Childhood Apraxia of Speech – PediaCast 300
Mary Cousino, a speech and language pathologist at Nationwide Children’s, drops by the PediaCast Studio to talk about Childhood Apraxia of Speech. We discuss the cause, diagnosis and treatment of this and other common speech problems. Be sure to join us!
- Speech and Language Development
- Childhood Apraxia of Speech
- Speech Therapy
- Speech and Language Pathology at Nationwide Children’s Hospital
- Childhood Apraxia of Speech (American Speech-Language-Hearing Association)
- Apraxia-KIDS (resources for families, researchers and professionals)
- National Institute on Deafness and Other Communication Disorders (NIH)
- Speechville (Apraxia Articles and Resources)
- PediaCast 289 – Nasal Speech & Velopharyngeal Dysfunction
- CONTACT DR MIKE – Ask Questions, Suggest Show Topics
- CONNECT NOW with a speech and language pathologist from Nationwide Children’s – Referrals and Appointments
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children’s, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It’s a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children’s Hospital. We’re on Columbus, Ohio. It is October 29th, 2014, Episode Number 300. We’re calling this one “Childhood Apraxia of Speech”. I want to welcome everyone to the program.
Episode 300, it’s been eight years in the making. I try to do this every once in a year, just a quick recap of where we’ve been historically. Each year, we get some new listeners out there, and some people wonder how in the world does a pediatric podcast get started, especially when it’s been around for eight years.
The quick story is I was in an office practice at that time, just practicing private pediatrics, and I looked at it as an extension of my office practice. Let’s face it, it was a legitimate excuse to geek out a little bit on technology. Podcasting was in its infancy. Prior to medical school, I have spent some time as a DJ at a skating rink starting at age ten. They paid me in refreshment items and I did the Saturday morning Kids Fun Skate. And then, I worked at two different radio stations during my college years, then kind of forgot about broadcasting and went into pediatrics.
So, when podcasting came out, it was like there was this opportunity to kind of marry two things I really love – pediatric medicine and broadcasting – and I can have fun and make a difference for families in the process. Really, the goal at that time was just, if you came in and you wanted to know why your kept getting ear infections, you could get the five-minute office answers. But if you really wanted to know what was happening down at the cellular level with why kids kept getting ear infections, you could go to the podcast and get the 20 t o 30 minute explanation.
So it was just an extension of my practice. But then, iTunes highlighted it, word-of-mouth spread and here we are, eight years and 300 episodes later with a fancy studio on the campus of the best children’s hospital in the world, with a fantastic loyal audience and listeners in all 50 states and well over 100 countries around the world.
Of course, we wouldn’t be gathering in this way if it weren’t for all of you, so thanks. I truly do mean that from the bottom of my heart. I really appreciate you taking time out of your day to make PediaCast a part of it, and help make the show what it is today.
So I feel like we deserve a little bit of a celebration. I wanted a big-impact topic for show number 300, and I really think childhood apraxia definitely fits that bill. Now, you may not have heard it called apraxia, but you have heard of it. Childhood apraxia of speech really represents your garden-variety speech problems that we see. And it’s a big deal for many families out there. It shows up in a myriad of ways which we’ll discuss. And lots of kids end up in speech therapy in an effort to correct the problem.
So we’ll cover apraxia in our usual nuts-and-bolts fashion with the definition signs and symptoms, the cause, diagnosis, treatment, long-term outlook, and of course, the hottest research topics in the world of speech disorders. So that’s all coming your way.
Also, in our usual fashion, I have our studio guest joining me. Mary Cousino is a speech and language pathologist at Nationwide Children’s, and she’ll help us fill in the details. Our discussion, by the way, will also include answers to some listener questions. I’ve been saving them. We do have several listeners who have written in and asked questions about various aspects of speech, and so we’ll get to some of those questions as we go through the course of this as well.
I did want to pass along some safety tips real quick for your evening out with the little goblins. Halloween arrives in a couple of days, and in fact, Beggar’s Night might be happening sooner than that in your community. So first off, fire — consider illuminating your jack-o’-lantern with a light bulb instead of a flame. However, if you simply must use a candle, make sure the pumpkin remains supervised. Keep it away from trick-or-treaters and watch out for house and lawn decorations because you don’t want them blowing into the candle and starting a fire.
Also, remember to remove flower pots, water hoses, patio furniture. Keep all of that stuff out of the way. Kids who are costumed aren’t going to have a great peripheral vision so want to make a path for them, and you don’t want anyone tripping and falling and possibly breaking an arm or two because that will definitely put a crimp into someone’s evening.
If you’re out driving during Beggar’s Night, make sure you take it slow and don’t wear a mask. If you’re walking keep a constant eye on traffic and make sure your costume is visible.
Of course, children of all ages should be chaperoned by a responsible adult while out and about. And remember to sort through your child’s baggage treats, removing and discarding any opened or otherwise suspicious items.
Of course, have fun. Your kids won’t be little forever, and now is the time to make some great family memories that will last. Of course, we want those memories to be good ones, so be sure to keep it safe.
