Prognosis for Apraxia: What does the future hold?

Prognosis for Apraxia: What does the future hold?

Prognosis for Apraxia

What Does The Future Hold?

Published | By

Lori Hickman, M.A., CCC-SLP

A prognosis is, at best, an estimate of how your child’s speech skills will improve with therapy. An exact outcome is impossible for any SLP to predict. There are many features/traits in a child’s life that will differ with each child, that have a great deal of influence in terms of the outcome for a child with apraxia of speech.

Factors Which Effect Long-term Outcome in Apraxia:

Etiology of the Child’s Apraxia of Speech

The term “etiology” means underlying cause. Two children with similar presenting symptoms initially, may have different outcomes because one child’s etiology may allow for new motor skill development more readily than the other child’s etiology. The difficulty for the clinician lies in the fact that only rarely do we know the etiology (cause) of a child’s apraxia.

Family History

When other family members have a similar speech history, it is reasonable to consider that the child’s long term outcome may be similar to that family member’s (providing, of course, that their etiologies are truly the same).

Severity of Apraxia

In general, the more severe the child’s apraxia, the longer they will need to receive treatment.

Presence of Oral as well as Verbal Apraxia

Children who exhibit an oral apraxia as well as apraxia of speech often require treatment longer than those children who exhibit only CAS.

Overall Health

Children whose overall health is good are more accessible to learning of all kinds than children who have periods of time when they are less “learning available” because of illness (middle ear infections, upper respiratory infections, etc.).

Cognitive Skills

Children with measured learning potentials in the average to above average range have a more favorable prognosis than children with cognitive delays.

Attention/Ability to Focus

Children with attentional issues will often require intervention for longer periods than children with average to above average attentional skills. This is because the SLP can focus on the child’s productions rather than on maintaining their attention, and because children with attentional issues tend to have more difficulty monitoring their own speech (which is very important for “carry-over” of skills to the conversational level).

Child’s Reaction to Their Intelligibility Deficit

Children who are seemingly unaware of, or unbothered by the difficulty other people have understanding them often require longer treatment.

Ability to Self-Monitor

Children who have average to above average abilities to monitor their own speech productions tend to make progress more quickly than children who are unable to “self-monitor” and continue to need the SLP or others to give them feedback regarding their productions. Self-monitoring is an important skill for children with apraxia to learn. This is the process by which they take skills learned in therapy and begin to use them in their spontaneous speech. The only way this can occur is for the child to begin to “hear” his/her own productions and “edit” them. If a child cannot perceive an error, it will be impossible for him/her to correct it.

Age at Which Intervention Begins

The younger the child is when treatment begins, the better his/her long term prognosis.

Appropriateness of Therapy

Because children with apraxia are different in terms of the etiology of the apraxia, the therapeutic approach utilized in their treatment needs to be tailored to their individual needs. A “one-size-fits-all” approach does not work for children with apraxia. Knowledge of the current approaches to the management of apraxia is necessary for the SLP to adjust sessions according to the child’s needs.

Frequency of Therapy

The more frequently the child receives appropriate therapy, the better his/her long term prognosis.

Comorbidity

The presence of other disorders with apraxia (such as hearing loss, dysarthria, etc.) will generally indicate a poorer prognosis than when apraxia presents as the only disorder/delay for a child. A “pure apraxia,” however, is not the norm. When a child is neurologically different in one way, it often means they will exhibit learning/motor/behavior issues in other areas of their development. Additionally, children with apraxia do not have the opportunity to interact with peers and adults in a typical way, and so are at greater risk for developing/exhibiting social, behavioral, language, etc. delays and disorders as a ramification of the disorder.

Motivation

A child who has a positive response to working with a therapist on increasing his/her speech intelligibility has a better prognosis than the child who is resistant or ambivalent towards his/her therapy.

Parent Involvement, Education, Support

A parent’s knowledge/understanding of their child’s apraxia increases their ability to respond in ways that encourage the child’s communication skills. They are also much better equipped to advocate in effective ways for the child with other people in the child’s life.

Parents should be wary of any prognostic statement which is absolute in either direction. It is not possible for a clinician to say with absolute certainty that a child will completely recover; conversely, he/she will not be able to tell you that your child will never talk.

To date, there are no definitive studies of the long-term outcome of children with apraxia. This is due to the lack of agreement/identification of this group of children, and also due to the fact that there are no two children with apraxia who are exactly alike in terms of their apraxic characteristics, so establishing a control group to determine efficacy and results of long-term therapy is very difficult.

The studies that have been completed on the various therapeutic techniques for the treatment of apraxia in children are limited but growing.

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (CASANA)
www.apraxia-kids.org

Will my child with CAS ever achieve normal speech?

By

Kathy J. Jakielski, Ph.D., CCC-SLP

This question, dealing with long-term outcomes and prognosis, is one that virtually all parents will wonder and ask at some point after learning that their child has CAS. This question might arise during the childs initial assessment, or later, sometime during intervention. It is an important question for both parents and speech-language pathologists (SLPs) to consider. Unfortunately, there is no research published to date that expressly addresses the answer to this question, so the response, at best, will be an educated guess based on the particular childs symptoms and the SLPs clinical experience with CAS.

