What is apraxia?
Apraxia, also known as dyspraxia, is a disorder that affects a child’s ability to perform coordinated movements and gestures even though the desire and physical ability are present. Apraxia can affect different parts of the body including the arms, legs, mouth, and throat. Apraxia of speech, also known as verbal apraxia or childhood apraxia of speech (CAS), is a speech disorder where children have 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.
CAS is a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in CAS is in planning and/or programming spatiotemporal parameters of movement sequences.
CAS must be differentiated from speech delay and from other childhood onset speech sound disorders, especially phonological disorders. While there may be some overlap between CAS and phonological disorders in how they manifest behaviorally at the more severe levels of impairment, there are some key distinguishing features that differentiate CAS from other types of speech sound disorders.
What causes apraxia in children?
The exact cause of apraxia is unknown, but it appears to be the result of damage to the parts of the brain related to speech and movement. Potential causes and risk factors include:
– Premature birth and low birth weight
– Brain injury or infection
– Neurological disorders such as cerebral palsy or epilepsy
– Genetic syndromes such as galactosemia
– Hearing impairment
– Autism spectrum disorder
– Metabolic disorders
– Stroke at or before birth
In many cases, the cause is unknown. Apraxia often occurs in isolation but can be associated with other developmental delays or disorders. There appears to be a genetic component in some cases as it may run in families.
What are the symptoms of apraxia in children?
The main signs and symptoms of apraxia in children include:
– Difficulty producing certain sounds or words correctly despite being able to physically form the words. The child knows what they want to say but the words come out wrong or distorted.
– Inconsistent speech errors – the mistakes vary each time the word is said.
– Difficulty combining and sequencing sounds and syllables into meaningful words.
-Simplifying words by replacing difficult sounds with easier ones or omitting difficult sounds (such as saying “kee” for “key”)
– Difficulty imitating speech sounds, especially complex words.
– Difficulty coordinating the lips, jaw and tongue to produce clear speech (Oral apraxia)
– Using excessive effort and concentration to produce speech. Appearing frustrated when speaking.
– Difficulty speaking smoothly, with appropriate rhythm, stress and intonation. Speech may appear fragmented or choppy.
– Better speech when singing than talking
– Easier time communicating through gestures, pointing or sign language compared to speech
– Age appropriate or advanced language skills for comprehension but struggles with expression
– Slow progress in speech therapy and behavior strategies compared to children with other speech disorders
How is apraxia diagnosed?
Diagnosing apraxia usually involves an assessment by a speech-language pathologist (SLP). There are no standard diagnostic tests for apraxia, but diagnosis typically includes:
– A detailed case history – The SLP will ask about the child’s developmental milestones, medical history, hearing and speech difficulties. Information from parents and teachers can help identify the symptoms.
– Evaluation of oral-motor skills – The SLP will observe how the child performs facial movements, chewing, swallowing and producing isolated sounds upon request. Oral apraxia will affect these voluntary movements.
– Speech and language assessment – The SLP will evaluate the child’s speech intelligibility, voice quality, rhythm and prosody. Receptive and expressive language skills will also be assessed.
– Testing speech motor planning and programming – The SLP will ask the child to produce sequences of sounds, words or sentences of increasing length and complexity to identify any difficulties planning and sequencing speech movements.
– Assessing consistency of errors – The SLP determines if the child consistently makes the same sound errors or if the errors are inconsistent. CAS typically involves variable errors.
– Hearing evaluation – Since some characteristics overlap with hearing impairment, an audiologic assessment is often completed.
– Observation of speech consistency across different settings – SLPs may communicate with teachers to help determine if speech varies by environment, as it does in CAS.
A diagnosis of CAS requires ruling out other conditions that could explain the symptoms, including neurological disorders, structural abnormalities and phonological disorders. It is a complex diagnosis that is best made by an experienced SLP familiar with apraxia.
What is the treatment for apraxia in children?
While there is no cure for apraxia, speech therapy is the main treatment approach. The goals of therapy are to improve the planning, sequencing and coordination of speech movements. Some therapeutic techniques include:
– Speech motor exercises – Targeted practice of sounds and sound sequences. Activities move from simpler to more complex.
– Physical cues – Tapping out speech rhythm, exaggerated lip/mouth movements, using hands to gesture.
– Verbal cues – Providing keywords or sound cues to trigger proper sequencing.
– Visual cues – Using pictures, written words, cards or sign language as prompts.
– Tactile cues – Having the child touch their face to cue proper positioning.
– Rhythmic practice – Combining exaggerated rhythm, pacing and intonation with speech practice. Songs and nursery rhymes are often used.
– Repetition and consistency – Frequent rehearsal and consistent stimulus presentation is key.
– Augmentative and alternative communication (AAC) – Supplementing oral speech through use of pictures, writing, gestures or speech-generating devices.
