Your baby’s babbling and toddlers first words can be music to your ears. When faced with a child who doesn’t speak or seems to have difficulty with words parents are often told that their child is “just a late-talker.” Unfortunately, all too often, that is not the case. The American Speech and Hearing Association (ASHA) estimates that 16 million Americans under the age of eighteen have a chronic speech-language disorder and that some 45 million Americans are affected by communication disorders of one kind or another which was announded by Congresswoman Carolyn McCarthy during the kick-off of the Better Hearing and Speech Month Health Fair in Washington, DC on May 8, 2002 .

Most parents, and even most pediatricians, are not concerned when faced with a two-year-old who passes all of his developmental milestones on time – except speech and language. However, they should be. It is vitally important to identify and treat speech and language challenges as early as possible in a child’s life, with a strong emphasis on the early intervention years of birth to three. At this age the brain is undergoing the most rapid development. No harm will come from therapeutic services. “Early intervention services are benign in their delivery but can be extremely beneficial. Don’t wait. Six months for a 2 year old is equivalent to a quarter of their lifetime developmentally” as Dr. Judy Flax says, who is a Research Coordinator of the Tallal Lab and a Senior Research Speech Pathologist for the Infancy Studies Laboratory at the Center for Molecular and Behavioral Neuroscience (CMBN) of Rutgers University, Newark, NJ

To find out about your nearest Early Intervention program you should call your local school district, they will be able to refer you to the program appropriate for your child’s age. Waiting to refer is a loss of precious time that may impact on the child’s learning ability and social-emotional well being in later years. Pediatricians and parents should insist on a speech and hearing evaluation as soon as there is a real concern about a child’s early language development. Early referral is endorsed by the American Academy of Pediatrics, and the American Academy of Neurology. In addition, “any child with a severe speech/language delay should have a comprehensive health and neurologic assessment to look for medical conditions that may be causing or contributing to the delay” as Dr.Marilyn Agin says, a developmental pediatrician who is the Medical Director for Early Intervention for NYC.

CHERAB is a non-profit foundation that focuses on raising awareness of Apraxia and other speech and language delays, and the importance of early intervention. Working with developmental pediatricians, speech pathologists, neuroscientists and major hospitals the CHERAB Foundation is working towards research on therapies which may help late talkers with Apraxia, Dysarthria, delayed language development, Autism and other speech and language impairments. A list-serv overseen by pediatricians, speech-language pathologists, and educational consultants is run by CHERAB and can be found at their web-site. Through the list you can connect to many other parents who have children who have speech or language delays, and find out what they have been able to do to help their child.

Some speech disorders can overlap, or be misdiagnosed. For example, “Verbal apraxia, a disorder of central nervous system (CNS) processing, and dysarthria, a disorder of output, are commonly confused”, says Dr. Andrew Morgan, chief of child development at the Chicago College of Medicine. “Experts are able to differentiate between these two disorders by listening carefully to a child’s speech and by identifying certain physical clues”, says Dr. Morgan, but adds, “These disorders are poorly understood by physicians and by a lot of speech therapists as well.” It is possible for phonological disorders, apraxia and dysarthria to all occur together in the same child. Speech Language Impairments, which is connected to language based learning difficulties may also be present. And the severity of each may vary.
Apraxia is perhaps the most misunderstood of all the speech disorders. So, what is apraxia? Verbal Apraxia is a neurological motor speech impairment that involves a breakdown in the transmission of messages from the brain to the muscles in the jaw, cheeks, lips, tongue and palate that facilitate speech. There is no obvious weakness in these muscles and the child may well be able to move them quite happily when not trying to speak. Apraxic children, who are usually seen as “just late talkers” when young, are able to comprehend language at an age appropriate level, however have difficulty expressing themselves using speech. With apraxia, a child knows what he wants to say but there is a road block obstructing the signal from the brain to the mouth. For any child with a speech disorder, but especially with apraxia, the earlier therapy is begun, the better the results for your child and their social-emotional development.

Your Child’s Language Development

So how do you know when your child is having problems with speaking? When is a good time to seek out help? Being aware of average speech milestones can also help you decide whether or not to speak to your doctor. Some guidelines are provided here for your information, but if you have concerns about your child’s speech or language development, or any other developmental issue, make an appointment with your pediatrician so you can discuss these issues. While the average milestones are a good way to measure development, every child develops at their own pace, and this overview should not be used to diagnose a specific problem.

