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The Late Talker

Read more about The Late Talker, a new book for families of children who are late to talk.

 

Late Talker or Apraxia?

The following are questions from emails sent to us. The answers, provided by Lisa Geng, have been approved by the Cherab Foundation advisors.

1. How can you tell the difference between a child with verbal (not oral) apraxia and one that is a late talker?

2. How can you tell the difference between a child that's not talking because he's shy, and one that has verbal apraxia?

3. Is it appropriate to ask for 5x a week, one on one therapy for a nonverbal 10 year old?

4. What are some strategies to help my child deal with his frustration due to speech challenges?

5. Are all late talkers apraxic?

6. Is there an association between apraxia and mental retardation?


Question
1. How can you tell the difference
between a child with verbal (not oral) apraxia and one that is a late talker?

You have a terrific website, but I could not find the answer to my question. How can you tell the difference between a child with verbal (not oral) apraxia and one that is a late talker? My son is 25 months old and communicates largely by saying "ah," pointing, and verbal expressions. He makes lots of sounds and shows no signs of oral apraxia. I'm planning to have him tested by an audiologist and speech therapist this month. Their results will be turned over to a speech development specialist. Before going through all this, I'd like to get a better understanding of what sets a late talker apart from a child with verbal apraxia. Do you know? I can't seem to find the answer to this question anywhere.

Thanks,
from California

Answer

Thanks you for bringing up such an excellent question, first of all! I left the "late talker versus apraxia" questions to be answered by links and evaluations from experts, however, there are "warning signs" of apraxia that I can point out from a parent's perspective.

Experts state that oral apraxia can be diagnosed as young as 18 months, while most experts believe that it's difficult to get a definite diagnosis of verbal apraxia until the age of 3. You say your son is 25 months with no signs of oral apraxia. This said, it's suggested that if apraxia is suspected, to begin appropriate oral motor therapy right away, because it won't hurt, and the earlier the better for therapy with apraxia. Even with early intervention, some children with apraxia may always need an alternative way of communicating (sign language, picture exchange communication, computer, etc.), but many will learn how to overcome the apraxia enough to talk and be understood.

Through Early Intervention (free through your state's Birth to Three program and through your local school district from 3 up) or through private (ie provided for by insurance or out-of-pocket), an expert (SLP, OT, developmental pediatrician, neurologist, etc.) will evaluate your child's ability to move his tongue on command and will assess his strength in various areas (physical, language, emotional, social, and intellectual development), all via fun ways using toys, so he'll love it. I recommend that you be in the room with him. I was ALWAYS there with Tanner, for all of his evaluations, testing, and therapy, except when he started the preschool disabled program. (We now can watch from a two way mirror.) Some therapists want to be alone with the child and some parents feel their child behaves better without the parent in the room. I believe that since my husband and I are with our son most of the time, our observation is important so that we may provide "carry through" therapy. For us, this has worked well.

Your child may be a late talker for a number of reasons other than apraxia. Most often, it is due to a speech delay, but like I said, early intervention is a free, federal program your child is entitled to if he qualifies, for whatever the reason for the delay in speech. There is a lot of research into the benefits of brain stimulation during the birth to three stage, so the "play therapy" your child would receive from early intervention will most likely benefit him for whatever the reason for the delay of speech. If your child just starts talking perfectly a week or a year later...great! And then do you really care what the reason was for his being a late talker? Since no large scale research has been done yet on the neurologically based condition that is referred to as "apraxia of unknown origin," all of us as parents of children with apraxia, have questions. But we may not have those questioned answered before our children are teenagers or adults. Our main goal at the Cherab Foundation is to help all children learn to talk, and we do know what works for teaching a child to communicate, overcome apraxia, and reduce frustrations for a "late talker". A few of the late talkers do have apraxia, and the fact that you're out there researching on the internet shows that you are the type of parent whose child is in good hands, for whatever the reason he is a "late talker." Knowledge is so powerful in helping us to help the children.

