Speech Consultation at the Mayo

When Chris heard I was bringing Kiera to the Mayo Clinic for a speech consultation, he joked with me that I was "bringing out the big guns."  I sure was.  I was tired of hearing people tell me that Kiera just needs time to adjust and that she's still learning English. She's been home for a year and turns four in March.  She starts kindergarten in a year and a half and can't communicate with more than one word, if she initiates speech at all.  I'm too impatient for a "wait and see" approach and have grown increasingly frustrated with her lack of progress despite the intensive speech therapy she's undertaken since July. 

Our consult at the Mayo Clinic was with Dr. Ruth Stoeckel, an expert in speech and language disorders.  This is the speech language pathologist recommended by my Facebook group for parents of children adopted from China who have speech and language delays. When I had no idea what to do next, this group offered their support and ideas. 

As expected, it took Kiera some time to warm up, so she wouldn't make a peep as Dr. Stoeckel tried to engage her.  She wouldn't even tell the doctor her name. As we know, Kiera responds to movement and once Dr. Stoeckel got her interested in a Nerf gun and was suddenly incredibly LOUD as she chased after the Nerf pellets. 

Dr. Stoeckel tested Kiera's receptive language first.  For conversational receptive language (tested using questions about the child, like asking how she's doing, what her name is, how many brothers and sisters she has, etc.) Kiera tested in the three-to-four-year-old range.  For academic receptive language, (tested by having her answer questions about a picture, such as asking where certain objects are located in a picture or what she sees) she tested on the level of a three-year-old.  Academic receptive language is considered harder and it's not surprising when kids score lower.  Overall, Dr. Stoeckel has no receptive language concerns and this is in line with what the school district found when they tested her in the early fall.

Dr. Stoeckel's speech evaluation revealed that Kiera can say a lot of words, but with a lot of errors. With the multiple speech issues the doctor pointed out, it now makes sense that Kiera's speech is so unintelligible. 

• Final consonant omissions - We're all familiar with how Kiera does not say the final letter in a word. "Hat" is "Haaa."
• Vowel distortions - She might pronounce the word "book bag" like "bay bye". We have a lot of vowel sounds in the English language (16?) and Kiera distorts a fair number of these.
• Fronting - She replaces certain sounds with other sounds, such as saying "tar" instead of "car."
• Cluster reduction - This is where she reduces consonants in a longer word or drops letters to make a word shorter or easier to say, such as saying "boon" instead of "spoon." I was told this is not unusual for this age and stage of English acquisition. 
• Glottal stop - not sure how to explain this one...

Sometimes two, or even three, of these speech issues are present in one word, which is why it's difficult to understand Kiera.  When she says "tating" instead of "skating," she's exhibiting cluster reduction by dropping the "s" and fronting by using a "t" sound instead of a "k".  "Stop" becomes "ta". Again, there's cluster reduction with the dropping of the "s", but also final consonant omission by not pronouncing the "p".

Dr. Stoeckel diagnosed Kiera with having a "speech sound disorder" and "delayed expressive language skills secondary to the speech sound disorder."  She didn't identify any obvious language disorder at this time, but said that could change as she gets older and she talks more and they can better diagnose her. 

Kiera has motor planning problems, which means it's harder for her to sequence longer words or phrases. This might explain why Kiera really doesn't talk with more than one word at a time and that her few two-word phrases are not more than two or three syllables in total.  (For example, she yells, "Do it!" if she wants to do something for herself, like get herself dressed instead of letting me help her.)  Or when you ask her to say a word with three or more syllables, she gets lost before she finishes saying the word. If you've noticed, typical of a kid Kiera's age, she "asks" a lot of questions.  For Kiera, that means every movement you make prompts her to ask, "Doing?"  Saying an entire sentence of "What are you doing?" is too much to sequence.  Plus, she's probably figured out that we know what she's asking simply by using the one word. 

Motor planning might also explain why she has trouble answering questions, like what she wants for lunch or even her own name. Kiera most likely knows what she wants, but something as easy as saying, "I would like a peanut butter and jelly sandwich" or  even, "peanut butter and jelly" is a lot for her brain to sequence and communicate with her mouth to say. While we may never know what other factors play into her inability to answer questions or initiate speech, she could be aware of the errors she makes and be self-conscious, or she could have adapted to her speech limitations and makes do with pointing or not getting what she wants. 

I had originally thought could possibly have Childhood Apraxia of Speech (Apraxia), and even the neurologist at the Mayo who reviewed the videos I had taken of Kiera speaking, thought that could be the case, but Dr. Stoeckel, an expert in Apraxia, says she doesn't have it.  However, the "motor planing with vowel movement" that Kiera presents is present in all kids with Apraxia. A small number of kids have motor planing issues, but not Apraxia, and Kiera fits in this category. The main clue that Kiera does not have Apraxia is that there is often consistency with her errors and when she has someone guide her through the word, she can often say it correctly by the third try.  (That is, if she's in the mood!) Kids with Apraxia will say the same word three different ways and not get it right.  There's no pattern to their errors.

Here are two resources that talk more about motor planning. They are specific to Apraxia, but the information is still relevant to Kiera. 

• http://www.apraxia-kids.org/library/what-is-the-difference-between-speech-motor-planning-programming-and-execution/
• http://www.tayloredmktg.com/dyspraxia/das.shtml
  

I was relieved to learn more about Kiera's speech needs, but I was also desperate to learn what the next steps should be in speech therapy. Most traditional speech therapy (sometimes called articulation or phonological) therapy doesn't focus on vowels and this is the area Dr. Stoeckel is most concerned about because they're the hardest to fix. She recommends motor planning therapy because it will improve communication efficiency.  This type of therapy is sometimes referred to as a "core vocabulary" approach.  Core vocabulary therapy focuses on teaching kids usable phrases instead of trying to learn how to pronounce individual sounds. She recommended a program called P.R.O.M.P.T.

Dr. Stoeckel recommended some speech pathologists at Children's Hospital of Minnesota, but unfortunately, we couldn't get Kiera on any of their schedules.  Since we haven't been happy with her progress at Gillette's, we'll still give Children's a try with a different speech pathologist.  Our first appointment is in mid-March.

Both Kiera and Matteo have been receiving speech services through the school district twice a week.  The wonderful part is that these services are free and the speech pathologist comes to our home. Their speech pathologist is familiar with Core Language Therapy and did some extra research to come up with a new game plan for Kiera.  Our goal now is to work with Kiera on familiar words that she needs to communicate.  We'll work on up to 10 each week. The task is to twice a day have Kiera practice pronouncing each word five times.  The idea isn't to quiz Kiera on what the picture is, because she most likely knows that, but to provide an example of how to say the word and then get her to repeat it. Because of her motor planning issues, Kiera might not be able to produce the word correctly on her own without watching and hearing someone say the word, which is why much of our "quizzing" her on names of objects has been mostly fruitless and frustrating for both us and Kiera.  The hope is that practice will increase brain "muscle memory" so that words her brain has struggled to communicate to her mouth to speak, or speak correctly, will become second-nature.

Because there's an emotional/psychological component to Kiera not being able to/wanting to speak, the speech pathologist also suggested we create a sticker chart and make a big deal out of Kiera using words to communicate her wants or needs, similar to what we did with Oliver and Soren during toilet-training.


I'm looking forward to a new chapter in Kiera's speech therapy, but I'm also overwhelmed because even under the best of circumstances with a proper diagnosis and skilled speech pathologists providing the correct kind of therapy, we still have a long road ahead of us and a lot work to do.