Overdue Apraxia Update

As you'll recall, Sheridan was diagnosed over a year ago with Apraxia of Speech, and I wrote a post about the criteria for Apraxia back then, as well. Since then, I've seen many helpful videos on youtube... parents who video their children periodically to see the progress (or not) a child is making. I've been thinking for some time that I need to do that, so this is my first of what will be a series of posts over time.

When I first posted Sheridan's diagnosis, many people sent me private questions about Apraxia or simply asked that I provide as much information as possible. So, for this post I'll include some information about what Sheridan's speech intervention looks like, show you some of the materials we're using, etc.

Some Basics to Lay the Foundation

Sheridan's SLP is allowing me to record and post portions of Sheridan's sessions. Although she uses a number of strategies with Sheridan (e.g., oral motor therapy, facilitating speech through play), the two things you'll see in the video below are Jane's use of PROMPT and Kaufman cards. Most speech sessions look like this:

1. Oral Motor (usually about 20 minutes)
2. Kaufmann cards using PROMPT
3. Play (during which Jane works to help Sheridan generalize the speech production beyond the cards, often using PROMPT when necessary)

Here's an online description of the Kaufman cards: The Kaufman K-SLP Treatment Kit 1 (basic level) employs a systematic treatment approach that controls the level of motor-speech difficulty by simplifying word pronunciation patterns.  Each card displays a series of “successive approximations” of the target word based on least physiological effort. This “word shell” approach is highly effective for quickly building motor-speech coordination and allows children to begin progressing immediately from a simple core vocabulary toward becoming effective vocal/verbal communicators.

The 5x7 cards are organized from the "easiest" words (from a motor planning, speech production perspective) and then build on those sounds to form progressively more advanced/difficult words (I'll show you what I mean in a second). Bonus: Nancy Kaufman is a woman after my own heart... look at those color-coded dividers. *swoon*

I was a little hesitant at first because all the cards use cartoon drawings. For example, the "daddy" does not, ah-hem, look like daddy. At. All.

So I was worried about whether or not these would make sense for Sheridan, and his ability to generalize from the specific drawing to real objects/people. I didn't need to worry. He totally gets it - calls that card "daddy" every time he sees it, calls Gary "daddy," and doesn't call random up-tight white guys "daddy." So we're good.

An example of an early card (from the CVCV group (by the way, C = consonant; V = vowel) would be dada, mama, moo moo.

The next level is VC (e.g., on, out, in, eat, ouch, arm). Here's an example:

Sheridan has difficulties with /r/ (as do many 3-year-old children), so he still approximates arm as "ahm."

The image on the left is the front of the card (what Jane shows Sheridan); the image on the right is the back of the card showing the progression of the speech sounds. So, at first, a child might approximate arm by saying "ah," but then progress to "ahm" and eventually to "arm." The top is always the goal word.

Next, CV includes words such as two, bay, tea, new, dough, tie. Here's a couple examples:

Sheridan does well with this card and says pie (though he does drag out the /i/ and /e/ at times).

Sheridan still struggles with /m/ versus /b/. Most often he says "be" or "m-be" here.

VCV cards include words/phrases such as: oh no, okay, oboe. Here's an example:

Notice that as words get more difficult, one might use a longer progression of approximations to get to the target word. Sheridan is doing really well with this particular word, and nearly always says "a-po"

CV1CV2 are words where the syllable is repeated, but the vowel changes (such as: puppy, mommy, baby). Here's a couple examples:

Sheridan currently says "tay-to," but sometimes needs prompting (meaning a physical PROMPT). Jane always notes which cards in a set Sheridan says spontaneously (on his own), and for which cards he needs a PROMPT. This helps us see with what sounds he might be struggling, and the progress he's making in a given set (e.g., today on set #3 he said 16 out of 17 cards - correctly - all by himself). 

One of Sheridan's favorite words... he immediately says "bubbos" when he sees this card.

Sheridan says "pee-po" - but occasionally needs prompting to get the "pee" on the front (he has a tendency to say the last syllable of a word; this is somewhat common in people with apraxia).

 The "hardest" set he's working on now is a set of 30 C1V1C2V2 "simple bisyllabics" (such as: muddy, honey, panda, marble... notice the consonant and vowel change in the second syllable). Here's one example:

Sheridan says "noo-do" with prompting (he doesn't know all the words in this set yet by sight). Notice that this word is a combination of the sounds he learned in earlier sets (new & dough).

