"Apraxia, What's That?"

Here are some answers from a developmental pediatrician which can help give you some "signs' to look for in apraxia.  A child with apraxia may or may not have all the characteristics listed here.

VERBAL APRAXIA:
Marilyn C. Agin, M.D.

Medical Director, NYC Early Intervention Program, Medical Director, CHERAB Foundation

Presented at: The First Conference for Verbal Apraxia, July 23-24, 2001, Headquarters Plaza Hotel, Morristown, New Jersey, U.S.A.

		Verbal Apraxia
		What’s in a Name and Definitions
		Neurodevelopmental Evaluation of Verbal Apraxia: HISTORY
		Neurodevelopmental Evaluation: Physical Neurologic Exam
		Assessment of Respiration and Phonation
		Oral Motor Assessment
		Speech/Language/Cognitive Assessment (1)
		Speech/Language/Cognitive Assessment (2)
		Association with Other Disorders
		Verbal Apraxia Controversies (1)
		Verbal Apraxia Controversies (2)
		Verbal Apraxia Controversies (3)
		Appropriate Therapy (1)
		Appropriate Therapy (2)
		Early Diagnosis (1)
		Early Diagnosis (2)
		Role of Essential Fatty Acids
		Information from Lori Roth MA CCC-SLP

VERBAL APRAXIA:
Marilyn C. Agin, M.D.

Medical Director, NYC Early Intervention Program

Medical Director, CHERAB Foundation

Presented at: The First Conference on Therapy for Verbal Apraxia, July 23-24, 2001, Headquarters Plaza Hotel, Morristown, New Jersey, U.S.A.  TOP

What’s in a Name & Definitions

What is apraxia, verbal apraxia (VA) (also known as apraxia of speech or verbal dyspraxia), orofacial apraxia and motor apraxia. How is VA 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 non-speech movements (e.g., blowing, puckering, licking food from the lips)

Motor apraxia involves the programming of hand or whole body movement.  TOP

Neurodevelopmental Evaluation of Verbal Apraxia: HISTORY

Limited Babbling & 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 problems  TOP

Neurodevelopmental 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  TOP

Assessment of Respiration and Phonation

Postural tone

Head and trunk control

Respiratory support for phonation

Ability to sound play  TOP

Oral Motor Assessment

Oral hypotonia

Drooling

Feeding

Suck swallow pattern

Chewing

Facial Expression  TOP

Speech/Language/Cognitive Assessment (1)

Receptive Language>expressive language

Normal to near normal cognitive abilities

Limited repertoire of consonant sounds ("da" maybe generic)

Sounds/syllable omissions, vowel distortion, cluster

increased errors with increased length of utterance

Inconsistency of errors  TOP

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  TOP

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  TOP

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  TOP

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) (3) Ferry , Hall $ Hicks (1975)

(2) Yoss & Darley (1974) (4) Horowitz (1984)  TOP

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 Apraxia of Speech

(2) Hayden (1998) PROMPT Manual  TOP

Appropriate Therapy (1)

Intensive and frequent

Individual (no benefit from group tx)

Repetitive practice for habituation of motor learning

Multisensory, including touch-cue system (PROMPT)

Core vocabulary

Successive approximations

Melodic, rhythmic (singing rhymes)  TOP

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  TOP

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 issues 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  TOP

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 dx and treatment plan  TOP

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?  TOP

 

APRAXIA Q&A 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 where 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? 

It's hard to say. 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 a year 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. These statistics can be obtained from the American Speech, Hearing and Language Association (ASHA). It is 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 late talker and speech disorder (apraxia)? 

I think you mean this question rather than the one you asked, but I will try to answer both. 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 /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 affect also in Verbal apraxia. I could go on but I feel you have the most important points and would be happy to tell you more if you need clarification. 

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. The above answer gave you the important criteria for differential diagnosis. 

How do parents react? 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 sends up a flag for them. Most do not understand the complexity of the problem initially. 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. So you see it's 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 signally 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.