Unbabbled: Speech Sound Disorders

Childhood Apraxia of Speech with Jennie Bjorem

Being told that your child has childhood apraxia of speech (CAS) can be shocking and confusing. Since this speech/sound disorder is so rare—occurring in 1-2 children per 1,000—many doctors, educators, professionals and even speech-language pathologists have minimal understanding of it. In this episode, we speak with speech-language pathologist and childhood apraxia of speech expert, Jennie Bjorem about the characteristics, diagnosis and treatment of apraxia. She also provides tips on where parents can find a speech pathologist with CAS experience and other reliable resources.

About Jennie

Jennie Bjorem, MA, CCC-SLP, has been a practicing SLP for over 20 years. Jennie’s areas of expertise include early intervention, parent education and childhood apraxia of speech. She is recognized by Apraxia Kids for Advanced Training in Childhood Apraxia of Speech, and travels the country presenting on the rare disorder. She owns a private pediatric clinic in Kansas and founded Bjorem Speech Publications, where she developed a variety of products to support speech/sound development at home and in therapy. Jennie is passionate about working with parents to help encourage their children in all areas of development.


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Stephanie (00:05):

Hello, and welcome to Unbabbled, a podcast that navigates the world of special education, communication delays, and learning differences. We are your hosts, Stephanie Landis and Meredith Krimmel, and we're certified speech language pathologist who spend our days at the parish school in Houston, helping children find their voices and connect with the world around them. Childhood apraxia speech is an often misunderstood and misdiagnosed motor speech disorder. Because it is so rare, many doctors, educators, and even speech language pathologists have minimal understanding of it. In this episode, we speak with SLP Jennie Bjorem, about childhood apraxia of speech. Jennie has over 20 years experience with expertise in early intervention and apraxia. She has extensive experience and training in childhood apraxia and is recognized by Apraxia Kids for advanced training in childhood apraxia of speech. Jennie travels, the country presenting on the topic of childhood apraxia. She is passionate about working with parents to help encourage their children in all areas of development. During the episode, Jennie discusses the characteristics of childhood apraxia of speech, best practices for diagnosis and treatment and ways childhood apraxia of speech differs from other speech sound disorders. She also gives tips to parents for how to find an SLP with experience in Apraxia and where to find reliable resources. Her advice at the end of the podcast to parents is so heartfelt, it brought Meredith and I to tears. Today, we are speaking with Jennie Bjorem and we're so excited to talk to her about Apraxia. So welcome. And thank you for talking with us.

Jennie (01:39):

Thank you for having me. I'm sorry. My voice is a little scratchy because I've been talking for a long time while we're here at the convention an entire day straight.

Stephanie (01:49):

We'll start off with just the basics. What is apraxia of speech for children?

Jennie (01:54):

So Apraxia of speech is a motor planning speech disorder that impacts the movement of speech, so that precise movement of speech. So if you think about all the different areas in your body that you have to use in order to motor plan for speech. So we think about, I always do this with little kids. I go into classrooms and speak to little kids and explain apraxia to them. I'm like, so what do we need? You know, what do we need to use for our speech? Well, we need to use our lips, our tongue, our vocal chords, our pallate, our lungs, our diaphragm. So all these different things that we need to use for speech, but the child has to be able to do all those movements precisely at the same time, at the same speed or change of speed, you know, so that those movements make speech sounds and sound in words. And so it's when there's that impairment and kids cannot motor plan all those things at the same time.

Stephanie (02:54):

Is there a difference between childhood apraxia of speech, developmental apraxia of speech, adult apraxia of speech?

New Speaker (03:00):

Now adult apraxia speech is more aquired. So that's like they didn't have apraxia before, you know, and then it's been acquired later on due to some sort of incident. Um, but childhood apraxia speech, we know that kids are born with it and, or, or it's some type of neurological event that happened in their early childhood or, you know, we just don't know the reason or they have comorbidity of some sort like autism or down syndrome that ap'raxia may more likely, uh, fall in the category.

Meredith (03:35):

When do you start to see signs of a proxy of speech and children? Is it come on gradually as language develops or do some children, does it feel like it comes on suddenly?

