Q.What do you mean he has dyspraxia?
A. Dyspraxia means difficulty with learned patterns of movement in the absence of damage to the muscles or the nerves. When different people talk about dyspraxia, you’d think they would all be talking about the same thing. However, that does not always seem to be the case. As a term, it is used by a range of professionals but to refer to rather different conditions.
A child diagnosed as having dyspraxia by a paediatrician,physiotherapist and occupational therapist will usually have generalized motor difficulties – where the child has problems co-ordination gross and fine body movements. (These children were once called “clumsy children”.) A child who has been diagnosed as dyspraxic by a speech and language therapist will have developmental verbal dyspraxia (sometimes referred to as “developmental articulatory dyspraxia”). This is characterized by marked difficulties in producing speech sounds and in sequencing them together into words. Expressive language is often delayed. In addition, such children will often (but not always) have an oral (or oro-motor) dyspraxia – a difficulty in making and co-ordinating the precise movements of the lips, tongue and palate required to produce speech. Voice production difficulties due to inco-ordination at the laryngeal level are also common. Some children will, of course, have both verbal dyspraxia and generalised motor dyspraxia. However, it is important for parents to recognise the distinction between different terms.
For example, some information that focuses on generalised motor dyspraxia may not be particularly relevant to a child whose primary difficulty is with speech.
Q.The Predominant Presentation
A. Pam Williams, Principal Speech and Language Therapist (Job Share) at the Nuffield Hearing and Speech Centre in London, says the important thing is to look for the predominant presentation for each child and then plan intervention accordingly. For a child with developmental verbal dyspraxia, that help is likely to be centered around speech and language therapy. “The Nuffield Centre Dyspraxia Programme” is a speech therapy resource designed specifically for the child with developmental verbal dyspraxia. “It is a resource where parents do a lot of the work in conjunction with the speech and language therapist,” says Pam Williams.
A. Two case studies from the AFASIC book Before School illustrate how the Nuffield Centre Dyspraxia Programme might be used to help a child who has developmental verbal dyspraxia.
Case Study #1:
Alex was seen for the first time at the Nuffield Centre aged 3 years. His feeding, both sucking and chewing, were difficult and his parents were worried that he was very quiet and not babbling by the age of 15 months. He said his first word at 18 months. He was first seen by the local speech and language therapist aged 2 years 6 months and attended for some group therapy. In the family, both his father and brother had some speech problems. On assessment at 3 years Alex was found to have normal hearing, his verbal comprehension was age appropriate and he was probably putting 3 – 4 words together but even his parents couldn’t understand him. He was diagnosed as having oro-motor and verbal dyspraxia. He presented with the following: a quiet voice, poor lip control with an open mouth posture and constant dribbling. There were no differentiated movements of his tongue. His palate was poorly co-ordinated. He had only 2 consonants “h” and “d” but a fair range of vowels. He was not able to sequence any sounds but did indicate the correct syllable structure of words. He attended therapy twice weekly which was aimed at developing oro-motor skills and establishing a sound system. He attended from the age of 3 years 2 months until he was 6 years. During that time he also attended two intensive therapy courses. Alex was reluctant to co-operate initially, showing the typically short attention span of young children, but with support from his parents he settled down and worked well on the development of oro-motor skills, the eradication of the dribbling and systematic development of a complete sound inventory.
He entered mainstream school at 5 and when he was reviewed at 6 years 4 months he was able to use a completely accurate sound inventory and had good control of his voice and intonation patterns.
Case study #2:
James was seen for the first time at the Nuffield Centre aged 5 years 7 months. He was first seen by a speech and language therapist local to his home 17 months previously. His parents had been concerned about his slow speech development for about 2 1/2 years. He attended for therapy regularly from the age of 4 years 4 months. The therapist concentrated on the development of language skills, following a widely accepted theory that the child must develop his language before the constraints of accurate articulation are demanded. In the family a cousin had a stammer. On assessment at 5 years 7 months James had normal hearing, verbal comprehension was age appropriate and his expressive language was at around the 4 year level of development. However, his articulation was so poor that he was almost totally unintelligible except to his mother and his sisters. He was diagnosed as having both oro-motor and verbal dyspraxia. He presented with the following: a weak voice, with laboured breathing patterns and control of volume. He had poor lip movements, a poor tongue tip with many involuntary movements and poor palatal closure. He had approximately 10 consonants which were not used accurately but a fairly good range of vowels. Sequencing skills were almost non-existent. He attended for once weekly therapy aimed at developing oro-motor and speech areas from the age of 5 years 8 months until he was 8 years 10 months. During that time he also attended three intensive therapy courses. James had already developed a range of incorrect and compensatory patterns so that progress was very slow. His co-operation was excellent and his mother worked steadily with him at home. Even when he achieved the new patterns easily in exercises, carry-over into his spontaneous speech took much longer. Reading, writing, and spelling problems were also evident and he needed extra help at school.
Now at the age of 9 1/2 years, James’ therapy is completed. He is very easily understood, virtually all sounds are stable in his system and new people whom he meets accept him as an entirely normal speaker.
* The children in these case studies fit the description of those who are likely to benefit most from the Nuffield Centre DyspraxiaProgramme.
