About
Apraxia
WHAT IS APRAXIA/DYSPRAXIA?
APRAXIA/DYSPRAXIA is a neurogenic (arising
in the brain) impairment involving planning,
executing and sequencing motor movements. By
definition, all forms of apraxia occur within
the absence of muscle weakness.
WHAT
IS VERBAL APRAXIA (APRAXIA of SPEECH)?
VERBAL APRAXIA affects the programming of the
articulators to perform the rapid sequences
of muscle movements in order to produce speech
sounds. It is a breakdown in the transmission
of messages from the brain to the articulators
(jaw, cheek, lips, tongue, and palate). With
verbal apraxia, a child knows what he/she wants
to say, but there is a breakdown in the transmission
of the message from the brain to the mouth.
Children with pure verbal apraxia may be able
to move their articulators for non-speech movements
but are unable to do so during speech. Verbal
apraxia can be referred to by a variety of names
in clinical literature, including apraxia, verbal
dyspraxia, childhood apraxia of speech, apraxia
of speech, developmental verbal dyspraxia, and
developmental verbal apraxia, and many professionals
also use these terms interchangeably.
WHAT IS ORAL APRAXIA?
ORAL APRAXIA involves non-speech movements
and often occurs in children with verbal apraxia.
Children with oral apraxia will have difficulty
with tasks such as blowing bubbles, puckering
their lips for a kiss, or licking food from
the lips. Frequently, children with oral apraxia
have difficulty moving the articulators independently
of each other; for example, when trying to stick
out the tongue, the jaw also moves forward.
Often, oral apraxia is the first sign of a possible
verbal apraxia in a young, non-verbal child..
WHAT
IS LIMB/MOTOR (“GLOBAL”) DYSPRAXIA?
LIMB/MOTOR APRAXIA involves the programming
of hand or whole body movements; it is also
called the “clumsy child syndrome.” A child
with limb/motor apraxia may have difficulty
performing motor movements, such as clapping
hands or performing finger movements, on command
or in imitation. We often see associations with
benign congenital hypotonia (low muscle tone—see
belows), and sensory processing dysfunction
(SPD—see below).
HOW COMMON IS
VERBAL APRAXIA?
The incidence of verbal apraxia is believed
to be between 1% if we are talking about a “pure”
apraxia, and 6-10% if we are considering a global
dyspraxia, with as it can be associated with
numerous other conditions, including oral apraxia,
hypotonia, and sensory processing dysfunction
(SPD).
WHEN SHOULD I
BE CONCERNED THAT MY CHILD ISN'T MEETING HIS/HER
SPEECH-LANGUAGE MILESTONES?
Although most late talkers eventually catch
up and speak normally, it’s important to be
aware of the warning signs that may indicate
a communication disorder and not simply a delay.
While children vary in the rate in which they
acquire language skills, there are commonly
accepted milestones that a child is expected
to reach (please refer to Publications page
for link to podcast and article, “The Late Talker:
When Silence isn’t Golden,” for milestones).
If your child is not meeting typical speech
and language milestones, you should discuss
your concerns with your pediatrician. The American
Speech-Language-Hearing Association (ASHA –
www.ASHA.org),
the non-profit organization that represents
more than 100,000 speech-language pathologists
supports parents investigating their concerns;
“When you become concerned, don’t delay. You
and your family members know more about your
child than anyone. No child is too young to
be helped. If there is a problem, early attention
is important. If there is no problem, you will
be relieved of worry.” Quite often, the children
who aren’t meeting some of the typical speech
and language milestones develop normally, and
it is subsequently discovered that the child
had a delay in maturation rather than a disorder.
However, when children are very young, it is
difficult to determine the difference between
a delay and a disorder, and a child who is not
meeting milestones should be closely monitored
and have a formal assessment by a speech language
pathologist or neurodevelopmental pediatrician.
WHAT IS THE PROFILE
OF A TODDLER AT CONTINUED RISK FOR SPEECH AND
LANGUAGE DELAYS AS A PRESCHOOLER?
Research has found that approximately 25% of
‘late talkers’ do not outgrow their delays by
the time they start school. These children are
subsequently at higher risk for language based
learning disabilities, academic difficulties,
social rejection, behavioral/self esteem problems,
anxiety, juvenile delinquency, and even suicide.
As such, it is important to identify children
who will not simply outgrow being a late talker
without intervention. But how do you do so?
