Delay Vs. Disorder

1. How can you tell the difference between a child with verbal apraxia (not oral apraxia) and one that is a late talker?

Experts state that oral apraxia can be diagnosed as young as 18 months, while most experts believe that it’s difficult to get a definite diagnosis of verbal apraxia until the age of 3. You say your son is 25 months with no signs of oral apraxia. This said, it’s suggested that if apraxia is suspected, to begin appropriate oral motor therapy right away, because it won’t hurt, and the earlier the better for therapy with apraxia. Even with early intervention, some children with apraxia may always need an alternative way of communicating (sign language, picture exchange communication, computer, etc.), but many will learn how to overcome the apraxia enough to talk and be understood.

Through Early Intervention (free through your state’s Birth to Three program and through your local school district from 3 up) or through private (ie provided for by insurance or out-of-pocket), an expert (SLP, OT, developmental pediatrician, neurologist, etc.) will evaluate your child’s ability to move his tongue on command and will assess his strength in various areas (physical, language, emotional, social, and intellectual development), all via fun ways using toys, so he’ll love it. I recommend that you be in the room with him. I was ALWAYS there with Tanner, for all of his evaluations, testing, and therapy, except when he started the preschool disabled program. (We now can watch from a two way mirror.) Some therapists want to be alone with the child and some parents feel their child behaves better without the parent in the room. I believe that since my husband and I are with our son most of the time, our observation is important so that we may provide “carry through” therapy. For us, this has worked well.

Your child may be a late talker for a number of reasons other than apraxia. Most often, it is due to a speech delay, but like I said, early intervention is a free, federal program your child is entitled to if he qualifies, for whatever the reason for the delay in speech. There is a lot of research into the benefits of brain stimulation during the birth to three stage, so the “play therapy” your child would receive from early intervention will most likely benefit him for whatever the reason for the delay of speech. If your child just starts talking perfectly a week or a year later…great! And then do you really care what the reason was for his being a late talker? Since no large scale research has been done yet on the neurologically based condition that is referred to as “apraxia of unknown origin,” all of us as parents of children with apraxia, have questions. But we may not have those questioned answered before our children are teenagers or adults. Our main goal at the Cherab Foundation is to help all children learn to talk, and we do know what works for teaching a child to communicate, overcome apraxia, and reduce frustrations for a “late talker”. A few of the late talkers do have apraxia, and the fact that you’re out there researching on the internet shows that you are the type of parent whose child is in good hands, for whatever the reason he is a “late talker.” Knowledge is so powerful in helping us to help the children.

2. How can you tell the difference between a child that’s not talking because he or she is shy, and one that has apraxia?

The diagnosis of apraxia, according to experts, is difficult to give until the age of 3.  Oral apraxia, on the other hand, can be diagnosed as young as 18 months.

My son Tanner seemed shy because he was dependent on people he felt comfortable with to communicate for him and understand him, but that “shy” behavior disappeared as we provided alternative means of communication. I didn’t think of it as much as shy as I did dependency.

His speech disorder didn’t go away when his shyness did. In other words, shy or not shy, Tanner has a speech disorder. Does your child speak clearly in front of anyone? Like you or your husband? Does your child speak in clear sentences at home? If so, then perhaps it is just shyness. If not, to help with any shyness/dependency, you might try Sign Language or Picture Exchange Communication. That would be where your child points to a picture of a juice box vs. a cup when you ask him what he wants his juice in, for example. You can do this for breakfast choices, anything! Also, let him know that “everybody has to learn to talk.” It’s true, you’re just leaving out the details!

Even if your child is showing improvement, you should be concerned if a therapist believes that lack of speech and/or un-intelligibility is from shyness if there are signs of oral apraxia. Again, oral apraxia is something that could be diagnosed as young as 18 months. Apraxia is neurologically based, and it is not a psychological disorder. Even though children can develop low self esteem from communication challenges, most children are still too young to know for sure if his or her progress is normal. If he or she does have shyness issues that affect speech, then that’s an issue that can easily be dealt with through simple methods. So I would highly recommend that you seek a second opinion from an SLP that is knowledgeable about apraxia and other motor planning disorders.

In addition to oral apraxia, it’s not uncommon for apraxic children to have other issues. (Don’t freak out – they’re generally treatable ones) like low tone/hypotonia which looks like the cherub baby, or sensory integration issues.

He’s at an age where you may start to notice these other added surprises and it’s good to know what they are so that you can help him if he has them. But while you’re getting second opinions on the “shy vs. apraxia” situation, these are other things to ask about.

This is something you could try:
Buy 2 blow horns. You blow into one and give the other to your child. Imitate (in a fun way) each other’s toots. Let him or her take the lead, then you take the lead. If your child can’t imitate 3 or 4 toots of a horn, he or she is not ready for 3 or 4 word sentences yet. It has to do with breath control.

3. Are all late talkers apraxic?

Many have noted that through my own personal story, both of my children were late talkers and apraxic. Sorry if our story is confusing, but I hope this explanation will clear things up.

The easy answer is no, a child can be a late talker and not have apraxia. But because you brought up my two “late talking” kids, we go to the tough question! The pediatric neurologist diagnosed our older son, Dakota, with oral apraxia at 2, but Dakota never had oral or verbal apraxia in the way our son Tanner does. Dakota’s “apraxia” was used as a symptom (like if you look up the word apraxia in the dictionary and use it as a definition to describe what is happening. Loss of ability to…) The word apraxia was used for Tanner as a diagnosis. Tanner has oral and verbal apraxia.

