Apraxia: Questions and Answers
by Lori L. Roth, MA, CCC-SLP Oral Motor and Verbal Apraxia Specialist
Common speech disorders:
There are several speech disorders affecting children. They include articulation problems, phonological processing disorder, verbal apraxia, oral motor apraxia and swallowing difficulties (which run the gammit from oral motor coordination problems to the inability to control food within the mouth resulting in gagging and choking), lisping (/th/ substituted for an /s/ sound in speech), stuttering, and voice problems (hoarseness, nodules on the vocal chords). These do not include cleft palate nasal speech and/or deaf speech, which are the result of serious and obvious physical disabilities.
Definition of apraxia:
Apraxia is a neurological disorder in which the inability to coordinate or initiate muscle movement prevents the action requested when the muscles are adequate for these motions. It was originally used for stroke patients (geriatric population) but has recently (past 20 years – 1980’s) been applied to children exhibiting coordination/ motor sequencing difficulties of speech sounds. Verbal apraxia is a neurological disorder where children are unable to coordinate and/or initiate movement of their articulators (jaw, lips and tongue) for the production of speech sounds. Oral motor apraxia is a disorder where the coordination of the articulators is hampered for non-speech (raspberries, blowing whistles) or vegetative (eating, chewing, swallowing) skills. Both coordination/initiation disorders are neurologically based and therefore may be present in conjunction with other disorders, i.e., ADHD, Autism, Downs Syndrome, Hearing Impairment, etc. Both disorders present with a range of severity: mild to severe.
How prevalent among speech disorders is apraxia?
In my practice I see 21 apraxic children weekly for therapy (total 40/week). I would guess that 4/15 children have a speech delay or disorder and 2 have some degree of apraxia, either oral motor and/or verbal.
How many kids per year are diagnosed?
Over 42 million Americans have speech disorders and 80% or 85% of the referrals to the Early Intervention Programs across the country are for speech delays (statistics from the American Speech, Hearing and Language Association, ASHA, the organization that certifies Speech Pathologists and Audiologists and sets the standards for these professions for training, research and practice.)
How do you tell the difference between a late talker and speech disorder (apraxia)?
Children with verbal apraxia present with “flags,” or criteria/symptoms which eliminate the label of late talker, a developmental disorder which will right itself without intensive, specific, one-on-one intervention. Apraxic children have never demonstrated early sound play. They tend to be quiet babies, often described as “serious” children. They do not, nor did they, babble(the noises babies classically make ie “gaga, googoo”). Apraxic children understand everything but, in contrast, cannot demonstrate their understanding with a verbal response. Most times, their imitative skills are good. When given a model, they can approximate the presented word, but they cannot produce the sound/word/sentence volitionally without this model. The number of movements required for sequencing to produce a message greatly affects the outcome. Their ability to repeat these series of movements in sequence for a particular word or sentence is significantly hindered. Their inconsistency for this task is the single most important criteria for a differential diagnosis for Apraxia of Speech. Children with verbal apraxia tend to be unable to find classic approximations for common words, or familiar phrases; “dit dow” for “sit down” or “tuck” for “truck” are beyond their capabilities. The prosody (melody) of speech, i.e., inflection, stress and pitch, are usually affected also in verbal apraxia.
How is a child diagnosed?
The best way for a child to be diagnosed is an evaluation by both a pediatric neurologist and an experienced speech pathologist. Standard tests for articulation delays are available but an experienced Neurologist uses both sound error tests as well as language tests for determination.
How do parents typically react when their child is diagnosed with apraxia?
What does it mean for the child and family? The words neurologically based disorder send up a flag for them. Most do not initially understand the complexity of the problem. It is only when they go on the Internet to the various sources (Cherab, Children’s Apraxia Network, ASHA) that they begin to understand the seriousness of the diagnosis. The parents go through a grief-process; because they now know the problem won’t right itself. Dreams and expectations need to be put on hold and a process of finding the “fighting spirit” must be brought to the forefront. Children need their parents to be advocates for them. Misunderstanding about their abilities, mislabeling of their condition and the misunderstanding of their speech makes these children more dependent upon their parents as translators, teachers and defenders.
What is appropriate therapy?
Research has shown that an intensive (3- 5 times/weekly), individualized speech therapy program should be started as soon as the child is diagnosed. Therefore, the earlier the child is identified the better the predicted outcome. Without this type of intervention, the child’s communication skills may improve as he grows older, but his speech will be filled with errors making him unintelligible to an unpracticed listener, set apart from his peers and significantly affect his self-image. Therapy does not provide a “quick fix”. Most apraxic children will be in therapy for over 2 years and often longer. However, all but the most severe apraxic children, if given the appropriate therapy, will eventually be competent oral communicators.
How important is it to get a diagnosis verses just continuing with regular speech therapy with no definitive diagnosis?
Traditional therapy tends to approach mis-articulation with tasks that at first drill sound production in isolation until mastery. Then the therapist designs tasks with the error sound in specific single syllable words in the initial or final or medial position until mastery. Following the mastery of this skill the words are put into short phrases, structured sentences and finally into activities which foster the carry-over into casual conversation. For children with verbal apraxia, therapy focuses on the motor movements in sequence for the production of a meaningful word. The faster the child can put these sounds into words (approximations) for functional communication the better these units will be practiced in daily activities. The experienced therapist will not necessarily follow the typical hierarchy of sound development (Vowels, PBMHW, TDN, KG, SH, CH, LSZ, J, TH) but will use the sounds the child can produce as a jumping off point for functional vocabulary and communication. Oral motor and imitation skills will be of significant concentration so as to warm-up the muscles to do the movement sequence. Focus on the vowel sounds preceding and following the consonant of practice will also be closely monitored to ensure the best possible production. Then intensive repetition of the word, words and phrases will be practiced to aid the muscles and neurological pathways in remembering the sequence of movement for this production. Tactile cueing (the touching of the face, and/or lips), visual models (mirror work), and kinesthetic cues will also be employed to give the child the most information the therapist can for the production of the sound, word or phrase. This is a much more complex therapy routine than the traditional techniques.
What can parents do to help?
Parents are an integral member of the therapy team. They are the best motivators, the best translators and the most invested partner. The experienced therapists would be well advised to make them the models during the treatment sessions. Use their list of their child’s wants, needs and likes as a loose structure for vocabulary expansion in therapy. And listen to their concerns, and elations as the child progresses. Each child is different but in general children build a core vocabulary of nouns, verbs, adjectives and prepositions. They produce each word singly and then in pairs. As the child becomes more flexible and comfortable with the vocabulary, he/she expands on the word order and length of word strings producing kernel sentences. From there, children group single sentences to short paragraphs and stories of events they remember, see or make up.