Many children with CAS ultimately do achieve normal speech, but some do not. It can be difficult predicting which children are likely to achieve normal speech by adulthood and which children are unlikely to do so. There are indicators that SLPs can use to help distinguish these two groups of children. In my experience, the most important indicators are child-specific, and include the severity of the child’s CAS, the child’s initial progress in intervention, and the presence and severity of co-occurring symptoms. The co-occurring symptoms that can affect prognosis most significantly, also in my experience, include language impairment, cognitive impairment, and oral/limb apraxias. Although the interaction of these disorders with CAS is unknown, the more severe the accompanying symptoms, the more challenging it can be for a child to achieve completely adult-like speech. Other child-specific indicators requiring consideration include the child’s motivation, cooperation, attention, continued progress, and accessibility to services. The more favorable these latter factors, the more positive a child’s prognosis will be.

I have worked with children with CAS in both research and clinical capacities for 20 years. During this time, I have observed children with CAS whose speech has resolved to normal (or near normal) status with intervention. Even children with moderate or severe CAS can achieve normal speech given appropriate and extended intervention services; however, I have found that this prognosis is most favorable for children with fewer and less severe co-occurring symptoms. Children with fewer and/or milder co-occurring symptoms tend to progress to normal speech by adolescence, when provided appropriate and sufficient speech intervention, even when the speech apraxia was more severe at the time of diagnosis. After discharge from speech intervention, one might notice mild speech errors when the older child or teenager is fatigued or stressed; otherwise speech remains well produced and understandable to any listener.

There also are other children with moderate or severe CAS whose prognosis for achieving normal speech by adulthood is poor. In my experience, these children initially present with multiple and more severe co-occurring symptoms. These children often continue to make progress in speech intervention throughout adolescence, and although they never achieve normal speech, progress is made and speech often remains their primary means of communication. Connected speech can remain challenging, as does the correct production of at least some of the suprasegmental aspects of speech (melody of speech, syllable stress, rate of speech, etc.). For the most severe of these children, alternative communication systems might be used in combination with verbal output to enhance communication. Using a combination of communication techniques can be particularly helpful to teenagers/young adults who find themselves in a variety of changing communication settings.

Overall, it is important to remember that children with CAS can and do make progress in speech intervention. The prognosis for normal speech will depend on a variety of factors; many of these factors are both child-specific and subject to change over time. Continue to believe in the child’s ability to progress and try to celebrate each positive step along the way!


(Dr. Kathy Jakielski is an Assistant Professor of Communication Sciences and Disorders at Augustana College in Rock Island, Illinois. She received her Ph.D. in 1998 from the University of Texas at Austin. Dr. Jakielski has a wide range of experience as a clinical speech language pathologist through her work in Head Start and public schools, hospital systems, as well as private practice. She has a particular interest in Childhood Apraxia of Speech and is coauthor of one of Apraxia-KIDS most popular articles, “Developmental Apraxia of Speech: Information for Parents.” Recently, she helped to facilitate our first Spanish translation article of this title, “Apraxia del Habla Infantil: Informacion Para Padres.” She is also a member of CASANA’s Professional Advisory Board.)

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (CASANA)
www.apraxia-kids.org

What will the future hold?

Parents have so many questions and worries about what the future will hold for their child.  Getting a picture of that future is challenging at best.  CASANA has now “grown” up with quite a few young people who have had the diagnosis of CAS and so we have a better perspective of the possible outcomes, though there is no longitudinal research to give clear answers for any particular child.

We know that kids who have had apraxia of speech as youngsters can grow into young adults who graduate from high school, find jobs, graduate from college, develop committed relationships and have children.   We know that many children with a history of CAS, and who get appropriate help, can learn to speak well, some quite well – to the extent that no one would ever guess that at one time they had a severe speech disorder.  Also, as indicated earlier, we know that children with apraxia of speech can come with a variety of other developmental problems or concerns, in addition to apraxia of speech.  For this reason, long-term outcomes do vary child to child.

Experienced speech-language pathologists suggest that long-term prognosis for clear speech is most favorable for children that have fewer and less severe co-occurring problems. Children with fewer or milder co-occurring problems tend to progress to normal speech when they have been given appropriate and sufficient speech therapy, even if their speech apraxia was more severe in the beginning.  However, even children with significant co-occurring problems can and do continue to make positive gains in their speech and communication with appropriate intervention.  Finally, motivation of the child and family often contribute in immeasurable and positive ways to long-term outcomes.

How will my child do over time? Will my child speak normally?

The question of how one’s child will do over time and if he or she will speak normally is perhaps the biggest question of all for parents of children with CAS.  While there are no hard and fast statistics, professional articles and experienced SLPs report that most children with CAS, with appropriate help, eventually learn to speak clearly.  Some children may have some minor differences in their speech patterns, such as less than crisp /r/ sounds or slightly “off” vowels.  In some children, their intonation may not be perfect or others may perceive some sort of accent.  However, most children will speak in a way that others understand.  Some children progress to the point that no one would be able to tell that at one time they had a significant speech problem.  A few children, despite the best efforts of all, may not develop into primarily verbal communicators.  These children will also make progress but may need augmentative or alternative methods for the long term to help them communicate.

