planning issues with speech

[caedmyn]

My 6 yo has been doing speech therapy for 1.5 years.  He can say all the sounds he's worked on when he's thinking about saying them properly, but in his day-to-day speech he doesn't say any of them properly (any of the sounds he has trouble with, not every sound).  The speech therapist told me the other day that she would have expected him to have obtained automaticity by now and he probably has some sort of planning issue.  How concerned should I be about this?  Is there something that should be done about it, or will it eventually resolve with continued speech therapy?

[PeterPan]

Well it sounds like she means motor planning, yes? Did you ask her to clarify what kind of planning? 

The unfortunate thing is that most SLPs seem kind of flummoxed by what to do for apraxia (motor planning of speech) problems. The things I've seen bantied about are just about astonishing, with therapists telling other therapists to use things because they're free online, etc. 

The test to quantify whether there are motor planning problems is the VMPAC. Sounds like your SLP is guessing, and that's sort of old school and what's left when you don't have the VMPAC. There may be another test by now, dunno. But you get in with an apraxia expert and you'd like to see that quantified and sorted out.

I agree with you that telling someone to try harder isn't really appropriate/kind/compassionate if there's a physical reason they can't do it. Just as a total side rabbit trail, I would also want his hearing checked and think through that phonological processing. How far has he gotten and how well is he discriminating sounds (minimal difference pairs) and has working on that bumped the speech at all? I really like Attention Good Listeners (DeGaetano) and if he is still having issues with discrimination I highly recommend it. Brilliant and easy to implement.

So I have no clue if it's motor planning or not. You'd like some data to sort that out. I always recommend PROMPT for motor planning of speech problems, and a person who has enough training with PROMPT (basic, bridging, certified, instructor, more is more better) can help you sort it out, especially if they're running the VMPAC or something equivalent. if the person only has that basic/intro training, the potential for errors in their analysis is high. You can use the PROMPT Institute provider locator, drive farther for the eval (to get the answer RIGHT) and then figure out how you want to handle therapy. It's ok to go to a lower trained person if they're committed to continuing their training and growing with him, sure.

Just in general, the reason this happens is because the therapist went for end goals (the sounds they wanted) without working through the heirarchy of production. So he could be missing key pieces like jaw stability, rounding, etc. So sometimes what the PROMPT therapist has to do is stop and go back and build those pieces. Cleans everything up and then the dc can move forward. So even if the SLP says he "has sounds" it doesn't mean he has all the movements to form them correctly over the long-haul. But that's stuff the VMPAC or equivalent testing will sort out for you. They go through all the pieces of the motor planning and can isolate them, demonstrate the issues, and quantify them. Then you'll know what you're dealing with.

[PeterPan]

52 minutes ago, caedmyn said:

How concerned should I be about this?  Is there something that should be done about it, or will it eventually resolve with continued speech therapy?

Well a dc should be completely intelligible at age 6. He doesn't have to have all his sounds, but he should be intelligible. This means someone talks to him in the store, he replies, and they can understand what he said. Even if he's Rs are not there or whatever, the person should be able to understand him without you having to step in. So yes, if he is not 100% intelligible at this point, it's an issue. If he is not able to use independently in everyday speech all sounds except the last few (th, r, etc.), it's an issue. There are charts for that. If his NARRATIVE LANGUAGE is not developing and he demonstrating age-appropriate narrative language skills, it's an issue.

What can the outcomes be with apraxia, if it's apraxia? There's a range of severity. Could be mild and he just sounds like he has an accent or it could be moderate or severe, meaning that without a change he'll probably sound as bad in 5 years as he does now. Sorry to be so entirely pessimistic. What you can ask is whether they can quantify the severity of the praxis with data so you can make informed decisions. I don't know that there's a lot of data on severity of the praxis and outcomes. Almost all therapy is crap worthless for apraxia. When you have people being told is apraxia and they do therapy and then like WHOOSH the sounds come in perfectly, that (from what I've been told) is called a developmental delay, not apraxia. 

So yes, if it's moderate to severe, the potential for a very bad outcome by continuing with a non-expert is there, absolutely. I don't think "experts" in apraxia are necessarily expert anyway, because some of them are still using Kauffman, etc. You also have to factor in not only the severity of the praxis and the quality of the therapy but also just the reality of the dc. Severe praxis plus severe language delay is going to be a lot more of a slog than severe praxis plus moderate language delay. The dc's overall developmental situation will matter. There has to be communicative intent, and the therapist can't get language out that isn't ready, developmentally, to happen. 

So would I be concerned? Yes. Would I freak out, no. There are excellent interventions available (PROMPT) and you can have a good outcome. It's a good sign that he has communicative intent. You'll probably want to go ahead and run psych evals pretty soon and examine the larger developmental questions. The biggest hole we had with ds was language. He had so much memorized language that we really did not understand the extent of his language delay and deficits. I spent a LONG TIME under the vague, completely incorrect assumption (that probably nobody told but I just thought in my pea brain) that if I got the motor planning complete the language would be there. Well it wasn't and now we've had a lot of payback and a lot of ground to cover. 

I'd like to say something positive, but to me that's all just emotion. You need some data to sort out what's going on and make a plan. The truth is it really depends on the exact mix going on with your dc (severity of each piece, how they're interacting together). You've already got behavioral challenges and phonological processing problems, yes? So you want evals. If there was a dc to push for evals on, this is the one. Just saying. Like I know you've been in circles on that, but this is the one. 

[kbutton]

My son doesn't have things automatic, but he started later than your son (we were told he didn't need therapy, yada, yada). He has had PROMPT for apraxia, so if motor planning alone were the issue, then we're doing good stuff for it. In my son's case, he has a connective tissue disorder that makes jaw stability hard to obtain for long--he fatigues big time.

My son essentially turns his good speech therapy on and off. I worry that he'll lose ground if we stop, but he is still making progress on his last few sounds. He understands cognitively exactly what the exercises accomplish and why he does them. He literally refused to allow the therapy until he had a convincing and thorough explanation. He relies on that understanding to make himself speak correctly, and that still isn't enough for automaticity.

I am not sure what the long-term data is across the board for automatically using good speech, accounting for both apraxia and non-apraxia-related speech problems.

[exercise_guru]

I can share our experience in integrating the R into normal everyday speach.  Its like a motor planning repetition issue only that part is happening in the brain. The solution we found is to "turn on" the speach process several times a day and create opportunities to increase repetitions. The answer to most remediation is repetition and if the research in interactive metronome is accurate it takes 10,000 repetitions to build a new skill and probably a lot more remediate a skill. 

You child is much younger than mine so he hasn't had as many years to break and build a bad habit in speach. 

We are fixing this problem of integration into everyday speech with a few method. My son creates a video each day of some sentences that are created and then we watch it back and praise and get feedback. Its only a 2 minute video and we focus on first getting the sound to appear in a sentences once. Then once that is accurate we put the sound in the sentence twice. We build the sentences in while using the videos as feedback and self monitoring. It works but it takes time to integrate. Repetition, praise, repetition praise. We used pennies for reward for a long time or skittles whatever.  

The other method we use is a bit more sophisticated we use a metorome and say the sentences at an even slow temp. Then when we can nail the sentence we dial the sentence up 5bpm and repeat until we master the sentence at that temp. We continue to do this until over time we can pronounce the sentence at a normal speed. IF the sentence jhas too many complicated R's in it we simplify and focus on one spefic sound in the sentence until we get a very simple sentence. 

To keep it interesting we make up silly sentences and we do "I say " you say and then use the video as feedback from the video.