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Expressive Language 1 Standard Deviation Above Receptive Language?

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Any ideas?


Background: My son is 2 years, 9 months. We are beginning speech therapy for dyspraxia (apraxia), articulation errors, and phonological mapping errors. We are also looking to address some apparent auditory processing issues and sensory issues. We are supposed to start transitioning to school services at 3, but his articulation is just shy of the two standard deviations below average you need to be eligible for school services, so that's not guaranteed. For the moment we are ignoring an odd dysfluency where my son repeats the last sound in a thought or sentence, because his older sister also did that and it has since extinguished in her speech. (Are we going to the park-k-k-k-k?) It's not echolalia.


We just completed an expressive and receptive inventory with his SLP (I'm unsure of the title) and the results were 1 standard deviation apart, with a higher expressive than receptive score. Not only were the scores showing higher expressive than receptive abilities, he didn't understand the concept of "not" in the receptive test, but he uses it in a variety of contexts. What would this mean? I've tried googling, but all I'm getting is autism or aspergers. It could be that, but that wouldn't be the first conclusion I'd jump to. Is this an auditory processing issue, and how?

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At the moment, I'm not quickly coming up with a really good reference to share with you, but it is often said that it is common for children with an auditory processing disorder to have lower scores on receptive language tests than for expressive language tests.

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He does not sound just like my son, but if you think it might have to do with how he is hearing letter sounds/speech sounds, there is a section in The Mislabelled Child by Eide.


My oldest son had some issues that seemed similar to dyspraxia (with some nonstimulable sounds, some trouble moving his tongue in his mouth). But, then he had some articulation errors I now think were caused by a problem with sound discrimination.


In (I think) the language section, he has a little set of questions, that are going to help determine if articulation errors might be caused by mishearing sounds, or by motor problems. I do think my son had a little of motor problems and a lot of mishearing sounds.


I think "phonological" can be a code word for mishearing sounds, sometimes, but I am sure not always. We had that word used with my son also.


My son is much improved, but it did take time and therapy. He went to speech therapy for this for about 8 months in 1st grade, 2x/week. At that time his articulation age was 2 years 11 months, and below the 10th percentile. Last Winter in 2nd grade his articulation score from the school speech therapist was 103 up from 63 the year before. So for him at least it has been treatable.


Here is what I would like to ask the therapist: Does this receptive score accurately reflect his abilities, or is it showing a weak area for the purposes of finding out what help he needs?


B/c, if this was my son, that is what it would show in a way.


For those tests sometimes there is not context, sometimes the therapist might be allowed to repeat a question only one time. Now -- with no context and no repetitions, my son could have just not registered or picked up on the word "not." But it wouldn't mean he didn't understand it or know it.


What we saw with him -- lots of copying other kids instead of directly following directions in a group, sometimes not understanding sentences.


What I would say -- it was like a lot of words were homophones to him, b/c they might sound the same to him. Then it would be worse if there was noise, if he couldn't see the person's face, etc.


I am going to see if I can find a video kind-of about it, also.


And -- this easily is not what is going on. I am just mentioning it.

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This article has some details, it was a high hit on google. I think the similar section in the Eide book is maybe a little better.


Where I disagree with this article: I think it is not either/or. It is two aspects for a lot of kids, I think.


But from other reading, when there is not good consistent articulation of a sound, sometimes (but not always), this can mean there is not a "stable model" for that sound. But speech therapy and some programs (a lot related to reading/dyslexia) can work to create the "stable model." Some kids with an articulation error do have a stable model of the sound, but some do not. It is not either/or for a kid who also has articulation errors for other reasons. But if they don't have a stable physical model that can make it more difficult to form the stable auditory model, if that is also difficult.


Separately, I read a book about auditory processing from the library. My son seems to only have problems with what is called: sound discrimination, auditory discrimination, phonological processing. (Auditory processing can include a lot of specific things, this is just one area.) He does not seem to have problems with background noise or other things, specifically. Those things might make it a little more challenging for him, but they are not specifically the problem.


Really he hears much better now.


Oh, I was going to say, he also never had an interest in silly kids books, rhyming books, word play, etc. when he was younger. He loved being read to but just didn't like books that were about having an interest in words. He liked stories for the plots and characters. But now (he has just turned 8) he does like to listen to rhyming books and silly books (maybe with a sentence where every word starts with the same letter, silly poems, etc) that I read to his little sister. But when he was younger they were nothing to him. I would always have described his listening comprehension as high, and I just didn't know why he didn't like certain kinds of books. Now I think it was part of this.