– Focus on successful productions – Positive reinforcement of correct speech attempts helps promote new motor patterns.
Treatment plans are tailored to each child’s specific needs and focus on improving intelligibility and speech accuracy. On average, children may attend speech therapy 1-3 times per week for several years. Some children benefit from individual therapy while others do better in small groups. Many therapists use a combination of both.
What is the prognosis for children with apraxia?
The long-term outlook depends on the severity and the underlying cause. In many cases of childhood apraxia, speech intelligibility improves with targeted intervention but some residual difficulties typically remain. Persistence is key – apraxia is a motor-planning disorder, so consistent practice strengthens those neurological connections.
While every child is different, some general trends in apraxia prognosis include:
– Most children with apraxia will improve significantly with speech therapy by around age 5, though progress is often slow. Support may be needed through elementary school.
– Children whose apraxia results from neurological injury/illness tend to have greater persisting speech challenges than children with idiopathic apraxia.
– Children with more severe apraxia symptoms, receptive language deficits and oral-motor limitations tend to have poorer outcomes. Mild-moderate apraxia often resolves earlier.
– Apraxia persisting into later childhood is linked to higher likelihood of literacy deficits and learning disabilities. Ongoing academic support may be needed.
– Children who demonstrate age-appropriate language comprehension skills despite apraxia tend to have the best prognoses for reaching functional speech. This allows them to communicate nonverbally.
– Early intervention improves long-term outcomes. Children who receive intensive speech therapy before age 5 generally make the most gains.
While apraxia can be challenging to treat, most children can achieve functional communication through speech and/or augmentative methods. With therapy, many go on to develop normal language and literacy abilities.
Can children with apraxia participate in normal activities?
Yes, apraxia does not have to limit a child’s ability to engage in regular childhood activities. However, some accommodations and support strategies may help children with apraxia fully participate.
Here are some tips for encouraging participation:
– Provide extra time for verbal responses. Don’t rush. Allow the child to process questions and formulate responses.
– Simplify multi-step directions. Break tasks down into smaller steps. Use gestures to aid comprehension.
– Offer picture schedule boards, visual aids and written instructions when possible.
– Allow alternative communication methods like pointing, sign language, writing or typing.
– Model activities first. Demonstrate the steps before asking the child to perform them.
– Give positive reinforcement for efforts and close approximations. Don’t require perfect speech.
– Advocate for the child when needed. Educate peers and adults about apraxia and ways to support communication.
– Make sure the child has access to any necessary speech therapy or special education services. These supports will build skills.
– Don’t exclude the child from activities if they can comprehend instructions and participate, even if speaking is difficult. Focus on abilities.
– Develop a joint plan with the child’s speech therapist to work on target skills within regular activities.
– Offer opportunities for the child to practice speech but don’t mandate it if they are not comfortable. Confidence comes with time.
With the right adaptations to promote comprehension and participation, children with apraxia can thrive in school, social situations, sports, hobbies and other childhood activities they enjoy. The key is supporting strengths while building communication skills.
How can families support children with apraxia?
Here are some important ways that parents and families can provide support:
– Have realistic expectations for progress and celebrate all achievements, both big and small. Improvement takes time.
– Advocate for your child to receive sufficient speech/language therapy and special education services at school. Meet regularly with the treatment team.
– Include the child in family discussions as much as possible. Avoid speaking for them. Listen patiently.
– Expose your child to language-rich environments – books, songs, rhymes, conversation. Auditory input is beneficial.
– Reduce pressure to speak and don’t reprimand speech errors. Be positive. Children with apraxia experience enough frustration already.
– Let your child take the lead in social situations where possible. Don’t push for lengthy conversations.
– Help siblings, relatives, teachers and peers understand your child’s challenges. Promote compassion.
– Work with the speech therapist to implement suggested strategies at home. Consistency between environments is key.
– Explore augmentative communication tools like picture boards, tablets, sign language that can supplement your child’s speech.
– Focus on connecting with your child through activities you enjoy together. Don’t let apraxia define your relationship.
– Seek support from other parents of children with apraxia through groups and online communities. You are not alone!
The most important things are providing unconditional love, emphasizing your child’s strengths, celebrating small steps, advocating for support and working as a team with therapists and teachers. With family support, children with apraxia can gain confidence and reach their full potential.
Conclusion
Apraxia involves significant speech challenges for children, but intensive therapy can help improve skills and intelligibility. While progress is often gradual, long-term outcomes are best when treatment begins early. Most children with apraxia gain the ability to communicate effectively, allowing them to participate in school, activities, and life. With family support, a knowledgeable treatment team and consistent hard work, children with apraxia can go on to lead fulfilling lives and accomplish their dreams and goals. Communication may always require extra effort for them, but their perseverance and resilience serves as an inspiration.