Early Intervention for Apraxia of Speech

When your toddler isn't talking, the instinct that something deeper is going on can hit hard. As a mom to a child with apraxia of speech, I know firsthand how frustrating it is when you suspect apraxia as early as 18 to 24 months, yet are told to wait until age three for a diagnosis.

My Early Intervention Experience with Apraxia of Speech

My journey through that in-between period began at age 27 months. Up until that point, I had been buried with my son’s other health issues: horrific eczema, asthma, six ear infections, multiple rounds of antibiotics, steroid creams, breathing treatments, gut issues, and food allergies.

After I cleaned up his diet and added a few basic supplements, his health started improving. But then I noticed that he wasn’t talking like the other kids his age. My time as a mother during the wait-and-see phase was filled with worry, frustration, confusion, and overwhelm.

My son started speech therapy at 27 months old with our state-funded early intervention program. Her job was to teach me how to help him to speak. She introduced me to the basics of speech therapy. She taught us a little sign language, gave me literature to read, and encouraged simple communication like “more” and “eat.”

Two months later, a second SLP entered the scene. She was the first person to tell me that she suspected Childhood Apraxia of Speech.

During speech therapy, she read him books, sang songs, and did cutting and pasting exercises. One of the first nursery rhymes she started with was, “Five little speckled frogs, Sat on a great big log. Eating the most delicious bugs.” My son just stared silently at her, big smile planted on his face, while she belted out this tune each week.

Once she started drilling words, she didn’t work on the same letter or words each week, and some of the first words she introduced to him were two-syllable and not simple. I pressed her to make an “official” apraxia diagnosis prior to age three, but she would not. Her response was, “It doesn’t matter if he has x, y, or z. I’m still going to treat him the same way.”

When she said this, I remember thinking, If we don’t know what it is, how in the world are we going to fix it? Fear and frustration quickly set in as the weeks dragged on.

A few days before my son’s third birthday, she officially diagnosed him with Childhood Apraxia of Speech. At that point, I had some education under my belt and knew I must find a better solution as soon as possible.

At this time, I had the following frustrations:

• The early intervention time before his official diagnosis felt wasted and I had seen no progress with his speech.

  
  

• Why did he do basic speech therapy if apraxia was suspected?

  
  

• What would it have hurt to go ahead and start apraxia-specific therapy like Kaufman cards, Prompt, DTTC, and/or hand cues?

  
  

• Why can’t apraxia be diagnosed before age three?

I hear these same concerns from other parents and and asked two SLPs to provide insight on how to make the best use of the time prior to an official speech diagnosis.

Speech-Language Pathologists Provide Answers to Apraxia of Speech Early Intervention Concerns

Katie Grecco, our fifth SLP, who did an amazing job in helping my son to overcome apraxia, answered this question:

What can a parent do while waiting for an apraxia diagnosis so they don't feel like they are wasting valuable early intervention time?

“From the perspective of a speech-language pathologist who has worked with children in early intervention as well as in Pre-K who present with characteristics of Childhood Apraxia of Speech, I recommend focusing on the following three areas:

1. Imitation: Make motor and vocal imitation fun and within the context of play.  Include large motor movements, mouth movements, animal sounds, non-speech sounds (example: gasps of excitement), isolated vowel and consonant sounds, simple syllable shapes (consonant + vowel, duplicated syllables), simple two-word combinations.

2. Praise and celebrate all communicative efforts and imitation attempts. Even when your child tries and isn't successful, let them know what a great job they are doing by trying their best.  Continue to simplify your target so they are able to be successful even if you need to reduce your expectation.

3. Supplemental communication aids: Use of simple core vocabulary boards can be a wonderful tool for learning and using language while also reducing frustration.  Here's one of my favorites: Core Board - WordPower - Tell Me Board, along with a video about how to use these tools at home: "How to Use a Communication Board to Get Your Child Talking.".  Always verbalize along with using the pictures/symbols to teach and encourage language use.”

   
   

Shandy Laskey -- Speaking of Health & Wellness, LLC -- speakingofhealthandwellness.com

Shandy Laskey, SLP and Functional Nutritional Therapy Practitioner, elaborated further and answered each of these pre-apraxia diagnosis questions:

Why do basic speech therapy before the age of three if apraxia is suspected?

I can't speak specifically to Jake's experience because I wasn't his SLP, but I will say that most SLPs are not diagnosing Childhood Apraxia of Speech (CAS) before age three because it's difficult at that age to differentiate between CAS and other speech-language disorders, especially other motor speech disorders. It is especially difficult to differentiate and identify if it's CAS when a child younger than three years old has less than 50 words. 

In many cases, a skilled SLP can identify whether the child is experiencing a motor speech issue in the 18-24 month range as long as the child is using enough verbal speech to assess their motor movements and speech patterns.

It's important to see CAS as one of the diagnoses under an umbrella of motor speech disorders, understanding there are more motor speech disorders than just CAS. For example, dysarthria can look similar to CAS under age three, especially when a child is using very few words.

The specific diagnosis becomes more important as the child grows older because the therapeutic approach should shift as they mature and have more capacity for more intensive speech-language therapies and approaches.

It's also important to note that some children with CAS also have Whole-body Apraxia or a Developmental Coordination Disorder, informally known as dyspraxia. When this is the case and you can clearly see that the child has difficulty with motor planning throughout their body, for gross and fine motor movements overall, not just for speech. In these cases when the child is younger than three, we need to zoom out and focus on supporting coordination of the whole-body and gross motor movements before focusing intensely on motor planning for speech.