Adapted from Clinical Practice Guidelines Communication Disorders III 22-25

So how do you know when your child is having problems with speaking? When is a good time to seek out help? Being aware of average speech milestones can also help you decide whether or not to speak to your doctor. Some guidelines are provided here for your information, but if you have concerns about your child’s speech or language development, or any other developmental issue, make an appointment with your pediatrician so you can discuss these issues. While the average milestones are a good way to measure development, every child develops at their own pace, and this overview should not be used to diagnose a specific problem.

Typically seen in first 6 months
· Responds to name by looking for voice · Can regularly find speaker or source of sound · Cooing, gurgling, chuckling, laughing ·Imitates sounds and actions · Enjoys social games (peek-a-boo, pat-a-cake) · Babbling (bababa, mamama)

Cause for concern in first 6 months
· Cannot focus, easily over-stimulated · Seems unaware of sound, Cannot find source of sound · Seems unaware of people and objects in environment · Does not seem to understand or enjoy imitating · Lack of connection (eye contact, vocal turn-taking)
· No babbling, or babbling with few consonants

Typically seen in first 9-12 months
· Attracts attention by vocalizing · Waves bye · Vocalizations that sound like first words (mama,dada) · Clearly indicates desire for objects · Imitates new sounds and actions

Cause for concern in first 9-12 months
· Easily upset by sounds that would not upset others · Lack of response indicating comprehension of words · Lack of consistent patterns of babbling · Does not clearly indicate desire for objects

Typically seen in first 12-18 months
· Single word production begins · Requests objects: points, vocalizes, word approximations · Gets attention vocally or physically (mommy) · Knows adult can do things for them (wind up a toy) · Uses “ritual” words (bye, hi, please, thank-you)
Protests: Says no, shakes head, moves away etc) · Comments: Points and vocalizes or uses word approximations) · Acknowledges: Eye contact, vocal response, repetition of word

Cause for concern in first 12-18 months
· Lack of communicative gestures · Does not attempt to imitate or produce single words
· Does not persist in communication (may hold hand up for help, but gives up if adult does not respond immediately) · Limited comprehension (understands less than 50 words) · Limited vocabulary (speaks less than 10 words) · Lack of new words between the age of 12-18 months

Typically seen in first 18-24 months
· Uses mostly words to communicate · Begins to use two word combinations (more cookie etc) · By 24 months has more than 50 words, or word approximations

Cause for concern in first 18-24 months
· Relies on gestures to communicate · Limited vocabulary (speaks less than 50 words)
· Does not use any two word combinations · Limited consonant production · Mostly unintelligible speech · Regresses in language development: Stops talking, repeats phrases inappropriately

Typically seen in first 24-36 months
· Engages in short dialogues · Expresses emotions · Begins using language in imaginative ways · Begins providing descriptive details when speaking · Begins to use articles and word endings (a, the, ing,) uses plurals (cats)

Cause for concern in first 24-36 months
· Words limited to single syllable and no final consonants · Few or no multiword utterances · Does not demand a response from a listener · Asks no questions · Speech difficult to understand · Tantrums when frustrated · Echoing of speech without communicative intent

In addition, the policy statement from the neurology journal Neurology, (August, 2000), states that Absolute Indications for Immediate Evaluation include,
· No babbling or pointing or other gestures by twelve months
· No single words by sixteen months
· No two-word spontaneous phrases by twenty-four months
· Any loss of any language or social skills at any age.

Written By Lisa Geng in 2000

My son Tanner was diagnosed with both severe oral as well as verbal apraxia, but each child is different, and some may not go through all the signs that Tanner had, with his severity, and/or some children may have other aspects.

Here are the “late talker vs. apraxia” or delay vs. disorder signs that I saw/see in my four year old Tanner as he was/is “learning to talk.”

1. It took forever for Tanner to learn how to say ANYTHING other than the word “ma” or the sound “mmm,” which were his only “words” up until almost 3 years old. Even though the therapy he received was not appropriate for apraxia (we didn’t know this at the time), it was some type of therapy, and it took months of this speech therapy, 1/2 hour sessions, two or three times a week (from 2 years, 4 months, to 2 years, 8 months) for him to learn simple sounds like “t” or “ch” or “sh,” sounds most babies and toddlers say when they babble.

During this time, even though Tanner was in speech therapy, we followed our pediatrician’s advice that Tanner was a “late talker” and never knew Tanner was qualified for early intervention by the state (a federal program) so we paid out of pocket for all the therapy (insurance didn’t cover it and even though we appealed, at that time, we didn’t know how to fight the denials). Tanner did babble with some of these sounds, though rarely. Many apraxic children babble very little. The problem was that when Tanner wanted to use one of these sounds, on command, he didn’t know how. Many parents of apraxic children have examples, like us, of their child starting to develop speech and then, for some reason, they lose the speech they had developed. Since there is still no large scale research on apraxia in children, nobody knows why this happens. In a small research project by Tom Campbell out of the Pittsburgh Hospital, the findings were that it required 81% more therapy for apraxic children to show results than children with severe phonological delays.