All right, couple more items of business, our 700 Children’s blog is available at 700childrens.org. Some recent topics: Keeping your Kids Safe From Radon, Tips to Prevent Your Child From Choking. Also Trick-or-Treating with Food Allergies, we have some tips that you need to know with regard to that. Be sure to check out those and other great articles again at 700childrens.org.
Of course, PediaCast is your show; we pride ourselves on that. So if you have a question for me or you’d like to suggest a topic idea, it’s easy to get in touch. Just head over to pediacast.org and click on the Contact link. Also, the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals, so if you have a concern about your child’s health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right, let’s take a quick break. I’ll grab a sip of water. You can tell from last week, my voice was a little more hoarse than it is this week. But it’s still recovering. We’ll grab a sip and we’ll get to Mary Cousino. We’ll talk childhood apraxia of speech, right after this.
We are back. Mary Cousino is a speech and language pathologist at Nationwide Children’s Hospital. She works with a wide range of ages and wide range of speech and language problems. Today, she’s great to take time out of her busy office schedule to visit the PediaCast studio and talk about a very common problem, childhood apraxia of speech.
o let’s extend a warm PediaCast welcome to Mary Cousino. Thanks for joining us today.
Mary Cousino: You’re welcome. Good to be here.
Dr. Mike Patrick: Yeah, I really appreciate you stopping by. I almost said doctor because most of the time, we do have physicians on the program. We talk about different conditions that kids have. But speech and language therapist, it’s funny because I can’t even invite a doctor here, because we just don’t know about these things.
Dr. Mike Patrick: All right, let’s start out with the… Let’s talk about what’s normal before we talk about what’s not normal. If you could just describe typical speech and language development for us, so we have a basis to compare the abnormal with.
Mary Cousino: Great. I’d love to. The first thing everyone needs to know is that typical speech and language development doesn’t just happen at a year-old. It starts from the very, very beginning when you talk to your baby, when you play with them. So it starts from the beginning, it’s not just a thing that happens when they’re a year-old. But in that first three months, they might recognize their mom’s voice and they have different cries for different needs.
By the time they’re a year-old, they’re recognizing words for common items that they’re exposed to — cap, ball, truck — those sorts of things. They can use gestures to indicate that they want something. They can imitate sounds and they might have one or two real words.
Between one and two, they learn how to identify body parts. They can follow simple commands. They like to listen to short stories and rhymes. They can point to pictures. They say more words every month. By the time they’re two, they might begin to use some putting one or two words together to make a really short phrase, such as “What’s that?” “Where kitty?” those sorts of things.
Between two and three then, they understand the differences and meaning to some things, like go and stop and big and little. They can follow a request like, “Go get the book and put it on the table.” So two simple parts. They can listen to stories for longer. They begin to enjoy maybe singing along to music, and they have a word for almost everything by the time they’re three.
By the time they’re three, they’re also using two and three words together when they talk. They’re using sounds like the P, B, M. Those should have developed earlier, but by the time they’re three, they should had used a K and G, F, T, D and N. By the time they’re three, they should pretty well be understood by almost all of the familiar listeners. They can ask for objects by naming. They can ask why questions, which is a fun one by this point, because that’s all they do. They may start to stutter a little bit on some words and that’s where parents get really concerned but it can be a normal developmental thing.
Three to four, they hear you when you call them from a different room. They may not respond but they can hear you. They can understand simple colors and shapes. People outside of the family by the time they’re four usually understand almost all that they say. They begin to develop some simple grammatical structures like plurals from three to four.
And then by the time, they’re in that four to five year, they understand words for order like first and last, and time – today, tomorrow. They understand longer directions. They say all their speech sounds in words, but they may have a few mistakes on harder sounds like the L and the S and the R, and those sort of sounds. They begin to be able to name letters and numbers and they can tell short stories and keep the conversation going.
So these are just basic milestones kinds of things.
Dr. Mike Patrick: That’s great. Now, as you’re describing that, so there’s really two kinds of language we’re talking about — receptive language, where the child understands what folks around them are saying, and then expressive language where they’re saying it themselves.
Mary Cousino: Correct.
Dr. Mike Patrick: And then, you did put in some large timeframes in there — so between one and two, between two and three, between three and four. There really is a large variety, isn’t there, in terms of from month to month when this is happening. So then, of course, parents are apt to compare one child to another whether it’s two kids in their own family or their neighbor’s kid, or their cousin’s kid. Speak a little bit to that variety that you see and what’s normal.
Mary Cousino: I frequently will tell parents, there is a huge wide range of what’s considered typical. So, it’s so hard to compare and a lot of parents sometimes will compare an older child to a younger one, or younger to an older, saying “Well, my other one was doing this.” And it can still be perfectly normal if the younger one isn’t doing that.
Dr. Mike Patrick: Yeah. My kids were extreme examples of that. My daughter, at 18 months, she could recite nursery rhymes back to you, and pretty much strangers could understand what she was saying. My son was close to two and still sort of grunting and pointing at things, but then he has ramped up very quickly after that. It does bring about a little bit of a concern when you have two such extreme examples.
