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
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):
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):
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.
American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical Report].
American Speech-Language-Hearing Association. (n.d.). Selective mutism, its assessment and treatment, and its occurrences.
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.
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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.