There is no blood test or simple diagnostic
test, and instead, the diagnosis is made by
a thorough evaluation by a qualified and knowledgeable
professional, such as a speech language pathologist
or neurodevelopmental pediatrician, as noted
above. Warning signs of speech and language
disorders show up within the first year of life,
and toddlers with these predictors should be
referred for early intervention. In a study
by Olswang in 1998, predictors and warning signs
for continued delays were described, and are
listed below. The greater number of the following
risk factors that your child exhibits, the greater
the need for speech language therapy, particularly
as your child approaches 3 years of age.
• Limited variety in babbling
structure: babbling is limited in both
the variety of consonant and vowel sounds as
well as the complexity of the babble.
• Limited consonants: children
using a reduced number of consonant sounds are
a greater risk of delay. It has been found that
children who use only 4 consonant sounds and
limited vowels are at risk for continued delays
in the future.
• Vowel errors: errors
in vowel production are rare in typical development.
There is cause for concern if a child produces
numerous vowel distortions (like ‘ buh '
for ‘ boo ') at 3 years of age.
• Small vocabulary for
age and less diverse use of verbs: There
is frequently a greater use of ‘all purpose'
words, such as ‘ there , here ,
put , want , go ,
and make ,' rather than more specific
and sophisticated words or phrases.
• Comprehension
delay: A delay in receptive language
(understanding language) greater than 6 months
(for example, a child who is 24 months in age
but has the comprehension skills that are expected
at 18 months).
• Few spontaneous imitations, and
direct modeling and prompting required to elicit
imitation of words or sounds
• Little symbolic play:
The development of play and language
are linked, and a toddler who does not engage
in pretend play – such as pretending a block
is a telephone or feeding a bear – or who does
not develop of sequences of pretend play, like
feeding a bear and putting it to bed, should
be considered for intervention.
• Few
communicative gestures: Children who
do not gesture (e.g. shaking his head, waving
goodbye) or use minimal gestures are at higher
risk for persistent delays than toddlers who
use communicative gestures. However, children
with apraxia are the exception to this rule;
these children often develop elaborate gestural
language to compensate for their lack of verbal
abilities.
•
Few conversational initiations: Children
at risk for persistent delays initiate few conversations,
and tend to prefer to initiate conversations
with adults more than with peers.
•
Paucity of communicative interactions
w/ adults: Some toddlers have limited
interactions with adults as well.
• Recurrent ear infections:
Children with recurrent otitis media
(acute ear infection) with residual fluid behind
the eardrums (effusion) may increase the risk
of speech and language delays.
• Significant
family history: There is an increased
risk of delay for children whose parents or
siblings with a history of speech, language,
or learning difficulties.
• Socioeconomic
status: Children born into poverty
have an increased likelihood of persistent delays.
In an additional study by Rescorla in 2002,
it was found that children at 24 months who
have less than 30 words and no two word phrases
(like ‘mama go’ or ‘more cookie’)
were at continued risk for ongoing delays. These
children were found to continue to have weakness
in language related skills at 8 and 9 years
of age, and at age 13, two thirds were still
behind their peers in grammar, vocabulary development,
and reading.
HOW DO I KNOW
IF MY CHILD IS SIMPLY A ‘LATE TALKER' OR IF HE/SHE
HAS APRAXIA? WHAT ARE THE SIGNS OF VERBAL APRAXIA?
Apraxia is a complex disorder, and there is
no definitive medical test that can lead to
a diagnosis of apraxia. Professionals look to
a constellation of signs and symptoms in order
to diagnosis apraxia. A child who is a late
talker and exhibits many of the following signs
and symptoms should be evaluated to determine
whether or not he or she has apraxia.
Children who have subsequently diagnosed with
verbal apraxia often share a history of some
common signs. These children, during infancy,
often engage in limited sound play and babbling.
Their parents often describe them as ‘quiet’
babies. Often, the variety of sounds that they
use in their babble is limited, and they may
only use a few consonants and vowels. While
the first words of these children may emerge
on time, the vocabulary growth is slow, and
they often rely on elaborate nonverbal or gestural
communication instead. Frustration and behavior
problems emerge as the child has difficulty
communicating. As babies, frequently these children
drool excessively and display signs of oral
apraxia. They have a later transition to solid
foods that expected and frequently have feeding
difficulties. As well, there is often a family
history of speech, language, or learning problems.
Other signs of verbal apraxia include the following:
• Receptive (understanding) language
skills are typically stronger than expressive
(spoken) language
• Cognitive skills are normal or
close to normal
• The child uses a limited repertoire
of consonant sounds (for example, “da” may be
generic, and be used as an all-purpose word
for many objects)
• Sound and syllables are omitted
from words (e.g. ‘ma' for ‘ mama '),
vowels are distorted (e.g. ‘duh' for ‘ day
'), and consonant clusters are simplified
(e.g. ‘poon' for ‘ spoon ')
• Errors increase as the length
of utterance increases
• Errors are inconsistent. The same
word may be produced differently each time the
child attempts to say it.
