Tag Archives: Speech and language pathology

Motor-Speech Disorder Not Otherwise Specified

Not quite apraxia, definitely not dysarthria, it looks like Noah has landed with Motor-Speech Disorder Not Otherwise Specified.  Pure apraxia exists in children without other neurological compromise, and one of the features of apraxia is inconsistent errors.  Obviously, since Noah has Down syndrome he is not without other neurological compromise, and most of Noah’s speech errors are consistent, so we can’t quite land on apraxia.  Motor-Speech Disorder is the umbrella under which apraxia and dysarthria fall under; the NOS is a relatively new addition to the group.

The biggest part of the apraxia dilemma is that there is no official criteria, so a child presenting to one SLP may be diagnosed according to her criteria and not be diagnosed at a different SLP based on her criteria.  This is the kind of stuff that drives a momma whacko.

The good news is that since apraxia is a motor-speech disorder, and since PROMPT is all about addressing oral/motor/speech issues, the fact that Noah is landing in motor-speech disorder NOS versus apraxia means the treatment is the same regardless.  So, I continue to think we’re in the right place as far as treatment goes.

There’s not much literature out there on MSD NOS now; although Marcus (Noah’s SLP) says there is research currently being conducted.  So in time we’ll have more information – I’m fairly confident the research will tell us PROMPT (tactile cueing) is the right road to be on.

As far as Noah’s progress, Marcus says he is doing well.  He is able to produce more accurate sounds and I think his jaw sliding is improving.  Marcus is starting to add concepts like positional words into their sessions, so Noah is getting language as well as speech practice.  I’m so anxious to see carryover from Marcus’ sessions and my work with Noah into his natural language routine.  That is coming so very, very slowly.  In theory, it will happen in time and practice as we continue on with speech therapy.

One bright spot to our week – Noah has started saying “Caelie” and “Leah.”  He has done it a few times on his own without any prompting.  This is a huge distinction in my eyes – being able to mimic a word is great, but it’s not really communication.  Having Noah run towards me shouting “Caelie, Caelie” since he knows we’re going to be meeting her for lunch is definately communication.

I’m so thankful for the little things along the way that show me he is moving foward.

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Mystery Bag – Using Touch to Identify Objects

The idea for a mystery bag activity has been on my mind since Noah (6 – with Down syndrome) played a game similar to Ned’s Head in speech therapy a few months back.  You know how those ideas get planted, you sit, you watch, and you say I could do that!

The concept for this game is you stick your hand into the bag (or stocking) and identify what you are pulling out before you pull it out, or you put your hand into the bag trying to pull out a particular item.

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I was planning on using a pillowcase or paper sack, but when I saw this Christmas stocking pin, http://pinterest.com/pin/234961305531199323/ from the original blog post at  http://littlewondersdays.blogspot.com/2010/12/whats-in-stocking.html,I decided I liked the stocking idea way better.

I wanted to use this to practice vocabulary with Noah, so I made up a bunch of PECs to go along with unique items that would fit into the stocking.  I came up with three pages worth, so even if you don’t have everything, you can pick and choose which ones you want to use.  You’ll find the free printable cards in PDF format here:  Mystery Bag.

Thanks to www.mrsriley.com for giving me such an easy way to make these cards.  For www.mrsriley.com members, you can find my fully editable file here:  http://mrsriley.com/app/#fileID=61953.

I just stacked the cards right-side down and let him take one from the top of the pile, insert hand into filled stocking, pull out matching object, wallah.

(By the way, I’m experimenting with auditory bombardment, which is basically reading a list of target words while your child is sitting passively.  In many circles it’s not considered productive, but I’m operating on the assumption that Noah has to hear and identify a word before he can start the motor planning process to say the word, so I want him to have as much exposure to the word as possible.  It’s an easy, fast exercise, and it can’t hurt to try something new, right?)

Anyway, back to the mystery bag.  I read through the cards and show them to Noah before he starts the game and after he finishes the game – my version of auditory bombardment.

Noah had no trouble with this the first time we played.  Granted, I only put items in the bag that were extremely different from each other.  I have to say I was impressed with how readily accessible Noah’s sense of discriminating touch was.  Makes me think sandpaper letters or something along those lines might be a way to help him with his letter recognition.

Hope you had a sweet Valentine’s Day.   Yuk yuk.  Very punny, as my kids would say.

Assessments Are Not Our Friends

Well, I got Noah’s assessment/evaluation report back from his new speech therapist last this week.

I read through it in the speech therapist’s office during Noah’s appointment. Kind of hard to hold back the tears.

(A lot of this is pretty technical and maybe uninteresting, but writing (typing) really helps me process it all.  I won’t hold it against you if you duck out of this post early.)

The therapist said it was pretty consistent with the diagnosis of Down syndrome.

Noah underwent the PROMPT Neuro-Motor Speech Assessment, the Oral and Written Language Scales – 2nd Edition, the Primary Test of Nonverbal Intelligence and the Diagnostic Evaluation of Articulation and Phonology.

