- What is apraxia of speech and how does it differ from a developmental delay of speech?
- What is the usual prognosis for children with apraxia of speech?
- What is the usual method of treatment for apraxia?
- What causes apraxia?
- Will my child ever be able to speak “normally”?
- What are other associated features of apraxia?
- How do you know if you have a “good” therapist?
- Will my insurance company pay for therapy?
What is apraxia of speech and how does it differ from a developmental delay of speech?
Apraxia of Speech is considered a motor speech disorder. For unknown reasons, children with apraxia have great difficulty planning and producing the precise, highly refined and specific series of movements of the tongue, lips, jaw and palate that are necessary for intelligible speech. Apraxia of speech may also be called verbal apraxia, developmental apraxia of speech, or verbal dyspraxia. No matter what it is called the most important concept is the root word “praxis.” Praxis means planned movement. So to some degree or another, a child with the diagnosis of apraxia of speech has difficulty programming and planning speech movements. Apraxia of speech is a specific speech disorder.
A true developmental delay of speech is when the child is following the “typical” path of childhood speech development, albeit at a rate slower than normal. Sometimes this rate is commensurate with cognitive skills. In typical speech/language development, the child’s receptive and expressive skills are pretty much moving together. What is generally seen in a child with apraxia of speech is a significant gap between their receptive language abilities and expressive abilities. In other words, the child’s ability to understand language (receptive ability) is broadly within normal limits, but his or her expressive speech is seriously deficient, absent, or severely unclear. This is an important factor and one indicator that the child may be experiencing more than “delayed” speech and should be evaluated for the presence of a specific speech disorder such as apraxia. However, certain language disorders may also cause a similar pattern in a child. A gap between a child’s expressive and receptive language ability is insufficient to diagnose apraxia.
What is the usual prognosis for children with apraxia of speech?
Prognosis means how the child might be expected to do in the future if he or she receives proper treatment. The answer to this question is that outcomes vary, however, children with apraxia of speech can and do improve! The factors that appear to contribute to prognosis include:
- individual characteristics of the child; these include receptive ability, cognitive ability, desire to communicate (communication intent), age at which appropriate treatment is begun (preschool age being desirable), and attention span.
- the extent to which other medical, speech and/or language issues are present.
- the extent to which therapy is tailored to the unique issues present in the child.
- the extent of family participation and involvement in therapy and follow-through at home.
With appropriate help, most children with apraxia of speech make wonderful gains in their expressive speech ability. However, it is also true that in some situations, despite everyone’s best attempts, a child may not evolve to be primarily a verbal communicator.
Be careful of those who want to make detailed projections regarding how your child will do in the future, especially if they have not worked with or gotten to know your child.
What is the usual method of treatment for apraxia?
It is possible to speak only generally about effective therapy practices. Unfortunately, research into effective methods for providing treatment to children with apraxia is limited. However, in the professional literature various techniques described, including PROMPT method, Integral Stimulation, Adapted Cueing, Touch Cue, Melodic Intonation Therapy, Rate Control Therapy, etc. Although these therapeutic approaches differ somewhat, they do have common features. Most notably these include:
- principles of motor learning such as a high degree of practice and repetition, correction and feedback, slowed rate, and a focus on targeted motor placement and productions
- heightened sensory input for control of the movement sequences and sensory cueing such as visual, tactile, and kinesthetic cueing; touch cueing; verbal cueing.
- use of rhythm and melody
- focus on speech movements versus individual sounds
Many experienced speech-language pathologists use an eclectic approach rather than a “one approach fits all” notion, incorporating many of the methods mentioned above and using them based on the individual child’s needs. There is no one “program” that is right for every child with apraxia and commercial products and programs can be tools for use in therapy by a SLP who understands the nature of apraxia and how to treat it. However, such programs are not alone the solution.
Children with apraxia of speech reportedly do not progress well in their actual speech production with therapy tailored for other articulation problems or with language stimulation approaches. Additionally, in young children the motor/sensory techniques, drills, etc. should be woven into play activities that are highly motivational to them. What experienced therapists and families report is that children with apraxia need frequent one-on-one therapy and lots of repetition of sounds, sound sequences, and movement patterns in order to incorporate them and make them automatic.
Also, many therapists recommend the use of sign language, picture books, and other means to augment speech in the child who is not clearly understood. This approach may be called “total communication.” Having the child pair a vocal word attempt with a sign enhances the chance that the listener will be able to “catch” the communication (if the spoken word isn’t understood, perhaps the sign will be). Having others understand the communication can offer the child motivation and the feeling of success in using their voice to communicate. Many children with apraxia of speech, even at young ages, have some awareness of their difficulty. Providing successful communication experiences only encourages the child. Also, for children with apraxia of speech, signs can become important visual cues to help them know how to place their mouths, etc. in order to produce the desired word. When pairing of spoken word and sign is consistent, the child may come to associate the visual image of the sign with the placement of their articulators. Parents should not be afraid about using sign language with their child. Children will drop the signs on their own as their speech becomes understood.