There's 12 more sets after these... and just because Sheridan is on set 6, doesn't mean his speech is perfect on sets 1-5. He still practices the other sets and is working on improving his speech on those words.

And Now... The Video

This video was taken this past Spring when Sheridan was 2 years, 8 months old. At that point he had been receiving two hours of speech therapy every week (two 1-hour sessions each week) for about six months. (Now he receives three 1-hour sessions each week).

A few things to note about the video:

1. Sheridan is working only on sets 1 (CVCV) and 2 (VC) at this point in time.
2. You'll see Jane using PROMPT when she uses physical cues to help Sheridan remember/feel how to make specific sounds.
3. You'll see Sheridan get really frustrated a couple times because some sounds were really hard for him (for example, /e/ as in eat). Many vowels were really difficult for him.
4. But know this... Sheridan LOVES (seriously loves) these cards. So much so that we bought a set so he could practice whenever he wants (sometimes he asks every day, sometimes he asks once a week... we follow his lead).
5. Notice that Sheridan often leans into Jane so he can be prompted. 
6. He often prompts himself, as well.
7. I provide the sound he's working on, and the target word so you can get a feel for how this works.
8. It's worth watching to the very end so you can see that, despite his frustration at times, he truly loves Jane (and he's a little obsessed and extra excited for some of the cards... we often have to hide the up card).

Turn your volume up so you can hear Sheridan :)

What's My Name?

For the past few months Sheridan could approximate the syllables of his name with some prompting. This morning, he climbed up on our bed (his daily ritual to help wake up his night-owl parents) and proudly started saying his entire name, unprompted! This evening I was able to get quick video of it - it's not quite as clear as it was this morning... but it's still AMAZING. I owe you all an apraxia update, but that will have to wait. For now, enjoy :)

You'll notice he prompts himself for the "sh" sound (which actually comes out closer to an "s" sound), his "ri" sound is more like a "wah" sound, and "dan" is pretty darn close ;-)

Eleven Criteria for Apraxia of Speech

Many people have reached out to me asking about the "signs" of apraxia I mentioned in my last post. My time is still being ruled by the two men of the house, so I thought that the least I could do is slap up the 11 criteria for apraxia until I have more time to post about Sheridan specifically...  

You all know I'm not a speech language pathologist (I don't even play one on TV), so keep reading with that in mind. Seek out a professional who knows apraxia if some of this raises an eyebrow for you.

Sheridan's SLP used the Differential Diagnosis for Childhood Apraxia of Speech assessment (adopted from Ruth Stoeckel, MA, CCC-SLP and David Hammer, MA, CCC-SLP, members of the Childhood Apraxia of Speech Association Professional Advisory Board - by the way, I found their Family Start Guide to be a useful overview). 

Here are the 11 criteria, in no particular order of importance... 

1. limited phonemic repertoire (e.g., limited vowel and consonant sounds)
2. frequent omission errors
3. predominant use of simple syllable shapes (e.g., “buh buh”)
4. reduced expressive language (speech) compared to receptive language (comprehension)
5. high incidence of vowel errors
6. increased errors on longer units of speech output
7. difficulty imitating words or phrases correctly
8. altered suprasegmental characteristics (A.K.A. prosody, or the patterns of stress and intonation in language)
9. impaired volitional movements
10. inconsistent speech errors (e.g., may be able to produce accurately a sound/word in one context but is unable to produce the same sound/word in a different context)
11. reduced/irregular diadochokintic rates (a person's ability to make rapid speech movements using different parts of the mouth; ability to accurately produce a series of alternating sounds)

Other signs often go with the diagnosis (but aren't enough to actually distinguish those who have apraxia from those who don't). One example is a loss of previously spoken words (e.g., used to say "baby" consistently but no longer says the word).

The Childhood Apraxia of Speech Association noted that SLPs do not demonstrate consistency in which characteristics they place more weight on than others in a diagnosis (so are some of the 11 criteria more indicative of apraxia than others?).  It is not clear which or how many characteristics must be present for the diagnosis (I've seen a few sources say a child must clinically meet at least 8 of the criteria, but other sources say 7 or 9). Also, many of the cites I found indicated that children must have a decent repertoire of words before a diagnosis can be attempted (in other words, they have to have enough speech sounds and words in order to detect these errors).