OK, let’s talk about childhood apraxia of speech then. What exactly is meant by that term?
Mary Cousino: Childhood apraxia of speech, it’s not the typical speech sound disorder that we always hear about, but it’s a motor planning problem — so the brain planning the movements that it needs for speech. It’s not weakness or any of that. It’s just the motor plan. So the brain’s not telling the mouth where to go for a specific sound or word, so these children just take a stab at it. It doesn’t always sound the same when they say the same word.
Dr. Mike Patrick: So it’s not an anatomical problem, like we talked about few months ago when we talked about velopharyngeal dysfunction. This is really more of a planning thing but it’s looking more at the brain and pathways involved to make speech happen.
Mary Cousino: Absolutely.
Dr. Mike Patrick: How common is this condition?
Mary Cousino: It is not very common. There’s a range, but typically the experts say that two to three children per thousand. So it’s not a common thing, and a lot more research needs to be done to really get a better determination of just how prevalent it is.
Dr. Mike Patrick: Sure. Now, compare that to kids who have problem in terms of pronouncing certain letters. With that, what is the problem there?
Mary Cousino: Sometimes it’s a phonological problem, and by that I mean, we have certain patterns for making certain sounds, like the T and D are made with the tongue up in the front part of your mouth and the K and G are made with the tongue in the back part of your mouth. They may might do everything with the tongue up but everything’s in the front. So a K and G sounds like a T or a D.
Dr. Mike Patrick: In the introduction when I said this is the garden variety speech problem, I was way off base right?
Mary Cousino: Yeah, you were pretty much way off base.
Dr. Mike Patrick: And that’s why we don’t invite a doctor in to talk about these things. We really need the expert of a speech and language pathologist.
Do you see this more commonly, apraxia, do you see this more commonly in boys versus girls or is it about the same?
Mary Cousino: In my practice, I see quite a few boys, but you see it in girls as well.
Dr. Mike Patrick: So in your experience, you tend to see a little bit more in boys?
Mary Cousino: A little bit, but I don’t think that that’s anything that’s been borne out by research.
Dr. Mike Patrick: Got you. Does it in run in families? Do you think there’s a genetic component to it?
Mary Cousino: I do. We see so many sibling groups where they have some degree of motor planning issues. So if you have a family history of having some speech sound disorders and learning disabilities, that sort of thing, we see a lot of our apraxic kids who have that kind of family history.
Dr. Mike Patrick: Sure. What about ethnic groups? Do you see in folks who speak other languages other than English in dual-language home, is this a common developmental problem? Or there isn’t seem to be much ethnic variation?
Mary Cousino: I don’t think there’s much ethnic variations. Again, I don’t think that’s been looked at in terms of research, but you know, it’s motor planning. It’s more a brain thing than a developmental thing.
Dr. Mike Patrick: Got you. So do we understand what causes this?
Mary Cousino: We really don’t. Again, this is an area that researchers are just beginning to look at and to develop some really meaningful research on. We just know that it’s not as common as it’s sometimes diagnosed to be, but it’s a newer kind of research focus.
Dr. Mike Patrick: Are there a lot kids who get diagnosed with apraxia that really have more of a phonological issue?
Mary Cousino: Yes. Yes.
Dr. Mike Patrick: OK, that’s where I was getting the impression, because if you do some research on it, some places make it sound like this is becoming more and more common. But really, it sounds like this is an issue that happens between the brain and actually making the movements as opposed to just not understanding how to make the movements correctly.
Mary Cousino: Right. And it seems more common because there’s more emphasis now. So we just hear about it more, it’s just like any other diagnosis when you start to hear about it. A lot of people, even speech pathologist, we don’t learn a lot about it in grad school, so most of the information you learn, you find out on your own. So it gets over-diagnosed, because there are measures that indicate but they’re not all inclusive, but diagnoses are given from that just one.
Dr. Mike Patrick: Yeah, and it would seem to me too, when parents if they start to research stuff, they’re going to come across, “Oh this apraxia, this fits what’s going on with my kid,” and so they may come in with the preconceived notion that that’s what this is. I think just from a doctors point of view and this may also be totally off base, but there comes a time when it doesn’t really matter what you call it. You know what you need to do to try to fix it. And so, if a parent wants to call it apraxia, but it’s really more of a phonological air that they’re not doing something right, as long as you can help their speech, that’s all that anyone cares about regardless of what label you put on it.
Mary Cousino: Yes, but it’s a different treatment. It’s a different type of treatment. So if you call it apraxia but you do just the typical things with speech sound disorders, you’re not going to have real good results. So it matters to the practitioner.
Dr. Mike Patrick: Right. It’s going to determine which course you go from the parent standpoint, whatever you tell him we need to do, we’re going to do it, so maybe there’s some kids that get labeled apraxia when that’s really not what’s going on.
Mary Cousino: That is true. Sometime it has to do with reimbursement, too. If you get a good diagnosis of apraxia, sometimes it’s covered by insurance.
