Zooming in on Apraxia in Children-

Through the Lens of Speech Production Disorders

By Keren Abramson, SLP (CASLPO)

Is your young child's speech unclear, limited or absent for his age? Does he show awkwardness or groping during his efforts to verbalize? Has he demonstrated a need to seek nonverbal means of communication?

If you answered "yes" to any of these questions you should contact a speech-language pathologist for an evaluation. After examining many variables the child may be diagnosed with a speech production disorder. The particular type will be determined by the profile exhibited during the assessment. Treatment will be based on the diagnosis and will include consideration of a multiplicity of associated, relevant factors.

WHAT ARE SPEECH PRODUCTION DISORDERS?

Simply stated, when a child has difficulty expressing himself through speech, and his limitation(s) are demonstrated in a fashion that does not reflect a more predictable developmental delay, the child may be exhibiting a speech production disorder. There are several types of disorders, and even more terms to label them. Often the diagnostic label not only categorizes the profile, but also reflects the diagnostician's orientation when viewing and treating the disorder (eg. causal, motor-based, language-based, or along a continuum). Some commonly seen terms are cited below. The focus of this article will be on the last category, i.e. apraxia/dyspraxia.

Articulation Disorders refer to sound distortions, substitutions, omissions or other such misarticulations that are produced unconventionally, with signs of disorder.

Fluency Disorders:

Phonological Processing Disorders are often manifested in unintelligible speech. They are typically viewed as language-based disorders since phonology of language involves the process of fitting speech sounds into words and continuous utterances according to rules that govern language.

Dysarthric Speech, generally characterized by weakness and/or changes in muscle strength, coordination and tone, results in speech production that is often imprecise with slurring and sound distortions. The different subtypes (e.g. flaccid, spastic, ataxic) represent various profile configurations.

Dyspraxia/Apraxia terms guide one to a realm of speech production disorders that encompasses a scope of terminology such as oral apraxia, verbal apraxia/dyspraxia, apraxia of speech, congenital dysarthria, planning apraxia of speech, executive apraxia of speech, developmental verbal dyspraxia, developmental apraxia of speech (DAS), childhood verbal apraxia, and childhood apraxia of speech (CAS). The common denominator is the motor planning difficulty attributed to nervous system deficits. It may occur at the basic level of imitating a simple non-speech oral motor act or, as one moves along the continuum from oral motor and motor speech impairments, to phonological (sound) system disorganization and unsystematized expressive language. There is typically a marked difference between automatic and volitional speech.

In Nancy Kaufman's approach in combining phonological process and developmental apraxia of speech theories, she suggests that the former theory answers the question of why the deviant speech patterns occur through neurologically–based faulty motor-speech programming. The latter, phonological processes theory answers the question of how children simplify difficult oral (verbal-motor) output by employing (subconscious) phonological processes. (Seminar Presentation: Evaluation and Treatment of Children with Apraxia of Speech, Feb. 12. 1999, Toronto, Canada)

Motor planning is considered to be a high-level, complex form of functioning. It requires intact sensory integration skills, conscious attention, and organized programming of the refined, minutely timed execution of speech sounds patterned to represent the child's thought through sounds, words and language. Coordination of breathing, voicing and articulatory mechanisms is involved. Components of speech such as pitch, loudness, and prosodic features (stress and intonation) are inherent in the spoken process. In a child with a motor planning speech production disorder, key symptoms are displayed in combining any, and often several of these elements. The symptoms can be complex with unpredictable variations.

Some children with oral-motor disorders may demonstrate oral hypersensitivity. They may exhibit tactile defensiveness, rigidity in or around the lips and mouth. They may display an aversion to some foods, to teeth brushing and touching around the mouth.

Hyposensitive children have reduced sensation in their mouths. They can display weak lip muscles, may drool excessively and may typically overstuff their mouths with food or habitually attempt to bring objects to their mouth.

Some children exhibit both hyper- and hypotonicity and reactions in the mechanical speech system.