2. Tanner did not go through normal speech development as he aged. He would say a sound (before 3) or word (3 and up) and not say it again for months. Most children with delays of speech will learn sounds and words and build upon that, in a developmentally typical pattern.

3. Another frustrating aspect of verbal apraxia is that even when Tanner learned how to say a sound like “p” before a vowel, he could not say the same sound after a vowel, so he would either drop it, or change it to another sound. For example, if the therapist modeled (said) the sounds “pa,” Tanner could say “pa.” If the next word the therapist modeled for him was “up,” Tanner would say “uf.” This has to do with the difficulty of movement of the tongue and mouth positions. Professionals refer to this as “motor planning” (which is why apraxia is also called a motor planning disorder.)

4. Tanner understood us and knew what he wanted and developed his own “sign language” to try to communicate. They say this is very common with apraxic children. When Tanner has more to tell us than he is able to say yet with words, he now also uses sound effects with his unique sign/body language. He’s actually pretty good at making himself understood. (Remember Harpo Marx?) Many children with apraxia have high receptive (understanding) ability, and low expressive (talking) ability. There was never a doubt to anyone that Tanner was intelligent and apraxia does not affect a child’s cognitive (intelligence) ability. (To discern your child’s cognitive ability, view what his/her evaluations state about expressive and receptive ability.)

Due to the differences in appropriate therapies and treatments, it is horrible that apraxic children are sometimes misdiagnosed as autistic, or even mentally retarded. Apraxia can co-exist with conditions like autism, cerebral palsy, downs, etc., but apraxia is often times there “alone.” (I’ll explain later on.) Too often, children are diagnosed as having “receptive” delays, when they do not have receptive delays. Receptive delays are a “red flag” that there could be cognitive issues going on. It’s one thing if there really are cognitive issues, but seek second opinions privately from a speech and language pathologist, developmental pediatrician and/or neurologist knowledgeable about apraxia and other disorders.

5. Even when Tanner learned to say the sound “t,” if he tried to say the word “pot” it would come out “pop,” because he will switch the “t” to a “p.” The professionals say this is due to motor planning difficulties and children with apraxia will carry the sound from the beginning of the word to the end.

6. Tanner’s intelligibility will “break down” the longer the word or sentence is. Even with a model, he can’t repeat back a longer sentence using all the words yet, he will repeat back only a few of the words.

7. Tanner never “picked up” speech like other children. He also seemed to regress and didn’t talk at all when he was around large groups of children that were talking and playing, even when they tried to play with him. He tended to do better with one other child, or his brother and maybe one more. Then he would try to talk too. Tanner’s older brother was also a late talker, but that was because of birth injuries that he was in therapy for from birth. (He’s doing great now! He’s 6 and unless I tell someone, they never would have known.) Where Tanner wilted in
groups of children, Dakota thrived, and Dakota did “pick up” speech when I put him in a wonderful preschool a few times a week.

8. When Tanner started to use words, he would repeat the same sound over, using sentence inflections, rather than saying the different words. A good example is, he would point to the door, or out the window, while saying, “die, die, die, die, die.” Of course that meant, “I want to go outside.” I heard some apraxic children are monotone, but that wasn’t Tanner.

We would have to say to Tanner, “I…want…to…go…outside,” really emphasizing and waiting after each word, so he could repeat it. Tanner can now say many words clearly, but he still does better when he hears someone say them first. Now at 4, Tanner will, “I doe side now peas. Tay?”

9. Tanner’s apraxia still affects his ability to use the back of his tongue to say sounds like “k” or “g.” He substitutes the “k” for the “t,” so cookie is “tootie.” And the “g” for the “d,” so girl is “dirl.” He has yet to make either the “k” or the “g” sound, but we are working on it. When Tanner said, “hud n’ tiss,” the other night, I had to stop and switch the “d” and “t” to know he was asking for a hug and a kiss.

10. Tanner talks better when he is singing, or playing, when he isn’t thinking about it.

11. I could go on, but another one Tanner has developed now that he is really pushing himself is stuttering (dysfluency.) This does not always happen with apraxic children, it’s partly developmental, but it’s not uncommon with apraxia. Many children with apraxia can get “stuck” here for a bit. I say how cruel, he has trouble talking, and to add stuttering to that is like adding insult to injury. Many experts say his brain is working faster than his mouth. You can visibly see him struggle to talk when he does. Lots of thought goes into each word; you don’t see that with late talkers. I never did.