Dr. Mike Patrick: Got you. Yup. So what signs and symptoms would a parent be on the lookout for? What would true apraxia really look like in the home, what would make a parent think that’s what this really could be?
Mary Cousino: It can start from very young. A lot of these kids are quiet babies. They don’t do a lot of babbling or vocal play when they’re infants. And then, as their children start to talk, they may start to talk late. They may say a word and you think, “Oh, that’s their word.” And then, you’ll never hear it again. You hear a lot of just random things when they tried to talk, and some kids are very, very quiet and don’t try a whole lot.
Dr. Mike Patrick: Sure. So from a practitioner and a parent standpoint, when I hear that and I take it an isolation of the social development of a child, I start to think maybe autism. Are there kids and they get that confused in terms of what the diagnosis is?
Mary Cousino: Absolutely. Sometimes kids who are apraxic are misdiagnosed as autistic.
Dr. Mike Patrick: Sure. And really for autism, you’re probably going to have that social issue of the child not really bonding with others, including the parent — not involved in social play and all that, with the language problem.
Mary Cousino: Absolutely.
Dr. Mike Patrick: See, so the doctor did help there a little bit.
Dr. Mike Patrick: Otherwise, I’m playing by the seat of my pants here.
What kind of co-existing problems then might you see with apraxia?
Mary Cousino: You can see autism and apraxia at the same time. It’s a rare child who is just purely apraxic. We see a lot of Down Syndrome kids with apraxia. There are lot of different co-existing kind of things.
Dr. Mike Patrick: And some of them depends on underlying ,neurological problem that then could..
Mary Cousino: Sometimes, yes.
Dr. Mike Patrick: That could do this. Really, I mean, not necessarily an injury but something that they’re born with, like Down Syndrome.
Mary Cousino: Yes.
Dr. Mike Patrick: Got you. How do you go about diagnosing apraxia?
Mary Cousino: OK, it’s a fairly complex process. I know here we’ve developed the competency for diagnosing it, for evaluating apraxia, and it has to do with basic language testing. You usually see a child with higher receptive skills (what they understand) than expressive (what they can actually say), but you have to do a lot of other things. You have to look at movement, and you differentiate between movement for just a regular stick out your tongue. Kids could stick out their tongue, do all kinds of things with their tongue, but when you asked them to get that same movement, but in a speech sense, they can’t do it.
For instance, if you ask a kid to put their tongue tip up at the top of their mouth, they may be able to do that, but then you ask them to say L or N, they can’t do it. So, it deals with the processing of speech and not necessarily other movements. So they may eat right, they may eat very well. They can do a lot of things, but then when you apply it to speech, then it doesn’t happen.
Dr. Mike Patrick: Is it always a pronunciation issue, or is there also a problem with just melody of speech and can’t hear?
Mary Cousino: Big problem with melody of speech. Usually, when we talk about speech sounds, we’re talking about consonants. But in these kids, the vowels are usually a huge issue — just getting the placement for the vowels. So what happens when these kids try to put syllables together, sometimes if it’s a weak syllable, like in banana, they’ll drop the weak syllables so they’ll come out with ‘nana’. And if you put that together in a sentence and all the weak syllables are dropping out, it’s unintelligible even if they get most of the speech sounds.
Dr. Mike Patrick: So this really does take someone who knows what they’re doing to try to sort out exactly what’s going on. And you really want to sort out what’s going on, so you know the proper treatment.
Mary Cousino: Absolutely. A lot of times, these kids also can’t… They don’t imitate well, so you can say whatever word and they’ll say it one way the first time. They’ll say it differently the second time, differently the third time, just because they’re taking shots in the dark trying to do it.
Dr. Mike Patrick: And that would be more of a red flag for being apraxia versus a phonological problem, where there you’d think they’d keep making the same mistake over and over again.
Mary Cousino: Yeah, they’re pretty consistent.
Dr. Mike Patrick: Talk a little bit about the role of hearing with language development. So whenever you have a child with any kind of language issue, that’s really one of the first things you want to make sure is not going on, isn’t it?
Mary Cousino: Absolutely. Evaluations, our evaluations, there’s always a statement about hearing. If we can’t do a screening in the office because the child might be too young, then we always recommend a full hearing evaluation.
Dr. Mike Patrick: So, really, any parent out there, if your child’s having speech problems, of course, you want to bring it to the attention of the their doctor, but hearing screen is definitely one of the first things that you want to do then.
Mary Cousino: Absolutely.
Dr. Mike Patrick: OK, so let’s say, you have a kid and you do diagnose apraxia. That’s what you really think is going on. How do you go about treating that?
Mary Cousino: OK, all the research has shown that the most effective way of treating it is with a focus on… It’s more motor learning theory, and motor learning theory deals with a system of reinforcement, queuing and imitation. It’s not the typical way to treat speech sound disorders. You don’t identify one sound, for instance, and say I’m going to beat that sound to death until they have it. This one I know, not everyone does it this way, but the way I do it is I pick functional words that are within that word shape, like a consonant and a vowel together — words that give them power like ‘no’, ‘mine”, which is a CVC (consonant-vowel-consonant) word. Those sorts of words have power and they give them the beginning of understanding that when I say this, it gets me something.