Associated and Coexisting Factors:

  1. Other language symptoms may be present (approximately 50% of the time). They may appear early (e.g. in disordered grammar) or when the child is older and trying to use language as a tool (such as when he is "reading to learn as opposed to learning to read"). (Velleman, 1994) Children with apraxia of speech may also have an expressive language disorder. (Kaufman)
  2. Oral apraxia (which affects non-speech mouth movements) may be present jointly with verbal apraxia and/or with other forms of apraxia, such as limb apraxia. (In the latter case a physical or occupational therapist should be consulted.) (Velleman, 1994)
  3. "Children with apraxia of speech can also have oral motor weakness as an additional factor to their motor-speech programming issues…They would then necessitate oral-motor strengthening exercises, and perhaps oral-facial myology or myofunctional therapy." (Kaufman)
  4. When children with spoken language problems demonstrate difficulty with phonological awareness, they are most at risk for related specific literacy problems. (Stackhouse, 1997, p.169). She also pointed out that, "Although recently work has clarified how visual deficits may also affect reading performance, there is an overwhelming consensus that verbal skills are the most influential in literacy development (Catts, Hu, Larrivee,& Swank,1994)." (Stackhouse, 1997, p.163)

WHO DIAGNOSES AND PROVIDES TREATMENT IF A SPEECH PRODUCTION DISORDER IS PRESENT?

A qualified speech-language pathologist must be sought. Ideally, the professional should have a special interest, extra experience and additional training in oral motor disorders/apraxia.

Many people have met others who have benefited from professional intervention on their child's behalf, and they often offer their suggestions and share their experiences. It is wise to contact the local professional speech and language association to make inquiries and request referral names and advice.

Canadian Association of Speech-Language Pathologists and Audiologists (CASLPA): http://www.caslpa.ca/english/profession/links.asp

American Speech-Language-Hearing Association (ASHA):

http://www.asha.org

HOW DOES A SPEECH-LANGUAGE PATHOLOGIST ASCERTAIN A DIAGNOSIS?

A speech-language pathologist performs a complete diagnostic work-up in order to make a differential diagnosis. This typically includes gathering a reviewing records and information concerning: hearing status and history, pregnancy and birth history, developmental milestones, communication profile, receptive and expressive language skills, and assessing current performance in some of the above areas as well as articulation/oral motor abilities and skills (automatic and volitional), voice, prosody,

phonemic awareness, communication impact, stimulability, etc. Formal, standardized and informal measures and procedures are used.

Children with Autistic Spectrum Disorder are often more challenging to assess due to such factors as reduced communication ability, interest and or attention, perceptual issues, non-speech motor functions (e.g. posture and gait, muscle tone, restlessness/lethargy), hypersensitivities, and diet restrictions that may coexist with speech production and language disorders.

Once a diagnosis has been determined, statements concerning it and prognostic information are outlined. Usually, however, it is very difficult to predict speech outcomes with exactness. (For an article on this topic see: Lori Hickman, http://www.apraxia-kids.org/definitions/prognosis.html, "Factors in Long-term Outcomes for Children with Apraxia of Speech", 2002)This is followed by a customized course of therapy. If the support of other professionals (such as: audiologist, developmental pediatrician, occupational therapist, psychologist) is recommended then appropriate referrals are made.

WHAT DOES TREATMENT INVOLVE?

For best results, intervention should usually begin expeditiously, and typically, service provision necessitates relatively high demands in terms of frequency, intensity and length. Adjustments to this are based on needs and may be contingent on the integration of coexisting speech, language and communication elements, other physical and/or neuromotor factors, as well as practical considerations.

For more information on this subtopic, refer to "Literature Review: Frequency and Intensity of Therapy for Children with Apraxia of Speech", http://www.apraxia-kids.org/definitions/frequency.html

Therapy strategies need to consider "the maturation level of the child, the child's general cognitive abilities, possible dual diagnoses and other deficit areas such as fine motor skills, and parent motivation. When we discuss intervention strategies we must take into account individual strengths as we develop a multi-sensory, multi-modality communication therapy course of action." (David Hammer, http://www.apraxia-kids.org/slps/hammer.html, "Brief Thoughts about Therapy", 2002)

WHAT RESULTS CAN I EXPECT FROM TREATMENT?