What would it hurt to go ahead and start with apraxia therapy like DTTC, Kaufman, or Prompt?

It's very nuanced! These approaches are excellent for children with diagnosed CAS, especially school-aged children, in conjunction with other diet, nutrition, lifestyle supports. While these therapies are often recommended for children with CAS, they are applicable and supportive for children who have motor speech disorders, which CAS falls under the umbrella of.

In my clinical opinion and experience, whenever a child is struggling with what appears to be a motor speech disorder, multi-modal / multi-sensory cueing techniques and hierarchies (auditory, visual, tactile) should be utilized for support, regardless of age, and if there's a diagnosis of CAS.

That being said, some of these approaches in their pure forms can sometimes be too intensive for some children. Especially for very young children, which is why they aren't the default for most Early Intervention SLPs.

When I was an Early Intervention SLP working with children younger than three, I incorporated techniques from these motor speech-based approaches and blended multi-modal cueing hierarchies into my child-led, play-based therapy sessions.

Before age three, therapy really should be child-led and family-centered vs. drill based therapies or other intensive types of motor speech-based therapies. You don't want to lose a kid in the therapy session. It’s all about maintaining rapport and you have to "meet them where they are.” But that doesn't mean that a skilled SLP can't or shouldn't be utilizing all of the tools in their toolkit when they see that the kiddo is struggling with motor planning for speech.

What can a parent do while waiting for an apraxia diagnosis so they don't feel like they are wasting valuable early intervention time?

I love this question because there's so much that parents can do to support their children at home. Rather than focusing so much on the diagnosis during those early years, focus on the tailoring the approach to meet your child's needs. During this time, kids need the foundational supports in place before starting more intensive speech-language therapies for CAS.

If I personally had a child who was suspected to have CAS and was in the 18-24 month range waiting for formal CAS diagnosis, here are a few things I would consider:

1. Speech therapy: While SLPs are a wonderful resource, it's important note that not all SLPs are created equal and on the same page. Find someone who you can see building a great rapport with you and your child, and ask if / how they're using motor speech-based strategies and/or multi-modal cueing hierarchies in their sessions (even when they're play-based, child-led, and family-centered).

2. Anything that can be done to support the child's central nervous system, especially younger than age three, can be really transformative in addition to speech therapy. Examples include:

• Movement-based therapies like reflex integration and neurodevelopment movement

• Craniosacral therapy or craniosacral fascial therapy

• Pediatric neurological focused chiropractic care (ex: PxDocs)

3. Consider occupational therapy (OT) or physical therapy (PT) if the child is struggling with coordinating motor planning of their whole body. Keep in mind that the movements of speech production are our finest fine motor movements that we use, and development builds upon development. We develop gross motor skills before we develop and master fine motor skills.

4. Lower “total load” with diet changes, targeted nutrition, and lifestyle changes.

5. Diet and bio-individualized nutrition supports the child's overall health, wellness, development, and central nervous system regulation. While there isn't a large body of research looking at diet, nutrition, and CAS, there is some research that exists, in addition to growing body of anecdotal evidence from families, like Tori and Jake's story. There are more and more case reports coming out all the time about individuals (both children and adults) whose motor planning disorders improved when they changed their diet, especially the removal of gluten containing foods, and improving the gut-brain connection.

6. “Clean up" the diet by removing artificial colors/dyes, artificial ingredients, GMOs, gluten, dairy, corn, and soy and focus on the gut-brain connection.

7. Assess if there are any nutritional deficiencies that could be playing a role (Vitamin E and Omega-3, for example) and address deficiencies with targeted supplementation as needed.

8. Spend plenty of time outside daily, getting lots of movement and "heavy work" for regulation (bonus if they're barefoot).

9. Drop down to the child's level whenever possible, so that they feel seen and heard while struggling to get their words out. This also helps them to see mouth movements clearly.

10. Try your best not to talk for your child or complete their sentences while they're attempting them with you. Stay patient and model the correct form back to them once they've said it.

11. Incorporate daily, at-home speech-language development practice for at least 10-20 minutes. For example:

• Get down on the floor with your child and let them lead the play. Follow their lead, meet them where they are, and use minimal language. Also, repeat the words or phrases they've said back to them with clear and exaggerated speech modeling.

• Place toys near your face to get them to look at your mouth while you speak.

• Don't withhold anything from your child making them "work" for it with their speech. This is a quick road to shut down and self-esteem issues.

I hope this has been supportive and gives you, the reader and presumably the parent, a sense of direction. I'm wishing your child and family all the best!

I'm so grateful to Katie and Shandy for sharing their knowledge and expertise on this topic. They are the best-of-the-best! I hope you were able to find a few pieces of gold to help you in your own early journey with apraxia or other speech-language disorder.

Although this was an abundance of information, it was created on hypotheticals for general educational purposes. There are still more interventions that can be done, but I hope this gets you trending in the right direction.

It is key to understand that each child is unique and what works for one child, may or may not work for another. A skilled SLP or other holistic, integrative, etc. professional, will always be able to provide outside-the-box solutions to best meet your child's goals and needs.

Question: What has your own experience been like with early intervention prior to age three? Has it been positive or negative? Would love to hear your story in the comments.

All the best,

Tori

Guest writer:

Shandy Laskey, M.A., CCC-SLP, FNTP

Speaking of Health & Wellness, LLC 

speakingofhealthandwellness.com 

Shandy also serves as the Director of Community Development for Documenting Hope.