Case Study: Apraxia of Speech, Dyspraxia

Submitted by:
Christine King, COTA/L & Kathy Carley, MS, OTR/L

Organization:
Project CHILLD, Beverly MA

Client:
3.6-year old male at intake

Presenting Problem:
Apraxia of Speech, Dyspraxia

Background:
This case reports on a client’s progress over a 3-year period, using standardized testing and clinical observation to measure changes in language and motor skills. “Robert” participated in a clinic-based iLs program from December 2010 through March 2011, and an additional 10-day intensive program in April of 2012. He returned to Project CHILLD in the Spring of 2013 for further evaluation.

The case begins with a brief summary from his mother, which nicely sums up his progress to date, and then moves chronologically from 2010 to the present. The videos show Robert in 3 stages: in Dec 2010 prior to therapy, March 2011 post-therapy, and April 2013 at 6 years of age.

“When Robert was first diagnosed with Childhood Apraxia of Speech, we (his parents), did not know what to expect for his future. Would he ever speak? Would he be able to attend our town public school and learn alongside his typically developing twin sister? In September 2013, Robert entered Kindergarten in a general education classroom in our town. His age-level speech and other skills give him full access to the classroom, playground, cafeteria, and all other aspects of Kindergarten life that children love to participate in. He continues to receive speech services to fine tune his articulation and occupational therapy to improve his handwriting, but the outlook for Robert’s success in school is very positive. Most importantly, Robert loves school and is extremely happy.”

Prior to iLs 2010/2011

Language Skills

• Expressively, Robert could independently produce fewer than 15 sounds, and consistently used approximations.
• Robert was able to follow his classroom routine as well as 1-2 step directions. With the use of a communication program, Robert was able to answer some ‘wh’ questions by selecting from a field of 8-12 items; he could identify all peers, teachers and therapists by either their label on his iPod Touch or by pointing in context.
• Robert’s intelligibility remained significantly impaired; just before beginning iLs, he seemed to plateau and even regress.

Motor Skills

• Robert had difficulty with reciprocal crawling and demonstrated strong ATNR and STNR reflex patterns.
• Robert presented with moderate difficulty in the areas of postural control, motor planning, bilateral coordination and fine motor skills, and presented with gravitational insecurities.
• He was unable to form prewriting shapes, or use functional grasp on scissors or writing tools.
• Robert was unable to jump with a two-foot take off, lift his head or upper extremities against gravity from a prone position, or assume supine flexion.

After First iLs Intervention: Mid 2012

Robert showed dramatic improvement is the area of speech and language. His private SLP, who has been with us since the end of April 2011, has rewritten his goals three times since May because he is progressing so quickly. He is no longer using any assistive device for communication. Robert demonstrates improvement in vestibular processing. He is able to jump with a two-footed take off, and his ability to balance on one foot is emerging. Robert demonstrates improved strength and endurance; he is able to hold his upper body against gravity in prone. Robert has made gains in the area of ADLs. He is dressing himself, washing himself in the tub and is completely potty trained. 

Current: April 2013

CELF-Preschool Test Results The CELF-preschool is a norm-referenced assessment tool that looks at a student’s overall language abilities including receptive language, expressive language, content, structure, and working memory. Robert’s overall expressive language skills fell in the high average range (90%ile). Results of the CELF-Preschool indicate that Robert’s overall receptive language skills are average/above average for his chronological age (96%ile).

CELF-Preschool Test Results 2013
Subtest	Raw Score	Scaled Score	Percentile	Range
Sentence Structure	21	14	91%ile	Above Average
Word Structure	22	13	84%ile	Above Average
Expressive Vocabulary	36	13	84%ile	Above Average
Core Language Score	40	119	90%ile	Above Average
Conc & Following Directions	22	16	98%ile	Above Average
Recalling Sentences	33	13	84%ile	Above Average
Word Class (Receptive)	20	13	84%ile	Above Average
Word Class (Expressive)	20	15	95%ile	Above Average
Word Class (Total)	28	15	95%ile	Above Average
Receptive Language Index	43	127	96%ile	Above Average
Expressive Language Index	39	119	90%ile	Above Average
Language Content	44	129	97%ile	Above Average
Language Structure	40	120	91%ile	Above Average

Pre-Literacy Skills Screening (PLSS) The PLSS is a screening tool designed to look at a child’s overall phonological awareness. Phonological awareness refers to ones’ ability to examine language independent of meaning and to manipulate its component part. This current screening tool is broken down into 9 subtests; Rhyming, Sentence Repetition, Naming, Blending, Sentence Segmentation, Letter Naming, Syllable Segmentation, Deletion, and Multisyllabic Word Repetition. Prior research has found that children who perform below the 20%ile on each subtest experience difficulty in the area of reading acquisition.

