The following are tips for parents who suspect apraxia of speech may be an issue in their child and are seeking a speech/language evaluation. The tips were put together by an experienced mom involved with the Apraxia-KIDSSM Network.
I am not a speech pathologist. However, over time; through my own experience with my son; conversations with speech pathologists; and reading professional literature, I have gained some information and offer you my thoughts, opinions, and ideas to consider when you are seeking a comprehensive speech and language assessment. This will be especially tailored toward parents who suspect apraxia of speech but broadly can be relevant to other parents as well.
First, it seems to be the general rule that when there is concern for a child’s speech and language development, hearing tests are conducted to rule this out as a potential cause of the child’s problems. All of the other ideas addressed here will assume that this was the first course of action taken.
A speech language pathologist is the type of professional who is trained and qualified to evaluate your child’s speech and language development. As much as some other professionals have to offer (i.e. pediatricians, neurologists, psychologists, etc.), they do not have the special training and background in speech and language pathology that is necessary for the evaluation and diagnosis of speech/language problems. You should not rely on them to determine your child’s speech and language problems, although they can offer helpful information and referral. In the case of suspected apraxia of speech, parents will want to secure a speech language pathologist who has experience in the diagnosis and treatment of motor speech disorders or oral-motor functioning. Be prepared to request the evaluation be done with someone who has this experience. Do not hesitate to ask someone this question!
Know what you want out of an evaluation. Another way to think about it is to answer the question, “what do I want to know about my child upon completion of the evaluation?” Have goals for the evaluation and make sure those goals are communicated clearly to the evaluator ahead of time; that the evaluator understands your goals; and that the evaluator feels he can address those goals. An example is that when I took my son for a comprehensive evaluation, by phone and ahead of time, I told the evaluator that I wanted to know specifically why my son couldn’t talk (etiology); what was the name for his problem (the diagnosis); what could be done to help him (recommendations for treatment); and what kind of progress could be expected for Luke if he received appropriate treatment (prognosis). A good evaluator will most likely make a point of asking you your goals for the assessment, but regardless, don’t hesitate to speak up and offer them. I suspected that something had been missed by his early intervention therapist and so I arranged for a private evaluation.
NOTE: It is not always possible, even for the best of evaluators, to draw firm conclusions on diagnosis. Speech and language is extremely complex. The evaluator may need to go with “hunches”; recommend further specific evaluations by another person; or recommend trial therapy to try out their “hunches”. This can be frustrating but you should know it is a reality.
If at all possible, interview speech language pathologists and select someone to evaluate your child. I have nothing against new and/or young speech therapists, however, my thinking is that I want someone with solid experience to evaluate my child. Don’t hesitate to ask the evaluators about their credentials (go for at least a Master’s level with Certificate of Clinical Competence- CCC); and their experience (both in length of experience and population they have served). Children should be evaluated by clinicians who work with children! Also, as mentioned earlier in this paper, if you suspect that your child may have apraxia of speech, ask the evaluator about their experience in diagnosing and treating children with this condition. Sometimes it is not possible to personally select someone, but I recommend still interviewing the person ahead of time.
Understand that there are many reasons that children may not be developing age-appropriate speech and/or language skills. Some children experience a developmental delay of speech – their speech is following a pretty typical path of childhood speech development, although at a slower rate and often commensurate with cognitive ability. Other children experience a specific speech and/or language disorder in which their speech is “off track” and not developing on a delayed course. It is my belief that these specific disorders should be identified as early as possible so that a child’s speech therapy can be individually targeted to their particular problems.
Apraxia of speech is not a developmental delay of speech. It is a specific speech disorder and is not likely to improve without properly tailored therapy. This is one reason why early diagnosis is best.
A complete speech and language evaluation includes more than a determination of the child’s age levels for expressive and receptive communication skills. It should include:
- a medical, social, and speech/language development history
- an examination of the physical structures of the oral cavity, if the child is able to cooperate
- examination of the speech subsystems and physiological support for speech (body position; breath support; etc.)
- examination of oral/motor functioning to determine any weakness, paralysis, in-coordination of the speech musculature, difficulties in motor planning, sequencing, and execution of speech sounds/words
- determination of language and speech skill development
The clinician may also try various facilitative methods with your child (i.e.: they may try various interventions to see how the child responds). This may also help the clinician draw conclusions and make recommendations. The clinician should then, based on all of the information, try to draw diagnostic conclusions (diagnosis); determine the impact of the problem on the child’s functioning (severity of the problem: mild, moderate, severe); make recommendations for therapy; and perhaps offer prognosis (best guess on how the child may do with appropriate help).