There are a number of factors that are likely to influence progress for children with CAS.  Some of these factors are:

  • the severity of the problem
  • The existence or co-occurrence of other disorders or problems, such as other speech or language diagnoses, poor health, attention issues, and cognitive problems
  • the age at which the child began appropriate intervention
  • the child’s ability or opportunity to practice speech outside of direct therapy time
  • the child’s intent to communicate and willingness to make speech attempts

Although research is needed, it may be that CAS which is associated with genetic, metabolic, or neurological conditions may be more challenging than for children that have CAS for unknown reasons (idiopathic CAS).  It does appear that each issue, in addition to CAS, and which is layered over top of it contributes to more uncertain progress and long-term outcome.  There is much to learn and research is needed to identify children who are most in need of help and those who are likely to need long term communication support.

No one can totally predict the child’s ultimate success at becoming a verbal communicator.  Thus, be wary if you are told that your child will never learn to speak or conversely that it won’t be long until your child is speaking perfectly.  The act of learning to speak clearly is typically long and challenging for children with truly do have apraxia of speech, but they can and do make great strides and much progress with speech therapy appropriate to their needs.  With appropriate help, there are many reasons to be hopeful!

Progress and Long-Term Outcomes

With appropriate early intervention and ongoing support, most children with CAS can improve their speech production skills and develop functional speech. The period of time this outcome requires is individualized and most likely based on the unique characteristics of the child and the level and quality of the intervention provided. Previous literature had cited “slow or little progress” as a “characteristic” of apraxia. Currently it is recognized that while treatment is intensive and extends over a number of years, these children are very capable of making wonderful gains and developing intelligible speech. Progress, is of course, individualized, however unproductive therapy should not go on indefinitely. If the child is not making noticeable and meaningful progress over several months of treatment, the SLP needs to regroup and examine the reason.

If a child fails to make significant and adequate progress despite receiving speech therapy intervention, the following questions need addressed:

  • Is the diagnosis correct?
  • Is the frequency of therapy adequate for the child’s needs?
  • Is the intensity appropriate? For example, is therapy offering the child dozens and dozens of “practice moments” or is the child sitting, listening and not practicing speech much at all?
  • Is the therapy tailored toward motor speech methods and techniques to the extent required for adequate progress?
  • Is the therapeutic environment safe and motivating to this child? Is clinician – child rapport adequate?
  • Are other issues interfering with progress? (i.e., can the child sustain enough attention to participate? Has the child had health related problems? Is the family following through with practice at home or is the child willing to practice at home? Could other diagnoses contribute to lack of adequate progress?)

If after addressing these issues, progress is still not adequate, ask for consultation from a colleague with more experience with this particular disorder.

Some long-term residual issues that may persist even after the child attains intelligibility include sound distortions and prosody deficits (rate, timing, stress, intonation). If these issues are present, therapy strategies can continue to target them. Additionally, speech therapy may need to continue to address linguistic or pragmatic needs presented by some children.

Truth or misleading? ``Children with Apraxia of Speech Make Very Slow Progress``

By

CASANA

The Childhood Apraxia of Speech Association of North America (CASANA), along with members of its Professional Advisory Board, has engaged in discussion about the misleading impression that children with apraxia of speech make very slow progress in speech therapy. Some children are diagnosed with Childhood Apraxia of Speech (CAS) by speech-language pathologists who are using “slow progress” as the differential characteristic of the disorder. Is it true that children with CAS make very slow progress in therapy? Here is what we think:

  • Children with apraxia of speech often make slower progress than children with other types of speech sound disorders. (Note: slower than other types of disorders; not slow in and of itself)
  • Children suspected to have CAS but who make very rapid progress in speech therapy that generalizes easily to new contexts, both in and outside of the therapy room, most likely have a phonological disorder and NOT CAS.
  • With appropriate goals, informed by detailed assessment – AND – appropriate, well executed speech therapy that incorporates principles of motor learning, children with apraxia of speech can be expected to make good, steady progress in therapy, especially those with age appropriate or near age appropriate cognitive and language skills.
  • Both parents and SLPs should not blindly accept that, “progress will be or is slow because the child has apraxia.”

Discussion:

Speech progress may be very slow, even with appropriate planning and therapy, when other co-existing problems add to the challenges, including delayed cognition and/or receptive language, poor attention or behavior, and other significant speech diagnoses such as dysarthria. Additionally, children with CAS who are in poor health and not able to take full advantage of the learning and practice opportunities available to them, may demonstrate very slow progress in speech production skills.

With appropriate goals and intervention, parents of children with apraxia as the primary diagnosis should expect progress in their child’s use of intelligible words within a three-month period. (Children with apraxia plus other complex challenges likely will have more limited progress.) If this progress does not occur for a child whose primary diagnosis is CAS, an SLP should consider the following questions:

  • Is the diagnosis correct?
  • Are the goals and stimuli appropriate?
  • Are there additional diagnoses that should be considered, in addition to CAS?
  • If there are other diagnoses, is one of them really the bigger challenge to the child’s speech production skills?
  • Is the intensity of speech practice, both in therapy and at home, sufficient?
  • Is the frequency of direct speech intervention sufficient?

Remember that although speech progress can be slower for children with apraxia than it is for children with other speech problems, there should be noticeable and ongoing progress in the child’s ability to independently produce intelligible words. While their words may not be “perfect”, one can observe increased movement toward intelligibility. Parents will want to be in contact with their SLP to discuss expectations and what modifications the SLP will make if progress is not being made.

© 2011, Childhood Apraxia of Speech Association of North America (CASANA); All rights reserved.