Jennie (03:43):

I don't feel like it comes on suddenly. I'd say all of our families complain of, you know, kids not talking, not babbling, that they're pretty quiet, that they're easily frustrated that they're, you know, not saying their first words, that they have limited sound repertoire, meaning that they don't have a lot of sounds that they're able to say. And so those complaints get I also, one of the biggest complaints I get from families is behavior. Like, I don't know what to do this kid, you know, we're seeing so much behavior and, and like, many of my families will say that they just give the child everything they want or need because the child can't communicate and they're crying and they feel bad. And so then it exasperates the behavior. Um, so I get that a lot with my families, but so those would probably be the early signs of apraxia that we see. And, you know, we can see this pretty early on as young as 12 months. There's some research, um, recent research stating early signs of apraxia. Yeah. And so that's extra helpful when you're going to assess a child with apraxia of speech, you can kind of look at their history to see if they fall in that category of those early signs of childhood apraxia.

Meredith (05:02):

And as a speech language pathologist, once, once you get a child in your clinic, because a lot of those red flags you mentioned could be for other language or speech disorders, what do you start looking for as a speech language pathologist of what could be apraxia or another articulation disorder or phonological disorder?

Jennie (05:19):

You're asking what signs?

Meredith (05:21):

Yes, for a differential diagnosis.

Jennie (05:24):

So there's about 11 different signs we look for and kids do not need to have them all. Uh, we really look for, you know, a certain number of signs over different assessments. So meaning that over different speech tasks. So we may do an articulation test. And then instead of having the child say the word once, we'll have them say it twice. So we can kind of look for those inconsistent patterns, vowel distortions, and intrusive Schwab is when a child adds the uh sound. So if they say the word, no, and then they say the word Noah, and then they have that uh sound added in. Segmenting or disrupted movement in speech is common property issues, eaning a child has inappropriate prosody or very much of the time we'll see no prosody. Where prosody means volume rate, stress, how our speech sounds in a rhythm. So if we speak like this, we sound segmented and our prosody is not appropriate. But, um, we also may have kids that use inflection wrong. If they're speaking, where are we going to the zoo? Or are we going to the zoo to, you know, they may have, or like the inappropriate stress, what are we gonna do today are really good examples of inappropriate stress or inappropriate prosody. And that would be a sign that it possibly is CAS childhood apraxia of speech mixed with other signs, right? So we have to look across many different speech tests. So the thing is, you know, people, what will happen is I'll have parents message me a lot. And like my kid's not talking. I think they have apraxia. Yeah. I'm like, well, how many sounds and how many words do they have? And are they combining them? No, they're not doing anything. Then we cannot diagnose apraxia. Yeah. Right. Because we need more signs. Now we can assume that that child is language delayed and speech delayed because they don't have a lot of sounds in their repertoire. And then we're going to do early intervention therapy to get them using more sounds in their play and, and talking. But, uh, we can't diagnose apraxia until we really have a child using, um, sounds and, uh, movement patterns through words or consonant, vowel combinations, even.

Stephanie (07:59):

What things do you use to diagnose childhood apraxia?

Jennie (08:04):

So I use the DEMSS, which is Edythe Strand's new assessment. Um, when I went to her training, she had, the DEMMS was not out yet, but when, um, she was presenting, she was like, you don't even need to buy the DEMSS. You can make your own DEMSS. It's easy. You're just going to pick these words, these words, these kinds of words, and these kinds of words. And then you're going to look for this consistency across, you know, across, uh, speech tasks. So I've also created my own informal assessment. Now Edyth's is standardized, mine's informal. So I think it just depends on the child, which one I use. And so I use both of those interchangeably. So that's what I use. And I use a lot of parent report. Um, you know, many times, parents have already, by the time they've come to me, they've already researched so much about childhood apraxia. And they're like, they're doing this and this and this and this and this. And then it's hopeful because then I know from parent report and then I can really pull stuff out of the child to get a better answer of, Hey yeah, I'm seeing this or no, that's, that's more typical for other speech sound disorders. And then you have to diagnose, you have to like dissect, not diagnose, but you have to dissect because many kids have a phonological impairment along with childhood apraxia speech. And then you have to, you have to rule out dysarthria as well. So, which is way less common. And that's pretty easy to rule out right away if you just see, but if you're having any breath support issues and you've got to kind of look at the history of the child for dysarthria, but yeah. I mean, those assessments work really well. And sometimes it can't be done in one day sometimes, an apraxia diagnosis has to be looked at over the course of weeks or months.

Stephanie (10:02):

Yeah. It's very tricky to diagnose and takes a full battery of assessment and seeing them in multiple different areas, I think, to rule out all of those things and it becomes more difficult, like you said, when they might have both.