Our nonprofit Cherab email list addresses the issue of late talker versus apraxia, with a focus on medical research, early intervention and education. We have medical, speech and educational professionals on this list, from our organization, who have volunteered to answer your questions. We also have many other wonderful parents and professionals on this list from all over the world. You may wish to post some of your questions there.

Here are the "late talker vs. apraxia" or "delay vs. disorder" signs that I saw/see in my four year old, Tanner, as he was/is "learning to talk."

Apraxia is a disorder, and it will not self resolve; typical delays of speech will self resolve (meaning even without therapy the child will "learn to talk.") For more information, see parent friendly signs of verbal apraxia and parent friendly signs of oral apraxia.


Question
2. How can you tell the difference between a child that's not talking because he's shy, and one that has apraxia?

Based on what I have read, I believe my 3 year old son has oral apraxia, as he has many of the symptoms. For the past year he has been in speech therapy and has made some progress. His current speech therapist attributes his speech delay solely to shyness. I know that his shyness is only a small element of his speech delay. Although he is saying many words, his speech is very unclear to anyone outside of the family. He still cannot say any 4 to 5 word sentences confidently. It takes a lot of prompting from me to get him to expand his speech.

Recently he was tested to see if he qualifies for the school district's preschool speech therapy program. During the assessment I asked the speech therapist for her impressions. She said she thinks (our son) has poor oral motor planning but would have to consult (our son's) current speech therapist for confirmation of this diagnosis.

The IEP for (our son) is scheduled for next Friday and I'm extremely nervous about what they will propose for therapy. From what I have read, working  individually with a speech therapist is most effective. I know they are  going to push for him to be in a small group preschool format. Obviously I  will fight for what is best for (our son) . How often did Tanner meet with his speech therapist?

I am thankful to have found your website. Any additional information on Tanner's therapy that you can give me will be greatly appreciated. Please add me to your e-mail list. I would like to watch the Inside Edition T.V.'s segment on apraxia and The Children's Apraxia Network. Thanks!"


Answer

The fact that you are continuing to learn more is wonderful. Keep up the great work! We always say late talker vs. apraxia, but now we have with (your son) "shy vs. apraxia!" I believe this is an easy one to answer!

About the diagnosis of apraxia, according to experts, it's difficult to give a definite diagnosis of verbal apraxia until the age of 3, your son's age. Oral apraxia, which you say your son shows signs of, on the other hand, can be diagnosed as young as 18 months.

My son Tanner seemed shy because he was dependent on people he felt comfortable with to communicate for him and understand him, but that "shy" behavior disappeared as we provided alternative means of communication. I didn't think of it as much as shy as I did dependency.
His speech disorder didn't go away when his shyness did. In other words, shy or not shy, Tanner has a speech disorder. Does your son speak clearly in front of anyone? Like you or your husband? Does your son speak in clear sentences at home? If so, then perhaps your therapist is correct. If not, to help with any shyness/dependency, you might try Picture Exchange Communication. That would be where your son points to a picture of a juice box vs. a cup when you ask him what he wants his juice in, for example. You can do this for breakfast choices, anything! Also, let him know that "everybody has to learn to talk." It's true, you're just leaving out the details!

Even though your son is showing improvement, which is great, it concerns me that your son's therapist believes that his lack of speech, and his unintelligibility, is from shyness, and yet he is showing signs of oral apraxia. Again, oral apraxia is something that could be diagnosed as young as 18 months. Apraxia is neurologically based, and it is not a psychological disorder. Even though children can develop low self esteem from communication challenges, your son is still so young to know for sure that what he is going through is not normal. If he does have shyness issues that affect his speech, then that's an issue you can deal with in simple ways.
But I would highly recommend that you seek a second opinion from an SLP that is knowledgeable about apraxia and other motor planning disorders.

In addition to oral apraxia, it's not uncommon for apraxic children to have other issues. (Don't freak out - they're generally treatable ones) like low tone/hypotonia which looks like the cherub baby, or sensory integration issues. He's at an age where you may start to notice these other added surprises and it's good to know what they are so that you can help him if he has them. But while you're getting second opinions on the "shy vs. apraxia" situation, these are other things to ask about.