• Voicing errors (e.g. ‘baba' for
‘ papa ' or ‘doo' for ‘ two ')
• Connected speech is more unintelligible
(difficult to understand) than expected relative
to productions at the single word level
• More errors w/ greater articulatory
adjustment (mama vs. balloon)
• Difficulties with the prosody
of speech, with excess equal stress making speech
sound robotic (Shriberg, Aram
& Kwiatkowski, 1997)
• Slow rate of speech, with significant
difficulty producing syllable sequences repetitively
(e.g ‘puh-tuh-kuh, ‘puh-tuh-kuh, puh-tuh-kuh')
• Speech intelligibility is positively
influenced by context and content that is over-learned.
For example, the word ‘mama' does not require
motor planning after it has become over-learned
and is used regularly. However, nonsense syllables,
novel words, or words attempted ‘on command'
(‘say ___') do require motor planning and are
therefore more challenging
• Groping, “trial and error” behavior
(dysfluencies, silent posturing) can occur
• Often children exhibit a mixture
of apraxia along with oral motor weakness
• For children who have developed
expressive language, they exhibit a more limited
vocabulary, grammatical errors, and disordered
syntax
• In the s chool age child, there
are often learning difficulties with reading,
written expression, and spelling
WHAT NEUROLOGICAL
SOFT SIGNS OFTEN OCCUR WITH APRAXIA?
Apraxia appears to be a neurologically based
disorder that can run in families. Children
with apraxia frequently have a constellation
of ‘neurological soft signs’ that are associated
with apraxia. These include the following:
Benign Congenital Hypotonia
(decreased muscle tone) of the trunk, which
often results in delays in sitting, crawling,
and walking. Children with hypotonia often sit
with a rounded back and or in a ‘W’ position
with their legs due to the laxity of the ligaments
at the hips. The low muscle tone may extend
from the trunk into the oral musculature, such
as the lips, cheeks, and tongue.
Gross and fine motor incoordination
may also be seen. A child may have
difficulty running smoothly, throwing and catching
a ball, or holding a pencil with an appropriate
grasp.
Motor planning difficulties
may extend beyond simply speech production to
motor skills as well. A child with motor planning
difficulties may have trouble imitating sequences
of motor movements (like clap hands and touch
head) or playing pat-a-cake or doing jumping
jacks.
Sensory integration/self-regulatory
issues are also frequently seen in
children with apraxia. Children with sensory
integration dysfunction (DSI) have
difficulty properly processing the senses of
touch, taste, smell, vision, and hearing. Some
children can be sensory seeking ,
in that they seek out sensory input due to being
underresponsive to sensation. For example, a
child who is sensory seeking might be hyperactive,
have decreased attention, crash into objects,
and touch other people inappropriately. Other
children are sensory-avoiding ,
and may have a heightened sensitivity to sensory
experiences, dislike being touched, dislike
loud noises, avoid messy play, and be intolerant
to daily tasks like hair washing and tooth brushing.
Children with DSI can have also have a mixed
response to sensory input; they can be sensory
avoiding as well as sensory seeking to different
stimuli. For example, a child may seek out rough
play and always want bear hugs, while at the
same time, dislike walking on grass or touching
sand. Some children with DSI also have self-regulatory
issues ; they have difficulty calming
themselves and self-soothing, and also often
have difficulty establishing regular sleeping
and eating patterns.
Delayed or mixed hand dominance
is often seen in children with apraxia. In typically
developing children, hand dominance typically
develops around 2 years of age, the time when
the brain begins to allocate tasks specifically
to the right and left hemispheres. In most individuals,
language lateralizes to the left hemisphere,
however, in children with apraxia, the emergence
of hand dominance is often delayed, or a child
will show mixed dominance, indicating a delay
in brain specialization.
WHAT WILL TYPICALLY
TAKE PLACE IN AN ASSESSMENT FOR APRAXIA?
- Assessment of Regulation and Phonation:
The SLP will look at your child's h
ead and trunk control , postural
tone , whether or not there
is adequate respiratory support to produce sounds
(phonation) , and your child's
ability to engage in sound play.
- Oral Motor Assessment :
A look at whether or not your child
has oral hypotonia (low tone in the tongue,
lips, and cheeks) and if he/she drools. An assessment
of feeding, including an observation of chewing,
swallowing, and coordination of sucking and
swallowing. As well, we wills look at the variety
of facial expressions your child produces and
whether or not he/she can perform non-speech
tasks with the articulators, such as sticking
out the tongue or rounding the lips.
