It's been a long time since I've talked about Ava's speech in more than a passing manner. Fall seems like as good a time as any to check in. It's been a long time and many of you started reading between my last update and this one so I'll begin with some background so you can understand how far she's come.
Ava was not talking at 22 months. She had a history of reduced babbling and an extremely limited phonemic repertoire (d, m, h and a couple of vowels). The only syllable shape she produced was CV. She used the word approximation "da" with an upward inflection for almost everything accompanied by pointing to the object she wanted. She could not imitate. She was beginning to give up on trying to talk at all turning to gestures instead.
At that point I abandoned the wait-and-hope-she-miraculously-catches-up approach and began to make phone calls. We briefly saw a local SLP who had put a flyer in the daycare who agreed that Ava's speech was significantly delayed and that she had many of the red flags for Childhood Apraxia of Speech. I called around and discovered that one of the national experts on CAS lives in our area and set up an appointment with her. We've been seeing her twice a month for well over a year and she's wonderful. We also had Ava assessed by early intervention, wrote an IFSP, and began receiving services. Finally I set up a program of home therapy with her.
At that point I knew Ava was delayed - really delayed. What I couldn't yet anticipate was prognosis. It would depend on how well she responded to therapy. Some children respond well to therapy and make progress quickly. In those cases, prognosis is pretty good. In other cases the children, parents, and therapists work hard, frequently and intensely and progress is still slow. In those cases, prognosis is poorer. You know you're going to have to work harder and longer. You know progress will be slower and that the child may not ever have typical speech. I didn't know which category Ava would fall into, but I feared, based upon how delayed she was that she would fall into the second category.
We were so lucky. Ava responded well to therapy. Really well. I was doing updates on the blog every 2-3 weeks and it was like I was describing a completely different child. First she was learning to produce new consonants and vowels. Then she added more complex syllable shapes. She went from one syllable to two and from one-word utterances to multi-word utterances. We went from almost no speech to lots of speech that was extremely difficult to understand because there were multiple errors in every utterance.
Slowly we worked on speech errors. Some sounds and categories of sounds she learned quickly and easily. /s/ and /l/ came relatively quickly even in blends. Now she uses them conversationally with no problem. Other sounds we've worked on for well over a year and they're still a struggle (/k/, /g/). As more sounds came in and fewer sounds are left that are in error she became easier to understand.
Right now she's intelligible most of the time. She struggles most with sounds produced in the back of the mouth. She fronts /k/ and /g/ producing /t/ and /d/ instead. She also fronts /ch/ and /J/. /th/ is produced as an /f/. There are plenty targets left to work on. The almost complete absence of back sounds certainly impacts her speech in a noticeable way. Her language helps her though. She's using long sentences in conversation. You usually have enough context from the conversation and from the rest of the words in the sentence to figure out the one or two words that would have been unintelligible in isolation. You can ask her to tell you a different way or give you a clue and she is able to rephrase her message to help you.
Ms. J (our local apraxia expert) has even suggested we take a hiatus from visiting her because Ava has made such great progress. We're stuck working on trying to break through on those back sounds and I can do that myself with her at home.
Ava is heading off to preschool next week and I am not worried about her speech significantly impacting her experience there. Yes, her speech is not typical, but she is understandable. I am so grateful that all her hard work has paid off. Prognosis is good. If we keep working, I expect that the remaining speech errors will be corrected in time. At some point, I truly think her speech will be typical. Until then, we'll keep working at it.