him with verbalizing what he wants. He couldn't tolerate the swing today and was not as interested in the ball pit as he was yesterday. He played on the computer, recognizing action verbs. He is able to use the mouse and point to the picture, clicking the one the computer asks him for. Tonyia then tried to get him to recognize audio sounds and then click a picture from 9 choices of what he heard. This was a little harder, as he didn't always concentrate on what he was hearing and would pick any picture.

We are limiting his in-home hours to 5 hours a week, instead of 8, since we will be beginning OT/SI soon and I felt like I could do some of the in-home stuff myself.

Over the last 2 weeks, Bill and I have integrated "circle time" into our bedtime ritual. After bath and brushing our teeth, we now sit down, with 5-6 'props' in the center. Each kid can choose a song to sing, using the props as guides (bus for "wheels on the bus", star wand for "twinkle twinkle", toy boat for "row row your boat", and pom poms for "shake your sillies out", drums for "boom boom", and a spider for "itsy bitsy spider"). Normally, John will play along, but not always sing all the words out loud, piping in here and there. Tonight, John was very vocal in every song and fully participated in ALL of the songs.

At Church on Sunday, John said the "our father" with everyone, out loud. It is neat to hear his language developing. After "circle time", we have prayer time. We start with the sign of the cross, then go into the "our father" and then each of us says our own "Dear Jesus" prayer. Katie's is very dramatic, heartfelt, and oftentimes very long (sometimes we have to jump in and remind her with "amen"). John has always said a "Dear Jesus" prayer, but we weren't sure what he was saying. Over the last week, it's been so cute to hear his little words thanking Jesus for his "momen" and his "daden" and "kayden". (Mommy, Daddy, and Katie) He prays for Katie's school and John's school, and he always smiles after he says "aden" (amen).

I can't tell you how neat it is to hear and understand the words coming out of his mouth.

Good Days and Bad Days

With any child, there are good days and bad days. Everything on Monday seemed to lead to what I am now calling a bad day. It started with John's refusal to eat his eggs. Katie came with us to Early Start Pre-School on Monday morning. All John wanted to do was "check his schedule" and skip all the activities that the schedule told him to do.

I think John is getting bored with all of the "un"scheduled activities in this class. Mom sure is getting bored with it! Sometimes it feels like we are trying to "pass the time" until John gets his one-on-one work time with the teacher. Some of the other activities, which include Imaginary Play, Outside Time, and Gross Motor skills are led by the parent or caretaker of each child.

Imaginary Play involves a play kitchen, which doesn't always have the food, pots, pans, and plates. There are only so many things you can do---open the microwave, put the corn in the refrigerator, wash the dishes, etc. The girls play the kitchen well. John will attend for a few minutes, but usually is ready to move on to other things. I don't blame him. He did really well last week, washing dishes in the sink, putting them in a bin that he called the dishwasher, putting them away, putting food on the plates, and starting the process over. But, this Monday, he didn't want to play with the Kitchen. SO, I let him go outside.

Outside time includes riding bikes, wagon rides, playground equipment, a play house, etc. John usually will fit everything in to his scheduled 20 minutes. About 2 weeks ago, John discovered the swing. Well, on Monday, the swing wasn't set up. So, he busied himself with running back and forth between the playground side and the bike side. Katie couldn't keep up. She just wanted to sit and play. At first, I kept making her join us. Finally, I gave up and let her have fun on the playground equipment without my immediate supervision. She's old enough now for me to just check back and forth. It's hard having them both at class. John doesn't like it when I give Katie any attention at "Ja's Skool".

Circle Time, Fine Motor skills, and Table Time are led by the therapists. Circle time went fine and Katie got to participate, which made her happy. Fine Motor Skills was an activity where the kids got to put their hands in the glue to stick fish, crabs, and sharks in the sea (a big poster hanging on the wall) and then finger painting their sea creatures. Although John wanted his hands in the glue and the paint, he was more interested in going to the "ba-oom to wah ans" (bathroom to wash hands).

Washing his hands has become a big thing these days because John is close to being completely potty trained!!!! He decided that Katie wore underwear and so should he, so he refused to wear pullups and diapers. Two potty accidents taught him to tell us he needed to use the bathroom and from there, we've progressed quite nicely. Even now if he starts to have an accident, he can stop it and tell me he's going to have an "acdent", while grabbing his crouch! He has 4 stickers this week for pooping on the potty seat. Now, this is very rare for a child with John's issues to be potty trained. It was something I wasn't ready for, but John made sure this was something he learned. Again, an example of his 'scattered level of skills'.

I digress, back to Monday and the "bad day". Work time was especially hard. He didn't want to look at the teacher and she was having to constantly remind him to "check his eyes". With his eye contact issues, they have him make sure that he tells the person what he wants by looking at them. So, if he wants the school bus to "go", he has to say "go" by looking at the person that will push it to him. Some days this is easy and some days this is hard. Monday was hard.

After school, we went home for lunch and a nap so we could go to speech class. Our next door neighbor came over to babysit Katie and she brought movies. John didn't want to go to speech class anymore. Leaving was a battle. Once we got to class with Tonyia, we started the eye contact battle again. He did everything he could not to look at her ---turned around, closed his eyes, put his head down, yawned a lot, kept pointing out the clock, etc. She worked him hard for the first 25 minutes, but she told me we were going to stop because she thought he needed to move around. We went into the START gym and he played in the ball pit and swung on the swing. He didn't want to do much in the gym either. He kept pointing out the clock.

After speech, we went to the second session of Neurofeedback. Well, John didn't want them to hook up the EEG monitor. He cried, squirmed, kicked, and got very upset. I told them that I was taking him home. It was a bad day and forcing him to do it would have been torture for him and me. So, we went in the elevator to go down to the first floor.