About sentences... With Tanner, at 2.8 he was in therapy 2 to 3 times per week for 5 months, at that point working on basic sounds, and he couldn't even put "ch" together with "oo." When he was 3 years old, your son's age, he had a surge and was up to 20 or so words! But they were all pretty simple words, and he wasn't up to even 2 word sentences. Tanner turned 4 this past June, and he is talking in 2 to 8 word sentences that are understandable to anyone.

The reason I am telling you this is because if your son does has apraxia, I would let the experts on apraxia guide him to longer sentences when he is ready. Tanner's therapist had a great example of how many words in a sentence Tanner was capable of saying.

This is something you could try:
Buy 2 blow horns. You blow into one and give the other to your son. Imitate (in a fun way) each other's toots. Let him take the lead, then you take the lead. If your son can't imitate 3 or 4 toots of a horn, he is not ready for 3 or 4 word sentences yet. It has to do with breath control.


Question
3.
Is it appropriate to ask for 5x a week, one on one therapy for a nonverbal 10 year old?

"We have a 10 year old son that is completely non-verbal. He has been getting speech therapy since he was 3, although not very intense. Would it be unreasonable to ask for half hour a day, 5 days a week from the school?"

Answer

There are so many unknowns to directly answer your question. For example, has your son ever had a diagnosis that explains why he is nonverbal? If so, who diagnosed him, and when? Was he ever diagnosed or misdiagnosed as having cognitive issues/autistic/mentally retardation, etc.? Have you taken him privately to a developmental pediatrician, neurologist or speech and language pathologist that is knowledgeable about apraxia and other disorders? Does you child use picture exchange communication, sign language, or augmentative devices to communicate now? Is he mainstreamed, and if so, how does he perform in school both academically and socially? Does he play appropriately, with friends, or alone?

Your son's school is required to provide him with appropriate therapy, either in district or out of district. They aren't necessarily going to tell you this, of course. What this means is that once you know what your child requires (even if that is 5 days a week, intensive one on one
"appropriate" therapy), if that's what experts evaluate that he needs (again, seek diagnosis and therapy outside the school) because of his diagnosis, then they need to provide "appropriate" therapy. If they can't do so within their own program, then they are required by law to find alternative situations. Again, this can include paying for you to take your son to an outside
therapist, paying for an expert to work with your son in the school and give direction to the school based SLP to follow, or even out of district placement. This means that a private school could be paid for by your school system if the district is unable to provide appropriate therapy.

Your son's school system might say they are providing him with appropriate therapy, have done so for the past 7 years, and that he is not responding. If, however, your child is severe apraxic, the type of therapy he has received does not sound appropriate according to the experts. Without knowing what his reason is for being nonverbal, or what therapy he receives, that's hard to say. This is again why it's so important to have some experts outside of the school overseeing your child. It's important to have a hero for your child, outside of the school, especially since your child is 10 years old and non verbal.

These same "outside the school" experts on apraxia and other disorders (developmental pediatrician, neurologist, SLP, OT, etc.) can diagnosis the reason for his being nonverbal, watch over your child, provide therapy as often as you can afford, and make sure your child is meeting the IEP (individual education program) goals that he/she helped to set. I believe you will need to pay for these second opinions or therapy sessions (hopefully through your insurance,) because if they are on the school's salary, I don't believe results are always going to be unbiased, which is what your child deserves/needs. Know that you can have it written into the IEP that you want evaluations (from now on) every 3 weeks, 2 months, 6 months, whatever your son's (private) therapist believes is necessary. Many people think, like my husband and I did, that IEPs were yearly. However, they are contracts between the school and you and your child. Just like any contract, it's negotiable. In your child's case, you've given the school 7 years to help, and perhaps they have done "everything that is appropriate," but why wait another day if they have not.