What is ``Good Progress`` and What if Progress is Poor or Slow?

What does “good progress” mean?  Consider this question: if, after six months of speech therapy at the rate of two or three or four times weekly, your child had two additional sounds (phonemes) and was capable of producing or could approximate two words, would you consider that the therapy was working?  Probably not.  Children with apraxia of speech take a great deal of effort from the SLP and the children themselves expend incredible effort, especially early on.  It is not “easy” therapy, but two phonemes (sounds) in six months?  Several new word approximations over the span of 6 months?  That rate of progress should likely be questioned.  Parents should not settle for limited progress without examining what is occurring.  We do not suggest that limited progress means that the speech therapy is “bad”.   Instead, we suggest that when therapy is not leading to good progress, key questions can be asked, such as:

  • Is the diagnosis correct? Does the child REALLY have apraxia of speech?  Is the SLP pretty certain after working with him/her for 6 months?  There have been more than a few occasions in which CASANA has helped families get connected for second opinions only to learn that, in fact, the child’s biggest issue is not really apraxia of speech, rather, it is some other significant speech, language or cognitive disorder.  Also, remember that CAS is both overdiagnosed and underdiagnosed.  Children are being given the diagnosis when in reality it is likely that the child does not truly have apraxia, and, children who probably really do have it, are not being diagnosed.
  • Is there something else beyond apraxia going on that is interfering with progress?   Does the child, for example, have significant:
    • attention issues?
    • behavioral issues;
    • health issues;
    • family issues, (and so on).

Other problems may be interfering with your child’s ability to benefit from speech therapy.  For example, a child with obstructive sleep apnea or constant colds, enlarged tonsils and adenoids, etc. may be getting insufficient sleep and thus is constantly tired and unable to fully benefit from therapy.  Or, for example, a child is very distractible, so much so that she/he is totally unable to attend to the clinician’s face in order to pick up on important cues to articulatory placement or verbal cues and may not be benefitting entirely from the speech therapy process.

  • Is the frequency of therapy sufficient for this child? Is the child getting that recommended range of therapy weekly?  For example, suppose that a child with severe apraxia of speech is receiving 20 minutes of speech therapy weekly.  It is not hard to understand why there would be little benefit and painfully slow progress.  Often, the pace of progress may pick up nicely when additional appropriate speech therapy is added.
  • Is the intensity of therapy sufficient for this child? Has this child been getting enough practice opportunities within each session?  Is this child actually receiving group treatment instead of individual treatment? A child who is mostly silent during the therapy sessions is not going to have good progress.  The clinician would have to modify what they are doing to engage the child and enable them to take some communication risks so they gain many, many practice opportunities in each speech therapy session.
  • Is the therapy approach appropriate (think “principles of motor learning”)? Consider all of the principles of motor learning that were discussed earlier. Is this what therapy looks like for this child?  Time and time again, CASANA has seen that when children begin to receive therapy appropriate for their core issue of speech motor planning difficulty, the pace of progress picks up significantly and is noticeable – sometimes even immediately.
  • Is there appropriate follow through happening at home? If there is no follow through happening at home, which serves to extend the child’s practice opportunities, perhaps this has made for less than optimal progress. Also, if the family does not feel competent or secure enough to practice with their child or if the child refuses to practice with parents, the child may not be getting additional practice that can truly make a difference in rate of progress.

If, after asking these questions and adjusting whatever needs to be adjusted, the child continues to make poor progress, hopefully the child’s SLP would feel an obligation to invite a more experienced colleague or supervisor to observe therapy sessions and see if a fresh or external eye may see something that the SLP has been unable to see.  Another strategy would be to refer to a developmental behavioral pediatrician for a review of all the child’s development and health issues.

Children with multiple and complex issues, in addition to CAS, are likely to have slower rate and extent of progress, however, it is best to pause and evaluate now and then to be sure that therapy is as effective as it can possibly be!

How Fast Will My Child Progress in Speech?

First, there obviously is no “guaranteed” outcome for a child with apraxia of speech. However, many, many children can learn to speak quite well and be entirely verbal and intelligible if given early appropriate therapy and enough of it.

However, children with apraxia of speech often make slower progress than children with other types of speech sound disorders. (Note: slower than other types of disorders; not slow in and of itself.)

Children suspected to have CAS but who make very rapid progress in speech therapy that generalizes easily to new contexts, both in and outside of the therapy room, most likely have a different type of speech sound disorder and NOT CAS..

With appropriate goals, informed by detailed assessment – AND – appropriate, well executed speech therapy that incorporates principles of motor learning, children with apraxia of speech can be expected to make good, steady progress in therapy, especially those with age appropriate or near age appropriate cognitive, behavior and language skills.

Neither parents nor SLPs should blindly accept that, “progress will be or is slow because the child has apraxia.”

Speech progress may be very slow, even with appropriate planning and therapy, when other co-existing problems add to the challenges, including delayed cognition and/or receptive language, poor attention or behavior, and other significant speech diagnoses such as dysarthria (muscle weakness & low muscle tone). Additionally, children with CAS who are in poor health and not able to take full advantage of the learning and practice opportunities available to them, may demonstrate very slow progress in gaining speech production skills.

With appropriate goals and intervention, parents of children with apraxia as the primary diagnosis should expect progress in their child’s use of intelligible words within a three-month period. (Children with apraxia plus other complex challenges likely will have slower progress.)