Dr. Mike Patrick: So they have some incentive really to want to be successful at this.
Mary Cousino: Yes.
Dr. Mike Patrick: This really takes frequent intensive treatment, doesn’t it?
Mary Cousino: Absolutely. The standard best practice — and this was developed by the American Speech-Language-Hearing Association which backs a lot of the research and has come up with position statement and a technical paper on childhood apraxia of speech — it recommends the best treatment is frequent short treatment sessions if possible. I had one very severe little boy who I saw him five times a week initially, and he was fortunate because insurance covered it.
Dr. Mike Patrick: In terms of success, when you do the frequent intensive treatment, do you see success with this?
Mary Cousino: Absolutely. These kids, it’s slower progress and it evolves into something else with the speech sounds. But yeah, it just takes longer.
Dr. Mike Patrick: That must be really hard for parents in today’s world where we want immediate results — we want everything done right now — for them to be taking their child somewhere three to five times a week and not seeing immediate results. I could imagine someone would get frustrated and start to question whether this is really going to be helpful.
Mary Cousino: Well, that’s another reason that I teach the vowel words first, because if all of a sudden they can say no, the parents are really are happy when they hear any word, especially the first words that I teach is mom, dad. Even if it’s ‘dada’ or ‘momma’, if they can say that, the parents are just thrilled if you have a non-verbal three-year-old, and all of the sudden, they’re able to say mom or dad.
Dr. Mike Patrick: That’s fantastic. Now, in some more severe cases, let’s say you do this and you really aren’t seeing success, what kind of strategies can you use to improve a child’s communication whose apraxia is not improving.
Mary Cousino: The very most severe sometimes, you recommend an augmentative communication device. Right now, iPads are awesome and they have some really good programs for communication. I don’t know very many, even three-year-olds who can’t navigate an iPad these days.
Dr. Mike Patrick: They’re sometimes better than the parents.
Mary Cousino: Yes.
Dr. Mike Patrick: We talked about screen time and kids getting away from screen time and there’s a big push to the American Academy of Pediatrics. But in this case where it’s augmenting their communication, this really is not screen time. This is really a medical device for them.
Mary Cousino: Yes, this is how they get their wants and needs met, if it’s taught right and if it’s followed through within in the home. We also do signing and those sorts of things, but not as many people understand that.
Dr. Mike Patrick: Yeah, yup. Maybe within the family, the parents could learn it, but that’s not really going to help a child who’s interacting with another social group that may not understand those.
Mary Cousino: Correct.
Dr. Mike Patrick: So what kind of complications can arise if apraxia is not treated.
Mary Cousino: I can give a really good example. I have a thirteen-year-old that I’m treating. He’s been in speech therapy in school but it’s never been approached in the most effective way, and here’s a thirteen-year-old and I can understand him.
Dr. Mike Patrick: And that’s really going to really get in the way of academics, school performance, friends, social groups – really impacts so many aspects of a child’s life.
Mary Cousino: It does. And then, the other thing with apraxia is that there’s sometimes a link between their phonological awareness, how they hear sounds and how they connect them together, that is typically a problem for these little ones. So those phonological awareness skills, like putting sounds together to make a word, rhyming words. Just kind of word play and sound play they don’t get, and which has huge implications for reading later.
Dr. Mike Patrick: What’s the long-term outlook for these kids? If things are improving, then do they graduate from therapy and they stay improved or is there ever regression with this kind of thing?
Mary Cousino: No, because there’s not a regression. Once you build the motor patterns, they’re there. I like to tell parents when I’m explaining it to them for the first time, I’ll say, “You know how an athlete, a professional athlete starts out just like any other kid where they throw a ball and it goes wherever. But through practice, practice, practice and just work, then eventually they develop a kind of muscle memory. And then, they can do it. They don’t’ have to think about it. That’s the way speech should be, but for these kids we have to build that muscle memory. Now, once they’ve got it, they’ve got it.
Dr. Mike Patrick: It’s kind of like riding a bike.
Mary Cousino: It is kind of like riding a bike. But when you put all of the other factors in, like the placement, the motor placement changes when you add other things around it, when you add other words, other sounds. There are all kinds of things that change it, which makes it part of the reason that it takes longer. But once they are intelligible, for the most part, they’re intelligible now. If they learn a new word, especially a multi-syllable word, then they have to go to the process again and really practice saying it for them to get it.
Dr. Mike Patrick: Do you ever use a mirror for them to watch themselves or would that actually interfere?
Mary Cousino: Sometimes I do, but the most effective thing for them is face-to-face. Watch me, do what I do. So establishing that eye contact, well, that eye to mouth contact is probably one of the most important things, because they can imitate the movement sometimes better than the sound.
Dr. Mike Patrick: Sure. Is there a way to prevent apraxia from happening in the first place?