A word on prognosis – the evaluator may cautiously and conservatively offer this. They can be cautious for good reason. Speech pathologists cannot fully predict the future and there are many variables involved – including the uniqueness of each child! All of us parents want to know, “will my child be OK – eventually?” Although evaluations tend to focus on weaknesses, the speech pathologist should also be able to tell you various strengths and abilities your child has that will serve them well in therapy and could even share their previous experiences with children who may share similarities to your child. But they can only give you their best and human guess for the future. Children may either exceed or fall below an original prognosis and parents should keep a balanced view of this. Your child’s prognosis is enhanced by early, accurate diagnosis; therapy tailored to their problems; and your ongoing involvement throughout.
However, even given the above, be cautious about an evaluator who makes predictions about the entirety of the child’s life. I have had reports from parents that after their child’s diagnosis of apraxia of speech, the evaluator informed them that their child would never have speech that would be understood outside of the family. These children were only 3 years old! This kind of discussion should tell you that the evaluator may themselves have been unsuccessful in the treatment of children with apraxia of speech. Other speech and language pathologists, who do experience good outcomes, will likely inform parents that apraxia of speech is a challenging speech disorder; the outcomes can be variable, but proper therapy can go a long way in expanding the expressive ability of children with apraxia of speech.
Your input in the evaluation process is extremely important. The younger the child the more the evaluator will need to rely on your observations. It could be helpful to make a list of things you have noticed to take with you to the assessment – perhaps things that have made you worry. Additionally, many speech pathologists will welcome audio/video tapes of your child. This can be especially beneficial if your child does not verbalize to his potential in the evaluation setting. With older children, the evaluator will hopefully be able to elicit direct samples from them
Because of the wide availability of publicly funded early intervention programs, I would like to offer some thoughts about them as it relates to speech and language evaluation. First of all, let there be no question that my personal belief is that the early intervention programs have helped children enormously since their inception and have proven very valuable to both children and families. However, I have also observed some weaknesses in regard to speech and language evaluation. For instance: Because eligibility for services is based on a child having at least a 25% delay (in some states, 33% delay), determining an age level in expressive/receptive communication skills (via the various checklist instruments available) sometimes appears to be the exclusive focus. As I stated earlier, age-level functioning alone does not constitute a complete, comprehensive evaluation. Ask if the evaluation will be comprehensive.
Some early intervention speech therapists do not feel they are able to offer specific diagnosis. And indeed some are not qualified, having completed the bachelor level of study only.
Sometimes evaluations in early intervention programs are a multidisciplinary affair. At the evaluation, many disciplines (physical therapy, occupational therapy, speech therapy, psychology) may be present TOGETHER and simultaneously evaluating the child across all developmental domains. Although there may be some benefits to this approach, it can also serve to dilute the quantity and breadth of information a single evaluator can obtain during the time frame.
If you chose to go through an early intervention program for an evaluation, keep these issues in mind and ask questions ahead of time.
In summary, there are many reasons a child may experience difficulty in speech and language development. There are specific language disorders; hearing impairments; pragmatic disorders, speech motor disorders, fluency disorders, phonological disorders, functional articulation problems, etc. as well as children who experience a true developmental delay of speech. In real life, many children experience a combination of problems that together impact the child. It is important for your child that someone (a speech language pathologist) assists in figuring out the nature of the problem(s) and the relative contribution of a number of problems on the child’s overall functioning. With this information, an appropriate and individually-tailored therapeutic plan for intervention can be developed.
Do not be dissuaded from pursuing an evaluation by a speech language pathologist if you are worried about your child. If YOU are concerned then you should pursue it. Many well wishing and good-intentioned friends, family, and physicians may try to minimize your worries. My personal favorite was always, “You know, Einstein didn’t talk until he was four.” (Sigh.) Listen to your instincts about your own child. If nothing else a comprehensive speech/language evaluation will ease your mind and truly tell you if it is nothing to worry about. And don’t forget that speech pathologists are human and can be wrong. If you have already had your child evaluated and were told not to worry, yet your child does not seem to be progressing on his own, then pursue a second opinion. Additionally, if your child is currently in speech therapy but does not seem to be progressing, you may want to have another speech pathologist take a look.
One of the difficult jobs we have as parents is being our child’s foremost and staunchest advocate. Negotiating the medical and professional world is rarely easy and often frustrating. Keep your wits about you and follow your instincts! It is my sincere hope that sharing some things I have learned from my experience will make your journey a tad bit easier.
(Sincere thanks to David Hammer, M.A., CCC-SLP, for reviewing this paper.)