Jennie (10:15):

Right. And you know, sometimes it's really clear cut. You're like, yep, that's it. Those are the ones I love because then I'm not questioning myself. Right. But, um, when it's not clear, cut, you do have to dig in more and really begin to understand their motor system and really figure out how it works for them. And the cool thing. I think one of the things you asked, what do I use to, um, to assess childhood apraxia speech? What's so different about assessing childhood apraxia of speech versus other speech sound disorders, is that I want them to say the word, right? So I'm going to give them all the cues possible to get them to get it right, because guess what, that's going to give me a lot of information on my assessment telling me, Oh my goodness, this kiddo really works well with this type of queuing, this type of queuing, this type of queuing. And when I backed off a little bit and had them do it again, then I saw inconsistencies, vowel distortions, segmenting. What are those signs that I'm seeing? And so that's a huge difference between regular like artic or phonology testing is that I'm going to have the child say each word twice, and then if they get it wrong or it's different than I'm going to cue them in many different ways to get them to say that word correctly. Yeah.

Stephanie (11:33):

A much more dynamic assessment.

Jennie (11:34):

Way more dynamic.

Meredith (11:37):

So if a parent feels like their child has apraxia of speech, or if they know their child has apraxia of speech, what would they expect from treatment? What would treatment look like?

Jennie (11:48):

Well, I also think that depends on each individual therapist and each individual child. So every therapist looks a little different in their practice. So I see kids from age two to six or seven is most of my caseload. And so I use DTTC, um, dynamic temporal and tactile queuing by Dr. Edythe Strand. And I take a very play-based approach. So for me, we're a lot of times on the floor playing. And then I have a very small group of target words that I really work on to teach queuing, to teach motor planning, to teach, um, those specific words. And I find that depending on the child, I find that once children kind of begin to understand queuing that motor plan, that my goal and my hope is that it'll start to generalize over to other words, or when I bring in new targets, those kids are going to learn those targets faster because they know we have to work on it and high repetitions, and they know we have to, and they've seen it work before. So then the child has buy-in. So I think that's a huge thing for me. And I talk about that a lot on my Instagram is that children getting buy in, like if they don't have buy in and they don't believe in their therapist and they aren't seeing progress themselves, then they're not going to have the buy in. And then they're not going to work as hard as it takes to do therapy for childhood apraxia speech. So for me, my therapy may look a little different than somebody who's prompt certified, or that somebody that used the Kaufman program, but as long as you are, you know, following the research and taking a motor based planning approach, and you're working on movement patterns and not sounds then that's key.

Meredith (13:32):

Do you find that apraxia treatment generally has to be more intensive or more frequent than maybe articulation or phonological processing treatment?

Jennie (13:40):

There is some research out there that shows that it takes three times as much therapy therapy for kids with childhood apraxia speech to make a similar amount of progress as it would for a child with a phonological disorder. So, yes, and most of the kids I see and, you know, depending on, you know, family, you know, schedules and dynamic, and depending on if, um, you know, what the families can afford and what insurance covers or doesn't cover, then, you know, I have kids that will come three, four, five times a week for 30 minute sessions. And then I encourage them to, you know, if they're in a school district, obviously, you know, Hey, if you can get 15 minutes a day from your speech therapist at the school district, that is awesome. I've had families come to me and be like, they're only giving me 15 minutes a day. I'm like, yeah, this is great. That's the best news ever, because you don't see that a lot. So I just really encouraged shorter increments, but more frequently across the week.

Stephanie (14:42):

One of the things you talked about was being very play-based, especially for the younger kids. I love that because it adds like some functionality and liked that. What things do bring into do play-based type therapy?

Jennie (14:55):

You know, not a lot. Sometimes I don't bring a whole lot of anything. Sometimes kids bring their own things and I've talked to 'em, this is a really great, I love this for parents and therapists, but, um, so when kids bring their own things into therapy and a therapist takes those away and puts them away and doesn't like, let that child number one address it, or you may maybe like even utilize that in therapy, somehow you're taking away their, um, their thing that's really close to them that they may be able to talk about and communicate about. So you're taking away their context. So I always encourage therapists and parents to allow me, you know, to keep the item in there or use it as a, Hey, it can watch us, or it can play, or, you know, if it's a little robot or whatever it is, a dinosaur, I try to incorporate it into my therapy if I can, because then it's not taking that context away from that child. It gives them a context of what they feel comfortable and confident talking about. Um, so I try to incorporate their things that they bring. I mean, as simple as Dixie cups or, um, balls, and, you know, we may do silly things or writing on the table or, um, you know, I just, I typically don't have a ton of ton of things. I'm just very, I, I typically don't do worksheets or anything like that. It's just, even with my little bit older kids, we're just finding fun things to do, to play. A lot of stickers. Uh, we do silly things. So it's, it's, it's kind of more about me and the child.