- Assessment tools: The SLP
will most likely perform ‘standardized’ tests
to determine how your child performs as compared
to other children his/her age. She may also
perform informal, non-standardized testing as
well to gain additional information about your
child’s skills. Some of the more common areas
of assessment that the SLP will perform include
the following:
- Language tests: Language
tests evaluate your child’s expressive and
receptive language skills, including skills
like understanding and use of vocabulary,
sentence structure, and grammar, as well
as how your child follows commands and answers
questions.
- Non-verbal communication, pragmatics:
The SLP will also be interested
in learning how your child uses the
language he/she has. She will look at what
your child uses language for, like asking
questions, requesting, greetings, as well
as how well your child is able to participate
in conversations. She will also look at
your child’s non-verbal skills, such as
the use of gestures and eye contact, during
interactions.
- Speech production/Articulation:
The SLP will want to evaluate what
sounds your child produces and what types
of sound errors affect his/her productions.
By listening to your child speak in conversation
and during play, she will make a judgment
on your child's clarity of speech; that
is, how ‘intelligible' your child's speech
is. As well, the SLP may use a ‘traditional'
articulation test, which assesses a child's
ability to produce consonant sounds in single
words. The most common of these tests is
the Goldman Fristoe Test of Articulation
(GFTA), which involves naming pictures of
common objects. There are two tests which
are specifically designed to evaluate children
with motor planning disorders: the Kaufman
Speech Praxis Test (KPST) and the Verbal
Motor Production Assessment for Children
(VMPAC). The KPST is for children ages 24
to 71 months of age, and requires children
to imitate sounds in isolation, single syllable,
and multi-syllable words, and measures connected
speech, identifying the level of breakdown
in productions. The VMPAC is for older children,
ages 3 to 12 years, and looks at the most
basic requirements for speech production,
such as breath support, up to complex sound
sequencing.
WHAT CONDITIONS
CAN APRAXIA BE ASSOCIATED WITH?
• Cerebral Palsy
• Down Syndrome
• Other neurologic syndromes
• Autistic Spectrum Disorders (ASDs),
with approximately 60% of children with ASDs
having motor speech disorders as well.
WHAT TYPE OF
THERAPY IS MOST APPROPRIATE FOR CHILDREN WITH
APRAXIA?
The most appropriate therapy for a child with
verbal apraxia is different than what is considerate
appropriate for a child with a more traditional
articulation issues. The following are some
general guidelines of what should be included
in a therapy program for a child with a diagnosis
of verbal apraxia:
• Begin with development of imitation
skills: Since the crux of verbal apraxia is
a difficulty with production of sounds and words
on command, this is a very basic skill that
will need to be focused on.
• Emphasize movement sequences at
syllable level rather than sounds
in isolation
• Therapy should be intensive and
frequent
• Individual therapy is recommended,
as there is no benefit from group therapy for
children with apraxia: “Children with apraxia
of speech required 81% more individual
therapy sessions…to achieve a similar functional
outcome” Campbell (1999) Clinical Management
of Motor Speech Disorders
• Repetitive practice for habituation
of motor learning: In order for a production
to become automatic and easy for a child, frequent,
repetitive practice is required.
• Developing an alternative communication
system for while the child is learning to speak:
Apraxia is a disorder with a difficult course,
and it can often take some time for a child
to learn enough speech in order to functionally
communicate. As such, it is important for a
child to have an alternative means of communication
in order to reduce frustration and allow effective
communication while he/she is learning to speak.
The use of a ‘total communication’ approach,
incorporating and encouraging oral communication
while at the same time using other methods of
communication is recommended. These alternative
communication methods can include sign language
(which research suggests promotes the development
of verbal skills), Picture Exchange Communication
System (PECS) (a program that involves the child
giving a picture of a desired object in order
to obtain it), or a high-tech device (typically
for more significantly impaired children, and
are tailored to the individual).
• Multisensory, including touch-cue
system (PROMPT): Therapy should include as many
modalities as needed to elicit target productions,
including auditory and visual cues (e.g. ‘look
at my mouth’), as well as touch-cueing, preferably
through the use of PROMPT (link to PROMPT section
below)
• Core vocabulary: Developing a
core vocabulary of a few functional words, such
as ‘more,’ ‘help,’ and ‘up,’ should be one of
the first goals of your child’s speech therapy.