Some “soft” neurological signs that are not uncommon to apraxic children:

I thought Tanner only had apraxia, with no other issues, but I was wrong. These other “issues” however are typically overlooked by us as parents, and by many pediatricians, however these are the conditions that neurodevelopmental MDs (developmental pediatricians and pediatric neurologists) are trained to spot. ”Soft signs” which typically present as mild in most of our children -which is why they are overlooked -such as hypotonia or fine or gross motor planning issues of the body, or sensory integration dysfunction.

Even though all of us and Tanner’s regular pediatrician thought Tanner was fine outside of being “just a late talker” had other “neurologically based” signs, hypotonia and sensory integration disorder that none of us knew how to spot. I know that “neurological soft signs” may sound severe, and perhaps they could be, but fortunately because Tanner had early intervention, he is overcoming them, and they are now only noticeable to experts. Both were treated by Occupational Therapists, Physical Therapists and even his Speech Professionals as well.

Hypotonia, or low tone, gave Tanner the appearance of a Cherub, and that was his nickname when he was 2, “Cherub Boy.” Everyone said that Tanner looked like a Cherub because he was so cute. Hypotonia, however, needs to be addressed, because it affected Tanner’s truncal strength and breath control, which is important for many reasons, including speech.

Tanner also had mild sensory integration (SI) issues. There is lots of information online about SI, but mostly it makes the child seem like the tantrum child, for “no” reason. Children with hSI do not sense things like we do, the same way all the time. One example from when Tanner was a baby (and this is before I knew what SI was, or that Tanner had it) is that he would sometimes “freak out” when I tried to bring him into a store. He would scream like he was in intense pain, like there was a pin in him, tighten his whole body and act hysterical. Other shoppers would look at me like, “What are you doing to that child!” My sister, who is a certified nanny, was often with me when this happened, and we would check his diaper, offer a bottle, take all his clothes off, looking for what was causing the screaming, but we never found anything. This same child would go for shots and wouldn’t cry. I used to call him the “tough one.” More recently, I was tickling his arm and he said, “Ow! Hurt me.” I asked him, “Does this hurt?” and tickled him again. He pulled his arm away and said, “Yes.” Sometimes if I pat his head he says “Ow,” too. SI is another unknown one, and it can affect different senses. For Tanner, it’s touch.

Read more about Parent Friendly Signs of “soft signs” to look for in any late talker

Dear Parents;

All these terms thrown at you and nowhere to go to get answers to your questions about your child’s diagnoses? Here are some critical differences that may help you to determine what, and if, your child is Verbally Apraxic. Your reports from therapists may contain the phrases in italics below.

Your child may say the same word four different ways. Sound errors are significantly inconsistent.

Your child adds vowel sounds to the end of words that finish with a consonant (Up-pa). Intrusion of a vowel.

Apraxic children may be able to produce sounds in imitation, which they do not use in connected speech.

Your child becomes less and less understandable as his speech unit gets longer. Severity of apraxia increases as the length of the word or utterance increases.

Your child tends to mix-up consonants within a word. Sound swapping errors are common (efelant vs elephant). Metathetic errors are frequent.

Your child may drop final consonants in single syllable words (omission errors) simplifying his/her speech unit to contain consonant-vowel pairs in short strings. “Cat come home” = “Ca co hoe”.

Your child may not be able to change his pitch during speech production. Prosodic disturbances of speech, pitch, stress and rate are frequently in error.

Your child may use only /b/, /m/, /d/, /g/, /z/ with simple vowels like /uh/, /ah/, /oh/, but not /p/, /t/, /k/, or long vowels /ay/, /ee/, /i/ or /ow/. Voicing errors, nasal resonance errors, and lengthening vowels before omitted consonants are present.

Your child has difficulty repeating two different consonant + vowel pairs over and over again. Marked difficulty repeating series of speech sounds in diadokokenetic series /patika/.

Other elements of difference include:

a big discrepancy between your child’s ability to move his/her lips, tongue and jaw for eating or non-speech activities and the use of these parts during speech on command.

general normal EEG/MRI results

the ability to understand everything said to him/her. Normal receptive language.

traditional speech therapy techniques are ineffectual. General speech progress is slow and requires intensive, appropriate, speech therapy.

Apraxia of speech is not a developmental disorder but a neurological disorder. A pediatric neurologist evaluation along with a speech assessment from an experienced speech therapist will be crucial for an accurate diagnosis.

After that, the therapy approach should focus on the motor planning issue, as well as the language issue. Reading and writing expression will need consideration as well. Just presenting a word as a model will not meet an apraxic child’s needs for therapy. Visual cues and kinethestic or tactile information must also be provided. The goal of therapy should always be to increase the automatic movement of speech and increase functional communication as quickly as possible.