The evaluation report is broken down into the following sections (I’ve summarized most of this)

Physical-Sensory Neuro-Motor Speech –  Noah’s mouth and face is physically within normal limits except for a high and narrow hard palate.  Noah had difficulty with imitating lingual (tongue) motor movements.  Noah improved when movements were demonstrated for him visually.  He was able to round his lips with tactile kinesthetic support (therapist’s hands on Noah’s mouth/face).  Diadokokinesis – “Noah was able to produce p^p^p^ and t^t^t^ verbal approximations with decreased rhythm.  He was not abl eto generate k^k^k^, p^t^p^t^p^t^, nor p^t^k^p^t^k^.”

Summary:  Noah’s oral muscles are normal structurally, but he lacks the functional control required for speech.

Diagnostic Evaluation of Articulation and Phonology score – .1%.  Percent of consonants correct = 18%.  So he’s on the chart, but just barely.  This score is measured against typically developing peers. 

MOTOR SPEECH/PROMPT Assessment – Adequate to low global tone – this is a good finding for a person with Down syndrome.  Noah’s global tone is relatively good.  Phonation and breath support are adequate.  /a/, voiceless phonemes and nasals /m/ can be produced.  Consistent resonance.  No hyper/hypo nasality.  Jaw does not demonstrate controlled degrees of freedom.  Overexcursion noted.  Anterior and lateral jaw sliding.  Lips do not move independently from jaw.  Lips do not demonstrate consistent control for appropriate protrusion and retraction.  Tongue does not move independently from jaw for anterior to posterior lingual contractions.  All oral muscles move appropriately during connected speech.  Facial muscles do not show appropriate combined alternating movements.  All muscle groups do not exhibit symmetrical movement, independent and coordinated functioning in connected spontaneous speech.  Timing for co-articulation is normal for age.

COGNITIVE – LINGUISTIC – Expressive-Receptive Language – (again measured against neuro-typical peers) – He wasn’t even on the charts for oral expression, listening comprehension was at the .1 percentile. 

Summary:  Severe expressive-receptive language disorder.   Strengths in the area of comprehension of simple linguistic concepts – quantitative, spatial, pronouns and colors.  Increased use of symbolic representation skills – parallel play, symbolic play and pretend play.  (Let’s hear it for Miss Lindsey and Michelle who worked on all this stuff so hard with Noah!!!!)  Noah was also able to follow 1-2 step commands with the use of gestural cueing. 

Weaknesses – Comprehension of more difficult linguistic concepts as well as use of verbal communication output. 

PTONI – Primary Test of Nonverbal Intelligence.  This is the one that killed me.  This test evaluates Noah’s general reasoning ability.  “The PTONI provides information about a child’s general intellect.”  Noah’s score did not even register in the percentile ranks – it was so low (11).  This puts him in the category of “Very Low.”  See, when you look at the current research on people with Down syndrome, their degree of intellectual disability now expected falls in the mild to moderate range.  “Very Low” means to me he’s probably even further down the curve than average Down syndrome.  I know, I shouldn’t care about these things, but this is my kid we’re talking about here.  I should ask for clarification from the speech therapist on my assumptions about these scores.

SOCIAL EMOTIONAL General Behavior Observation:

Attention – appropriate level of arousal and age-appropriate focus to tasks.  (YAY ) Minimal redirection and modeling was given for start-to-finish sequences and unfamiliar motor/action schemas.

Rate of Processing/Responding – Processing Rate seemed appropriate but inconsistent.  He responded to his name but did show difficulty with imitation of oral motor sequencing.

Emotional Control/Affect – Appropriate.  (YAY)

Drive/Motivation:  Noah present with increased motivation and curiosity for social engagement or joint interactions and/or routines.  YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY YAY (It’s in his blood, by the way – thanks, Mom!)

Memory:  Within Normal Limits (YAY – this is HUGE in learning)

Highlights of the summary – Noah was pleasant, transitioned easily, cooperated, motivated.  Participated in turn taking.  Adequate communication intent and sustained focus to tasks with appropriate affect.  Noah appeared to enjoy his interaction with the clinician.  Use of communication for behavioral regulation (requesting/protesting) falls in the verbal category.  (YAY!!!!  We’re finally out of “nonverbal.”  Hallelujah!  Communication for comfort, greeting, calling , requesting permission and showing off and joint attention, commenting requesting, providing information fall in preverbal to verbal category.  (I’ll take it!)

IMPRESSION – Severe cognitive-linguistic language disorder.  Severe neuro-motor speech disorder.

Mom’s impression:  This report reads like a gosh-dang prescription for PROMPT therapy.

Sigh.  So much for hoping for mild to moderate.   I haven’t had the heart to Google any of this stuff.  Maybe I will, maybe I won’t.  It won’t change anything.  And really, interpreting and summarizing all this has allowed me to see some encouraging things (hence the YAY YAY YAYs).  The first read was a bit like a kick in the teeth, if you know what I mean.

Please pray for Noah – for the words of his heart – and for his momma too – that she might have a little wisdom and discernment in what to do to help her courageous hero.

Thanks and Blessings,

Alyson