Prognosis for Apraxia: What does the future hold?

Prognosis for Apraxia

What Does The Future Hold?

Published | By

Lori Hickman, M.A., CCC-SLP

A prognosis is, at best, an estimate of how your child’s speech skills will improve with therapy. An exact outcome is impossible for any SLP to predict. There are many features/traits in a child’s life that will differ with each child, that have a great deal of influence in terms of the outcome for a child with apraxia of speech.

Factors Which Effect Long-term Outcome in Apraxia:

Etiology of the Child’s Apraxia of Speech

The term “etiology” means underlying cause. Two children with similar presenting symptoms initially, may have different outcomes because one child’s etiology may allow for new motor skill development more readily than the other child’s etiology. The difficulty for the clinician lies in the fact that only rarely do we know the etiology (cause) of a child’s apraxia.

Family History

When other family members have a similar speech history, it is reasonable to consider that the child’s long term outcome may be similar to that family member’s (providing, of course, that their etiologies are truly the same).

Severity of Apraxia

In general, the more severe the child’s apraxia, the longer they will need to receive treatment.

Presence of Oral as well as Verbal Apraxia

Children who exhibit an oral apraxia as well as apraxia of speech often require treatment longer than those children who exhibit only CAS.

Overall Health

Children whose overall health is good are more accessible to learning of all kinds than children who have periods of time when they are less “learning available” because of illness (middle ear infections, upper respiratory infections, etc.).

Cognitive Skills

Children with measured learning potentials in the average to above average range have a more favorable prognosis than children with cognitive delays.

Attention/Ability to Focus

Children with attentional issues will often require intervention for longer periods than children with average to above average attentional skills. This is because the SLP can focus on the child’s productions rather than on maintaining their attention, and because children with attentional issues tend to have more difficulty monitoring their own speech (which is very important for “carry-over” of skills to the conversational level).

Child’s Reaction to Their Intelligibility Deficit

Children who are seemingly unaware of, or unbothered by the difficulty other people have understanding them often require longer treatment.

Ability to Self-Monitor

Children who have average to above average abilities to monitor their own speech productions tend to make progress more quickly than children who are unable to “self-monitor” and continue to need the SLP or others to give them feedback regarding their productions. Self-monitoring is an important skill for children with apraxia to learn. This is the process by which they take skills learned in therapy and begin to use them in their spontaneous speech. The only way this can occur is for the child to begin to “hear” his/her own productions and “edit” them. If a child cannot perceive an error, it will be impossible for him/her to correct it.

Age at Which Intervention Begins

The younger the child is when treatment begins, the better his/her long term prognosis.

Appropriateness of Therapy

Because children with apraxia are different in terms of the etiology of the apraxia, the therapeutic approach utilized in their treatment needs to be tailored to their individual needs. A “one-size-fits-all” approach does not work for children with apraxia. Knowledge of the current approaches to the management of apraxia is necessary for the SLP to adjust sessions according to the child’s needs.

Frequency of Therapy

The more frequently the child receives appropriate therapy, the better his/her long term prognosis.

Comorbidity

The presence of other disorders with apraxia (such as hearing loss, dysarthria, etc.) will generally indicate a poorer prognosis than when apraxia presents as the only disorder/delay for a child. A “pure apraxia,” however, is not the norm. When a child is neurologically different in one way, it often means they will exhibit learning/motor/behavior issues in other areas of their development. Additionally, children with apraxia do not have the opportunity to interact with peers and adults in a typical way, and so are at greater risk for developing/exhibiting social, behavioral, language, etc. delays and disorders as a ramification of the disorder.

Motivation

A child who has a positive response to working with a therapist on increasing his/her speech intelligibility has a better prognosis than the child who is resistant or ambivalent towards his/her therapy.

Parent Involvement, Education, Support

A parent’s knowledge/understanding of their child’s apraxia increases their ability to respond in ways that encourage the child’s communication skills. They are also much better equipped to advocate in effective ways for the child with other people in the child’s life.

Parents should be wary of any prognostic statement which is absolute in either direction. It is not possible for a clinician to say with absolute certainty that a child will completely recover; conversely, he/she will not be able to tell you that your child will never talk.

To date, there are no definitive studies of the long-term outcome of children with apraxia. This is due to the lack of agreement/identification of this group of children, and also due to the fact that there are no two children with apraxia who are exactly alike in terms of their apraxic characteristics, so establishing a control group to determine efficacy and results of long-term therapy is very difficult.

The studies that have been completed on the various therapeutic techniques for the treatment of apraxia in children are limited but growing.

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (CASANA)
www.apraxia-kids.org

Will my child with CAS ever achieve normal speech?

By

Kathy J. Jakielski, Ph.D., CCC-SLP

This question, dealing with long-term outcomes and prognosis, is one that virtually all parents will wonder and ask at some point after learning that their child has CAS. This question might arise during the childs initial assessment, or later, sometime during intervention. It is an important question for both parents and speech-language pathologists (SLPs) to consider. Unfortunately, there is no research published to date that expressly addresses the answer to this question, so the response, at best, will be an educated guess based on the particular childs symptoms and the SLPs clinical experience with CAS.