Robert’s screening results were in the above average range for all subtests.

Goldman Fristoe Test of Articulation ln addition to spontaneous speech samples, observations, and teacher reports, the Goldman Fristoe Test of Articulation 2 was administered in order to assess overall articulation skills.

Robert showed solid vocabulary skills, as he was able to spontaneously name all but one of the test pictures. Robert said “light” instead of lamp and therefore the word “lamp” was elicited via imitation.

The following sound substitutions and/or omissions were noted:

Initial Position	Medial Position	Final Position
w/l	w/l	-l
w/r	w/r
	s/ch Rasel/Rachel
f/th- (thumb)	f/th-	f/th-(bath)
d/th+(dis/this	d/th+(feather)

Robert simplified the majority of the blend sounds, but is developmentally appropriate for his age level.

Robert simplified the majority of blend sounds (i.e b/br, dldr, flfl, f/fr, gw/gl, s/sl, k/kl, p/pl). These sound substitutions were also noted in phrases, sentences, and conversational speech. Blend simplification remains developmentally appropriate for his age level. However, children with Apraxia of speech have greater difficulty blending sounds and, as a result, these sounds may not develop naturally. It is recommended that these sounds and blends be directly targeted in order to maximize acquisition of sounds.

Language Summary:
Formalized testing (CELF-P, Goldman Fristoe, and PLSS) demonstrates above average receptive and expressive language skills. Per teacher report and observation, he is demonstrating strong receptive and expressive language skills that both support as well as enhance the skills noted during formal testing.

As stated by his private speech therapist, “Robert continues to present with mildly decreased mandibular control characterized by lateral sliding and a decreased ability to produce finely graded movements often opening the mouth too wide. Lingual movement continues to improve; however, he continues to present difficulty with the independent, symmetrical muscle movements required for smooth, effortless speech production. Prosody at the sentence/conversational level continues to be atypical and may be characterized as “flat” or “choppy”. Mild to moderate dysfluencies have been observed, characterized by sound/word/phrase repetitions.”

Current performance of motor skills June 2013:

Postural Control – Age appropriate performance for maintaining supine flexion and prone extension

Motor Planning – Improvement in sequencing and timing, able to tie shoes, riding two-wheel bike, demonstrating age appropriate bilateral skills such as scissor use

Gross/Fine Motor – Forming 26/26 letters, Robert scored in the average range in the area of visual motor integration

Reflex integration – Decreased presence of ATNR/STNR.

Activities of Daily Living – Independent with dressing, toileting

Current Treatment Plan:

• Robert continues to benefit from Occupational Therapy once a week in both clinic and school setting to continue to address postural control and stability as well as grasp patterns.
• Robert continues to benefit from Speech Therapy once a week in both clinic and school settings to address prosody and mild dysfluency.
• Robert is now seeing a developmental optometrist to address convergence excess and occulomotor dysfunction.

Comments by Ron Minson, MD, iLs Clinical Director
This case is representative of a number of positive features.  First, it speaks to quality intervention at a young age, when the brain is resilient and not only open to, but seeking, input from the environment. Next, it demonstrates the power and effectiveness of multiple disciplines working together to help build neuropathways.  In this case, occupational therapy, speech therapy and iLs combined are more than the sum of its parts.  There are many disparate anatomical structures that underlie both dyspraxia and apraxia of speech that required  a multidisciplinary approach, including iLs, to provide the multisensory input for improving the functions and connections among all the structures involved in speech, motor planning and execution.

And, not to be missed, is the wisdom of the therapist to inform the family about the importance of returning to therapy at a future time to further increase and solidify gains. The cooperation of this child’s parents is exemplary. This team working together has opened the door for this child to have a future not otherwise possible.

Videos:
Robert after 15 iLs sessions:

Robert after 31 iLs sessions:

Robert in 2013