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Verbal
Apraxia
Marilyn C. Agin, MD, Medical Director,
New York City Early Intervention Program and Medical
Director, Cherab
Foundation
Presented
at the First Conference for Verbal Apraxia, July 23-24, 2001, Headquarters
Plaza Hotel, Morristown, New Jersey
What’s
in a Name and Definitions
Neurodevelopmental Evaluation
of Verbal Apraxia: History
Nerodevelopmental Evaluation: Physical
Neurologic Exam
Assessment of Respiration and Phonation
Oral Motor Assessment
Speech/Language/Cognitive Assessment (1)
Speech/Language/Cognitive Assessment (2)
Association with Other Disorders
Verbal Apraxia Controversies (1)
Verbal Apraxia Controversies (2)
Verbal Apraxia Controversies (3)
Appropriate Therapy (1)
Appropriate Therapy (2)
Early Diagnosis (1)
Early Diagnosis (2)
Role of Essential Fatty Acids
What’s in a Name and Definitions
What
is apraxia, verbal apraxia (or apraxia of speech or verbal dyspraxia),
orofacial apraxia and motor apraxia. How is verbal apraxia treated?
Apraxia
is a neurogenic impairment involving planning, executing and sequencing
motor movements. Verbal apraxia affects the programming of the
articulators and rapid sequences of muscle movements for speech sounds
(often associated with hypotonia and sensory integration disorder).
Oral apraxia involves nonspeech movements (e.g., blowing, puckering,
licking food from the lips). Motor apraxia involves the programming
of hand or whole body movement.
Neurodevelopmental Evaluation
of Verbal Apraxia: History
- Limited babbling
and oral play
- Late transition
to solids, feeding difficulties
- Drooling that
exceeds typical expectations
- History of
accompanying oral apraxia
- May have elaborate
nonverbal or gestural communication
- First words
may emerge on time, but vocabulary growth is slow
- Increased frustration,
behavior problems
- Family history
of speech, language, learning problems
Nerodevelopmental Evaluation: Physical
Neurologic Exam
- Hypotonia (truncal)
- May have gross
and fine motor incoordination
- Motor planning
difficulties
- Sensory integration/self-regulatory
issues
- Delayed or
mixed dominance
Assessment of Respiration and Phonation
- Postural tone
- Head and trunk
control
- Respiratory
support for phonation
- Ability to
sound play
Oral Motor Assessment
- Oral hypotonia
- Drooling
- Feeding
- Suck swallow
pattern
- Chewing
- Facial Expression
Speech/Language/Cognitive Assessment (1)
- Receptive language
> expressive language
- Normal to near
normal cognitive abilities
- Limited repertoire
of consonant sounds ("da" may be generic)
- Sounds/syllable
omissions, vowel distortion, cluster
- Increased errors
with increased length of utterance
- Inconsistency
of errors
Speech/Language/Cognitive Assessment (2)
- Prosodic disturbances
(monotone)
- Groping "trial
and error" behavior (dysfluencies, silent posturing)
- Expressive
language: more limited lexicon, grammatical errors, disordered syntax
- School age
child: learning difficulties -- reading, written expression and spelling
Association with Other Disorders
- Some examples
are:
- Cerebral Palsy
- Down Syndrome
- Other neurologic
syndromes
- Autistic spectrum
disorders
- Role of "motor
apraxia" in autism (1)
- Role of verbal
apraxia in speech and language acquisition (2) (little research is available)
(1)
Rapin, ed (1996) Preschool Children with Inadequate Communication
(2)
Wetherby, et al (2000) Autism Spectrum Disorders
Verbal Apraxia Controversies (1)
Nomenclature:
Name borrowed
from adult model
In adults,
apraxia is an acquired condition
Stroke
or head injury
Affects
Broca’s area and sensorimotor cortex of the dominant hemisphere
Verbal Apraxia Controversies (2)
Etiology
Specific site
of lesion has not been demonstrated on a consistent basis in children
EEGs suggested
that praxis area in young children involved large cortical areas of
both hemispheres with lateralization to left hemisphere in later childhood
(1)
Other studies
(2,3) report "soft signs" on neurologic exam
Early neuro-imaging
studies typically negative (4)
Most studies:
small samples, outdated
(1) Rosenbeck
& Wertz (1972)
(2) Yoss & Darley (1974)
(3) Ferry , Hall $ Hicks (1975)
(4) Horowitz
(1984)
Verbal Apraxia Controversies (3)
Diagnosis:
Exclusive vs. Inclusive
Group of speech
researchers see verbal apraxia as solely a motor speech disorder (1,
2)
This renders
apraxia a rarity (estimates 1-2%/1000 live birth)
Misses a great
many children with more global dyspraxic syndromes associated with verbal
apraxia
They propose
that verbal apraxia is more like a symptom cluster or even a spectrum
disorder
(1) Hall et al.
(1993) Developmental Apraxia of Speech
(2) Hayden (1998)
PROMPT Manual
Appropriate Therapy (1)
Intensive and
frequent
Individual (no
benefit from group therapy)
Repetitive practice
for habituation of motor learning
Multisensory,
including touch-cue system (PROMPT)
Core vocabulary
Successive approximations
Melodic, rhythmic
(singing rhymes)
Appropriate Therapy (2)
Difficult course
resistant to "traditional methods"
Regression and
learning to speak one word at a time
Use of "total
communication" approach (e.g. sign language, PECS and augmentative communication
devices)
Oral motor techniques--if
indicated
"Children with
apraxia of speech required 81% more individual therapy sessions…to achieve
a similar functional outcome" Campbell
(1999) Clinical Management of Motor Speech Disorders
Early Diagnosis (1)
Ongoing developmental
surveillance and screening by pediatric practitioners
Policy statement
from the AAPediatrics and the
American Academy of Neurology-CNS
Dispel the myth
that all "late talkers" (with no receptive language are "Little Einsteins"
(He/She will outgrow it)
Listen to parental
concerns because they are accurate indicators of true problems
Dworkin et al
(1997) Contemporary Pediatrics
Glascoe (1995)
Pediatrics
Early Diagnosis (2)
Referral
to Early Intervention
Improves outcome
At no cost for
families (in most states)
N-D specialists
(neurologists developmental pediatricians) should work collaboratively
with SLPs (speech language pathologists) in determining correct diagnosis
and treatment plan
Role of Essential Fatty Acids
Supplementation
appears to cause dramatic leaps in development in children receiving combination
of fish oils (omega-3s) and borage or evening primrose oil (omega-6 oils)
The effect is
greater than one can expect from speech therapy alone
Can this effect
be clinically validated and how do we account for it?
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