We got stuck in the elevator for 25 minutes! We were going from the second to the first floor. It got stuck between floors. Before we got in the elevator John was crying. Getting stuck was the best thing that happened to him all day. I had apple juice with us and he drank that, danced around, pushed buttons, and kept squealing in delight, "elvater!" The best part was when the firemen let us out and showed him the fire truck.

The family then went to get dinner at Rubio's, where Katie vomited in the trash can outside before we ate. She continued with the flu all night long.

Monday was a bad day.

Casa Colina: Early Start Pre-School & Speech Therapy

One of the first forms of early intervention that John received was an Early Start Pre-School class at Casa Colina in Pomona, California. The Early Start class is focused on developing the goal areas of gross motor, fine motor, sensory, communication, cognition, socialization/play and self-help. Children work individually and in groups with their parents and child therapy instructors as they rotate through a series of activity centers.

John attends the class two times a week for 2-and-a-half hours each time. Upon arriving, John must find his picture and place it on his schedule. After completion of each activity, he is instructed to "check his schedule". Using a laminated paper with a check mark on the front and piece of velcro on the back, John takes it to his schedule hanging on a wall. He places the 'check' next to the first activity, which is dipicted in a photo. The first activity is to 'wash hands'. John takes the photo to the sink, places it in a folder and proceeds to wash his hands. He is given a second 'check' to take to his schedule.

The next photo announces that its "circle time". John takes the photo and finds a square to sit on with the other children. He hands the photo to the teacher, announcing that he is ready for "Circle Time". The teacher shows the children a board that has pictures that represent different songs they can sing. Each child, in turn, chooses the song that everyone will sing. A picture of raindrops represents the first verse of the song "if all the raindrops". After the group sings the song, the child who picked the song is given a "prop" for that song. A rain stick is given for "If All the Raindrops". The child watches it fall and then is instructed to turn it over and watch again. They then must hand it over to the next child sitting next to them. After the prop makes it's way around the circle, the next child picks the song they want. John's favorites are "Boom Boom Ain't It Great to Be", where he can play the beat on the drum, "Wheels on the Bus", and "If All the Raindrops". He doesn't sing much at school, which is surprising because he does at home, but he loves the pantomime gestures and passing each of the props.

The schedule order is then different for each child, but each will have time outside on the playground, project time at the table, imaginary play, work time, and gross motor skills activities.

We have learned, through Outside time, that John loves the swing. He could swing for the whole 20 minutes. I started going through counting and alphabet games while we swing. He loves to talk and verbalize while swinging. (more on this in a later blog).

I have never let John play with glue or scissors up to this point because I just felt that he wasn't ready. Well, a kid is never going to learn if you don't teach him! So, he's learning to cut with scissors and squeeze out the glue. He loves the glue and the first week called it "gluke", but has already corrected himself and says it just right! Already, he has made a shaker, 2 caterpillars, a texture book, and a flag. He wanted to glue paper with the glue side up, but he learned quickly that his hands get messy that way and paper won't stick.

He has a 20-minute one-on-one work session where individual goals are set and then worked on to meet. John sorts colors and shapes, does animal puzzles, strings beads, blows bubbles, plays with Mr. Potato Head, and various other activities to strengthen his skills in each of the developmental areas. How they play with him is the key to his success' thus far. John came in to this program very impulsive. If a teacher held two objects, one in each hand, asking for him to pick the red one, John would reach for both without listening to her directions. By the second session, they had him waiting, looking at each one and then choosing. His first reaction is definitely impulsive, but slowing him down is the key. He has a very busy brain, which is easily distracted. He learned the "clean up" song really fast and he says and signs "all done" pretty quickly after starting a task. The therapists are really good at making him do it "one more time" and "we will be all done". I think he enjoys cleaning up and finishing more than anything else, but he is learning so much.

In addition to his early start classes, he attends 2 hours of speech therapy a week. Speech therapy is play based therapy that works on his language skills. They use a reward system (for John it's bubbles) to get him to say his words. They play with cars, Play Dough, flash cards, balls, etc. while concentrating on his verbal skills. John loves coming to "school", but speech therapy wears him out. About 30 minutes into a session, John becomes distracted and begins to look around and "space out". This is the most important time to keep going --trying to increase his attention span.

We've been in the program for 6 weeks and he has improved so much! I can't believe the changes we have seen both at home and in the classroom. He tested at a 6-9 month age level for language 2 months ago. Last week, they told me his language has already gone up to 17-18 months age range.

Things we've noticed:

• He sits during circle time
• John never sits still and the first day, I chased him around the room, leading him back to his square and having to hold him in my lap
• By the third class, I was able to sit behind him
• He has poor posture, which I never noticed before because he would never sit still; he sits leaning back on his hands or slumped over his knees
• His language is controlled
• There is intent behind his words; he communicates to have needs met
• "all done" and "more" have helped us understand when he is ready to do something
• he points to objects and tells us what they are
• He is engaging
• The inability to engage, which he showed during his Regional Center testing, is one huge part of the Autism diagnosis
• He is able to follow direction
• He is able to get my attention and tell me about an object or what he wants
• There is a 'give' and 'take' in play with him
• His attention is increasing
• Work wears him out
• John yawns about 10 minutes into every work session
  
• John gets tired after school
• John tends to have melt downs when he is tired

Goals we are working on:

• Building towers with blocks
• Increase attention
• Completing tasks
• Articulation in Speech
• Jumping from 2 feet
• Decrease impulsiveness
• Stringing multiple beads
• Blowing bubbles

This has been the best experience so far. I can't believe his progress in the little time he's been attending Casa Colina. I can't wait to see what the next few months brings us.