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Childhood Apraxia of Speech

I am thrilled to feature this guest post by Alyssa Gilligan, M.S., CCC-SLP. Alyssa is the founder/owner of Crescendo Speech Therapy in Baltimore, Maryland. She specializes in treating children with autism spectrum disorder and motor speech disorders with a focus on early intervention. She graduated with her masters in speech-language pathology from Towson University and has been a speech-language pathologist for 6 years. www.crescendospeechtherapy.com

May is Apraxia Awareness month! Childhood apraxia of speech (CAS) is a congenital, neurological motor speech disorder that impairs a child’s ability to motor plan the oral movements needed to produce words. Children with CAS typically have a good understanding of language but are not able to express themselves and approximately 1 in 1000 children will be diagnosed with CAS.

The act of speaking is actually quite complicated! It starts with an idea that is formulated into words and/or phrases. Your brain then has to decide what sounds and in what order are needed to say each word. Your brain sends that information to your muscles in your mouth that are needed to move. Then you move your muscles! Children with CAS have difficulty sequencing the sounds in the correct order and then sending that message to their muscles.

Common symptoms of CAS include highly inconsistent speech with frequent vowel errors and will often say the same word many different ways. They may have prolonged pauses between sounds or syllables as well as inappropriate stress on syllables or words. You may also notice “groping” behaviors in which you may notice your child struggle to achieve the correct mouth posture to produce the word. CAS may be diagnosed by a speech-language pathologist that has experience with motor speech disorders. You can find an experienced SLP on the Apraxia-Kids.org website!

CAS requires a special type of speech therapy that is specific to motor speech disorders and often involves multi-sensory cues including touch cues, visual cues, and auditory cues. Additionally, it is recommended that they participate in intensive speech therapy for at least 2-4 days a week.

Interventions specific to CAS include Dynamic, Temporal, and Tactile Cueing (DTTC), Rapid Syllable Transition Training (ReST) and Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT) therapy.

With the right speech therapy and the support of the entire community, children with apraxia can and do make amazing progress in the ability to speak!

-Alyssa S. Gilligan, M.S., CCC-SLP

Applied Behavior Analysis (ABA) and Speech Therapy: What's the Difference?

Guest post! Alyssa Gilligan, M.S. CCC-SLP is a speech-language pathologist specializing in the treatment of children with Autism. She works at an ABA center in Hunt Valley, Maryland and works very closely with the ABA team!

"Applied Behavior Analysis (ABA) is an intervention strategy commonly used with children with Autism Spectrum Disorder. ABA involves the use of research proven, behavior based strategies to teach communication, life skills, social skills, and academics. It focuses on the principles of motivation and reinforcement to increase positive behaviors and decrease negative behaviors.

An ABA program is developed by a Board Certified Behavior Analyst (BCBA) who supervises a Registered Behavior Technician (RBT) that works with the child under the direct supervision of the BCBA. The program development is based on detailed analysis of data collected by the RBT and goals are added and modified based on that data!

ABA and speech-language therapy have a lot in common. An SLP and a BCBA working together can make miracles happen! The SLP provides knowledge and expertise of developmental milestones that assist the BCBA in developing new goals. For example, providing education on which grammatical markers the child should be using, knowing what play skill the child needs to learn next, or knowing at what stage of narrative language the child is. Alternatively, the BCBA can assist the SLP in identifying motivators and developing custom reinforcement systems to increase the child's participation in therapy.

ABA is also excellent at helping with generalization! The SLP might teach a new skill to a student but may not have the opportunity to work on it outside of the therapy room. The BCBA would then make similar goals and practice the skill in the natural environment.

In short, ABA and speech make a really powerful team!"

Alyssa S. Gilligan, M.S. CCC-SLP

How much Speech Therapy is "enough"?

Every child is different, as are their individual needs- so, there is no blanket determination on how much speech therapy children should receive weekly. A question that comes up often is “My child gets speech in school - is private therapy really necessary?” Though the research on service intensity is all over the place (due to all of the variables that come with the large population who need speech therapy!) in the world of therapeutic services, the general rule of thumb is more and earlier is always better. This is based on over 40 years of research, which supports that early intervention is crucial during the early brain development period (before 3 years old) for short- and long-term progress.

