Developmental Milestone

Drumroll please.

The results of Brad's most recent annual speech eval are in, and he's testing in the average range or better for receptive, expressive, simple narratives, complex narratives, pragmatics - everything!  Yay!  It took him until age 6.5 to get there, but he's there.

Previous posts on prior speech evals here, here, and here.  

It's been a long journey.  It's not over yet, but this is me, smelling the roses.  

Speech Update: Four Years, Three Months

I received the written report from his most recent speech evaluation. (A post on last year's evaluation here.)

Bad News First: Overall, his expressive communication was pegged at two years nine months. Over the twelve months from May 2009, he only progressed five months. He scored a 63 on the expressive language portion of the Reynell Developmental Language Scale, a test in which the mean for his age is 100 plus or minus 15. So that's discouraging.

His deficits appear to stem from four types of issues: verbal/visual association errors, paragraph comprehension, semantic errors and rigidity. The examiner also observed "as expressive language tasks became more complicated and Brad was ask to describe pictures or re-tell narratives, he began to resist." Go figure. He's four years old!

Excerpted from the report, for your information and amusement:

Although Brad responded accurately with regard to production of grammatical skills, errors were noted in semantic abilities. For example, when asked to label an illustration of a group of men, Brad responded, "children." When shown a picture of several people trying to escape the rain and asked, "What's happening," Brad responded, "It's not raining." The examiner continued "It is raining. And the people are getting ____" and Brad responded, "frozen." He provided definitions for concrete or abstract concepts with inconsistent accuracy. When asked, "what's an apple - what do you do with an apple?" Brad responded correctly by showing the examiner eating. Error responses were predominantly reiterations of the targeted concept. For example when asked, "What does cold mean, "Brad responded, "I'm cold." Brad's motivation waned when asked to describe a group of illustrations depicting a family engaged in various tasks. He fell out of his chair and told the examiner that the task was "so so hard. It might take a very long time." With encouragement, Brad provided short sentences that in general described the pictures. For example, in response to a picture of a family washing the dishes, Brad responded, "She's making a recipe." In response to a picture of the same family setting the table, Brad provided, "He's making dinner." Brad substituted "he" and "she" pronouns thoughout.

The picture card sequence probe outlined in the language comprehension section of this report was used to assess Brad's formulation skills for sequenced activities. Brad experienced difficulty on this task. He repeatedly pointed out numbers on the cards that existed outside the illustrations. He appeared to focus on pictured details and neglected salient features of the illustrations. For example in the sequence that depicted a girl making her bed, the line that the sheet's border had created intrigued Brad. He ran his finger along this line and asked the examiner about the "rope."

That's Brad in a nutshell. Marching to the beat of his own drum. Falling behind in communication but getting ahead in numeracy.

As a parent reading the report, it was hard for me to figure out how much was attributable visual/verbal association problems versus semantics versus he's four years old and the exam was taxing on his attention.

The good news: The perpetual tough grader wrote:

In contrast to previous testing, Brad made several improvements in nonverbal and verbal pragmatic skills. During current assessment, Brad followed the examiner's gaze and engaged in joint attention.

He also did very well with object identification, sentence completion, syntax construction and pragmatic judgment, scoring within the average range for each of those assessments.

Back To School

I'm writing to report that there's not a whole lot to report. Which is good, I suppose.

We're back to four days a week at integrated pre-school ("integrated" meaning special needs and typical peers). As I have blogged, Brad is in a great program with a rich curriculum, including motor group and one-on-one speech. It wasn't all good news last year though. In last year's class, he had difficulty keeping up and tended to withdraw.

Over the summer, Brad had a good teacher, who REALLY REALLY understood Brad and appreciated him. (Well, technically, I think the summer program is camp, but it was at the same place.) Anyway, according to her, Brad came out of his shell during the course of the summer. Brad showed her that fullness of expression that we see around the house. She loved him. Well maybe she loves all of her students, but still, I was enjoying her Brad appreciation.

Anyway, out with the old and in with the new. His teacher for this year (September through May) has yet to bond with him on that level. But I'm hopeful they'll get there. And the class mix seems to be better for Brad, in terms of age and temperament and whatnot.

One thing new on the roster: they might add a twist to Brad's one-on-one speech pullouts. They suggested one-on-two, meaning one speech therapist for two children. To facilitate a friendship and administer therapy at the same time. Call me crazy, but I like that idea a lot.

Go sox!