Mary Cousino: No, not really, Again, we really don’t have the deep-down research base to tell us that, but it’s like a lot of other speech and language disorders. We don’t know what causes it, we just know what’s effective for treating it.
Dr. Mike Patrick: What other speech disorders do you see and treat in your office setting?
Mary Cousino: In my office setting, right now, I’m pretty well specialized to apraxia. So that’s most of the kids I see, but we work with basic developmental language problems where a child is a little bit behind and understanding and using their speech.
We do articulation therapy, just traditional articulation therapy. If they’re having problems with a specific sound, we do that. And then, phonological processes that we’ve talked about. We help them establish those right patterns for making sounds. We work with stuttering, we work with voice, swallowing, feeding. There are a lot of different things, a lot of different areas that we work with.
Dr. Mike Patrick: With regard to delay in speech, do you ever see kids who their delay is just because they’re not being stimulated enough at home?
Mary Cousino: Absolutely. There’s a parent program called it takes to talk. It’s kind of group program, I think you can find it most places. I know here at Nationwide Children’s, we offer it. And it’s really a parent training in how to talk to your child and how to get them responding verbally and understanding.
Dr. Mike Patrick: Not to put the blame on parents, parents don’t necessarily… We don’t have training courses on how to be a good parent, but it is important to talk to your kids, to interact, to read to them, all those things, right from an early age.
Mary Cousino: Absolutely. From the time they’re born.
Dr. Mike Patrick: Then, also, I have mentioned this. We talked about nasal speech and velopharyngeal dysfunction with Dr. Adriane Baylis. That was back PediaCast Episode 289. So if you’re listening to this one and you want to hear another PediaCast on some speech issues, you want to check that one out. Again, PediaCast 289 with Dr. Adriane Baylis.
You mentioned stuttering as well. Is that part of apraxia or is that something completely different?
Mary Cousino: It’s something completely different.
Dr. Mike Patrick: And what, what causes stuttering? As I say, what-what-what causes stuttering?
Mary Cousino: Again, it’s kind of like apraxia. We don’t know. Some kids, family history plays into it. Again, if they have a parent who stutters, so we might come up with… The child might stutter as well. Again, we think it has to do with something in the brain, but those are hard areas to get into to pinpoint.
Dr. Mike Patrick: I’d always explain it and maybe this is just wrong and a myth, but that they were thinking like they were in the middle of their sentence but their mouth was still trying to do the beginning of their sentence, and so slow down. Is that completely old wives’ tale?
Mary Cousino: Slowing down can help, but it sounds weird.
Dr. Mike Patrick: Yeah.
Mary Cousino: You may start out treatment like that, but the goal is to get them sounding like a typical kid. Now, the little disclaimer I put on that, not like a 13-year-old girl. Because a 13-year-old girl, it’s unbelievable how fast they talk. Typically, we just want them to sound like their peers.
Dr. Mike Patrick:. What are some of the hot topics in the speech and language research right now?
Mary Cousino: Wow, we address so many areas. But I think right now, the biggest push in all of the research having to do with speech, speech language, all of it, is evidence-based practice and evidence-based evaluating based on real data. Not just a lot of times, we’ll treat something because that’s the way it’s always been done, and it’s not necessarily the best way to treat something. So we’re really looking at building our evidence-based knowledge.
I know here at Nationwide Children’s, we’re in a push to investigate, to research, to come up with the best practice that we can possibly find based on that evidence-based research. That is really the overall hot topic in speech right now.
Dr. Mike Patrick: So what works, and show me that it works, with some numbers.
Mary Cousino: Yes.
Dr. Mike Patrick: Great. Let’s go to some listener questions. The first one is from Jennifer in Colorado. She says, “As a first time mom and type A personality, I’m a huge worrier. Those well baby visit checklist always give me anxiety and I worry that we will fail the next visit. My 17-month old says ‘dada’, ‘doggie’, and ‘this’ — I’m very certain the last one was my fault — and chit chats nonsense all day. He seems to understand everything I say. He responds with nods, pushing back, or looking, getting the object I’m talking about.
“My pediatrician is fairly old which I love because he keeps my first-time-mommy worries at bay and doesn’t seem concern about the lack of speech. What is normal? When should I legitimately start to worry or get more active in encouraging speech? I already do this but it seems to frustrate my child. What other resources can I use to help to move the speech process along? Thank you, Jennifer.”
So for a 17-month-old, it sounds in her description that really, it’s sort of typical 17-month-old, would you say? Or do you think that it’s a little delayed?
Mary Cousino: No, I think it sounds really typical and what she’s talking about where it just goes on and on, that’s called jargon; and it eventually develops into the melody of speech. You can tell when they’re asking a question, but you can’t understand anything they’re saying. They’re playing with sound and conversational kinds of skills without having the vocabulary to do that. So that’s really typical developmental thing. Eventually, she’ll start to hear words kind of sprinkled in there.
Dr. Mike Patrick: So she’s really getting the melody down right now, without the words. She’s humming.
Mary Cousino: Well, there’s a little… Yeah.
Dr. Mike Patrick: Yeah, I know, I know.
