Red flags for CAS in young children

Childhood apraxia of speech is a complicated disorder that can be difficult to identify, due to its huge variability in presentation and similarities with phonologically-based speech sound disorder. The task is even more challenging when working with very young children with limited vocalizations. But what if there were specific red flags to look for in young children, similar to those we use for suspected autism or hearing impairment?

Overby et al. reviewed hours of home video footage of infants and toddlers to determine if there are clinical red flags that are reliably associated with a later diagnosis of CAS or speech sound disorder. Turns out, the speech characteristics of young children who later receive a diagnosis of CAS are markedly different from those of typically developing children. Between birth and 24 months, the following atypicalities were observed in children with a later diagnosis of CAS: 

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  • Limited vocalizations with few “speech-like” sounds

  • Lack of a speech-like consonant by 12 months

  • Limited consonant repertoire

    • specifically, < 3 consonants at 8–16 months and/or < 5 consonants at 17–24 months

  • Lack of velar productions and favoring of bilabials

  • Favoring stops & nasals

  • Limited syllable structures

    • productions between 13–18 months were largely vowels, lacking CV or CVC structures

As an early interventionist, being aware of these red flags may help to tease out language versus speech difficulties and provide appropriate interventions at a younger age. Infants and toddlers with a later diagnosis of speech sound disorder showed a similar, but less severe profile, and the results did not quite reach significance. However, it is important to be aware of this pattern so that we can provide all children with the most optimal early intervention services.

 

Overby, M.S., Caspari, S.S., & Schreiber, J. (2019). Volubility, consonant emergence, and syllabic structure in infants and toddlers later diagnosed with childhood apraxia of speech, speech sound disorder, and typical development: A retrospective video analysis. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2019_JSLHR-S-18-0046.

Infant Directed Speech: Not just for play!

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How often do you coach parents of the infants and toddlers on your caseload to incorporate language elicitation strategies into play? Probably a lot. And for good reason—infant directed speech (the spontaneous changes in a caregiver’s language and speech that support language development, commonly called “motherese”) is often automatic for parents when playing hide-and-seek or exploring those new birthday toys.

But how often do you coach parents to address communication development during feeding?  If this is already a part of your practice, pat yourself on the back!  Currently, the majority of research on infant directed speech is within the context of play, but this study found promising results when examining changes in mothers’ speech and language with their infants and young toddlers across play, milk feeding and solid feeding routines. See the full article for a handy graphic about specific differences across these conditions and a detailed explanation of what we know about infant directed speech so far, but here are some key take-aways when it comes to feeding routines and capitalizing on infant directed speech:

  1. Caregivers naturally make more attention-directing statements during solid feeding compared to their adult-directed speech baselines.

  2. Caregivers’ type-token ratios are higher during feeding than even in play. (And that skill can be really difficult to teach!)

  3. Feeding happens at least three times a day, every single day.

  4. You can address feeding and language goals simultaneously.

Admittedly, this study has some significant limitations. The sample size was fairly small and consisted of a very heterogenous group of mother–child dyads without any significant medical diagnoses or feeding difficulties. This study is also one of just a few to take an in-depth look at infant directed speech during feeding, and the authors have several suggestions for further investigation in this area. But if you are already inclined to work language development into all parts of a toddler’s day (and let’s face it—of course you are, you’re an SLP), this study should be a great excuse to have a snack with your next client and their caregiver!

  

Zimmerman, E., Connaghan, K., Hoover, J., Alu, D., & Peters, J. (2019) Is feeding the new play? Examination of the maternal language and prosody used during infant-directed speech. Infant Behavior and Development. doi:10.1016/j.infbeh.2019.01.005

Additional commentary:

  • The first author of this paper was interviewed in a podcast episode discussing this paper. Check it out!

  • In the United States, is seems like we’ve put a lot of value on parent–child play; however, this hasn’t always been the case. This opinion piece is an interesting commentary parent–child play interactions.

Babble Boot Camp: Yes, it’s a thing

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Pretty much all therapy we do is reactive, as in response to a diagnosed speech or language delay. But what about preventative therapy? As early interventionists, we often see young children who have diagnosed conditions that will almost certainly lead to speech and language delays. What is the best way to work with families in this particular situation? Peter et al. studied a preventative intervention they coined “Babble Boot Camp.” Aside from the adorable name, this parent-implemented program actually had some pretty neat results.

The children in this study had been diagnosed with Classic Galactosemia (CG), which is a genetic disorder that can be diagnosed at birth. Children with CG have a very high rate of speech and language disorders, but, as is typical with EI, often don’t receive intervention until the speech and language delays become apparent. Instead of waiting for the inevitable, these researchers started young—at two months, to be exact.

Babble Boot Camp is a program of activities and routines specifically developed for children in the pre-speech or very early speech and language stages of development. Parents met with an SLP via telepractice for 10 minutes per week to receive training and consultation. Examples of activities included reinforcing and stimulating coos and babbles, joint book reading, naming objects, imitation, and expanding children’s utterances. The SLP provided ideas for incorporating these techniques into routines and daily activities.

