June 26, 2006 / 27 Comments
… from a parent
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 processing disorder.
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 processing 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 processing disorder issues. There is lots of information online about sensory processing disorder (SPD), but mostly it makes the child seem like the tantrum child, for “no” reason. Children with SPD 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.
PARENT FRIENDLY DESCRIPTION OF APRAXIA FROM AN SLP
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
HOW DO I KNOW IF MY CHILD IS SIMPLY A ‘LATE TALKER’ OR IF HE/SHE HAS APRAXIA? WHAT ARE THE SIGNS OF VERBAL APRAXIA?
Apraxia is a complex disorder, and there is no definitive medical test that can lead to a diagnosis of apraxia. Professionals look to a constellation of signs and symptoms in order to diagnosis apraxia. A child who is a late talker and exhibits many of the following signs and symptoms should be evaluated to determine whether or not he or she has apraxia.
Children who have subsequently diagnosed with verbal apraxia often share a history of some common signs. These children, during infancy, often engage in limited sound play and babbling. Their parents often describe them as ‘quiet’ babies. Often, the variety of sounds that they use in their babble is limited, and they may only use a few consonants and vowels. While the first words of these children may emerge on time, the vocabulary growth is slow, and they often rely on elaborate nonverbal or gestural communication instead. Frustration and behavior problems emerge as the child has difficulty communicating. As babies, frequently these children drool excessively and display signs of oral apraxia. They have a later transition to solid foods that expected and frequently have feeding difficulties. As well, there is often a family history of speech, language, or learning problems.
Other signs of verbal apraxia include the following:
• Receptive (understanding) language skills are typically stronger than expressive (spoken) language
• Cognitive skills are normal or close to normal
• The child uses a limited repertoire of consonant sounds (for example, “da” may be generic, and be 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 ‘)
• 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.
• 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 of speech, with excess equal stress making speech sound robotic(Shriberg, Aram & Kwiatkowski, 1997)
• 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 (dysfluencies, silent posturing) 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
WHAT NEUROLOGICAL SOFT SIGNS OFTEN OCCUR WITH APRAXIA?
Apraxia appears to be a neurologically based disorder that can run in families. Children with apraxia frequently have a constellation of ‘neurological soft signs’ that are associated with apraxia. These 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 seen. 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 (like clap hands and touch head) or playing pat-a-cake or doing jumping jacks.
Sensory processing disorder/self-regulatory issues are 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 underresponsive 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 , and may have a heightened sensitivity to sensory experiences, dislike being touched, dislike loud noises, avoid messy play, and be intolerant to daily tasks like hair washing and tooth brushing. Children with DSI 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.
Read about parent friendly “soft signs” of apraxia here
WHAT TYPE OF THERAPY IS MOST APPROPRIATE FOR CHILDREN WITH APRAXIA?
The most appropriate therapy for a child with verbal apraxia is different than what is considerate appropriate for a child with a more traditional articulation issues. The following are some general guidelines of what should be included in a therapy program for a child with a diagnosis of verbal apraxia:
• Begin with development of imitation skills: Since the crux of verbal apraxia is a difficulty with production of sounds and words on command, this is a very basic skill that will need to be focused on.
• Emphasize movement sequences at syllable level rather than sounds in isolation
• Therapy should be intensive and frequent
• Individual therapy is recommended, as there is no benefit from group therapy for children with apraxia: “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
• Repetitive practice for habituation of motor learning: In order for a production to become automatic and easy for a child, frequent, repetitive practice is required.
• Developing an alternative communication system for while the child is learning to speak: Apraxia is a disorder with a difficult course, and it can often take some time for a child to learn enough speech in order to functionally communicate. As such, it is important for a child to have an alternative means of communication in order to reduce frustration and allow effective communication while he/she is learning to speak. The use of a ‘total communication’ approach, incorporating and encouraging oral communication while at the same time using other methods of communication is recommended. These alternative communication methods can include sign language (which research suggests promotes the development of verbal skills), Picture Exchange Communication System (PECS) (a program that involves the child giving a picture of a desired object in order to obtain it), or a high-tech device (typically for more significantly impaired children, and are tailored to the individual).
• Multisensory, including touch-cue system (PROMPT): Therapy should include as many modalities as needed to elicit target productions, including auditory and visual cues (e.g. ‘look at my mouth’), as well as touch-cueing, preferably through the use of PROMPT (link to PROMPT section below)
• Core vocabulary: Developing a core vocabulary of a few functional words, such as ‘more,’ ‘help,’ and ‘up,’ should be one of the first goals of your child’s speech therapy. These words should be practiced over and over until your child can produce them automatically and as his/her single word vocabulary increases, he/she can move on to word pairings, like ‘mama help.’
• Use of sound approximations in a hierarchy towards target word (Kaufman hierarchy approach): As part of building a core vocabulary, a child can be taught to use word approximations to start with, a method that is part of the Kaufman Speech Praxis Treatment Kit (link to Nancy Kaufman’s site or super duper who sells?). The child is taught an approximation of a target word – such as ‘opuh’ for ‘open’ – that requires less motor complexity, thereby ensuring greater success in his/her productions.
• Incorporating melody and rhythm: The use of activities such as singing rhymes or tapping the table while saying a sequence of syllables can help to improve rate and intonation of speech as well as sequencing.
• Slowed rate with movement activities: Marching or banging a drum while saying sequences of sounds and syllables
• Carrier phrases: The use of carrier phrases can help your child use language more automatically; for example, phrases like ‘Ready, set, ___’ and ‘One, two, ___’ help cue your child with what word to use.
• Oral motor techniques – if indicated: Children with verbal apraxia often have oral apraxia or may have low tone in the oral musculature. These children may benefit from oral motor therapy, which can involve increasing sensory awareness of the articulators, improving imitation of non-speech movements, and strengthening the muscles of the jaw, tongue, and lips. Although ‘controversial,’ oral motor therapy may improve feeding skills, drinking, drooling, as well as clarity of speech.
As noted above, multisensory therapy techniques that allow the child to hear, see, and feel how a sound is produced are most effective for children with motor speech disorders. While a child with a more traditional articulation issue may only need auditory and visual cues to remediate their errors, it is not sufficient for children with severe speech disorders.
PROMPT,an acronym for ‘Prompts for Restructuring Oral Muscular Phonetic Targets,’ involves the therapist applying pressure to specific places on the child’s face, lips, and chin to help the child form the shapes with the articulators that are needed to make certain sounds. PROMPT helps develop a ‘motor memory’ for how a sound is produced by physically helping the child through the movements for speech. As well, the tactile input provided by the clinician gives the child a feeling for how the sound is produced, which is extremely important for a child with a motor speech disorder.
WHAT CAN I DO AT HOME TO HELP WITH THERAPY?
Your child’s SLP will probably give you homework to carry over in between therapy sessions. But you can incorporate “therapy” into everyday play with your child. Some ideas to try: sing songs like Old MacDonald and see if your child will fill in E-I-E-I-O; read repetitive books, like Brown Bear, Brown Bear What Do You See or Peek-a-Who, and see if your child can fill in some words; recite nursery rhymes with your child, encouraging his/her to complete some of the phrases. Many more ideas here