Meredith (16:36):

Do you use all the cards and materials that you've made? Do you use those in a play based way?

Jennie (16:42):

Yes, absolutely. So the main cards I use are the Bjorem speech sound cues, and I use those in play-base. So if I usually have them spread out on the table or spread it out on the floor and we're talking about something, or if there's like, you know, say, where are our target words are mamma dadda, E, dino, because dinos an important word for this child. Me, no, hot. Let's say we've chosen like 10 of these words. And I know we're going to use all these words in our place scenario that all have those speed sound cues out there. And if the child goes off or hot, I said, Oh, you gotta get your hot dog sound. And I'll just quickly hurry and pull my hot dog sound and I'll tell him h-ot. And then we worked together using DTTC that simultaneous production so that the child is working on that target within play. And so I might withhold things. So if, if I were making the dinosaur eat, then, um, and I say, the food is hot, and the child says, I'm like, he's so hungry. He wants to eat, but the food's hot. And the child goes, ah, ah, and I say, Oh, well, let's use your hot dog, sound. H-ot. And then we practice it, practice it, practice it. Then I will give them the little hot food. Then, then they could feed the dinosaur and then I'll take the hot food away and then we'll do it again. And again, again, as long as the child will tolerate my, so, you know, material management, understanding how to play and high repetitions within that play. You know, it just kind of depends on each child. I use a little clicker or my fingers to like always get at least five repetitions. So they know that, um, every single time I ask them to practice the word, they have to do five.

Meredith (18:21):

Oh, that's great. That predictability is there. And I love that you're using your materials in a play-base way. Um, and not just sitting at a table and drilling.

Jennie (18:29):

Yeah, no, I don't do any drill. I love that. Yeah. I don't do any drill. The only time I will, um, flip through the Bjorem speech sound cues is number one. If for some reason the kids love it. They love to try to practice the sound and put it in. So I usually do it to kind of check on sound repertoire. So, okay. What time, you know, it's been three or four weeks since we've looked at what sounds are in your repertoire. Let's see if you've added any more, you know, let's see if you can imitate any more, get a closer production to as particular sound. Yeah.

Stephanie (19:00):

This is a total side note, but I've just been enjoying that. It's so naturally to you to use all of these cues, that it's a podcast and they can't see you, but as you're making all these sounds, you're doing the cues and doing your hands. I love it. Second nature. You talk in your answer. There I go. So back on track, how much parent involvement do you have?

Jennie (19:23):

A hundred percent. All of the time. Parents are a hundred percent of the time in my therapy room. I'm always talking about why I'm doing things, how I'm doing things, what I want them to do, what I want it to look like. And if they don't feel comfortable and confident, I just say, don't do it yet. We'll do more parent training so that you can do it. Cause I'd rather you do it right than wrong. And us have to go back and remoter plan something or, you know, do it over again. So, um, lots and lots and lots of parent involvement. Actually. I think it's the number one important thing within my therapy sessions, me personally. So parents aren't allowed to stay in the lobby. They have to come back to the therapy room, no break for those parents, no break. This is not a break time.

Stephanie (20:06):

But that's fantastic because since we know frequency is important and those kids use the cues to be successful, like you can't follow them around all day, cuing them. Nope. You can't having that parent buy in increases the success of the kids and the parents and yeah.

Jennie (20:21):

And so much parent education. And about sounds like parents have no idea there's voiced and voiceless sounds. They don't understand that there's front and back sounds. They don't understand that there's nasal sounds. I had a parent email me the other day or message me on my Instagram the other day. She's like his end sounds, sounds so nasal. And I was like, that's great because they are yeah. And it was like really, really encouraged. And you know, I was really encouraging. That's what we want.

Stephanie (20:48):

That's really great point because I don't know if I've ever even broken it down that much with parents, unless it was that specific sound. The kids are working on of like how much we use and how different the sounds are within your mouth. It's just, it comes so naturally to parents that like, this is how we make the sound. You have to think about it.

Jennie (21:08):

If I make them say them out loud, I make them feel where they're at. Where's the air going? What does it take? What motor plan does it take to make that sound? Now add more, two more sounds with it to make a word and think about the motor plan that that requires for your child. And so that just comes naturally to us because we don't have to think about that. That the children have to think about every single motor plan. And so that becomes difficult.