Many children with CAS ultimately do achieve normal speech, but some do not. It can be difficult predicting which children are likely to achieve normal speech by adulthood and which children are unlikely to do so. There are indicators that SLPs can use to help distinguish these two groups of children. In my experience, the most important indicators are child-specific, and include the severity of the child’s CAS, the child’s initial progress in intervention, and the presence and severity of co-occurring symptoms. The co-occurring symptoms that can affect prognosis most significantly, also in my experience, include language impairment, cognitive impairment, and oral/limb apraxias. Although the interaction of these disorders with CAS is unknown, the more severe the accompanying symptoms, the more challenging it can be for a child to achieve completely adult-like speech. Other child-specific indicators requiring consideration include the child’s motivation, cooperation, attention, continued progress, and accessibility to services. The more favorable these latter factors, the more positive a child’s prognosis will be.

I have worked with children with CAS in both research and clinical capacities for 20 years. During this time, I have observed children with CAS whose speech has resolved to normal (or near normal) status with intervention. Even children with moderate or severe CAS can achieve normal speech given appropriate and extended intervention services; however, I have found that this prognosis is most favorable for children with fewer and less severe co-occurring symptoms. Children with fewer and/or milder co-occurring symptoms tend to progress to normal speech by adolescence, when provided appropriate and sufficient speech intervention, even when the speech apraxia was more severe at the time of diagnosis. After discharge from speech intervention, one might notice mild speech errors when the older child or teenager is fatigued or stressed; otherwise speech remains well produced and understandable to any listener.

There also are other children with moderate or severe CAS whose prognosis for achieving normal speech by adulthood is poor. In my experience, these children initially present with multiple and more severe co-occurring symptoms. These children often continue to make progress in speech intervention throughout adolescence, and although they never achieve normal speech, progress is made and speech often remains their primary means of communication. Connected speech can remain challenging, as does the correct production of at least some of the suprasegmental aspects of speech (melody of speech, syllable stress, rate of speech, etc.). For the most severe of these children, alternative communication systems might be used in combination with verbal output to enhance communication. Using a combination of communication techniques can be particularly helpful to teenagers/young adults who find themselves in a variety of changing communication settings.

Overall, it is important to remember that children with CAS can and do make progress in speech intervention. The prognosis for normal speech will depend on a variety of factors; many of these factors are both child-specific and subject to change over time. Continue to believe in the child’s ability to progress and try to celebrate each positive step along the way!


(Dr. Kathy Jakielski is an Assistant Professor of Communication Sciences and Disorders at Augustana College in Rock Island, Illinois. She received her Ph.D. in 1998 from the University of Texas at Austin. Dr. Jakielski has a wide range of experience as a clinical speech language pathologist through her work in Head Start and public schools, hospital systems, as well as private practice. She has a particular interest in Childhood Apraxia of Speech and is coauthor of one of Apraxia-KIDS most popular articles, “Developmental Apraxia of Speech: Information for Parents.” Recently, she helped to facilitate our first Spanish translation article of this title, “Apraxia del Habla Infantil: Informacion Para Padres.” She is also a member of CASANA’s Professional Advisory Board.)

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (CASANA)
www.apraxia-kids.org

What will the future hold?

Parents have so many questions and worries about what the future will hold for their child.  Getting a picture of that future is challenging at best.  CASANA has now “grown” up with quite a few young people who have had the diagnosis of CAS and so we have a better perspective of the possible outcomes, though there is no longitudinal research to give clear answers for any particular child.

We know that kids who have had apraxia of speech as youngsters can grow into young adults who graduate from high school, find jobs, graduate from college, develop committed relationships and have children.   We know that many children with a history of CAS, and who get appropriate help, can learn to speak well, some quite well – to the extent that no one would ever guess that at one time they had a severe speech disorder.  Also, as indicated earlier, we know that children with apraxia of speech can come with a variety of other developmental problems or concerns, in addition to apraxia of speech.  For this reason, long-term outcomes do vary child to child.

Experienced speech-language pathologists suggest that long-term prognosis for clear speech is most favorable for children that have fewer and less severe co-occurring problems. Children with fewer or milder co-occurring problems tend to progress to normal speech when they have been given appropriate and sufficient speech therapy, even if their speech apraxia was more severe in the beginning.  However, even children with significant co-occurring problems can and do continue to make positive gains in their speech and communication with appropriate intervention.  Finally, motivation of the child and family often contribute in immeasurable and positive ways to long-term outcomes.

How will my child do over time? Will my child speak normally?

The question of how one’s child will do over time and if he or she will speak normally is perhaps the biggest question of all for parents of children with CAS.  While there are no hard and fast statistics, professional articles and experienced SLPs report that most children with CAS, with appropriate help, eventually learn to speak clearly.  Some children may have some minor differences in their speech patterns, such as less than crisp /r/ sounds or slightly “off” vowels.  In some children, their intonation may not be perfect or others may perceive some sort of accent.  However, most children will speak in a way that others understand.  Some children progress to the point that no one would be able to tell that at one time they had a significant speech problem.  A few children, despite the best efforts of all, may not develop into primarily verbal communicators.  These children will also make progress but may need augmentative or alternative methods for the long term to help them communicate.