What causes apraxia?
Apraxia of speech is felt to be a neurogenic (neurologically based) speech motor disorder. Many (or perhaps most) children with apraxia of speech have no abnormalities as detected by MRI scans. Others may have specific damage to a part of the brain that can account for the problem. In the latter case, some children are born with such damage and other children acquire damage to the brain by accident or illness. In the last five years there has been significant interest by researchers in the role that genetics may play in childhood apraxia of speech. Some researchers believe that it is likely apraxia is not caused by any one factor and that there may be different subtypes of CAS based on the particular underlying cause. Currently, research is continuing on the underlying causes of Childhood Apraxia of Speech.
Will my child ever be able to speak “normally”?
With appropriate therapy (see above) and a lot of follow-through by parents and others, many children with apraxia of speech can become effective verbal communicators. Will speech ever be entirely “normal”? We can report that we know of children who ultimately become good speakers and their “problem” is not detectable to nonprofessionals. In other children, lingering articulation issues follow them. Childhood Apraxia of speech is a serious and challenging speech disorder. A lot of hard work on the part of therapist, parents, and child needs to occur. We can honestly say, however, that as parents use the Apraxia-Kids network to report on the successes and accomplishments of their children, we hear many reasons to hope for the best.
What are other associated features of apraxia?
Some report that “pure” apraxia of speech is quite rare. It appears that frequently children may experience other speech/language issues in addition to the apraxia. For instance, a child may have both apraxia and dysarthria, another motor speech problem involving weakness or paralysis to some degree of another. We know that apraxia of speech may be accompanied by diagnoses such as autism, Down syndrome, or cerebral palsy. Some children with apraxia of speech go on to experience difficulties in reading, spelling, or math while others do not. Many children with apraxia of speech also have fine motor difficulties with their hands, making certain tasks more difficult. Others do not have these problems. Some children experience sensory-related issues as well as apraxia of speech. These children may have sensitivities to sound, clothing, textures, getting their hands messy, etc. They may also have sensory integration difficulties in which they lack awareness of where their bodies are in space or are awkward or uncoordinated. Some recent studies indicate that other developmental concerns are likely in children with a diagnosis of CAS.
How do you know if you have a “good” therapist?
It is important to know that not all speech-language pathologists (SLP) are equally skilled in providing treatment to children with apraxia of speech. Some are better trained than others are and some have evolved their expertise through years of experience. Parents should look for a speech-language pathologist who has experience and success in working with children with apraxia of speech. Don’t hesitate to ask prospective SLP about their experience, credentials, and success with these children. A good SLP will take into account the uniqueness that your child brings. A good SLP will involve you in the therapy process and will understand how important you, the parent, are in the ultimate success your child will experience. Good SLPs will invite you to observe therapy sessions, give you techniques you can use at home, listen to your ideas and concerns, communicate with others in your child’s life, try to provide you with helpful information, and respect your knowledge about your child. A good SLP will readily admit what he or she doesn’t know. A good SLP will be concerned if your child is not progressing and will not let unproductive treatment go on indefinitely. A conscientious SLP will then seek out additional information, change techniques, consult a colleague, or refer you to someone else.
It may be also helpful to identify some “warning signs” regarding speech-language pathologists. The following may be reasons you may want to consider finding a new SLP:
- the SLP tells you that children with apraxia will never develop intelligible speech.
- the SLP tells you it doesn’t matter what your child’s diagnosis is, their treatment will be the same as for other speech problems.
- the SLP does not include you or teach you how to help your child.
- the SLP is not helping your child to progress and doesn’t seem concerned.
- the SLP does not have experience working with children who have apraxia of speech and appears unwilling to learn.
Will my insurance company pay for therapy?
This also is quite variable and depends greatly on your particular plan. We do know that many parents have difficulty getting insurance companies or HMOs to pay for treatment. One factor that seems to be extremely important is how the speech pathologist that did the evaluation describes your child’s problem. Typically, it is wise to ask the evaluator to avoid using the word “developmental” in the diagnosis. Thus insurance companies who say they do not pay for developmental delays often challenge a diagnosis of developmental apraxia of speech. It is better if the evaluator uses terms like: apraxia of speech, oral/motor speech disorder, neurogenic speech disorder, oral and verbal apraxia. It is also important for the evaluator to describe the likely outcome for your child if they do not get appropriate treatment. Sometimes having the evaluator recommend a trial course of therapy in order to assess how the child does sits better with insurance companies.
If your claim is denied, always appeal the decision. Try to enroll your child’s pediatrician and other medical professionals in advocating for your child. Find out why the claim was denied and resubmit the claim addressing these issues.