Lori Roth MS CCC/SLP

Written By Lisa Geng as posted to the Cherab Foundation grouplist

Other than not talking yet -you can look for any neuro “soft signs” even before the trip to the neurodevelopmental doctor (developmental pediatrician or pediatric neurologist) If your child has any of the following signs-don’t panic -all of them in almost all cases can be overcome -and the earlier the intervention the better as always.

Without neurological soft signs -it’s harder to diagnose a nonverbal two year old – which doesn’t mean you can’t start appropriate therapy just in case if apraxia is suspected -can’t hurt and will probably help no matter what the reason. Even a two year old with “just” a simple delay in speech can be mentally stimulated to talk sooner while having fun with some early intervention speech therapy that may look lots like play to the untrained eye. A big question is did he ever have sounds that he lost -did he ever regress?

A neurodevelopmental medical exam will look at a number of things in your son outside of communication skills, or receptive and expressive language -including physical development and motor skills, thinking and learning cognitive development etc.

Soft signs in apraxic children are typically mild -but in most cases there -most of us just didn’t know what they were because up till Cherab nobody pointed them out. I try to raise awareness because if your child has any of the following -as a parent you will know once pointed out-and so will the neuro MD you bring your child to.

When you run a large support group -you tend to see what is happening in a group -so support groups are excellent for really getting to the facts and the “norm” -and I’ll get to the EFA question in that regard too. I try to put the neuro soft signs in a way that everyone will understand -and these soft signs are all based on my son Tanner -who I and everyone including his first pediatric group all thought was a normal baby other than he was just a late talker.

This same child showed all the strong warning signs -we just didn’t know -however -all the soft signs were picked up right away by all the neurodevelopmental MD’s Tanner has seen once I insisted on taking him (his regular pediatrician wanted to wait till three) -as well as by the PTs, OTs and SLPs too. I could now kick myself that I didn’t see them then -but how would I know? That’s why I want to let all of you know -to prevent it from ever happening to another.

With the following information that I learned from personal experience the hard way costing valuable early intervention time while Tanner’s brain was the most malleable – the many children like him could be receiving therapy younger and have a greater chance for success.

Here are a few quick parent friendly signs of oral apraxia:

If you put peanut butter anywhere on his lips can he lick it off or does he use his fingers? Did he blow out the candles on his birthday cake when he turned two? Can he imitate funny faces? If you take his picture and say “smile” does he smile?

Here are some quick parent friendly signs of mild hypotonia:

A child with hypotonia will feel heavier than a child of the same weight without hypotonia (kind of like the difference between picking up your child when he’s fast asleep vs. awake) Hypotonia can be anywhere in the body. Does your child appear to tire faster than other kids his age walking in the mall etc.? Will you and your wife not dream of taking him anywhere without the stroller because you know if you don’t bring the stroller you will be stuck carrying him because if you don’t pick him up he will sit on the floor crying with his arms in the air for you to pick him up again? And since he’s nonverbal -you will get looks from people passing by, or perhaps even comments -that your child is acting spoiled. When you pick him off the floor -it’s not as easy as it looks for you -or others that try! Most will say “wow he’s solid!” when picking him up. “Solid” is the word used by almost everyone to describe your child when people pick him up come to think of it. His body may look small and light -and many times both look like a cherub, and feel a bit like a marshmallow -rounded and soft. He may sit in the “W” position. If a child has severe hypotonia -he may look a bit like a rag doll (those are the children however that are spotted early however) -gravity just pulls them down. For a school age child -look for the child who can’t sit at the desk long before leaning down on it. The child who when waiting on line will either lean or sit down. The child (or adult) with rounded shoulders who is always being told “stand up straight!” or “sit up!” etc.

Here are some quick parent friendly signs of sensory integration dysfunction:

This is tough because it can affect any of the senses -touch, sight, hearing, motion, etc. So in a nutshell -Your child will seem to be bothered (or even in pain) by something that others aren’t and will not be bothered by something most are if that makes sense.

