Case Study

Jasmine: A Three Year Old Girl with Childhood Apraxia of Speech

Apraxia of speech is a neurological difference resulting in difficulty planning and executing the movements necessary for speech. It is a disorder of movement. The brain usually knows what it wants to say but the message gets twisted on its way from the brain to the muscles of the articulation structures (lips, tongue, soft palate). Typically, children with childhood apraxia of speech will be delayed in talking because it is so difficult to put sounds and syllables together. When they do talk, these children will often use very short sentences, will omit many initial consonants, especially “y, l, r,” and may, if asked to say the same word three times in a row, say it differently each time. Children with apraxia of speech are sometimes very creative as two year olds, developing numerous intricate gestures to refer to specific objects, needs, and situations. When I met Jasmine, she was using just a few single words but had many gestures which she used to communicate. She also used noises like animal and vehicle sounds. She was initially very reluctant to attempt imitation of sounds and words which is very typical. It is my experience that these children know early on that talking is hard and will try to avoid it. What we first did with Jasmine was warm up her imitation ability with non-speech muscle movements such as clapping, waving, and tapping the table. Then we worked to find some consonant- vowel combinations she could produce, such as “ba” and “bee.” Then I used my bouncy ball and a wind-up bee in this manner: I wound up the bee and held it so Jasmine could see it, got her attention, cued her to use her lips by touching my own, and said “bee.” The second she imitated ‘’bee,” I released the toy and it “walked” toward her. The idea is to associate a desired toy or activity with the word then immediately reinforces the effort required to say the object’s name by giving her the toy as soon as possible. We did the same thing with “ball.” At the same time, we worked on finding a set of sounds that Jasmine could consistently imitate that would be consistent and would resemble an action verb. We settled on “doe” for “go.” I would say “go” and Jasmine would repeat “doe.” This of course was an intermediate step; we most certainly would be after “go” when she was able to make that sound. Soon, I was able to hold up, for example, the ball, and say, “Jasmine says ‘go ball. Go (and she produced “Doe”) ball (and she produced “ba”).” Then, immediately I rolled or bounced the ball to her. Again the most important concept was to show her the usefulness of language was worth the effort required to make the sounds and syllables. My experience with children with apraxia of speech is that they need to gain confidence that when they make the extra-ordinary effort required to produce an understandable word, they will be rewarded by being understood. Progress for these children requires many, many repetitions of functional words. As they do so, many seem to gain an understanding and acceptance of the extra effort required to produce understandable words. My task with Jasmine was to develop, within the first few months, a number of two and three- word functional phrases that she would imitate to get toys or to get the toy to “do” something.

As often happens, the repeated practice of the speech therapy functional phrases seemed to “jump start” other words and phrases for Jasmine that we had not taught. It should also be noted that at the beginning of most of our speech therapy sessions, we did some ‘mouth wake up activities by stimulating Jasmine’s hard and soft palate, her lips and tongue, and generally just creating some oral awareness of these structures. I used a toothbrush her mom had brought in as well as dental swabs and a tongue depressor and some hard plastic chew toys specifically made for oral stimulation. We had the mother do the same at home. Jasmine’s progress was caused primarily by her realization of the effort required to make understandable speech and her acceptance of that fact, not by the oral motor exercises. They however, did help to make it easier for her to get the articulators to do what she wanted them to do.

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