School speech-language pathologists (SLPs) and private SLPs achieve the same degrees, pass the same qualifying exams, and are held to the same license maintenance requirements; the biggest difference is the environments in which they work. Three big factors that should be considered when determining your child's therapy plan are case load, service delivery/ individualization of instruction (is your child being instructed in the ways that allow them to learn best?) and parent involvement.

Full Disclosure: I am a private SLP. I will offer my thoughts and personal practices, where appropriate, in the "private SLP" sections below. I worked as a graduate student clinician in a public school for one semester many moons ago; so while I have had some exposure to the inner workings of the school SLP system, my personal experience is limited. The following information is pulled largely from available research in the field, which is linked below!

Case Load: School Speech Therapy

According to the The American Speech-Language Hearing Association (ASHA) 2018 School Survey, the median monthly caseload size of ASHA-certified, school-based SLPs working full time was 48 students, with a range from 3 students to 145 students. This means that in some school settings, one clinician can have up to 145 students to provide speech therapy to and complete all required documentation. This is B-A-N-A-N-A-S! (insert Mockingjay gesture to all my school SLPs out there!) and very impressive to me. SLPs are Super Heroes!

Case Load: Private Speech Therapy

A private SLP's caseload is decided by the SLP! Personally, I try to see no more than 4-5 children per day, in order to leave ample time to prepare materials, complete documentation, track data and confer with parents! (see below!)

Service Delivery/Individualized Instruction: School Speech Therapy

In school settings, SLPs may push into the classroom and co-teach with the general education teacher, pull a small group to a separate area within the classroom, pull out a small group into a speech therapy room, or they could see your child individually. Most often, children are seen in small groups within the school setting. If your child is working on social skills, or presents with a mild language or articulation disorder, small group instruction may be exactly what they need! However, ASHA reports that, “caseload size, rather than student characteristics, frequently influences recommendations about program intensity and/or model of service delivery. Larger caseloads may necessitate the use of service models that are not appropriate for some students and that may affect the SLP's ability to provide Free Appropriate Public Education (FAPE)” as is mandated by IDEA.

This means that in order to serve all of the children who need them, school SLPs are often forced to determine which kind of therapy your child receives and how often they will receive it based on time constraints, rather than what may be most beneficial to your child. If your child presents with a moderate-severe language disorder, attention deficit difficulties, sensory difficulties, or significant speech-sound disorder, exposure to small group therapy may be beneficial to promote social skills and take advantage of group learning activities; however, TheraCare poses that if your child is in a 30-minute group with 3 other children, they may end up receiving about 10 minutes of direct therapy specific to their targets per session. Individual therapy may be beneficial to add to ensure they are receiving intensive and individual attention to their language needs.

Service Delivery/Individualized Instruction: Private Speech Therapy

In private therapy your child receives individual therapy with their SLP. The flexibility of a private SLP's caseload allows for the sessions to be tailored to your child's individual needs and goals.

Parent Involvement: School Speech Therapy

Collaboration with parents and SLPs in the school remains difficult for many reasons, including a) parents are not present in school b) large caseloads of the SLP and c) privacy restrictions on electronic communication. School based SLP’s may send home homework sheets to be completed at home, fill out a communication log to review what was targeted in session, or send out monthly newsletters to review highlights from sessions. Data and progress review are typically reserved for quarterly progress reports and Individualized Education Plan (IEP) meetings, which usually happen annually.

Parent Involvement: Private Speech Therapy

At the end of each session, parents are updated on progress. SLPs have the opportunity to model strategies and activities and instruct parents in a 1-1 setting. Parents have the opportunity to ask questions face-to-face and can receive parent training as needed and requested! Increased collaboration opportunities with their child’s SLP often helps parents to feel more empowered and confident in their ability to help their children at home. Parent involvement has also been shown to enhance outcomes of speech therapy; therefore, this is a big area of focus after my sessions!

To wrap this post up, TheraCare said it best: “Giving your child the ability to receive therapy services in public schools and in a private setting maximizes their ability to make progress early. That means less services will be needed later on, when school coursework becomes more complex. Basically, the more therapy your child receives early on, the fewer services they will need later on! Public school services combined with private sessions makes for a one-two punch that tackles your child’s therapy needs early on.”

For a more visual explanation of differences between school and private therapy models, check out this blog by a former school SLP!

Jackie

Echolalia and Jargon: Defined

First of all, what are echolalia and jargon?!

These terms are often thrown around when talking about early development, but not always clearly explained.