Stephanie (21:29):

I mean, I think about the amount of talking we've done in the past few days and that'd be exhausting. I mean, it's exhausting.

Jennie (21:35):

I read a minute session for a child with apraxia is exhausting.

Stephanie (21:38):

Yeah. They're working really hard.

Meredith (21:40):

We talked a little bit about the materials that you have, which are so cute and functional and amazing. Where can people find your materials?

Jennie (21:46):

Um, so I sell all my materials on my website. So it's www.bjoremspeech.com. So it's B J O R E M is my last name. Um, but yeah, the, the blue deck is the one that most families with kids with apraxia by, or that speech therapists work with. And they all, they are awesome too, because we know kids with apraxia are more likely to have a phonemic awareness difficulties and, um, early reading difficulties or reading difficulties throughout the life span. And so we use the Bjorem speech sound cues also to work on phonemic awareness and sound a letter correspondence. So it gives them that beautiful visual and those cues that we're already using with the child. So they're just transitioning that over to early reading and it just works like a dream.

Stephanie (22:37):

That's great. So you mentioned that often when parents come to you, they've already done their research and Googled. If this is a family, that's just now starting down their path, do you have any resources that you like to point parents in the direction of first?

Jennie (22:50):

I always send them to apraxiakids.org and that's really what I tell them. I'm like, don't Google everything because you're just going to find, gonna go down a rabbit hole. Um, so just go to apraxiakids.org, call Apraxia Kids, they are going to be willing to help. They are the number one resource in North America.

Stephanie (23:08):

So if they're looking for a therapist, are there any questions they should ask their therapist to see if they have a background with treating children?

Jennie (23:16):

Absolutely first go to apraxiakids.org. I think there's a whole article on that there, which is a great resource. And they also have a, uh, a listing where you can put in your zip code and look for a therapist in your area. So that's another great place. And you know, the questions you're going to want to ask is like, how many kids a week do you treat with child apraxia of speech? What kind of training have you had with childhood apraxia speech? What approach do you use? Um, and those are kinds of things that parents really need to find out and they really need to find out if they take a play-based approach. And if they are using a motor planning approach and are they focusing on movement and motor planning or are they focusing on sounds, which is not what we want. So, um, you know, it is important to get the right therapist and it just makes, makes for a little bit more due diligence on the parts of the parents.

Stephanie (24:07):

Yeah. We have one last question. Okay. That we put every person in the hotspot at the end of the podcast, we ask, if you had one piece of advice to give to the listeners, it can be about apraxia. It can be about general life at all. It's one piece of advice. What would you give?

Jennie (24:23):

Um, I'll go with the apraxia piece because it's, it's like it's my entire world and my heart. Um, is that just not to stress out about it. That, you know, look for the tools that are gonna help your child, but take that time to enjoy your child? Because I think parents get so caught up in, I gotta fix this. I gotta fix this. I gotta fix this. You gotta go, go, go, go, go, go, go. Just enjoy that time. Enjoy your child. And they are going to be who they are and they're going to your child's going to be an amazing, great person. Sit down and read a book with them. Snuggle them, love them. It goes by so fast. My son turns 18 next month. And in a blink of an eye, I walked out of his last hockey game this past week and the door shut behind me and the ice rink. And I just bawled. We've been playing hockey since he was five. And, um, man, it just goes so fast. So just enjoy their little precious brains and bodies and just love 'em up.

Stephanie (25:28):

It is hard when you're working so hard and advocating and doing so much for your kids. Sometimes you do get caught in that race. Yeah. I agree.

Meredith (25:36):

Your advice gave me goosebumps.

Jennie (25:37):

My tear. I've got a tear.

Meredith (25:44):

I know, I know we've got little kids at home, so the idea that you know, we're going to be there one day and it will be fast.

Jennie (25:50):

It's like a blink of an eye when people say that I'm not kidding. I'm literally crying now.

Meredith (25:56):

That's great advice, but I thank you for sharing.

Stephanie (25:58):

Thank you so much. I really appreciate you taking the time to talk to us. And I know this is going to be a wonderful resource to people out there.

Jennie (26:05):

Thank you.

Meredith (26:09):

If you're not already, don't forget to subscribe to the Unbabbled podcast on your app of choice. And if you like what you're hearing, be sure to leave a rating and review a special thank you to Stig Daniels. Amy Tanner, Amanda Arnold and Stella Limuel for their hard work behind the scenes. Thanks again for listening.