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A Case Study of Childhood Apraxia of Speech

The following is a case study which is based on several actual children I have seen over the years with the diagnosis of dyspraxia or apraxia. The name is fictitious.

Published | By
Patti Hamaguchi, M.A., CCC-SLP

Jamie, a six year-old boy, moved into town and entered first grade. He was very unintelligible (hard to understand), but seemed to have a lot to say.

His teacher said he did well on many of the math papers, but struggled with letters and sounds. Jamie had been receiving speech therapy for the past year and a half in his previous school, but his mother reported little noticeable progress.

We did a more complete educational evaluation, including a speech-language assessment. We found that Jamie had some fine-motor weaknesses and sensory integration delays, which were identified by the occupational therapist. The fine-motor weaknesses explain why he had such difficulty with such things as gripping his pencil and writing his letters on the line in an appropriate way. The sensory integration difficulties also explained why he was resistant to wearing clothes of different textures, was knocking into walls as he walked, and didn’t seem to sense when crumbs were left on his mouth after snack. The occupational therapist (“OT”) began therapy once a week in a small group in the therapy room. Later in the year, much of the therapy was done in the class.

The special education teacher did a learning disabilities assessment and found there was difficulty in most areas related to sequencing. Jamie could not put pictures of a story sequence in order, repeat words in order, or copy letters in order. His letter-sound understanding (“S” says “sss”) was adequate. He could read some memorized words, but could not sound out a new word, even when he knew each sound in the word. His math skills seemed to be age appropriate and his attention span was good. Special education help was initiated, with the special education teacher going into the first grade class to help Jamie during Language Arts.

In terms of the speech-language assessment, I found that Jamie’s difficulties were a pretty classic case of “dyspraxia”, also known as “Developmental Dyspraxia of Speech” or apraxia. While he had been previously identified as having a severe articulation disorder, the word dyspraxia never appeared in any of his previous evaluation reports. How did I know? Jamie was able to produce nearly all the vowel and consonant sounds in isolation. If I said, “Jamie, say ‘ah’ (as in *apple*), he could do it. He could say “apple” if he concentrated. He could say “pie”. But if I asked him to say “apple pie”, this is what I heard: “paboo bie”. If I asked him to say it three times, I would get three answers. Another attempt might sound like “pappie bah”. There was no consistency. He often produced single words clearly, but fell apart in phrases and conversation. Words with more than one syllable were also much more difficult for him to pronounce. Sounds that were produced in one word (the “s” in “bu*s*”) were left off in other places (“s” in the phrase “I *s*ee”). Moreover, his global difficulty with sequencing, fine-motor, and sensory integration was typical for children with dyspraxia. He could tell what he said wasn’t sounding right, and was visibly frustrated, but couldn’t *sequence* the sounds and syllables to match what I said.

This might explain why his previous therapy, which consisted of ear training and traditional articulation therapy (where he worked on one sound at a time in single words) wasn’t producing any significant change. He was also getting oral-motor therapy designed to strengthen his muscles. I’m guessing the previous therapist knew his mouth wasn’t doing something right. However, when I saw Jamie, his tongue, lips, and other muscles were not weak or lacking control during nonspeech tasks. Perhaps the therapy had done its job, I couldn’t tell. While some children with dyspraxia have difficulty with verbal as well as nonverbal oral movements, Jamie did not. He was able to open his mouth, stick out his tongue, and perform a variety of other commands with normal timing and precision. His chewing, drinking and swallowing were normal. His tongue did not protrude at rest, his jaw did not slide during speech tasks, and he did not drool.

Lastly, Jamie’s sentence structure (syntax) was fragmented. He said things such as “Morrow I bay di my dend” (Tomorrow I play with my friend) and I noticed some word-retrieval difficulties in conversation and on picture-naming tests. That is, he recognized a word’s meaning when he heard it, but could not remember it when asked to name a picture. This too, is not uncommon with dyspraxic children.

In terms of therapy, I began a very structured, systematic approach. I incorporated a variety of methods, such as the PROMPT technique (which Deborah Hayden wrote about in this web-site as well) and drills which work at the syllable level, then are incorporated into phrases and conversation. Words that were too difficult for Jamie to produce but of high interest, were broken down into easier “versions” so he could at least approximate a consistent way of saying what he wanted. I also began using the Phonemic Synthesis program, which helps children auditorily learn to blend sounds and sequence them. This helps their speech, decoding, spelling, and word retrieval. Initially, individual sounds within a syllable or word were cued with gestures to help Jamie sequence them. As he improved, each word in a phrase was cued. Without a great deal of home practicing, all of my efforts would have been of little benefit. However, Jamie and his mother were diligent and it paid off.

By the middle of second grade (a year and a half later), Jamie’s speech was significantly improved. By the beginning of fourth grade, he was done with articulation therapy and occupational therapy. However, Jamie still needed some special education support in Language Arts and work on developing his expressive language. As is sometimes the case, Jamie will most likely need some kind of speech and/or special education assistance for awhile. But he is a “normal” boy and looks and sounds like the rest of his friends at this writing.

About the Author

Patti Hamaguchi has a private pediatric speech therapy practice in Cupertino, California. She has a master’s degree in Speech-Language Pathology from the College of New Jersey and holds the CCC (Certificate of Clinical Competency) from ASHA. She is the author of Childhood Speech, Language & Listening Problems: What Every Parent Should Know (John Wiley & Sons, 1995) and It’s Time to Listen (Psychological Corporation/Communication Skill Builders, 1995). She was a contributing author to Parent Articles 2 (Communication Skill Builders, 1995). Before moving to California in 1996, Mrs. Hamaguchi was on staff at Sara Rosenfeld-Johnson’s Oral-Motor Speech-Language Pathology Associates, NY. For 16 years, she worked in public schools in NJ and CT.