Here are some of my son’s signs that boy do I wish I knew this is what he had when he was screaming and people were looking at me like “what are you doing to that poor child”

Your child may insist on a certain color cup each time -and will throw a fit if it’s any other. My son for would carry a small cap from a pen or some other small strange object around for hours -and if you tried to open his clutched hand – he would freak out -even if
you thought he was asleep and tried to take the pen cap away so he wouldn’t choke on it while he was sleeping -he would wake up and freak out if he wasn’t 100% asleep yet. He wouldn’t cry for shots – but would say “oww” and cringe if you patted his head or tickled his
arm. When Tanner was a baby (after the fevers and regression) his screams when I brought him to public places like the store would sound like high pitched extreme pain screams and he would stiffen his body -his eyes would bulge out -and he would do this just once
in a while (Thank God) but when he did -he would cry till he fell asleep in a sweat -with nobody being able to figure out what was wrong (my Aunt has her PhD in nursing and my sister is a professional nanny -nobody had a clue) Just strange stuff that seemed quirky. DSI can also be the child that throws a tantrum like he’s in pain -while you have no clue what he’s crying about. Why DSI happens to a nonverbal child who is too young to let us know is a cruel joke -so it’s important for us to know if this is what your child has. The Out of Sync Child is one of the books most of us buy when our child is diagnosed with any multi faceted neurologically based communication disorder like apraxia.

Here are some quick parent friendly signs of motor planning problems in the body:
Just like with speech -your child may be able to do something once and then appear not to remember how to do it again. His actions look forced or planned -he’s slower because you can see he’s thinking before each movement. His development is a bit off in that he can do many things advanced -but for some reason can’t seem to do certain simple things that a much younger child even should be able to do. Again -just doesn’t make sense.

Then you have to know if movement problems are from weakness (hypotonia) or motor planning (apraxia/dyspraxia) -just like with speech. Again -it could be a bit of both -and again -both are neurologically based.
Update 2003 -Not just autism -according to Dr. Geier, there is a much higher 30% rise in speech disorders in our children in the past ten years.

“The 2001 U.S. Department of Education statistics showed in children born in 1983 there were a total of 7,801 cases of speech or language impairment. Among children born in 1994, this number had risen to 211,984 cases (an approximately 30-fold increase)”

Mark R Geier MD PhD who compiled the stats above, is vocal in helping raise awareness to the 30% dramatic rise in children in the US with speech disorders in just the past few years. Outside of his recent papers, there is virtually no awareness to the rise in speech disorders. In speaking with Dr. Geier, he told me that the rise in autism was small in comparison to the rise in the numbers of children with speech disorders.

Due to lack of awareness -too many of our late talker children with multi faceted communication impairments, that are not autistic, are labeled PDD, or PDD NOS.

What does multi faced communication impairment mean? Read above -whether you want to call it apraxia or not -it’s children that are late talkers who are not “just starting to talk” like we all pray they will -and in most cases -they are children that also have one or more of the neurological “soft signs” listed above. Apraxia and autism two different examples of multi-faceted communication impairments. There may be some aspects that overlap or co-exist. It’s more common to find apraxia in an autistic or PDD child than it is to find autism or PDD in an apraxic child. You need to treat the symptoms and not the labels however.

“Apraxia” is the strange name diagnosis that has been the best kept secret for years -and it’s probably far more prevalent than autism. Try doing a search on the (American Academy of Pediatrics) AAP website for apraxia. I did one in February 2003 and I came up with “No documents matched the query ”

How can you have a pediatric condition rising in what appears to be epidemic proportions in some areas (like NJ where there is an apraxic child on almost every block) and yet complete and total silence?

Autism is on the rise – so is apraxia -with and mostly without autism. Just like sensory integration dysfunction or mild hypotonia -both which could be found in most apraxic children -apraxia co-exists in a large amount of conditions, syndromes, disorders and impairments, including and outside of autism and PDD…and it also stands alone as the child who is as one mother of a four year old just said to me “so normal I could smack him”…except he can’t talk. (other than “ma” “da” and 4 other “words”) Some late talkers may have hard signs of neurological problems such as myelin delays. Due to the apparent “pocket areas of more kids with apraxia -(for example more children with apraxia in the suburbs around NYC than in NYC even though the parents in the suburbs see the same MDs in NYC) As an inventor -I suspected there is some type of environmental damage that is affecting our children’s myelin. I came to this conclusion based on the fact that almost all the children in our group once on the right formula of Omega 3 Omega 6 EFAs started to talk within one to three weeks of given just a few drops of fish oil a day -which sounds crazy -but it worked. I came up with the myelin/EFA therapy based on the fact that EFAs have very strong remylenating properties (and OK so I watched the movie Lorenzo’s Oil)

I then presented my theory on why I believe that our children have some type of subtle myelin delays and why EFAs are helping our children’s speech, focus, behavior/mood and movement to PhDs, MDs and the Cherab grouplist starting in 2001. Due to one of my postings I was told -I was called into UNDNJ hospital by the hospital attorney Fred Kipperman Esq. in 2001 to do a presentation about my theory to a panel of neurodevelopmental MD’s (including pediatric neurologist Xue Ming MD PhD) on why I believe that most of the late talkers today do have some type of myelin delay whether it shows up in the MRI’s or not. Apparently they had the same idea for autistic children -and did find that even though myelin delays don’t show up on the MRIs in all cases -they do quite often “show up in the lab” Read a recent front page article about the groundbreaking work UMDNJ is doing here. It makes me feel good to know that EFAs are now taken seriously by some of the top neurodevelopmental MDs in the world- I just wish they would acknowledge this for more than autism. It would be one thing if they didn’t know.

