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…