Here, in New England, we are said to be stoic relative to others in, say, the midwest or the south. We don't feign pleasantries. We're not warm and welcoming to people we don't know. We keep to ourselves. As a general matter.

Unless you're wearing a Red Sox tee shirt, in which case puritanical stoicism gives way to two other Massachusetts traits: meatheaded-ness* and sports fanaticism. For the uninitiated, Massachusetts happens to be some sort of meathead mecca, for reasons I don't fully understand. Anyway if you're wearing a Red Sox tee shirt and it's the day of a game, perfect strangers have license to make remarks and engage you in conversation.

Which is fine, unless you have have a speech delay. I have blogged of my time as what I dub a "smile bully"; when Brad was 3 months old, I wouldn't leave him alone until he smiled. Well, what we have here are conversation bullies. People who won't be satisfied until they have elicited some sort of remark from Brad, like his favorite player or the anthem "go sox." Brad, of course, wants nothing to do with these well-intended people, understandably.

So I have resorted to taking the Red Sox shirts out of his rotation during game day. It's all I can do. Do you or yours ever get assaulted by conversation bullies?

*Patent-pending.

"Excuse me, Mommy."

Music to my ears.

After what has felt like a verbal plateau for the last six months, it appears Brad's speech is taking off again. He's surprising us lately with a fullness of expression and a budding personality. My fave: "excuse me, Mommy", used appropriately when he wants my attention. And if I don't attend right away, he keeps saying it, with increasing volume. And I'm only too happy to pay attention.

Speech Assessment

Now for the numbers.

I received a full evaluation report from Brad's private speech pathologist. The conclusion:

Brad presented with a mixed profile in receptive-expressive language skills with average receptive and expressive vocabulary, mild deficits in direction following, question comprehension and verbal reasoning, mild deficits in semantic organization, and severe deficits in language formulation for a variety of purposes. Deficits were also noted in Brad's symbolic play, as he did not engage in pretend play and dmonstrated some rigid and atypical play behaviors. With regards to speech skills, Brad presented with a mild phonological disorder with a motor component.

Drilling down:

Behavior: "bruxism" noted. That's medical-speak for teeth grinding, which is self-stimulatory. He does this quite a bit now. Also observed: reduced eye contact. But: "Brad maintained selective and sustained attention for the entire two-hour assessment and complied with both play and language based tasks."

Play: Rigidity observed. For example, "when given a chair, table, tablecloth, fork, knife, plate and doll, Brad placed the doll on the chair, pushed her to the table, and then set the table. He did this silently and did not narrate his play scheme or interact with the doll." Tough grader. I guess I should get used to it.

Receptive language:

• The Peabody Picture Vocabulary Test-4: Brad scored 88. The mean is 100 with a standard deviation of 15
• Verbal Comprehension Scale A from Reynell Development Language Scales: Brad scored 82. The mean is 100 wiht a standard deviation of 15.
• Informal probe: Answers yes/no and what questions accurately. Inconsistent accuracy for where questions. Innaccurate for why questions.

Expressive language:

• Expressive One Word Picture Vocabulary Test: Brad scored 98. Mean is 100.
• Expressive Language Scale from the Reynell Developmental Language Scales. Brad scored 70. The mean is 100 with a standard deviation of 15. This is by far his lowest score. Based on this, he was judged to have a severe expressive language impairment. "Error responses consisted of visual/verbal association errors. For example, when asked to label and illustration of a window, Brad responded 'book.'" But it was only pictures that tripped him up. He scored 100% identifying actual objects, and 63% with illustrations.
• Informal analysis: Possible language organization and/or word retrieval deficits. "Several lengthy response latencies were noted during both word-level and sentence-level testing. Response latencies ranged from two to eight seconds. this degree of response latency might have resulted from mild word retrieval deficits. Further characteristics of word retrieval difficulties were noted in Brad's use of non-specific terminology throughout assessment. Characteristics of language organization deficits were noted in difficulties disambiguating illustrations of visually similar objects, such as a feather and a leaf, and reduced use of specific vocabulary to describe part/whole relationships."

Speech

• Goldman Fristoe Test of Articulation- 2. Brad scored 108. Mean is 100. Mild speech dysfluency observed.

Me to Brad's SLP: He's Just Not That Into You

Or your dolls.

Allow me to explain.

I had Brad evaluated last week for private speech therapy. She raised the usual litany of concerns. Expressive language delay. Receptive language delay. No surprise there. What surprised me was her observation that his play is rigid and rote, and he has no imagination.

