What does “good progress” mean? Consider this question: if, after six months of speech therapy at the rate of two or three or four times weekly, your child had two additional sounds (phonemes) and was capable of producing or could approximate two words, would you consider that the therapy was working? Probably not. Children with apraxia of speech take a great deal of effort from the SLP and the children themselves expend incredible effort, especially early on. It is not “easy” therapy, but two phonemes (sounds) in six months? Several new word approximations over the span of 6 months? That rate of progress should likely be questioned. Parents should not settle for limited progress without examining what is occurring. We do not suggest that limited progress means that the speech therapy is “bad”. Instead, we suggest that when therapy is not leading to good progress, key questions can be asked, such as:
- Is the diagnosis correct? Does the child REALLY have apraxia of speech? Is the SLP pretty certain after working with him/her for 6 months? There have been more than a few occasions in which CASANA has helped families get connected for second opinions only to learn that, in fact, the child’s biggest issue is not really apraxia of speech, rather, it is some other significant speech, language or cognitive disorder. Also, remember that CAS is both overdiagnosed and underdiagnosed. Children are being given the diagnosis when in reality it is likely that the child does not truly have apraxia, and, children who probably really do have it, are not being diagnosed.
- Is there something else beyond apraxia going on that is interfering with progress? Does the child, for example, have significant:
- attention issues?
- behavioral issues;
- health issues;
- family issues, (and so on).
Other problems may be interfering with your child’s ability to benefit from speech therapy. For example, a child with obstructive sleep apnea or constant colds, enlarged tonsils and adenoids, etc. may be getting insufficient sleep and thus is constantly tired and unable to fully benefit from therapy. Or, for example, a child is very distractible, so much so that she/he is totally unable to attend to the clinician’s face in order to pick up on important cues to articulatory placement or verbal cues and may not be benefitting entirely from the speech therapy process.
- Is the frequency of therapy sufficient for this child? Is the child getting that recommended range of therapy weekly? For example, suppose that a child with severe apraxia of speech is receiving 20 minutes of speech therapy weekly. It is not hard to understand why there would be little benefit and painfully slow progress. Often, the pace of progress may pick up nicely when additional appropriate speech therapy is added.
- Is the intensity of therapy sufficient for this child? Has this child been getting enough practice opportunities within each session? Is this child actually receiving group treatment instead of individual treatment? A child who is mostly silent during the therapy sessions is not going to have good progress. The clinician would have to modify what they are doing to engage the child and enable them to take some communication risks so they gain many, many practice opportunities in each speech therapy session.
- Is the therapy approach appropriate (think “principles of motor learning”)? Consider all of the principles of motor learning that were discussed earlier. Is this what therapy looks like for this child? Time and time again, CASANA has seen that when children begin to receive therapy appropriate for their core issue of speech motor planning difficulty, the pace of progress picks up significantly and is noticeable – sometimes even immediately.
- Is there appropriate follow through happening at home? If there is no follow through happening at home, which serves to extend the child’s practice opportunities, perhaps this has made for less than optimal progress. Also, if the family does not feel competent or secure enough to practice with their child or if the child refuses to practice with parents, the child may not be getting additional practice that can truly make a difference in rate of progress.
If, after asking these questions and adjusting whatever needs to be adjusted, the child continues to make poor progress, hopefully the child’s SLP would feel an obligation to invite a more experienced colleague or supervisor to observe therapy sessions and see if a fresh or external eye may see something that the SLP has been unable to see. Another strategy would be to refer to a developmental behavioral pediatrician for a review of all the child’s development and health issues.
Children with multiple and complex issues, in addition to CAS, are likely to have slower rate and extent of progress, however, it is best to pause and evaluate now and then to be sure that therapy is as effective as it can possibly be!