But first, let me wear my detective hat!

by Noor Khatam, Bahrain

Once upon a time, in the wonder land as most of my kiddos think about it, I mean my speech and language therapy room. Little A attended accompanied by her mother. Little A is a 3 years old girl who is diagnosed with global developmental delay. I can’t even begin to describe how adorable she was, If so, I would be writing the longest blog that you will ever read.

However, I would like to share with you the detection part of my job.

To be honest, I love that part!

If you are a SLP and reading this you will probably agree that we have a lot of detection work to do for our clients. Don’t we? Still wondering about it? here we go.

In the evaluation session, I wore my detective hat and started the process of collecting information. I took a thorough case history. It revealed that little A was born with congenital heart deficits and she has gone through several heart surgeries. I did the oral motor examination and it revealed a triangular tip of tongue and spacing between her teeth. I noticed that the child was not able to imitate oral movements (e.g., tongue elevation, tongue lateralization). Furthermore, I did informal language evaluation and I noticed that Little A receptive language was so much better than her expressive language. She was producing few common words (mostly idiomorphs). Little A was enrolled in speech and language therapy program to enhance language acquisition.

We have been working on our expressive language targets. She progressed very well and turned to be much more self-confident communicator in a very short period. She can express her needs, desires and feelings. I was reviewing her therapy plan and I took a big happy sigh when I saw her progress regarding her expressive language targets. I took another worried sigh regarding her intelligibility of speech. So I decided to put on my detective hat again and do my detection work. I took a speech sample, analyzed it, I did articulation and deep tests. I was detecting for answers to the following questions:

  • What is the child’s speech sounds inventory?
  • Where is the correct and aberrant articulations occurring within the word? Is it prevocalic, intervocalic or postvocalic?
  • What are the syllable shapes that the child mostly using?
  • Is there a collapse or preservation of phonemic contrasts? In other words, is the child able to maintain the function of each phoneme?
  • What are the phonological error patterns that represented in the child’s system?

Finding the answers for the above questions, were not as easy as asking them. However, all my detection work revealed that the child has highly inconsistent speech sound productions. All the aberrant sounds were produced correctly in abnormal contexts. The good thing is that I found some patterns like (velar assimilations, cluster reductions, stopping and weak syllable deletion). However, for some errors I could not find patterns. I noticed a lot of speech sound distortions; this could be related to the abnormal teeth gaping.

Based upon that she has highly inconsistent speech sound productions, not able to imitate oral movements, varied productions of the words among repetitions, increased errors with increased syllable complexity. I found myself between two diagnosis, childhood apraxia of speech or inconsistent phonological disorders or it could be both of them. Regardless of the diagnosis, little A definitely needs my help. I decided to do my best and increase my detection work in sessions.

It helped me a lot to know the discriminative and non-discriminative markers for childhood apraxia of speech (CAS).

Discriminative markers for CAS Non discriminative markers for CAS
Sound – based errors
Distortions in vowels and consonants substitutions. Voicing errors
Difficulty initiating initial articulatory configuration.

E.g. when the child attempt to say (hi), she may not open her mouth for the /h/ sound.

Inconsistency across productions
Increased difficulty with more phonetically and phototactically (syllable shape) complex words.
Prosody – based errors
Difficulty with transitionary movement gesture. Slow speech rate or slow DDK
Phrasal stress errors.

E.g. when the child is producing the phrase (/baba come/) the child may stress the wrong word.

Lexical stress errors.

E.g. (/ma:ma/ we stress the first syllable, children with CAS may say the word with inappropriate stress).

Syllable or word inappropriate segregation