sound practice in action
Posted by Rebecca Siomra on March 4, 2015 12:03 AM
Every now and then, a very concerned, often nervous-looking, parent tentatively asks me, “Do you think my child has Apraxia?” In my life as a Speech-Language Pathologist (S-LP) working with preschoolers, parents put a lot of faith in my clinical judgement to help their children become better communicators. I need to honour that trust by being truthful with them and by giving them the best information and guidance that I can.
I need to start off by being clear that, as an S-LP in Ontario, it is beyond my scope of practice to make, or confirm, this diagnosis – that needs to come from a medical doctor – however, I am very happy to talk with parents about apraxia, to educate them and, to the best of my ability, support them in their journey.
When parents ask about Apraxia – more specifically called Childhood Apraxia of Speech (CAS) with this population – I like to ask them what are they seeing from their children and why they suspect that diagnosis. Their answers often include, “Well, when I googled my child’s speech patterns that’s what kept coming up.”
Now, I love internet searches as much as the next person, but, unfortunately, they don’t often ask questions to help fine-tune what you are looking for. Parents report reading that some children with CAS never learn to speak clearly and this scares them; they worry for their own child’s future. Common concerns parents report to me include:
• his words are so hard for me to understand; sometimes I just have to pretend that I understand
• all of his words sound the same
• her mouth/tongue doesn’t seem to move very much when she speaks
• he just can’t seem to get his words out
• I’m the only person who knows what she’s trying to say – what will happen at school?
• he hardly makes any speech sounds at all but uses lots of gestures to be understood
Here’s the thing about the term ‘apraxia’. It is only one part of the motor speech disorder family, but is often used to describe any part of that group. Truth be told, CAS is actually quite uncommon, relative to other speech disorders. Some research estimates 0.1-0.2% of the general population1 has CAS (for reference, approximately 10% of the general population is estimated to have a speech and/or language disorder). In spite of this low percentage, the terms ‘apraxia’ and ‘childhood apraxia of speech’ are sometimes used quite liberally in the community.
In my practice, I prefer to talk with families about the specific challenges their child is facing and address those, without worrying about labels. Frustrating perhaps for some, but I have my reasons. When I meet a child with a suspected motor speech challenge, I must first determine if it is a delay, or an impairment. In the case of a delay, skills emerge in a typical developmental order, with somewhat predictable errors, but simply later than expected. When there is an impairment, errors are unpredictable, often differ from typical development and/or may show extremes of typical speech movements.
Impairments can occur in several areas. Developmental Dysarthria is characterized by impaired muscle tone (too tight/tense or too loose/floppy), but word and sound productions are fairly consistent. With CAS, there are challenges with volitional control in the planning, sequencing and organizing of muscle sequences for speech. That is to say, the child might be unable to figure out how to get their mouth to produce a specific sound, or sequence of sounds, reliably. Areas impacted by CAS include any of, range, direction, coordination and timing of movements.
Tell-tale feature of Childhood Apraxia of Speech are:
• inconsistent errors in repeated attempts of the same word;
• disordered prosody (that’s the tune or melody of our speech);
• challenges with transitions between speech sounds.
As mentioned, ‘true’ CAS is not common, and most children with motor speech challenges present with a mixture of the types of speech characteristics mentioned above. This is why, as a S-LP, I feel it is so important to focus on supporting children to work through their specific error patterns, rather than worrying about how to label the disorder. When there is a motor speech disorder present, talking is HARD for a child, and they need encouragement and help, from a S-LP, and, through coaching, from their parents and other caregivers. Parents are encouraged to contact their local S-LP provider if they suspect their child needs therapy.
Some indicators of when to suspect a motor speech disorder:
• speech may sound ‘flat’ or choppy
• accuracy/clarity decreases as words/phrases become longer
• groping is observed (e.g., a child moves their mouth around in an attempt to figure out how to say a sound/word)
• inconsistent errors when the same word is repeated multiple times
• limited lip movements
• sliding of the jaw during speech
• excess or restricted jaw opening during speech
• open jaw at rest
For a parent, it can be heartbreaking to watch your child struggle in any area of development. Support to address motor speech difficulties, whether a delay or, an impairment, should be sought from a S-LP. A S-LP is able to evaluate a child’s articulation/phonology skills (which sounds are made and in which positions of words), as well as their neuromotor skills (how their mouth moves in speech), either informally or with structured testing. With this more specific, and appropriate, information, they will be able to determine any areas of weakness and to set suitable goals. Motor speech therapy can be intense for some children and families, not only due to frequency of sessions, but also because this is hard work. Re-training the motor speech system takes a lot of repetition, and careful goal selection, just as with learning any other motor task, from playing the violin, to cake-decorating, to learning play soccer. The intervention recommended to any child should be determined based on their age, maturity, nature and degree of speech/language challenge, as well as other developmental needs.
In my opinion, the first step in helping the family of a child with a motor speech difficulty is to educate and help them to understand where the breakdown is happening in their child’s communication system. Helping them to understand ‘the lingo’ and goals will help them be a more effective partner in therapy sessions, follow-through with homework between sessions and, if they must, to tackle the internet with a little more direction and specific questions. Parents and clinicians must have faith in each other, and be able to trust that they are both working in the best interest of the child.
1 Shriberg, l., Aram, D., Kwiatkowki, J. (1997) Developmental apraxia of speech: 1. Descriptive and theoretical perspectives. Journal of Speech, Language, Hearing Research, 40, 273-285.
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KAREN MACIVER LUX