So back to the soft signs…

If you want an accurate diagnosis for your child -please do not supplement your late talker with any EFAs before a neurodevelopmental exam. Children with signs of apraxia or autism, PDD or even certain syndromes after the “right” omega 3-6 formula of EFAs are no longer presenting with the symptoms -leading parents are professionals to conclude that either their child was repeatedly misdiagnosed -or if you look at the group -almost 100% of the children in our group show the same positive changes in the same one to three weeks once supplemented. And the even better news is that the positive surges in most cases do not stop. EFAs appear to help the brain “rewire” somehow. Perhaps soon we will know how.

Presented by Marilyn C. Agin , MD, Medical Director, New York City Early Intervention Program and Medical Director, Cherab Foundation Co-Author of The Late Talker book

Presented at the First Apraxia Conference hosted by Cherab Foundation, July 23-24, 2001, Headquarters Plaza Hotel, Morristown, New Jersey and all presented at Research Workshop – September 20-21 and on September 22, 2001 ‘ Fatty Acids in Neurodevelopmental Disorders’ St Anne’s College, Oxford, UK

What’s in a Name and Definitions

What is apraxia, verbal apraxia (or apraxia of speech or verbal dyspraxia), orofacial apraxia and motor apraxia. How is verbal apraxia treated?

Apraxia is a neurogenic impairment involving planning, executing and sequencing motor movements. Verbal apraxia affects the programming of the articulators and rapid sequences of muscle movements for speech sounds (often associated with hypotonia and sensory integration disorder). Oral apraxia involves nonspeech movements (e.g., blowing, puckering, licking food from the lips). Motor apraxia involves the programming of hand or whole body movement.

Neurodevelopmental Evaluation of Verbal Apraxia: History

• Limited babbling and oral play
• Late transition to solids, feeding difficulties
• Drooling that exceeds typical expectations
• History of accompanying oral apraxia
• May have elaborate nonverbal or gestural communication
• First words may emerge on time, but vocabulary growth is slow
• Increased frustration, behavior problems
• Family history of speech, language, learning problem

Nerodevelopmental Evaluation: Physical Neurologic Exam

• Hypotonia (truncal)
• May have gross and fine motor incoordination
• Motor planning difficulties
• Sensory integration/self-regulatory issues
• Delayed or mixed dominance

Assessment of Respiration and Phonation

• Postural tone
• Head and trunk control
• Respiratory support for phonation
• Ability to sound play

Oral Motor Assessment

• Oral hypotonia
• Drooling
• Feeding
• Suck swallow pattern
• Chewing
• Facial Expression

Speech/Language/Cognitive Assessment (1)

• Receptive language > expressive language
• Normal to near normal cognitive abilities
• Limited repertoire of consonant sounds (“da” may be generic)
• Sounds/syllable omissions, vowel distortion, cluster
• Increased errors with increased length of utterance
• Inconsistency of errors

Speech/Language/Cognitive Assessment (2)

• Prosodic disturbances (monotone)
• Groping “trial and error” behavior (dysfluencies, silent posturing)
• Expressive language: more limited lexicon, grammatical errors, disordered syntax
• School age child: learning difficulties — reading, written expression and spelling

Association with Other Disorders
Some examples are:

• Cerebral Palsy
• Down Syndrome
• Other neurologic syndromes
• Autistic spectrum disorders
• Role of “motor apraxia” in autism (1)
• Role of verbal apraxia in speech and language acquisition (2) (little research is available)

(1) Rapin, ed (1996) Preschool Children with Inadequate Communication

(2) Wetherby, et al (2000) Autism Spectrum Disorders

Verbal Apraxia Controversies (1)

Nomenclature:

Name borrowed from adult model
In adults, apraxia is an acquired condition
Stroke or head injury
Affects Broca’s area and sensorimotor cortex of the dominant hemisphere

Verbal Apraxia Controversies (2)

Etiology

Specific site of lesion has not been demonstrated on a consistent basis in children

EEGs suggested that praxis area in young children involved large cortical areas of both hemispheres with lateralization to left hemisphere in later childhood (1)

Other studies (2,3) report “soft signs” on neurologic exam

Early neuro-imaging studies typically negative (4)