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DD10 (almost 11) has an expressive score on the 5th percentile, but a receptive one on the 2nd percentile. It sounds very poor, but it is improving. Our initial pointer was toward an ASD diagnosis, but it has become clear, now that her language has improved to the point where it is functional, that the language issue was the root of all the problems. She definitely has CAPD. The use of 'not' or 'don't' is a classic for CAPD, as if you drop just that word it changes the meaning of the whole sentence.

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Yeah, I adjusted my own speech automatically, but I would see my son "get in trouble" with other people, who did not speak clearly to him (aka spoke in a way that the meaning would be ambigous to my son) and having a sentence with just "don't" was one that was big for him.


However for his age I think that is also just the best way to talk to kids.


If you see him seem to do "worse" with certain people or group situations, I would be aware, that maybe this is a reason why. Then maybe he is anxious b/c of not knowing what do and not anxiety per se.


This was not a huge deal for my son, but I wish I had known it earlier.


For him, in context it was never a problem. But then when you might not know to expect "do it" or "don't do it" then that is where it would be hard for him. So it was like, sometimes I would see it, and other times he was fine. But it would also come across as being negative about a change in routine, or as having a hard time transitioning, sometimes. B/c when it went from "do it' to "don't do it" he might not pick that up.


Another thing, I have been told that I use a lot of expressiveness in my gestures, and that would also have been cueing him. But I do not realize this. So I think I am just telling him, but I am not.


It is good to do, the thing is, if it might be a problem when that is not present, it is just good to know, maybe that is the reason for the problem.

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Wow, lots to think about now.


I'm not sure how much of the phonological mapping the SLP is attributing to the auditory processing and how much to the dyspraxia. He has very inconsistent mapping for a lot of his sounds, and will repeat a word back to you in different ways. He has sounds like an approximation for "k" that he can use, but not at the beginning of words. He has to "work hard" to get his sounds out, and his prosody (timing and stresses) stood out as dyspraxia to the SLP. For a long time, mama and dada sounded the same, but if he was sticking his tongue out while he said it he was trying to say dada. He didn't babble much. I'm not sure how intelligible he is to strangers, but the SLP and I both have trouble figuring out what he is saying, even in context. I don't know if he's making different sounds for the same letter because he is hearing them differently or because he doesn't know how to move his mouth when he makes that sound within a word. He does also have some consistent mapping errors.


I think the receptive score is showing something we need to work on, and the SLP did say that it is something we will work on, and in conjunction with the OT as well as soon as they can get us in there too. The SLP also thinks that his auditory processing is artificially lowering his expressive score, and that the difference between the two would have been even greater if it wasn't for the design of the evaluation. I was there for everything, and she did repeat the question more than once. For a few of the questions, he started to point to an answer before changing his mind to the correct answer. The SLP thinks he was starting to answer before he had figured out what the question was. The "not" questions were things like "which baby is not crying?" Reflecting afterward, I have seen him have trouble with it in day to day activities as well. He generalizes it in a lot of contexts, so I'm convinced he understands the concept. But how did he learn it if he can't hear it most of the time? I do try to reframe my statements for him now.


He can't do something and listen to you at the same time. (Or at least not listen and respond.) This is especially obvious when he's doing something sensory-related like playing with a tub of beans. If you put your hand on his shoulder and get his attention he will answer you happily, but otherwise you might as well be talking to the wall.

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You need to get his hearing checked. And no, timing and prosody aren't what they're looking for at this age to determine apraxia, mercy. When he's 3 they can give the VMPAC (test of motor control). It will look at all the basic motor control, things like rounding, jaw movement, putting lips together, etc. These are easily demonstrable even now. With what you're saying though, I would back up and get that hearing eval ASAP. Not a regular eval but the kind in a booth. Around here you get one for $300 in a booth that checks at the basic level and screens, then you go to the Children's Hospital and get the really expensive, even more sophisticated eval. You certainly have warrant for it. Look at what you said. If you talk to him when he's not looking at you, he doesn't respond. He may be reading lips. He may have hearing loss. He may have an auditory processing disorder, where he hears but doesn't process it all accurately. So you've got to get this eval'd. Yes you can have layers, and no apraxia almost never occurs in isolation. But for someone to say you have apraxia going on because there's a timing issue or prosody, that's too generic. They can and should be looking at actual, specific motor control issues. At that age my ds could not pick his jaw up if it dropped down while he was trying to speak. He had lateral movement from instability and low tone. He could not round. There are specific things in motor control a specialist will look for. Right now you're getting generic answers.

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We've had a regular audiologist evaluation in a booth with earbuds. The actual hearing part was fine. He can hear you when he's not looking at you. He just doesn't pay attention to what you're saying unless you cue him in some way. My sister had hearing loss as a child so that's one avenue that I've been extremely vigilant in checking. There were some identification tasks where he first pointed to the wrong picture then corrected himself at the audiologist. That lines up with what the SLP has seen regarding processing. I'm not sure where we are going regarding further auditory processing testing, but can he hear, period? Yes.


