Cortical Integrative Therapy in Apraxia of Speech

CASE REPORT

J.L. is a 7-year-old right-handed male, born at 6 pounds, 9 ounces following a normal (39 weeks) gestation. Mother experienced gestational diabetes during third trimester of pregnancy. Immediately after birth, symptoms of anoxia – abnormal cry, color, and breathing were noted, and infant was given oxygen. Mother reported that J.L. had difficulty with breast-feeding, with probable oral motor deficit noted. Normal hearing bilaterally and normal mobility of the inner ear system was observed. Father’s death from cancer occurred when J.L. was aged 10 months. J.L. began sitting at 9 months, crawling at 10 months, standing at 12 months, and became ambulatory at 13 1/2 months. He was finger-fed at 11 months, used a spoon to eat at 22 months, completed toilet training at 3 years, and dressed himself at 3 1/2 years. His early language development is described as follows: J.L. used single words and named simple objects at 22 months, he combined words at approximately 32 months, he asked simple questions and engaged in a simple conversation at approximately 3 years, 6 months. Mother noted that at age two, J.L. wasn’t saying as many words as other children of the same age. By age 2 years, 6 months, J.L. had achieved little progress. Mother noticed that by age two, J.L. was extremely sensitive to loud noises. J.L. was first evaluated for speech and language delays at age three. Results indicated a moderate receptive language delay and significant delays to expressive language skills and speech articulation. Based on J.L.’s extremely limited sound repertoire, a diagnosis of moderate to severe apraxia was first suggested. J.L. was also observed to have difficulties with attention and responding to verbal, visual, and tactile stimulation and cues.

At age three, J.L. was primarily using single words, with occasional two-word utterances. He required considerable structure and visual support. For speech and language services conducted at a therapeutic center at ages 4 and 5 (pre-school age), J.L. was using a picture communication board for initiating requests and making choices. Movement therapy focused on increasing the variety of sensory-motor activities he engaged in. J.L. was observed to benefit from activities that provided significant proprioceptive feedback, such as climbing and jumping. He demonstrated a pronounced reluctance to engage in a variety of movement activities and exhibited slow (i.e. clumsy) fine motor development in a carefully structured occupational therapy program. Between ages three and seven, J.L. achieved some progress in speech-language skills. But while his frequency of speech improved, he experienced difficulty with expressive grammar and speech intelligibility. Academic issues began in kindergarten. He began experiencing difficulty with classroom activities that required language processing and verbal expression. He often used pronouns incorrectly (e.g. “me” for “I” and “he” for “she”). When producing sentences, J.L. would sometimes leave a word out. Unfamiliar adults had difficulty understanding J.L.’s speech, especially out of context. J.L. would often use gestures or substitute words that he could say better in efforts to improve his communication skills. Sometimes he would become frustrated and say “never mind” in cases in which he was unable to get the listener to understand his message.

While attending first grade at his elementary school, J.L. received speech therapy, occupational therapy, remedial reading, and special education curriculum. He was experiencing difficulty across all subjects. Specifically, difficulties were noted in retaining information and following multistep directions. He had expressive language difficulties and fine motor difficulties (e.g. writing letters and numbers, using scissors, tracing, and buttoning his clothes). He could be inattentive and easily distracted at times. He often showed improvement when he received one-on-one help reinforced with constant repetition. He demonstrated consistent speech errors, such as substituting “f” for “s” or leaving out a consonant in the middle of a multisyllable word. His vowels often didn’t sound appropriate. While described by his mother as “an easy-going child who makes friends easily,” he most enjoyed solitary (self-driven) pleasures such as books with repetition (e.g. Brown Bear, Brown Bear), 25-piece jigsaw puzzles, building with blocks, and playing with Matchbox cars, trucks, and action figures.

At the age of six years, ten months, J.L. underwent an extensive speech and language evaluation. Testing included examinations for speech production (Goldman-Fristoe Test of Articulation -Second Edition or GFTA-2) and consistency of productions (Khan-Lewis Phonological Analysis -Second Edition or KLPA-2). He also was tested in speech intelligibility, oral mechanism, language, narrative skills, and phonological awareness. While his results in the GFTA-2 were in the low normal range, his KLPA-2 results were prone to serious errors such as deleting final consonants of words (e.g. scissors became “scisso”) and producing fewer syllables in target words (e.g. balloons became “bwon”). When J.L. performed a story re-telling, an unfamiliar listener without knowledge of the story understood only 34% of the words in J.L.’s speech sample. In an oral mechanism test, J.L. experienced difficulty with repetitions of the word “puppy,” which were slow, imprecise, and dysrhythmic and increased difficulty with expressing complex words and phrases. His language scores fell in the Delayed to Very Delayed range. Because his speech was difficult for adult listeners to understand, he received very low narrative skills scores. He had memorized a few rhymes (e.g. “house-mouse”), but demonstrated very poor rhyming skills. In summary, J.L. presented with a serious speech disorder (developmental apraxia of speech) that was adversely impacting his academic progress in most areas.

At the age of 7 years, 1 month, J.L. received further intelligence testing, specifically a Woodcock Johnson III Test of Achievement. He performed in the low range (70-79) on Broad Math and Math Calculation Skills when compared to others at his age level. His Broad Reading score fell in the very low range (60-69) for his age level as did his Written Language, Written Expression, Oral Expression, and Oral Language, and Listening Comprehension skill sets. His only relative strength area proved to be Picture Vocabulary (80-89) where he achieved in the low average range.