There are so many names for apraxia – the neurological based disorder we are talking about for example, names such as dyspraxia, verbal apraxia, oral apraxia,developmental apraxia, global apraxia, limb apraxia, oral motor disorder, etc. and because the speech and medical community are not always on the same page, names are used by professionals that are very confusing, or that even conflict, at times. Some neurologists are knowledgeable about apraxia, and some are not, some are knowledgeable about apraxia, but use other names to describe it. I’ll explain.

Tanner was diagnosed as havinig severe oral and verbal apraxia by various SLPs, OTs, a pediatric neurologist and a developmental pediatrician.  However, the same pediatric neurologist who wrote in an evaluation that Dakota has “oral apraxia,” diagnosed Tanner as having a “phonological motor processing disorder which effects motor planning and speech.” You see, this neurologist used the term “apraxia” as a symptom rather than a diagnosis since in his medical opinion the diagnosis “apraxia” was not clear. “Apraxia of what? The limbs, the eyes, it’s to vague a term!” is what he said to me in a frustrated way. “I don’t like this name apraxia, it’s too vague!,” he also said.  This was in 1999.  So even though this neurologist knew Tanner was diagnosed as having oral and verbal apraxia by many other speech professionals, and by a medical professional, and even though he understood what apraxia was, he still did not want to use the term “apraxia” to diagnose Tanner. He preferred the diagnosis “phonological motor processing disorder.” But if you run that past some SLPs, some will say that means something different than apraxia!

Since Dakota, our older son had “facial palsy” from crushed facial nerves, among other things, from a traumatic delivery, it created oral apraxia but this was describing the action of the nerve damage, not diagnosing him as being oral apraxic. It’s complicated, but yes, even though both our sons had oral apraxia, only Tanner has apraxia, the neurologically based speech disorder of unknown origin. So for all of you with one child with apraxia trying to explain this to family and friends, imagine us! Thank God that Dakota today is mainstreamed and getting top grades in school! We just can’t wait until Tanner makes it out of the woods, as well, at some point.

Once again though, our situation is unique and isn’t the best example of two typical “late talkers.” One was a late talker from birth trauma, and one was a late talker from apraxia, but they both were described as having apraxia. The average late talker does NOT have apraxia. Apraxia is not rare, but it’s not that common, either.

4. Is there an association between apraxia and mental retardation?

Children with apraxia have been MISdiagnosed as mentally retarded and autistic for far too long.

A child can have apraxia and have normal or brilliant intelligence; from what I’ve read, seen, and heard, most do. Just so you know however, a child COULD have apraxia and other issues, such as apraxia and mental retardation, or apraxia and autism, or apraxia and cerebral palsy, or apraxia and downs, etc. (Just like they could have a broken leg and autism.) This is why it’s so important to bring your child to developmental pediatricians and/or neurologists who are knowledgeable about apraxia as well as other issues. Don’t let anyone treat or educate your child as having cognitive challenges unless you know for a fact he does. And don’t leave it up to your child’s school to “find out” and classify him or her as mentally retarded. Find out by having your child privately evaluated by a medical authority (or two) that you respect, and who has experience and knowledge of apraxia and other issues.

Be careful of “receptive” language evaluations on written reports. Your child can have a severe expressive delay, but if they write a “severe expressive and receptive delay,” it means something different.  That’s a red flag that there could be cognitive challenges going on. It translates (in parent language) to “You’re talking to this child, but there is nobody home.” If that’s the case, again, see a medical professional, but if that’s not the case, if your child does understand and can follow simple commands, these are the first baby steps to misclassifying apraxic children. Take it seriously and find out privately.

Don’t just depend on one diagnosis, especially since many apraxic children have been misclassified or misdiagnosed. This is one of the reasons we so highly recommend testing by professionals that are knowledgeable about testing children with communication impairments.

Since so many apraxic children are intelligent and know they aren’t being understood, due to frustration some tend to withdraw, and be misdiagnosed as autistic.

Again, apraxic children can be brilliant and misdiagnosed or misclassified. What’s fortunate is that, because of the Internet, you can prove this point by speaking with the children who have grown up with apraxia or their parents.

The way apraxic children speak varies. You can listen to various apraxic children at The Talking Page. Our son Tanner used to sound deaf when he spoke, but what’s funny is that now that he goes to a school for the hearing impaired and deaf, he no longer sounds like he’s deaf, and he has many inflections when he talks or sings!

Lori Roth, who has worked with both deaf and apraxic children, believes that they both may learn to speak in similar ways, which is why so many apraxic children have done well in schools for the deaf or hearing impaired. It’s something to look into anyway. Dr. Agin can explain why apraxic children sometimes sound deaf from a medical aspect as well.

As far as people looking at your son when he babbles, I know how you feel! Tanner is a big kid, so even when he was only 3 he looked 4, and now at 4 and a half he looks like he’s at least 5 or 6. At three he had only a few simple sounds or words.

He went through the “babbling” stage after three too. His SLPs say that is typical, and a good thing, since it’s an important stage in language development that our apraxic children either miss, or don’t fully go through when younger. Apraxic children typically go through most of the “normal” stages of language development if they are getting appropriate therapy, but just LOTS slower and later than a typical “late talker” that is not apraxic. Today Tanner talks “like a baby” using 3 to 5 word sentences, and not only are we all proud of him, but he’s proud of himself! We don’t want to lose that healthy self confidence, so if he doesn’t notice any strange looks cast his way, I ignore them. But if these people say anything, or Tanner notices them staring at him, I use my now classic, “He’s learning to talk, and he’s doing great!” Works like a charm!