I think lack of muscle control due to weakness is dysarthria, right? We have some low tone issues, but that doesn't seem to be the reason he is having trouble. He does have trouble doing things like licking off his lips or his teeth, making faces, that sort of thing. His trouble lies more in coordinating than muscle weakness. We are doing some exercises and sensory chewing stuff because he has more trouble with the back of his mouth than the front, but that is more about sensory organization and stimulation than straight muscle building.


The prosody was one of the things that the SLP pointed out to me as easy to hear when I asked her why she was saying dyspraxia (apraxia) after the first few evaluations. She was telling me to look at the way he was visibly pausing and planning his movements very deliberately, and still struggling with them. I believe she also did some components of the Kaufman test.

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With more details that doesn't sound like my son.


However -- I think the word "mapping" might mean the same as "stable model" I have seen used.


So this is my opinion: for most kids they get consistent feedback between their pronunciation and their hearing, for their own speech. They link their mouth movements to what they hear, and adjust them to fit.


So if there might be a problem both ways, it might be a little chicken-and-egg. I think the therapist might see what he responds to, to some extent.


My younger son does have trouble with attending like you mention, that is what I hear it called when they don't realize you are talking to them or don't realize they should respond. He does have autism, but this is just one part of him having autism. But auditory processing difficulty of some kind I am sure is linked to this for him, and auditory processing difficulty is very common with autism, too. Autism is a productive, helpful diagnosis for him bc he has it. ABA therapy is helping him. But really my son has many signs.


But anyway, there are different ways kids develop the mapping. I have read about kids who develop it while looking at letters while listening, bc it gave them a visual key -- then with the letters like a map, they could start to match what they heard to the letters. My son had serious trouble even learning letters though (prior to methods used in speech therapy). But they can use things like looking at the therapist's mouth, looking at their own mouth in the mirror, sorting two sounds, looking at letters, etc. to eventually reach a place where they have a map for the sound a, the mouth position of a, the sight of the letter a ----- or this is the goal. When 1 or 2 of them are there, it is easier to get to the others. If they are all difficult, maybe there is incremental progress made on all of them.


Anyway that is my guess for maybe where some of it is going.


I had serious disagreements with the autism chapter in the Eide book. My son does have social feelings and connections. I see no reason to say "oh well then he should not be diagnosed with autism." Right now that is not on the diagnostic list. And ---- my son does fit the diagnostic list and benefit from ABA. But he does not fit with a lot of things about "this is how autistic children are." So I would just say not to get sidetracked there. But also -- I am only saying that bc you said autism has been mentioned. It would not occur to me if you hadn't mentioned it.

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Just going to about my son who does have autism.


He has some weakness in attending and eye gaze. That is where he doesn't respond, he doesn't look. Sometimes he looks, sometimes he doesn't. Sometimes he looks like he is not paying any attention at all, and then he reacts in a way showing understanding. Other times he does not react, like if you do the old "lets see if be responds if we talk about ice cream." (He is better than this now, but when he was 2-3 that is what I saw a lot.)


He is much more consistent with responding when he can see something. Like -- he will imitate freezing every time, but often does not pay attention to the word "stop." So that seems to be auditory to me.


But still -- I could see this behavior be just bc auditory processing, or part of autism. It is part of autism for my son. But I don't think it has to be at all.


We also spent about a year thinking my son's attending issues were due to fluids in his ears, and he did have fluids and get tubes. So apparently that can have the same appearance. I think that is worth checking on, too.

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No one else has said autism, but I really haven't asked about it either. I mentioned it because that was what kept popping up on my searches for the difference in expressive and receptive language, and I didn't know if that was the most common cause of those unusual scores. I'll be interested to see where my conversation with the SLP leads at our next visit.

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I tend to think someone would have said it to you. If it is just from searches ----- I can see why it would turn up in searches, but Internet searches can be unhelpful sometimes, with pages of top results about something more common but not what I'm looking for, if I don't know terminology to get a better result.


I think if you let your speech therapist know you are interested in more detail, she can tell you more. She will know what is specific to your child.

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I don't know enough to comment on the Speech Language tests. But I noticed you said ds was just short of qualifying for services. If he needs 2 SD in one area, would he qualify with 1SD in multiple areas? Also, I wanted to add that different testers can come up with different results. I'm not talking about re-testing with the same tests, but having a tester identify tests or subtests that will pinpoint areas of weakness.


If you can get SL services, even if it's not specifically for articulation, the ST could become a valuable ally for you.

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