Mary Cousino: Yeah, making a lot of sounds.
Dr. Mike Patrick: I try to simplify things.
Mary Cousino: Yes.
Dr. Mike Patrick: What about resources that parents can use to help move speech along? Do you have any ideas there?
Mary Cousino: Yeah, anything that’s put out by the American Speech-Language-Hearing Association . They have a lot of information on there. And the website is www.asha.org. There’s a lot on speech development. If you’re talking about apraxia, I tell parents, “Don’t Google it. Just go to this website. It’s www.apraxia-kids.org. It is the best website with information. It’s geared toward parents. There’s continuing education. There are all kinds of resources on there, and it really gives a god realistic understanding of what apraxia is.
Dr. Mike Patrick: And I’ll put links to all the things that we’re talking about here in the Show Notes, at pediacast.org for this episode, Number 300, so folks can find that easily.
Second question, this is Jenessa in Spokane, Washington, “Hi, Dr. Mike. I just listened to PediaCast Episode Number 277 about baby babbling, and thought I might ask about toddler speech development. Our son is almost 18 months old and start to say new words nearly every day. I began to notice in our family, as in others, toddlers tend to develop their own language that is sometimes unintelligible to people outside of the family or those who are around him or her often.
“I was wondering if you could talk some about what is normal in terms of toddler speech development, when they might need to see a speech pathologist, and when you might know — for example, my son says ‘that’ for ‘yes’ — and we know that but others do not that. Will he always mispronounce yes? And how this language refinement process works? Thanks so much. Jenessa.”
So here we have a kid who is about the same age as our previous listener, but this child is saying new words nearly every day. So if you’re comparing the two of them, you might get a little bit concerned, but this is also normal.
Mary Cousino: It is also normal and what she was describing, if the family can understand, then at that age, that’s great. Anytime they say a word or a series of sounds and it’s the same every time, that’s a true word, it just may not be produced correctly. So ‘that’ for yes is OK. What they need to do is they just need to model ‘yes’ all the time. Every time a child says “That,” you say “Oh, yes?” Eventually, they’ll begin to change that.
Sometimes parents feel like if a child says something that’s not correct, they’ll think it’s really, really cute. And so they’ll keep referring to that. I’m guilty of that. My daughter used to rock in her crib, and she bumped her head, and I said, “Don’t hit the headboard,” and she start to calling her forehead her headboard. So we just thought it was cute. Not always the best thing to do but…
Dr. Mike Patrick: Sometimes you need that little relief, though. You know what I mean, the comic relief, because they’ll figure that one out.
Mary Cousino: Yes. She did.
Dr. Mike Patrick: All right, let’s move on. Listener number three, this is Sheryl in Cherry Hill, New Jersey. “Hi, Dr. Mike. I really enjoy your podcast and find them extremely informative. My daughter was diagnosed with apraxia of speech at three years old. She’s currently in speech therapy and making great progress. However, at the time of diagnosis, there was a lot of conflicting information on the Internet about this disorder? Would you do a show on this topic, and also the implications this disorder has on academic performance. Thank you and keep up the great work.”
So I think we really covered most of Sherry’s questions.
Mary Cousino: Yeah, the thing with the kids who are truly apraxic, first of all, you can’t diagnose it much before age three, because it has to do with melody of speech. They have to have something to be able to make that diagnosis. But I think the thing that parents and practitioners need to be the most aware of is that right from the start, they have to work on phonological awareness because you have to build those skills for them to read. So, if you have a child that’s in therapy and they’re not getting that, you might want to talk to a speech pathologist about that.
Dr. Mike Patrick: When is the best time to refer a child to a speech and language pathologist?
Mary Cousino: I think that they can be referred early. If things are way off, if they’re not interacting at all, and they’re very young — if they’re 12, 18 months old — but there’s nothing, no eye contact, nothing, that would be a good sign to refer, at least to have things checked.
Dr. Mike Patrick: Yeah.
Mary Cousino: By the time they’re three and three-and-a-half and nobody understand a word they say. They got all this speech sounds but you can’t understand them at all. By the time they’re three, people should be understanding them. They may have some errors but not be completely unintelligible, and that would be a time to refer. If they’re having problems with stuttering behavior, and they’re looking like they’re fighting it, they notice it and they’re trying to get past it, that’s the time to go in. If their voice is hoarse and raspy, that’s the time to go in, have it checked out.
Dr. Mike Patrick: We have this pediatrician in one of our listeners who is reassuring, reassuring. Sometimes, that’s OK, too. Pediatricians do see a wide range of kids, so you do start to get an idea of what’s normal, what’s not normal and can provide reassurance. But then, there’s also some pediatricians that go the other way and they’re really resistant with real young kids to send them in. So, it’s one of those. You really want a nice partnership between the doctor and the parent, where the doctor’s in tuned to trusting the mom, but the mom’s also trusting the doctor, and hopefully come up with the best time together.