Again, it's a federal law that they are required to provide your child with appropriate therapy. And also again, please find out from outside experts what that appropriate therapy is for your child ...and then fight to have them provide that to him. Of course you can use information found on the internet to assist you, in additon to the diagnosis. Squeaky wheels do get the grease!
It's good to look into other local school districts' programs or pay for private therapy. I noticed some of the responses to your question from other parents said their child's therapist was only in the school for 2 days a week, so they couldn't receive any more therapy. If you show they are not providing appropriate therapy, then you can have them pay for your child's private therapy sessions, or pay for your private therapist or another expert on apraxia to come to your son's school as a consultant once or more a week. With some creativity and willingness, things can be worked out in most cases without having to go to a special ed attorney (another option of course.)

If your school tells you things that make you uncomfortable or that you believe are not accurate, tell them, "That's interesting. Could you put that in writing for me?" (For example if they say they can't provide more than two or three days of therapy a week.) Also know that you don't need to sign the IEP right away. You can take it home and show it to others. You can also take others with you to the IEP meeting, including your child's private SLP, or a parent advocate, or even a tape recorder!

Also see the Severity/Intervention Matrix and, if your son is apraxic, the citations regarding the importance of One on One Therapy.

You are an expert on your child, and you can back that up with knowledgable experts' assessments. Together, you are a powerful team that will find appropriate therapy for your child. Have you seen Ask the Doctor? Dr. Agin is brilliant, and can probably help as well.


Question
4. What are some strategies to help my child deal with his frustration due to speech challenges?

My son, who is now three, has been recently diagnosed with apraxia. He has improved drastically over the last three to four months. But he gets frustrated very easily. The harder he tries to say something, the more scrambled the words come out. I don't know what to say or do to help him, to help me understand. What are some at home activities that we can do to help him? During the week I only get to spend about three hours with him before he goes to bed and I want to make it count. Also,how can I go about finding a speech therapist in the Houston area that specializes in apraxia?"

Answer

Both our children were "late talkers" for different reasons, so when we saw our children getting frustrated, we automatically would say things like, "Oh I remember when I was learning that sound when I was your age. You're doing better than I did!" You can also say things like, "Just remember what you want to tell me so that when you learn to talk you can tell me, okay?" Our son Tanner used to smile when we talked to him about how one day he will be able to tell us all his secrets and sing songs to us. Now here it is a year later, and he is! Tanner still has a way to go, but he really is doing amazing!

Today our older 6 year old son's speech challenges are undetectable to anyone but a professional, but we continue to use this approach for our 4 1/2 year old with apraxia. Neither of our children were ever self conscious about the way they talked, and it's worked so well to boost their confidence that both children will talk or sing in front of groups of strangers, even our child with apraxia! When we won the competitive grant from Seton Hall University's Law School, Tanner sang to a roomful of lawyers. Maybe that's why we won, because he won their hearts! Each child is different, so perhaps the approach we did wouldn't work for your child, but it's something you may want to try.

Here is another trick to reduce frustration: we remember what our child says in our head so we don't have to ask him to repeat it. Scott Bilker uses a digital recorder so that he can play back the word or words again and again without asking his apraxic son to repeat. He's got a great site to visit to listen to children of various ages with apraxia speak.

Sometimes people, even family, may talk about a child who is "not talking yet" right in front of him. With family or friends I will usually cut them off with a look, and then say, "Yes, he's learning to talk right now, and he's doing great! Aren't you (your child's name)?" And then let them know I will talk to them more about how well he is doing after he goes to bed. I've used the same approach with children (or adults) we don't know who ask,"Why does he talk funny?" I'll say, "He's learning to talk, and he's doing great." In my experience that approach stops the questions immediately.

For any child learning to talk, research shows alternative means of communication are helpful for both reducing frustrations and encouraging healthy language development. This includes, but is not limited to, sign language, even baby sign, picture exchange communication (for example, where you have a child point to pictures of breakfast foods instead of telling you what they want for breakfast), augmentative devices, etc. It's a good idea to let your child "play" on the computer with age appropriate games if he is interested.

