Oral Apraxia

Quick Definition for those who don't know: Oral apraxia is difficulty with the motor planning involved in movements of the face, tongue, jaw that are not involved with speech. Examples include making a kiss, blowing bubbles, and sticking out the tongue.

We had a very interesting therapy session yesterday with our early intervention therapist. I mentioned that I was hoping to try to stimulate the /l/ sound a little because Ava needs to use it regularly in the name of someone close to her. Right now she substitutes the /y/ sound for the /l/. Her therapist suggested that we try to get her to lift her tongue up by holding a lollipop up near her upper lip and getting her to reach her tongue up to lick it. I thought it sounded like a fun activity and Ava rarely gets lollipops so she was going to love the activity.

It was incredibly hard for her. I know that Ava has some oral apraxia. I know she smiled late, blew raspberries late, and made kissing sounds late. I know she has trouble imitating things like sticking out her tongue, blowing bubbles, and biting her lip. I had never seen the struggle so clearly though. She just could not get her tongue to move up at all. She wanted to. She was trying so hard her whole jaw practically quivered. She tried to compensate by using her bottom lip to try to raise the tongue up which didn’t work at all. We finally got some success by bringing the lollipop down to her tongue and then having the tongue follow the lollipop up as we raised it a little.

Michael saw his sister getting a lollipop and wanted some too. We figured letting him do it would be a good model for her. He couldn’t do it either. His attempts looked exactly like hers. It’s fascinating that his speech is pretty good with no real signs of verbal apraxia at this point (even though his early development was worrisome), but he does have oral apraxia. I knew he couldn’t blow bubbles, but since he was talking just fine, I didn’t really examine the issue closer.

I’m not sure what the significance of the oral apraxia is. I haven’t really had a chance to process this new information. I need to think and then research a little. It doesn’t really change anything. Yes, I saw it more clearly today, but it has always been there. Perhaps though, I can use the new insight to find some new strategies for working with her. If nothing else, it very clearly reminds me why it’s almost impossible to teach her a new sound (for example /l/ by lifting the tongue or /f/ by biting the lip) by simply having her watch me do it and asking her to imitate the motion. She can’t. She really just can’t.

This is a striking example of why you can’t treat apraxia like other speech disorders. With an articulation disorder or a phonological disorder the children can watch you and imitate the oral-motor actions. Often, children with apraxia can’t. You need to use alternate strategies.

The Weekly Review: Week Two

Blog Post I Enjoyed Most: I really liked this post on Balancing Everything. I’m a teacher and an SLP so education themed posts always interest me. I’m also fascinated by the idea of homeschooling. I don’t think I could do it, but I admire the people who do it well. This is a post by a mom who homeschools four children. She describes the activities they did during a week of science exploration. She includes great pictures of some of their projects.

Interesting Apraxia Article: Speech and Language Development in Infants and Young Children by Caroline Bowen. This isn’t actually an article about apraxia. It’s an article about speech and language development. You have to know what is typical before you can decide how worried you need to be.

Sibling Moment of the Week You know the kind of awkward hug you give an ex-boyfriend when you encounter them on the street and you aren’t even sure that’s the appropriate way of greeting them? Well, I missed the very beginning of the interaction, but I walked in on Ava and Michael giving each other a very awkward hug. Then they just kind of stood there for a second. So, I said something to the effect of, “Oh, are you guys wrestling? How fun!” They immediately started giggling and kind of pushing against each other. Michael promptly pushed Ava over and fell right on top of her. They both busted out laughing and scrambled back to their feet with Ava pleading, “more, more.” So they go through the awkward hug process again, and again Michael topples Ava right over landing on top of her. Much laughter ensued. This went on several rounds until the game was ended by Michael’s head connecting with Ava’s check hard enough to leave a bruise. So, it didn’t end well but it was still a beautiful five minutes. Those moments when my children are playing with each other (not both playing with me, but truly playing with each other) captivate me. I love watching them bond as siblings.

Michael’s Question: We were reading Mouse Soup at bedtime. Michael knows his letters and a lot of sound correspondences, so I’m doing a little pre-reading skills work during our reading time. For example, I’ll point to each word of the title as I read it. Then I’ll ask, “Which word is mouse?” Then I pointed to the “m” and said mmmm, the “ou” and said ow, and the “s” and said sssss. I just kind of skipped the “e” since I figured that explanation was a bit too complex for now. He never misses anything though and interrupted the beginning of the story to ask, “Mama, why is that E there at the end of mouse?” To be honest, I didn’t quite know how to answer him. I said something about how sometimes “they” add a silent e to the ends of words even though it really doesn’t make much sense. I was so proud that he thought to ask the question though.

Ava’s new favorite word: No. (and not) She loves using it in the typical toddler defiant fashion. She’s also using it in a large percentage of her sentences. She’s obviously exploring the concept and testing it out. So, she’ll say something like, “Ava pink shoes. No mama pink shoes.” Or, she’ll say, “Mama no tickle.” Now imagine a negative attached to most of our conversations and you get the idea.

Birthday of the Week: Happy birthday to my wonderful husband. It was the first year the children could understand and participate in celebrating the birthday of one of their parents. They had a great time blowing up balloons and “helping” me put the letters on the cake. We were getting ready to surprise Daddy when he came home from work, but the kids managed to let the surprise slip before he got around the corner to where he could see the kitchen table. It didn’t matter though. He loved it anyway.

Good Luck

I feel like I’ve won the lottery. I know how astoundingly lucky we are that Ava has been so responsive to therapy (and fish oil supplementation?). I know that some children work just as hard, or harder, for months and see so much less progress. Their parents are right there with them feeling the frustration and fears too.

Three months ago all I knew was Ava had three words: /mo/ for “more”, /uh oh/, and /da?/ for everything else. I knew that she wasn’t even trying to talk anymore and was resorting to more and more gestures. I knew she didn’t even babble other sounds and that she couldn’t imitate. When she was evaluated by early intervention she tested at the 4 month old level. I had two different therapists besides myself tell me that Ava had many of the early red flag signs of apraxia.

I admit it. I panicked. As a speech-language pathologist I knew exactly what that meant. I knew we were dealing with a neurological motor planning speech disorder that can take several years of intensive speech therapy to address. And I so didn’t want that kind of struggle to be part of Ava’s life. I know hardships are a part of life, but she’s my baby and I didn’t want this one for her. I worked my way through the initial denial and then depression. I ended up in a productive place where I researched, planned and set up a therapy schedule for Ava.

I prepared my family for the worst. Severe apraxia seemed like a definite possibility given how behind she was. However, I told them that we wouldn’t know how bad it was until we saw how she responded to therapy. And it turns out, she responds well.

That changes things. The fear that she might still be using single words when she starts school is gone. Now, whether anyone will understand her…? We still have so far to go. By no means is her speech that of a typical two year old. But there’s been progress and that much is a profound relief.