Mary Cousino: That is absolutely correct. We get that. We hear that a lot from parents that either of the doctor was very supportive or resistant. In our profession, we’d rather have them be a little too cautious. We evaluate kids all the time. We say, nope, they’re perfectly developed, mentally OK, and that really reassures the parents, and gives them a resource if they have other questions.
Dr. Mike Patrick: I think some of the resistance on the part of doctors is probably a lack of really understanding and education because in our training, we don’t really get a lot of speech kind of training other than normal developmental milestones. Just an example, with me in this episode, not really understanding what apraxia is, I’m sure there are plenty of other doctors out there who also have misconceptions. I guess for my listeners who are medical providers, I would just say trust the speech and language pathologists and certainly send folks your way.
Mary Cousino: Thank you, yeah. The other thing that I would say is that for the physicians is just remember that it is a speech disorder, and that there are minute little things that we look for that you just don’t have time to do.
Mary Cousino: Absolutely.
Dr. Mike Patrick: What about older kids who have reading comprehension problems and school problems? Can those things stem from when they were younger and is there hope for older folks like that?
Mary Cousino: Yes. We have people here who do dyslexia and it’s a really big push in our national organization that we start to address literacy and reading. It’s just a part of communication.
Dr. Mike Patrick: Yeah, great. Tell us a little bit about the Speech and Language Pathology Clinic at Nationwide Children’s.
Mary Cousino: We are a fairly large group. There are 61 therapists. We have five offsite locations, as well as the main hospital, both outpatient and inpatient. Being so large and we have a really good staff that’s been retain for a long time, so we have areas of specialty. Dr. Baylis is part of our Cleft Palate Clinic and is amazing. I specialize in apraxia. We have people who specialize in augmentative communication. We have people who specialize in feeding and swallowing, rehabilitation for kids who have had accidents. There are so many areas of specialties that we have and we’re really fortunate here. We have a lot of people who are kind of general practitioners, but we also have a lot of people who are specialized.
Dr. Mike Patrick: it sounds a pretty rewarding field and career. What kind of training is required to become a speech and language pathologist?
Mary Cousino: You have to have a master’s degree in Communication Disorders or Speech Pathology, whatever the school decides to call it. You can’t practice without a master’s degree. There’s a state licensure that we have to have to practice, and most of us are certified by the national organization, ASHA.
Dr. Mike Patrick: So you would have a four-year undergraduate/ bachelor’s degree and then you do a two-year master’s degree program on top of that?
Mary Cousino: Yes.
Dr. Mike Patrick: Great. All right, we really appreciate you stopping by and setting me straight, and setting our listeners straight and helping us to understand. I really do appreciate you stopping by today.
Mary Cousino: Thank you. Thank you.
Dr. Mike Patrick: So again, if you head over to the Show Notes at pediacast.org, look for Episode Number 300, we’ll have links for you — the Speech and Language Pathology here at Nationwide Children’s Hospital, the American Speech-Language-Hearing Association. They have a particular page on childhood apraxia of speech, but really their whole site has lots of great resources. Then, Apraxia Kids, resources for families, researchers and professionals are available there. The National Institute on Deafness and Other Communication Disorders with the NIH has some great stuff.
Speechville, you didn’t mention that one though. I found that one on your site. Are you familiar with Speechville?
Mary Cousino: Oh, yeah. It has a lot of activities and those sort of things and some information.
Dr. Mike Patrick: And then Episode 289 on nasal Speech and velopharyngeal dysfunction.
Also, there’ll be a link that says Connect Now with a Speech and Language Pathologist from Nationwide Children’s. That’s for referrals and appointment. It takes you to our Welcome Center. And if you just let us know what problem your child is having and what kind of person you like to see, you put your contact information and then our hospital gets back in touch with you. It just helps to facilitate making the appointment and if any referrals are needed, they work with your regular doctor and your insurance company to get that all taken care of. So it’s just a nice way to connect with the hospital if you think your child would need to see a speech and language pathologist.
All right, so let’s take a quick break and I’ll be back to wrap up the show, right after this.
All right, we just have enough time to say thank you. I want to thank all of you for helping us to get to Show 300. Without an audience, we won’t be able to do it and so, I really just appreciate each and every one of you taking time out of your day to make PediaCast a part of it. Also, thanks to Dr. Mary — there I go again, I just do that. And she should be a doctor because she knows way more about this stuff than I do — Mary Cousino, speech and language pathologist here at Nationwide Children’s Hospital. Really, really appreciate stopping by the studio and sharing her knowledge with us.
That does wrap up our time together. PediaCast is a production of Nationwide Children’s Hospital.
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All right, that wraps up things for today. I hope everyone has a happy Halloween and I mentioned at the beginning of the show, stay safe out there. Make sure that your kids are visible and that you’re watching them, keep the path clear and watch out for any open flames in your pumpkins just to make sure. We just want everyone to have a safe and happy and fun Halloween.
Until next time, this is Dr. Mike, saying stay safe, stay healthy and stay involved with your kids. So long, everybody.
Announcer 2: This program is a production of Nationwide Children’s. Thanks for listening. We’ll see you next time on PediaCast.