All children who participated in this study showed greater babbling complexity and increased complexity of meaningful speech compared to the control child (who also had CG). The majority of the children also demonstrated age-appropriate expressive vocabulary and communication skills at 24 months, which is pretty impressive for children with such a high chance of delay. Although this study used a small sample size, it does provide preliminary evidence that a proactive approach to speech/language intervention may be effective in the long-term; so get those families enlisted!

 

Peter, B., Potter, N., Davis, J., Donenfeld-Peled, I., Finestack, L., Stoel-Gammon, C., . . . VanDam, M. (2019). Toward a paradigm shift from deficit-based to proactive speech and language treatment: Randomized pilot trial of the Babble Boot Camp in infants with classic galactosemia. F1000Research. doi:10.12688/f1000research.18062.1

Early object exploration linked to communication skills in preterm and full-term infants

A few months ago, we reviewed a study on identifying early learning delays in preterm infants. Well, this study provides us with an additional skill to keep an eye on when working with preterm and full-term infants. Keep reading to learn how object exploration at 6 months can predict communication skills at 12 months.

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Researchers observed 20 extremely preterm infants* (gestational age < 28 weeks) and 20 full-term infants engage in play with their mothers at 6 months and 12 months of age. (Note: the preterm infants were observed at their corrected ages; more on age correction here.) At 6 months, the researchers measured how often infants engaged in oral and manual exploration of toys. For example, an infant could engage in oral exploration by mouthing a rattle and manual exploration by transferring the rattle from hand to hand. Then at 12 months, the researchers measured the infants’ gestures, vocal productions, cognitive skills, and word comprehension.

Not surprisingly, the preterm infants tended to score lower on measures of cognitive skills and language skills than full-term infants. This fits with the broader findings of previous research showing that “preterm infants as a group, do not tend to catch up to peers’ language by school-age.” 

But what may take you by surprise is that neither neonatal condition (preterm vs full-term) nor cognitive performance were significant predictors of 12-month word comprehension, gestures, or vocal production when also considering object exploration. For all infants in this study, oral exploration at 6 months was a significant predictor of word comprehension at 12 months and manual exploration at 6 months was a significant predictor of gesture and vocal production at 12 months.

So what does this mean for EI SLPs? Diagnostically, we would certainly still consider preterm birth a risk factor for future language difficulties. However, we may also consider object exploration skills at 6 months as a possible predictor of communication skills at 12 months for both preterm and full-term infants. As for intervention, the authors note that supporting object exploration could enhance communication skills, but they didn’t explicitly examine whether or not this is the case. We’ll keep you posted as more comes out on this topic!

*One limitation of this study is that the extremely preterm infants selected to participate were deemed “healthy.” Many extremely preterm infants receiving EI services have health complications relating to preterm birth.

NOTE: Interested in another paper on the link between motor skills and communication? Check out this recent review on infant siblings of children with autism. 

Zuccarini, M., Guarini, A., Iverson, J.M., Benassi, E., Savini, S., Alessandroni, R., Faldella, G., & Sansavini, A. (2018). Does early object exploration support gesture and language development in extremely preterm infants and full-term infants? Journal of Communication Disorders, 76, 91–100.

Coordination Station: Combining verbal & nonverbal skills for infants with ASD

As early interventionists, we work on joint attention and early vocalizations with children all the time. However, do you ever target joint attention & vocalization together?

Heymann et al. studied the coordination of joint attention and vocalization in infants at high risk for autism. Infants in this study already had an older sibling with a diagnosis of ASD. Researchers followed these infants from 5 months to 36 months to track development of joint attention, vocalization, and whether or not the infant was eventually diagnosed with ASD or a language delay.

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As expected, infants who later developed ASD demonstrated lower joint attention and vocalization compared to their high-risk peers, and their communicative behaviors were less advanced. Interestingly, infants with ASD vocalized significantly less during joint attention moments compared to their peers as well. These differences in communicative skills have a feedback-loop effect on the child’s environment. Caregivers are less likely to respond to communicative attempts that do not include vocalization, so they might not even notice that a child is making a non-verbal bid for communication. Also, parents have been shown to use lower quality responses with infants who don’t use advanced behaviors. As you can see, infants with impaired communication skills may incite small or minimal changes in their home environment, and that is not ideal for language development!

So how can we take this information and apply it to our everyday therapy? The authors suggest targeting both vocalization & joint attention behaviors together could lead to enhanced communication skills in infants with ASD as well as their high-risk siblings. We can also coach parents to respond to less advanced and less salient communication bids from their infants. This information is also great to keep at the back of your mind while monitoring younger siblings of children with ASD so that they can receive intervention as early as possible!  

 

Heymann, P., Northrup, J.B., West, K. L., Parladé, M. V., Leezebaum, N.B., & Iverson, J.M. (2018). Coordination is key: Joint attention and vocalization in infant siblings of children with autism spectrum disorder. International Journal of Language & Communication Disorders, 53(5), 1007–1020.