The child's unique symptom profile, coupled with coexisting factors, and practicalities of life are some of the variables that can influence short-term as well as eventual outcomes of therapeutic intervention. One should not be surprised nor concerned if the speech-language pathologist seems to be somewhat vague or guarded when responding to questions about predicting outcomes or a prognosis.

Early intervention, frequent practice involving multiple repetitions in varied opportunities and circumstances as outlined by a speech-language pathologist, should all help to maximize improvement. One can reasonably expect that in most cases, steps progress methodically in a manner that is carefully designed to incorporate many traits, features and pragmatic considerations.

An excellent program designed by a speech-language pathologist for a given child will have the greatest chance for success when it is frequently and consistently implemented by others in the recommended manner. Treatment must be viewed as a shared responsibility.

(For more information on this topic, please refer to: "Factors in Long-term Outcomes for Children with Apraxia of Speech", by Lori Hickman, CCC/SLP, http://www.apraxia-kids.org/definitions/prognosis.html)

WHAT ARE SOME PRACTICAL SUGGESTIONS THAT I CAN KEEP IN MIND UNTIL I RECEIVE CUSTOMIZED GUIDANCE FROM A SPEECH-LANGUAGE PATHOLOGIST AND DURING THE INITIAL STAGE OF MY INTERVENTION?

  1. Contact an audiologist for a hearing evaluation. In some cases auditory perceptual and processing may also require examination.
  2. After/when assessing your child other professional referrals may be recommended (e.g. developmental pediatrician, psychologist, occupational therapist). Please consult with them as advised.
  3. If other types of therapies and learning environments are involved, try to coordinate communication amongst the professionals so that whenever possible, strategies and techniques can be integrated and carry-over opportunities can be maximized. A communication booklet is often very useful.
  4. Accept your child's attempts to communicate with warm appreciation. A feeling of comfort and security in this area will provide a good foundation for building speech and language structures. (a high percentage of human interaction involves non-verbal communication.)
  5. Don't be surprised if your child can say something one day and has difficulty repeating the utterance on subsequent occasions.
  6. If your child has received a diagnosis that may include communication impairment such as autistic spectrum disorder, a multiplicity of factors could be involved in his communication difficulty. These will be determined and clarified for you with professional help. Respond immediately in a positive and sensitive manner to any indications of communicative intent.
  7. If your child is showing some interest and/or ability in non-speech oral-motor and other interactive activities, such as songs, fingerplays, turn-taking exchanges, and imitation of environmental and other sounds, follow his lead. Join with him playfully in imitation. You may be able to pivot from these oral attempts to diversify and expand them somewhat.
  8. If he has difficulty performing some actions such as blowing, but he enjoys watching someone else doing it, accept his interest and continue modeling. He is still learning. Frustration, on the other hand, can lead to a breakdown in communication. When a speech-language pathologist becomes involved, activities will be assigned with discretion.
  9. Nurture interaction. Encourage functional communication. Help your child to recognize the power of communication.
  10. Try to understand the communication difficulty by taking his perspective for periods of time and operating from an insightful perspective. For an example of a sensitive approach, refer to "Teach Me to Talk-Help Me to Learn", by Donna Williams, SLP, http://www.apraxia-kids.org/families/donnawilliams.html.

The above suggestions are general in nature due to the fact that individualized strategies and techniques must be done through consultation with a speech-language pathologist. Genuine efforts that are attempted without such guidance can be contraindicative and may complicate the learning process. In order to expedite improvement in a child's speech, language and communication skills, it is best to contact a speech-language pathologist and seek early, tailored intervention.

Questions or comments concerning the contents of this article may be directed to Keren Abramson, speech-language pathologist at 307 Sheppard Ave. West, Toronto, Ontario M2N 1N6 Telephone: (416) 221-8361 Fax: (416) 221-7486