They were referred at a young age, they had marked oro-motor and voice production difficulties and they had sound production and sound sequencing difficulties. They also had regular practice at home which is essential because correct patterns of movement can only be established with daily practice and repetition over several months. The parents will therefore have a big influence and can really help the child succeed. The message seems to be: begin the therapy as early as possible, with therapists and parents working closely together.
Q. When To Begin
A. Each child will be different and progress at their own pace. Pam Williams comments that it’s best to begin therapy at around 3 years. A child who begins regular therapy at 3 years should have reasonably acceptable speech by school entry at 5 years. However, all is not lost for those children who start treatment later. A 5 year old may have acquired incorrect speech patterns but will be more mature and potentially responsive to therapy. “There will always be a positive side to the situation,” Pam Williams says. The therapy time for those children beginning later may not be much longer but it is possible that other difficulties may have evidenced by then and require attention. Some children will require more therapy – the severity of the difficulty and the motivation of the child will determine this.
A. Research has shown that dyspraxic children are at risk of having problems in developing reading, writing,and spelling skills, particularly those with a persisting problem at five years and/or who have a family history of speech or literacy difficulties. Spelling is often particularly at risk because it relies on segmentation of words into component parts and on making links between speech sounds and written letters. Both of these can present difficulties for children with developmental verbal dyspraxia. “In addition, children with generalised motor dyspraxia are likely to have handwriting difficulties, which is a further complication,” says Pam Williams. Pam Williams notes it can be hard to say whether any individual child who has dyspraxia will have difficulties with literacy. She says, “More and more we believe there is a link but we cannot always predict this of particular children. However, it is important to make the speech clear because the better the speech, the better the prognosis for literacy acquisition.”
Q. A Condition that “Unfolds”
A. Like other speech and language difficulties, dyspraxia is a condition that unfolds over time. A 2 year old with dyspraxia will not present in the same way as a 5 year old, or an 8 year old. For this reason, traditional labels like dyspraxia are now being questioned by some speech and language therapists. Children’s difficulties very often do not fit into neat boxes. It may be better to identify the child’s strengths and weaknesses and be watchful for changes rather than label and box the child. Pam Williams says, “The fashion of giving a very specific diagnosis may well be changing. Instead of identifying categories and sub-categories of conditions, speech and language therapists may now describe the child’s difficulties in general terms as developmental speech and language disorder but detail the precise presentation at a given point in time.
Q.The Nuffield Hearing and Speech Centre
A. The Nuffield Hearing and Speech Centre is part of the Royal National Throat, Nose and Ear Hospital, a division of the Royal Free NHS Trust. The Nuffield Centre can offer a second opinion to parents of children with developmental speech and language difficulties, including verbal dyspraxia. Gaining a second opinion from the Nuffield should be viewed as a collaborative approach to problem solving, where the views of local services are taken into account. “At all times, we believe it is important to keep the lines of communication open with the local services, ” says Pam Williams. The Nuffield Centre Speech and Language Therapy Department publishes the “Nuffield Centre Dyspraxia Programme” (1985, 1992) – a speech and language therapy resource. Speech and language therapists can purchase the programme from the Department and can contact them for training information. The Department can also provide information regarding referral to the Centre and produces a leaflet on developmental verbal dyspraxia for parents and teachers.
More Help and Information
Afasic has a glossary sheet on dyspraxia which is available from Afasic Central Office. Single copies available free. Please send a stamped addressed envelope.
A chapter on the Nuffield Dyspraxia Programme is in the Afasic book, “Before School”. Before School: A Handbook of Approaches to Intervention with Preschool Language Impaired Children, Published by Afasic, 1994. Cost: £10.00 Available from AFASIC central office
You can obtain information on dyspraxia from the Dyspraxia Trust. Much of this information tends to focus on generalised motor dyspraxia.
The Dyspraxia Trust
PO Box 30
Hertfordshire SG5 1UU
The Nuffield Centre Dyspraxia Programme (1985, 1992) is available from:
The Principal Speech and Language Therapist
Nuffield Hearing and Speech Centre
RNTNE Division of Royal Free Hampstead
Gray’s Inn Road
London WC1X 8DA
tel: 0171 – 915 1535
Two useful references are:
Stackhouse J. (1992) Developmental and Verbal Dyspraxia: A Review and Critique. European Journal of Disorders of Communication 27; 1, 19 – 34 and
Stackhouse J. (1992) Developmental Verbal Dyspraxia:A longitudinal case study. In Campbell, R. (ed) Mental Lives: Case studies in cognition. Blackwell.
You can obtain these (and other references) through joining the Turner Library at Whitefields School in London. Telephone: 0181 – 5313426
Written by Debbie Reeves, 1996, with many thanks to Pam Williams
Afasic – Overcoming Speech Impairments
Afasic is a parent-led organisation that helps children and young people who have a speech and language impairment. We provide information for parents – and professionals – and have a range of helpful publications. We organise conferences and seminars throughout the year. Members meet in local groups in many areas of the UK. If you would like more information about Afasic, or if you would like to support us by making a donation, then please contact Central office:
Afasic – Overcoming Speech Impairments
web site: http://www.afasic.org.uk
69-85, Old Street
London EC1V 9HX
Registered charity: 1045617