I'll be posting more as we learn more... from what I have gleaned so far, oral motor and PROMPT (Prompts for Restructuring Oral Muscular Phonetic Targets) are important and critical therapies, especially when used together. And other strategies can be helpful, as well. Most important is that apraxia requires intensive one-on-one speech therapy.

Anyway, we're still learning and we're grateful for any lessons learned you can share. We'll certainly be sharing what we learn :)

Birthdays, Hospitalizations, and Apraxia of Speech, Oh My!

It's been a while since I posted an update primarily because, well, like the rest of you, life gets crazy. Our crazy the last few weeks looked a little something like this:

ACT ONE
Sheridan celebrated his 2nd birthday and had an awesome party (that will get it's own post, thank you very much), but Gary was in the hospital and missed the party because... (drum roll please)

ACT TWO
Gary's appendix burst and it wasn't removed until 24 hours after it burst. Cue rampant infection, sepsis, almost dying (surgeon said if he had come to the ER even 30 minutes later he would have died), Sheridan developing behavioral issues because he missed his daddy so much, me trying to keep Sheridan's life as normal as possible (even though he would wander through the house to our bedroom calling "Dada" and "Daddy" looking for Gary), me trying not to pull my hair out, craziness. (A quick shout out to my family, my sisters, and one - make that two and three - close blogging friends from around the country for helping me survive the near loss of my husband - much love to you.)

After two weeks in the hospital Gary came home on antibiotics (the infection wasn't gone but the doctors had no better plan).

One week later he went back in after spiking a fever because his infection grew (despite 3 weeks on antibiotics) and he had another procedure to try to clean out/drain the infection.

Now he's home again (with a nasty, foul, way-cool drainage tube) and we're hoping the infection goes away and stays away. But this time he's in more pain and Sheridan doesn't understand why Daddy won't pick him up. Poor little man.

ACT THREE
And, as if this fabulous cake needed a big, heaping scoop of icing... Sheridan was diagnosed with Apraxia of Speech. Gary and I have suspected for some time, and we're not totally shocked by the diagnosis. I'm just sad. I feel for him. His receptive communication (what he understands/comprehends) is age appropriate, but his expressive communication (what he says, his actual speech) is really delayed. I will write a more detailed post about this, what criteria Sheridan exhibited - by the way, he exhibits 11 of the 11 criteria for an apraxia diagnosis - that boy scored 100%, just not on something we wished for :)

In the end, it'll all be just fine... Gary is on the mend and we are hopeful that this last surgical intervention took care of any remaining infection. And Sheridan is, as always, a very clever, silly, sweet, vocal little boy who just happens to call most things "buh buh" but can say "daddy" and "I did it" clear as day :)

I will leave you with this basic explanation of apraxia that was part of Sheridan's report:


Apraxia is a speech disorder that interferes with a child’s ability to correctly pronounce sounds, syllables, and words. It is the loss of ability to consistently position the articulators (face, lips, tongue, and jaw) for the production of speech sounds and for sequencing those sounds into syllables or words. It’s a planning/programming problem.

As a result, even though Sheridan knows what he wants to say, he cannot say it correctly at that particular time. Sometimes he cannot even begin. Either the wrong sound comes out, or many sounds are left out all together. At that time the motor plan is not accessible. These errors are not under Sheridan’s voluntary control so he often cannot correct them, even when trying his hardest. Frequently, a child will be able to produce a sound or word at one time and not be able to say it again when he wants to.

Cool Speech Therapy Blog

I've been hunting everywhere for good straw cups, nosey cups, etc. to help with oral motor skills, and stumbled across a blog called mommy speech therapy. Sheridan is too young for some of the content to be useful for us right now, but overall I thought this might be a really helpful blog for anyone looking for ideas on how to work on specific sounds, etc.

Heidi has written posts for specific sounds (like M, T, D, TH) and talks about language development, communication milestones, stuttering, etc. She's also written for other sites about sippy cups (a no-no) vs. straw cups, etc. (which is how I found her).

I think it's definitely worth checking out. I'm sure I'll use some of her ideas if I need some extra help working on specific sounds with Sheridan.