There are a number of factors that are likely to influence progress for children with CAS.  Some of these factors are:

  • the severity of the problem
  • The existence or co-occurrence of other disorders or problems, such as other speech or language diagnoses, poor health, attention issues, and cognitive problems
  • the age at which the child began appropriate intervention
  • the child’s ability or opportunity to practice speech outside of direct therapy time
  • the child’s intent to communicate and willingness to make speech attempts

Although research is needed, it may be that CAS which is associated with genetic, metabolic, or neurological conditions may be more challenging than for children that have CAS for unknown reasons (idiopathic CAS).  It does appear that each issue, in addition to CAS, and which is layered over top of it contributes to more uncertain progress and long-term outcome.  There is much to learn and research is needed to identify children who are most in need of help and those who are likely to need long term communication support.

No one can totally predict the child’s ultimate success at becoming a verbal communicator.  Thus, be wary if you are told that your child will never learn to speak or conversely that it won’t be long until your child is speaking perfectly.  The act of learning to speak clearly is typically long and challenging for children with truly do have apraxia of speech, but they can and do make great strides and much progress with speech therapy appropriate to their needs.  With appropriate help, there are many reasons to be hopeful!

Progress and Long-Term Outcomes

With appropriate early intervention and ongoing support, most children with CAS can improve their speech production skills and develop functional speech. The period of time this outcome requires is individualized and most likely based on the unique characteristics of the child and the level and quality of the intervention provided. Previous literature had cited “slow or little progress” as a “characteristic” of apraxia. Currently it is recognized that while treatment is intensive and extends over a number of years, these children are very capable of making wonderful gains and developing intelligible speech. Progress, is of course, individualized, however unproductive therapy should not go on indefinitely. If the child is not making noticeable and meaningful progress over several months of treatment, the SLP needs to regroup and examine the reason.

If a child fails to make significant and adequate progress despite receiving speech therapy intervention, the following questions need addressed:

  • Is the diagnosis correct?
  • Is the frequency of therapy adequate for the child’s needs?
  • Is the intensity appropriate? For example, is therapy offering the child dozens and dozens of “practice moments” or is the child sitting, listening and not practicing speech much at all?
  • Is the therapy tailored toward motor speech methods and techniques to the extent required for adequate progress?
  • Is the therapeutic environment safe and motivating to this child? Is clinician – child rapport adequate?
  • Are other issues interfering with progress? (i.e., can the child sustain enough attention to participate? Has the child had health related problems? Is the family following through with practice at home or is the child willing to practice at home? Could other diagnoses contribute to lack of adequate progress?)

If after addressing these issues, progress is still not adequate, ask for consultation from a colleague with more experience with this particular disorder.

Some long-term residual issues that may persist even after the child attains intelligibility include sound distortions and prosody deficits (rate, timing, stress, intonation). If these issues are present, therapy strategies can continue to target them. Additionally, speech therapy may need to continue to address linguistic or pragmatic needs presented by some children.

Truth or misleading? ``Children with Apraxia of Speech Make Very Slow Progress``

By

CASANA

The Childhood Apraxia of Speech Association of North America (CASANA), along with members of its Professional Advisory Board, has engaged in discussion about the misleading impression that children with apraxia of speech make very slow progress in speech therapy. Some children are diagnosed with Childhood Apraxia of Speech (CAS) by speech-language pathologists who are using “slow progress” as the differential characteristic of the disorder. Is it true that children with CAS make very slow progress in therapy? Here is what we think:

  • Children with apraxia of speech often make slower progress than children with other types of speech sound disorders. (Note: slower than other types of disorders; not slow in and of itself)
  • Children suspected to have CAS but who make very rapid progress in speech therapy that generalizes easily to new contexts, both in and outside of the therapy room, most likely have a phonological disorder and NOT CAS.
  • With appropriate goals, informed by detailed assessment – AND – appropriate, well executed speech therapy that incorporates principles of motor learning, children with apraxia of speech can be expected to make good, steady progress in therapy, especially those with age appropriate or near age appropriate cognitive and language skills.
  • Both parents and SLPs should not blindly accept that, “progress will be or is slow because the child has apraxia.”

Discussion:

Speech progress may be very slow, even with appropriate planning and therapy, when other co-existing problems add to the challenges, including delayed cognition and/or receptive language, poor attention or behavior, and other significant speech diagnoses such as dysarthria. Additionally, children with CAS who are in poor health and not able to take full advantage of the learning and practice opportunities available to them, may demonstrate very slow progress in speech production skills.

With appropriate goals and intervention, parents of children with apraxia as the primary diagnosis should expect progress in their child’s use of intelligible words within a three-month period. (Children with apraxia plus other complex challenges likely will have more limited progress.) If this progress does not occur for a child whose primary diagnosis is CAS, an SLP should consider the following questions:

  • Is the diagnosis correct?
  • Are the goals and stimuli appropriate?
  • Are there additional diagnoses that should be considered, in addition to CAS?
  • If there are other diagnoses, is one of them really the bigger challenge to the child’s speech production skills?
  • Is the intensity of speech practice, both in therapy and at home, sufficient?
  • Is the frequency of direct speech intervention sufficient?

Remember that although speech progress can be slower for children with apraxia than it is for children with other speech problems, there should be noticeable and ongoing progress in the child’s ability to independently produce intelligible words. While their words may not be “perfect”, one can observe increased movement toward intelligibility. Parents will want to be in contact with their SLP to discuss expectations and what modifications the SLP will make if progress is not being made.

© 2011, Childhood Apraxia of Speech Association of North America (CASANA); All rights reserved.

What is ``Good Progress`` and What if Progress is Poor or Slow?