I just read a book that was interesting, written by Jill Smith, MA and Howard Diller, MD, called Late Talking Preschool Children Children who may be diagnosed as PDD. The children studied in this book were not necessarily PDD, but they may be classified as such. The book is only about 80 pages, but the information was interesting in that they show the most important issue is to raise the self esteem of late talking children as soon as possible, and just like we did (parental instinct I guess), keep them from perceiving that something is "wrong" with them. The research involved teaching preschool late talking children to read, which increases their confidence, gives them another way to communicate, and (hopefully) prevents future learning disabilities. The book outlines the system they used to teach nonverbal preschool children to read.

There are quite a few home activities links and information you can find both at our site, as well as information on sign language and picture exchange communication. Apraxic children in general respond well to one on one time. Therapy comes in many disguises, so it's easy to "just be a mom" while you are incorporating some helpful therapy techniques into the time you spend playing and hugging him.

As far as a therapist in Houston that specializes with apraxia, have you checked with ASHA? We have their link at our site as well. If you still can't find someone, and no one emails you with names, let me know.


Question
5. Are all late talkers apraxic?

You mention that both your sons were "late talkers", but had apraxia. I thought there was a difference, meaning some kids are late talkers, but do not have apraxia. Did I misinterpret?

Answer

Sorry if our story is confusing, but I hope this explanation will clear things up.

The easy answer is yes, a child can be a late talker and not have apraxia. But because you brought up my two "late talking" kids, we go to the tough question! The pediatric neurologist diagnosed our older son, Dakota, with oral apraxia at 2, but Dakota never had oral or verbal apraxia in the way our son Tanner does. Dakota's "apraxia" was used as a symptom (like if you
look up the word apraxia in the dictionary and use it as a definition to describe what is happening. Loss of ability to...) The word apraxia was used for Tanner as a diagnosis. Tanner has oral and verbal apraxia.

There are so many names for apraxia - the neurological based disorder we are talking about when we say "Children's Apraxia Network" for example, names such as dyspraxia, verbal apraxia, oral apraxia, developmental apraxia, global apraxia, limb apraxia, oral motor disorder,
etc. and because the speech and medical community are not always on the same page, names are used by professionals that are very confusing, or that even conflict, at times. Some neurologists are knowledgeable about apraxia, and some are not, some are knowledgeable about apraxia, but use other names to describe it. I'll explain.

Tanner was diagnosed as havinig severe oral and verbal apraxic by various SLPs and by Dr. Marilyn Agin. However, the same pediatric neurologist who wrote in an evaluation that Dakota has "oral apraxia," diagnosed Tanner as having a "phonological motor processing disorder which effects motor planning and speech." You see, this neurologist used the term "apraxia" as a symptom rather than a diagnosis since in his medical opinion the diagnosis "apraxia" was not clear. "Apraxia of what? The limbs, the eyes, it's to vague a term!" is what he said to me in a frustrated way. "I don't like this name apraxia, it's to vague!," he also said. So even though this neurologist knew Tanner was diagnosed as having oral and verbal apraxia by many other speech professionals, and by a medical professional, and even though he understood what apraxia was, he still did not want to use the term "apraxia" to diagnose Tanner. He preferred the diagnosis "phonological motor processing disorder." But if you run that past some SLPs, some will say that means something different than apraxia!

Since Dakota, our older son had "facial palsy" from crushed facial nerves, among other things, from a traumatic delivery, it created "oral apraxia" but this was describing the action of the nerve damage, not diagnosing him as being oral apraxic. It's complicated, but yes, even though both our sons had oral apraxia, only Tanner has apraxia, the neurologically based speech disorder of unknown origin. So for all of you with one child with apraxia trying to explain this to family and friends, imagine us! Thank God that Dakota today is mainstreamed and getting top grades in school! We just can't wait until Tanner makes it out of the woods, as well, at some point.