These words should be practiced over and over
until your child can produce them automatically
and as his/her single word vocabulary increases,
he/she can move on to word pairings, like ‘mama
help.’
• Use of sound approximations in
a hierarchy towards target word (Kaufman hierarchy
approach): As part of building a core vocabulary,
a child can be taught to use word approximations
to start with, a method that is part of the
Kaufman Speech Praxis Treatment Kit (link to
Nancy Kaufman's site or super duper who sells?).
The child is taught an approximation of a target
word – such as ‘opuh' for ‘open' – that requires
less motor complexity, thereby ensuring greater
success in his/her productions.
• Incorporating melody and rhythm:
The use of activities such as singing rhymes
or tapping the table while saying a sequence
of syllables can help to improve rate and intonation
of speech as well as sequencing.
• Slowed rate with movement activities:
Marching or banging a drum while saying sequences
of sounds and syllables
• Carrier phrases: The use of carrier
phrases can help your child use language more
automatically; for example, phrases like ‘Ready,
set, ___’ and ‘One, two, ___’ help cue your
child with what word to use.
• Oral motor techniques – if indicated:
Children with verbal apraxia often have oral
apraxia or may have low tone in the oral musculature.
These children may benefit from oral
motor therapy, which can involve increasing
sensory awareness of the articulators, improving
imitation of non-speech movements, and strengthening
the muscles of the jaw, tongue, and lips. Although
‘controversial,’ oral motor therapy may
improve feeding skills, drinking, drooling,
as well as clarity of speech.
WHAT IS PROMPT?
WHY IS THIS A GOOD APPROACH TO USE WITH A CHILD
WITH APRAXIA?
As noted above, multisensory therapy techniques
that allow the child to hear, see, and feel
how a sound is produced are most effective for
children with motor speech disorders. While
a child with a more traditional articulation
issue may only need auditory and visual cues
to remediate their errors, it is not sufficient
for children with severe speech disorders.
PROMPT,an acronym for ‘Prompts for Restructuring
Oral Muscular Phonetic Targets,’ involves the
therapist applying pressure to specific places
on the child’s face, lips, and chin to help
the child form the shapes with the articulators
that are needed to make certain sounds. PROMPT
helps develop a ‘motor memory’ for how a sound
is produced by physically helping the child
through the movements for speech. As well, the
tactile input provided by the clinician gives
the child a feeling for how the sound is produced,
which is extremely important for a child with
a motor speech disorder.
WHAT ARE SOME
THINGS I CAN DO AT HOME WITH MY CHILD TO HELP
IMPROVE HIS/HER SPEECH?
Your child’s SLP should be able to provide
you with specific suggestions relating to your
child’s needs and goals. Below are some general
strategies that we often recommend from our
office:
• Target sound for the week: Working
with your child's therapy team, pick a target
sound or word of the week that everyone focuses
on. For example, if the word of the week is
‘on,' you can focus on this word as part of
your child's daily routine; as you walk into
a room and you turn on the light, have your
child attempt to say ‘on' before doing so;
as you are helping your child get dressed,
give your child carrier phrases, like ‘pants
__,' ‘socks ___,' ‘shoes __,' to complete
as you are putting his/her clothes on. Words
or sounds should be selected based on their
ease of production (you don't want to be expecting
your child to say a sound he/she may not be
capable of yet) as well as their functional
purpose.
• Low pressure verbal exercises:
Engage your child in low-pressure verbal activities,
where you are indirectly working on his/her
speech. Some ideas to try: sing songs like
Old MacDonald and see if your child will fill
in E-I-E-I-O; read repetitive books, like
Brown Bear, Brown Bear What Do You See or
Peek-a-Who, and see if your child can fill
in some words; recite nursery rhymes with
your child, encouraging his/her to complete
some of the phrases.
• Give your child choices: Instead
of telling your child “Say ____” in order
to get something, ask “Do you want ___or ___?”
This provides your child with a model of the
word he/she is trying to say, as well as reducing
the pressure of speaking on command.
• Repeat what your child has said
back to him/her: If your child says a word
or sentence incorrectly, such as ‘De tow say
moo,' instead of correcting, simply repeat
it back correctly: ‘You saw that cow. The
cow says moo.'
WE HAVE GIVEN YOU A COMPREHENSIVE OUTLINE TO
ASSIST YOU IN UNDERSTANDING THIS POORLY UNDERSTOOD
SPEECH DISORDER AND ITS ASSOCIATED SIGNS. OUR
PRACTICE OFFERS A COMPREHENSIVE EVALUATION,
THAT IS UNIQUE IN THE FIELD OF DEVELOPMENTAL
PEDIATRICS…
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