We have always expected that Susan would have speech difficulties by nature of being tube-fed. The muscles that babies use sucking down bottles and gumming cheerios are the same ones they use as they learn to speak. It takes a lot of unconscious coordination to move your lips, cheeks, jaw, tongue and breath in just the right way to form a pattern of words. Naturally, since Susan didn't use those muscles to eat in the same way that other babies did, it would take her longer to learn to talk. Enough time has passed though that we're aware that there are other factors effecting her speech than just poor oral-motor coordination.
The speech therapist at school works specifically on verbal skills needed to succeed in the classroom. Susan sees her during the school day, in two fifteen-minute sessions a week. I'm not there to see these sessions so I don't get to see how Susan behaves with her, or how much they can get done in such short meetings. I last met with this therapist in May, when the last school year was ending and we had to set objectives for the upcoming year. I was surprised that the therapist reported at the May meeting that Susan was only speaking in single words and needed to work this year on using 2-3 word sentences.
Around me, Susan jabbers all day long, and it's not just in single words or even in short sentences. Her classroom teachers tell me she talks in sentences there, too. So I don't know why she isn't talking in sentences to the therapist, but it might be related to some cognitive issue, like not understanding the directions to an exercise, or due to her lacking the social skills to respond to questions in the expected way. While she does speak in sentences, she doesn't really converse like other kids her age are able to do. It's hard to explain, but it's kind of like she's distracted and just not really following along with what other people are saying unless she is aware that they are speaking directly to her. It's a spectrum thing, I guess.
Anyway, the school therapist's report says she is showing "Sufficient Progress" towards the stated objectives of "using noun-verb responses for objects with 75% accuracy when prompted." Yeah, I don't really know what that means, either. She's doing well enough in speech therapy that they don't need to schedule a meeting with me. The teachers have commented to me that she is speaking a lot more this year than last, and that they're impressed with how much her vocabulary and conversing skills have progressed. That's cool.
The report from the speech therapist at Children's is more in depth and thought-provoking. Susan has been seeing this therapist, Ms. A, for about two years, initially for a half-hour a week, and now for an hour a week. This session is covered by health insurance and specifically addresses the oral skills associated with feeding. Generally, insurance wouldn't cover speech therapy, but in this case there's a clear underlying medical condition that justifies coverage. We're lucky on that one, I guess. I take Susan to see Ms. A after school one day a week. The therapy rooms at Children's have a two-way mirror to a dark hallway where I can sit and observe the sessions without Susan seeing me. (She does better when I'm not around, if I'm there she is too distracted.) Ms. A has been getting Susan willing to tolerate more sensation in and around her mouth without gagging, and tasting and chewing new foods. While there is absolutely progress from what Susan could do before she started seeing Ms. A and what she can do today, that progress has been slow and hard-won.
Over a few weeks, Ms. A. used The Goldman Fristoe Test of Articulation-2 to assess "production of phonemes in single words." Professor Wikipedia tells me that :
"a phoneme (from the Greek: φώνημα, phōnēma, "a sound uttered") is the smallest segmental unit of sound employed to form meaningful contrasts between utterances."
Ah. So the test is to see if she makes the right sounds to form words.
The report states that Susan has "apraxia-of-speech," symptoms of which (thanks again, Wikipedia) include:
"inconsistent articulatory errors, groping oral movements to locate the correct articulatory position, and increasing errors with increasing word and phrase length."
Or in other words, she doesn't speak very clearly. This doesn't really trouble me much because I can understand her, and so can others who know her or who are willing to listen carefully. She pretty much talks like a younger child who has not yet mastered speech. She's still learning. It takes time.
The test scores are a little distressing. The GFTA-2 showed "moderate to severe" impairment in articulation skills, and another test, the Preschool Language Scale - 4th edition, came back showing "severe impairment" in both receptive and expressive language. These tests are based on typical skills for her age level. Since I mentally "correct" for her age and tend to think of her as being like a younger child, I never consider her as "moderate to severely impaired" in anything other than feeding.
Generally, kids have developed their speech skills by the time they are eight years old. With Susan, it might take a while longer. I'm sure that it will get harder as she gets older because our brains get less efficient at interpreting speech as we age. This is why we have to push the therapy so much now, to maximize her chances at catching up to age level.