Most studies: small samples, outdated (1) Rosenbeck & Wertz (1972)
(2) Yoss & Darley (1974)
(3) Ferry , Hall $ Hicks (1975)
(4) Horowitz (1984)
Verbal Apraxia Controversies (3)

Diagnosis: Exclusive vs. Inclusive

Group of speech researchers see verbal apraxia as solely a motor speech disorder (1, 2)

This renders apraxia a rarity (estimates 1-2%/1000 live birth)

Misses a great many children with more global dyspraxic syndromes associated with verbal apraxia

They propose that verbal apraxia is more like a symptom cluster or even a spectrum disorder (1) Hall et al. (1993) Developmental

(1) Hall et al. (1993) Developmental Apraxia of Speech
(2) Hayden (1998) PROMPT Manual

Appropriate Therapy (1)

Intensive and frequent

Individual (no benefit from group therapy)

Repetitive practice for habituation of motor learning

Multisensory, including touch-cue system (PROMPT)

Core vocabulary

Successive approximations

Melodic, rhythmic (singing rhymes)

Appropriate Therapy (2)

Difficult course resistant to “traditional methods”

Regression and learning to speak one word at a time

Use of “total communication” approach (e.g. sign language, PECS and augmentative communication devices)

Oral motor techniques–if indicated

“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

Early Diagnosis (1)

Ongoing developmental surveillance and screening by pediatric practitioners Policy statement from the AAPediatrics and the American Academy of Neurology-CNS

Dispel the myth that all “late talkers” (with no receptive language are “Little Einsteins” (He/She will outgrow it)

Listen to parental concerns because they are accurate indicators of true problems
Dworkin et al (1997) Contemporary Pediatrics

Glascoe (1995) Pediatrics

Early Diagnosis (2)

Referral to Early Intervention

Improves outcome

At no cost for families (in most states)

N-D specialists (neurologists developmental pediatricians) should work collaboratively with SLPs (speech language pathologists) in determining correct diagnosis and treatment plan
Role of Essential Fatty Acids

Supplementation appears to cause dramatic leaps in development in children receiving combination of fish oils (omega-3s) and borage or evening primrose oil (omega-6 oils)

The effect is greater than one can expect from speech therapy alone

Can this effect be clinically validated and how do we account for it?

All these terms thrown at you and nowhere to go to get answers to your questions about your child’s diagnoses? Here are some critical differences that may help you to determine what, and if, your child is Verbally Apraxic. Your reports from therapists may contain the phrases in italics below.

Your child may say the same word four different ways. Sound errors are significantly inconsistent.

Your child adds vowel sounds to the end of words that finish with a consonant (Up-pa). Intrusion of a vowel.

Apraxic children may be able to produce sounds in imitation, which they do not use in connected speech.

Your child becomes less and less understandable as his speech unit gets longer. Severity of apraxia increases as the length of the word or utterance increases.

Your child tends to mix-up consonants within a word. Sound swapping errors are common (efelant vs elephant). Metathetic errors are frequent.

Your child may drop final consonants in single syllable words (omission errors) simplifying his/her speech unit to contain consonant-vowel pairs in short strings. “Cat come home” = “Ca co hoe”.

Your child may not be able to change his pitch during speech production. Prosodic disturbances of speech, pitch, stress and rate are frequently in error.

Your child may use only /b/, /m/, /d/, /g/, /z/ with simple vowels like /uh/, /ah/, /oh/, but not /p/, /t/, /k/, or long vowels /ay/, /ee/, /i/ or /ow/. Voicing errors, nasal resonance errors, and lengthening vowels before omitted consonants are present.

Your child has difficulty repeating two different consonant + vowel pairs over and over again. Marked difficulty repeating series of speech sounds in diadokokenetic series /patika/.

Other elements of difference include:

a big discrepancy between your child’s ability to move his/her lips, tongue and jaw for eating or non-speech activities and the use of these parts during speech on command.

general normal EEG/MRI results

the ability to understand everything said to him/her. Normal receptive language.

traditional speech therapy techniques are ineffectual. General speech progress is slow and requires intensive, appropriate, speech therapy.

Apraxia of speech is not a developmental disorder but a neurological disorder. A pediatric neurologist evaluation along with a speech assessment from an experienced speech therapist will be crucial for an accurate diagnosis.

After that, the therapy approach should focus on the motor planning issue, as well as the language issue. Reading and writing expression will need consideration as well. Just presenting a word as a model will not meet an apraxic child’s needs for therapy. Visual cues and kinethestic or tactile information must also be provided. The goal of therapy should always be to increase the automatic movement of speech and increase functional communication as quickly as possible.

Lori Roth MS CCC/SLP