Echolalia ("echo-lehl-ee-yuh"): repeating others' words and phrases with the same intonation and inflection. Echolalia can be immediate, (imitating what you say or ask,) or delayed (this is also sometimes called "scripting," and refers to repeating lines from T.V. shows, videos, or previously heard language repetitively). Here's an example of echolalia.

When echoing, children may be able to produce language that is more complex than what they are able to use functionally. Parents often (understandably,) express confusion about this when asked how their child communicates; "My child can speak in sentences...but it's only ever things he's heard before, and not all the time." For example, children may produce 3-5 word sentences that they've heard before, or sing songs in their entirety, but are unable or have significant difficulty using their own words spontaneously to express their wants and needs in an age appropriate way ("juice" or "I want some juice," to request). This tells us that though these children are able to repeat language they hear, (with an impressive amount of memory and mimicry!) they are not fully understanding the words as individual units that can be combined to communicate with others.

Jargon: strings of vowels and consonants with conversational intonation, without or with minimal production of meaningful words. Sometimes this sounds like, "bhjfblsdkhf mama fhdiskdf!!" :) The recent viral video of that adorable baby having a "conversation," with his father is a great example of jargon (if you haven't already watched it, you're welcome!)

What's "typical"?

Echolalia: Some echolalia is typical starting around 1 year, 6 months of age. Your child is actively absorbing language from their environment; you might hear them repeat your language as they are learning new words or concepts. For example, they may seem really interested in a new snack choice. You say, “These are grapes!” Child says, “Grapes!!” excitedly. Your child is repeating your words because they’re attributing it to this new object of interest. At this stage, your child should still be producing their own, non-echoed language in the majority of cases.

The occasional use of echolalia is usually eliminated by age 3. When a child produces primarily jargon and the majority or entirety of their intelligible language is echoed from others, it can be considered a red flag for developmental disorders, including Autism Spectrum Disorder, (otherwise known as "Autism," or "ASD"). Though echolalia is not the sole diagnostic indicator of ASD, research has found that up to 85% of verbal children with Autism exhibit echolalia in some form. There will be future posts on early warning signs of ASD, but in the mean time, here are videos and explanations of other "Red Flag," behaviors indicating concerns for Autism.

Jargon: Between 1 and 1 year, 6 months old, children produce jargon frequently! They are observing our inflection patterns, and attempting to participate in the conversation. The use of jargon should be eliminated by age 2. By 2 years old, your child should produce more novel (non-echoed,) words than jargon, and speak with about 50% intelligibility.

How do we help?

Echolalia: When a child is repeating your language frequently, avoid asking questions. Your child repeating what you’re asking is a sign that they a) don’t understand what you’re asking and/or b) don’t have the language to give you a response just yet! Repeating the questions repetitively often results in frustration… for the child and the parents! Here are some specific recommendations based on situation and type of echolalia you may be seeing:

*Avoid telling your chid, "Say ____." Your child will, inevitably do exactly what you ask.. and say, "Say, hi!" or "Say, bye bye!" It's best to model language exactly as your child would say it ("Hi, Mom!" "Want more snack.")

*Instead of asking questions, try leading with the answers. Consider: “Truck!” instead of “What is it?” when reading a book, “I’m eating!” instead of “What are you doing?” “I’m sad.” Instead of “Why are you crying?”

*If your child is repeating your language when they are sad or hurt, ("You're okay," while crying, "It's okay, come to Mommy!" when scared,) model language for them that fits the situation ("I fell down," "I hurt my hand," "I'm okay," "I'm scared")

*If your child is scripting language, and using it functionally ("Oh no! What will we do?" when something breaks,) offer a more flexible model ("The car broke. I need help.")

If your child tends to use the same phrase every time when requesting (“I want ____,” or “____, please,”) model different ways they can ask! Try things like “More ___, please!” or “Can I have ___?”

Jargon: The most important thing is to respond to your child's productions! Just as our rock star Dad did in the viral conversation video, responding to your child when they produce jargon is a crucial step in their development; you are teaching them reciprocity and encouraging engagement. If your child is producing jargon and is giving you a clear indication of what they are interested in or are trying to say, say it for them! For example, your child reaching towards bubbles and producing jargon while looking at you. Model, “Bubbles!” or “Want bubbles!” for them before engaging in the bubble activity. Repeat this model and then start to pause to allow your child the opportunity to fill in!

Happy Chatting!

Jackie