Oh really? I see him play with his brother all the time, and personally, I see mostly natural, unscripted play, with a lot of laughter. Brad has a sense of humor, albeit an immature one. Beyond that, I see a budding imagination, particularly when we use pretend food or stuffed animals.

The basis for the SLP's observation: it's the dolls.

The SLP did what every examiner does - she reverted to her preconceived notion of what inspires imagination in a normal kid. But Brad does not have an emotional connection to dolls or plastic representations of people. Why would he? In the world according to Brad, babies poop, cry, grab his stuff and don't share. He's around a baby - a sibling of one of Jeremy's friends - a few times per week. When he sees the baby, Brad goes right into bunker mode, protecting his booty of toys from the perceived threat because that's all that a baby is to Brad at this age.

So he lacks the emotional connection but he knows from past experience what to do with dolls. He puts them to sleep and says "shhhhh." He has memorized the play script. And being the pleaser he is, he happily goes through the script on request.

Fine, maybe I'm rationalizing. But the way I see it, he's acting in a rigid manner because we've reduced freeplay to an instructer-led service delivery model. Call me crazy but maybe play isn't always best when it's administered by a trained professional.

Not to worry though. I'm not shunning speech therapy. Brad is starting during the second week of July, two fifty minute sessions per week, covered by insurance at least for now. I plan to have a little heart to heart with the SLP before she starts however.

Developmental Coordination Disorder

At Brad's recent evaluation (second opinion), the developmental pediatrician gave Brad a new diagnosis - "developmental coordination disorder" or "DCD." DCD is often used interchangeably with the term "dyspraxia." In theory, DCD is the term favored in the US, although in my experience, dyspraxia is widely used in common parlance in the US.

The New York Times reports that approximately 6% of school age children have some degree of this disorder. Like PDD and sensory processing disorder, DCD is hard to define.

The DSM-IV criteria follows:

A. Performance in daily activities that require motor coordination is substantially below that expected given the person's chronological age and measured Intelligence. This may be manifested by marked delays in achieving motor milestones (e.g., walking, crawling. sitting), dropping things, "clumsiness," poor performance in sports, or poor handwriting.

B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living.

C. The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia. or muscular dystrophy) and does not meet criteria for a Pervasive Developmental Disorder.

D. If Mental Retardation is present, the motor difficulties are in excess of those usually associated with it.

In light of C (above), technically, Brad's PDD diagnosis should rule out DCD. (Or maybe it's the other way around?) Moving on.

Wiki describes the motor challenges associated with DCD as follows:

• Poor timing.
• Poor balance (sometimes even falling over in mid-step). Tripping over one's own feet is also not uncommon.
• Difficulty combining movements into a controlled sequence.
• Difficulty remembering the next movement in a sequence.
• Problems with spatial awareness, or proprioception.
• Some people with dyspraxia have trouble picking up and holding onto simple objects due to poor muscle tone.
• This disorder can cause an individual to be clumsy to the point of knocking things over and bumping into people accidentally.
• Some dyspraxics have difficulty in determining left from right.
• Cross-laterality, ambidexterity, and a shift in the preferred hand are also common in people with dyspraxia.
• Dyspraxics may also have trouble determining the distance between them and other objects.
• Some dyspraxics have difficulty achieving and maintaining continence either of bladder or bowel or both. Bedwetting or nocturnal enuresis is common.

Wiki indicates that the following speech and language problems are associated with DCD:

• Difficulties controlling the speech organs.
• Difficulties making speech sounds
• Difficulty sequencing sounds within a word
• Forming words into sentences
• Difficulty controlling breathing and phonation.
• Slow language development.
• Difficulty with feeding

The Wiki description certainly fits Brad's present condition, but I'm skeptical as to the role of dyspraxia with respect to Brad's speech for two reasons. First, the Wiki description is unofficial and therefore should not be relied upon as authority. Second, Brad had a significant receptive language deficit at 24 months. (Early Intevention pegged his receptive language at 10 months when he was 24 months old.) My understanding is that a motor planning deficit, such as DCD, does not cause a receptive language delay (although it could cause an expressive language delay because talking itself requires motor coordination or praxis). Moreover, DCD doesn't account for the Brad's social deficits. While dyspraxia may play a role in Brad's speech challenges today, including phonological problems and stuttering (or "groping"), DCD doesn't appear to tell the whole story.

Update: The DCD label was included in Brad's "impression" report; it was part of his official diagnosis.