What is apraxia?
Apraxia is a complex disorder, with no medical test offering a definitive diagnosis. Instead, professionals look to a constellation of signs and symptoms along with astute evaluations in order to determine if a child who is considered a late talker has apraxia
FROM THE ONSET
Children who have been subsequently diagnosed with verbal apraxia often share a history of some common signs. During infancy they engage in limited sound play and babbling, often described as ‘quiet’ babies by their parents. The variety of sounds displayed in their babble is limited, and they may only use a few consonants and vowels. While their first words may emerge on time, vocabulary growth is slow, and they often rely on elaborate nonverbal or gestural communication instead. Frustration and behavior problems emerge as the child continues to have difficulty communicating.[expand title=”Click here to see signs of verbal apraxia”]
Signs of verbal apraxia may include the following:
- Limited repertoire of consonant sounds (for example, “da” may be generic, and 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‘).
- The 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”.
- Vowel sounds are added to the end of words that end with a consonant (Up-pa).
- Marked difficulty repeating two different consonant + vowel pairs over and over again. EXAMPLE
- 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.
- The child may be able to produce sounds in imitation, which they do not use in connected speech.
- The child tends to mix-up consonants within a word. Sound swapping errors are common (efelant vs elephant).
- The child may not be able to change his pitch during speech production.
- Discrepancy between the 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.
- 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 (rhythm) of speech, with excess equal stress making speech sound robotic
- 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 (where they can’t find the right sound, or they open their mouth and no sounds come out) 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.
- Traditional speech therapy techniques are ineffectual. General speech progress is slow and requires intensive, appropriate speech therapy such as Prompt.
Children diagnosed with verbal apraxia may show the following signs which can throw off an initial diagnosis:
- The ability to understand everything said to him/her. Normal receptive (understanding) language.
- Typically normal EEG/MRI results.
- Cognitive skills are normal or close to normal.
NEUROLOGICAL SOFT SIGNS TYPICALLY SEEN WITH APRAXIA
Apraxia of speech is not a “childhood” or 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. Children with apraxia frequently have a constellation of ‘neurological soft signs’ that are associated with apraxia.[expand title=”Click here to see some examples of neurological soft signs”]
Neurological soft signs 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 observed 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. Examples include: Clap hands and touch head simultaneously, playing pat-a-cake, jumping jacks.
Sensory processing disorder is also frequently seen in children with apraxia. Children with sensory processing disorder (SPD) 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 under-responsive 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, leading to heightened sensitivity to sensory experiences, dislike being touched, dislike of loud noises, avoid messy play, and be intolerant to daily tasks like hair washing and tooth brushing. Children with SPD 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.
How One Community Is Helping a Girl with Apraxia (3 min 22 sec):
The Cherab Foundation (www.cherabfoundation.org) is a world-wide nonprofit organization working to improve the communication skills, education, and advocacy of the verbal disabled; all those with speech and language delays or impairments. Their area of emphasis is verbal apraxia, a severe, neurologically-based communication disorder that used to be rare in pediatrics but has been on the rise within the past two decades. (description taken from their website)
The Apraxia Network (apraxianetwork.org) is a northern New Jersey non-profit support group for families of children/adults with all aspects of Apraxia, located in Paramus. We are a New Jersey State Dept of Education Reg. Provider for CEU’s. Their goal is to provide literature, networking with other parents, support and the newest information in the field. (description taken from their website)
CASANA ( https://www.apraxia-kids.org ).The Childhood Apraxia of Speech Association is a 501(c)(3) nonprofit publicly funded charity whose mission is to strengthen the support systems in the lives of children with apraxia so that each child is afforded their best opportunity to develop speech and communication. They are the ONLY national nonprofit dedicated exclusively to children with apraxia and their families.