What does “good progress” mean?  Consider this question: if, after six months of speech therapy at the rate of two or three or four times weekly, your child had two additional sounds (phonemes) and was capable of producing or could approximate two words, would you consider that the therapy was working?  Probably not.  Children with apraxia of speech take a great deal of effort from the SLP and the children themselves expend incredible effort, especially early on.  It is not “easy” therapy, but two phonemes (sounds) in six months?  Several new word approximations over the span of 6 months?  That rate of progress should likely be questioned.  Parents should not settle for limited progress without examining what is occurring.  We do not suggest that limited progress means that the speech therapy is “bad”.   Instead, we suggest that when therapy is not leading to good progress, key questions can be asked, such as:

  • Is the diagnosis correct? Does the child REALLY have apraxia of speech?  Is the SLP pretty certain after working with him/her for 6 months?  There have been more than a few occasions in which CASANA has helped families get connected for second opinions only to learn that, in fact, the child’s biggest issue is not really apraxia of speech, rather, it is some other significant speech, language or cognitive disorder.  Also, remember that CAS is both overdiagnosed and underdiagnosed.  Children are being given the diagnosis when in reality it is likely that the child does not truly have apraxia, and, children who probably really do have it, are not being diagnosed.
  • Is there something else beyond apraxia going on that is interfering with progress?   Does the child, for example, have significant:
    • attention issues?
    • behavioral issues;
    • health issues;
    • family issues, (and so on).

Other problems may be interfering with your child’s ability to benefit from speech therapy.  For example, a child with obstructive sleep apnea or constant colds, enlarged tonsils and adenoids, etc. may be getting insufficient sleep and thus is constantly tired and unable to fully benefit from therapy.  Or, for example, a child is very distractible, so much so that she/he is totally unable to attend to the clinician’s face in order to pick up on important cues to articulatory placement or verbal cues and may not be benefitting entirely from the speech therapy process.

  • Is the frequency of therapy sufficient for this child? Is the child getting that recommended range of therapy weekly?  For example, suppose that a child with severe apraxia of speech is receiving 20 minutes of speech therapy weekly.  It is not hard to understand why there would be little benefit and painfully slow progress.  Often, the pace of progress may pick up nicely when additional appropriate speech therapy is added.
  • Is the intensity of therapy sufficient for this child? Has this child been getting enough practice opportunities within each session?  Is this child actually receiving group treatment instead of individual treatment? A child who is mostly silent during the therapy sessions is not going to have good progress.  The clinician would have to modify what they are doing to engage the child and enable them to take some communication risks so they gain many, many practice opportunities in each speech therapy session.
  • Is the therapy approach appropriate (think “principles of motor learning”)? Consider all of the principles of motor learning that were discussed earlier. Is this what therapy looks like for this child?  Time and time again, CASANA has seen that when children begin to receive therapy appropriate for their core issue of speech motor planning difficulty, the pace of progress picks up significantly and is noticeable – sometimes even immediately.
  • Is there appropriate follow through happening at home? If there is no follow through happening at home, which serves to extend the child’s practice opportunities, perhaps this has made for less than optimal progress. Also, if the family does not feel competent or secure enough to practice with their child or if the child refuses to practice with parents, the child may not be getting additional practice that can truly make a difference in rate of progress.

If, after asking these questions and adjusting whatever needs to be adjusted, the child continues to make poor progress, hopefully the child’s SLP would feel an obligation to invite a more experienced colleague or supervisor to observe therapy sessions and see if a fresh or external eye may see something that the SLP has been unable to see.  Another strategy would be to refer to a developmental behavioral pediatrician for a review of all the child’s development and health issues.

Children with multiple and complex issues, in addition to CAS, are likely to have slower rate and extent of progress, however, it is best to pause and evaluate now and then to be sure that therapy is as effective as it can possibly be!

How Fast Will My Child Progress in Speech?

First, there obviously is no “guaranteed” outcome for a child with apraxia of speech. However, many, many children can learn to speak quite well and be entirely verbal and intelligible if given early appropriate therapy and enough of it.

However, children with apraxia of speech often make slower progress than children with other types of speech sound disorders. (Note: slower than other types of disorders; not slow in and of itself.)

Children suspected to have CAS but who make very rapid progress in speech therapy that generalizes easily to new contexts, both in and outside of the therapy room, most likely have a different type of speech sound disorder and NOT CAS..

With appropriate goals, informed by detailed assessment – AND – appropriate, well executed speech therapy that incorporates principles of motor learning, children with apraxia of speech can be expected to make good, steady progress in therapy, especially those with age appropriate or near age appropriate cognitive, behavior and language skills.

Neither parents nor SLPs should blindly accept that, “progress will be or is slow because the child has apraxia.”

Speech progress may be very slow, even with appropriate planning and therapy, when other co-existing problems add to the challenges, including delayed cognition and/or receptive language, poor attention or behavior, and other significant speech diagnoses such as dysarthria (muscle weakness & low muscle tone). Additionally, children with CAS who are in poor health and not able to take full advantage of the learning and practice opportunities available to them, may demonstrate very slow progress in gaining speech production skills.

With appropriate goals and intervention, parents of children with apraxia as the primary diagnosis should expect progress in their child’s use of intelligible words within a three-month period. (Children with apraxia plus other complex challenges likely will have slower progress.)



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