Once again though, our situation is unique and isn't the best example of two typical "late talkers." One was a late talker from birth trauma, and one was a late talker from apraxia, but they both were described as having apraxia. The average late talker does NOT have apraxia. Apraxia is not rare, but it's not that common, either.


Question

6. Is there an association between apraxia and mental retardation?

"Hi! My name is Candace and my three year old son has apraxia. I have a few questions for anyone who is familiar with this language disorder. First, is there an association with apraxia and mental retardation? I asked a professional what they did 25 years or so ago with children who were late talkers and she said a lot of them were labeled mentally retarded. Also, she said that an IQ test is based heavily on language development. What are your thoughts? Second, people say that when my son does use his words (which is approx. of 20) that he sounds like a deaf child. Although my son had a lot of sinus infections, he did pass a hearing test. He has no high and low pitches to his voice and he mostly picks up the vowels. Is this typical with kids with apraxia? Third question, my son also babbles like a baby at times. When we are out in public, people tend to look at him. What do I do?"
Answer
I'm sure you will receive many responses to your excellent questions, but I wanted to address some of your questions right away, those that I have the ability to answer, even though I'm a parent, not a professional. (This is because of my e-degree and life degree in apraxia research!)
Children with apraxia have been MISdiagnosed as mentally retarded and autistic for far too long.
A child can have apraxia and have normal or brilliant intelligence; from what I've read, seen, and heard, most do. Just so you know however, a child COULD have apraxia and other issues, such as apraxia and mental retardation, or apraxia and autism, or apraxia and cerebral palsy, or apraxia and downs, etc. (Just like they could have a broken leg and autism.) This is why it's so important to bring your child to developmental pediatricians and/or neurologists who are knowledgeable about apraxia as well as other issues. Don't let anyone treat or educate your child as having cognitive challenges unless you know for a fact he does.  And don't leave it up to your child's school to "find out" and classify him or her as mentally retarded. Find out by having your child privately evaluated by a medical authority (or two) that you respect, and who has experience and knowledge of apraxia and other issues.

Be careful of "receptive" language evaluations on written reports. Your child can have a severe expressive delay, but if they write a "severe expressive and receptive delay," it means something different. That's a red flag that there could be cognitive challenges going on. It translates (in parent language) to "You're talking to this child, but there is nobody home." If that's the case, again, see a medical professional, but if that's not the case, if your child does understand and can follow simple commands, these are the first baby steps to misclassifying apraxic children. Take it seriously and find out privately.
Don't just depend on one diagnosis, especially since many apraxic children have been misclassified or misdiagnosed. This is one of the reasons we so highly recommend Dr. Marilyn Agin, because she has the background of an SLP, but is now a developmental pediatrician who specializes in autism and apraxia. She gives lectures to medical and other professional communities about these issues and others, and tries to raise awareness so that apraxic children will no longer be misdiagnosed, and will receive the appropriate therapy and early intervention. On top of that, Dr. Agin is the Medical Director for Early Intervention for New York City, the largest of it's kind in the USA. Dr. Agin states that since so many apraxic children are intelligent and know they aren't being understood, some tend to withdraw, and be misdiagnosed as autistic. Her information is at our website under Ask The Doctor.
Again, apraxic children can be brilliant and misdiagnosed or misclassified. What's fortunate is that, because of the Internet, you can prove this point by speaking with the children who have grown up with apraxia or their parents.
The way apraxic children speak varies. You can listen to various apraxic children at The Talking Page. Our son Tanner used to sound deaf when he spoke, but what's funny is that now that he goes to a school for the hearing impaired and deaf, he no longer sounds like he's deaf, and he has many inflections when he talks or sings! Lori Roth, who has worked with both deaf and apraxic children, believes that they both may learn to speak in similar ways, which is why so many apraxic children have done well in schools for the deaf or hearing impaired. It's something to look into anyway. Dr. Agin can explain why apraxic children sometimes sound deaf from a medical aspect as well.
As far as people looking at your son when he babbles, I know how you feel! Tanner is a big kid, so even when he was only 3 he looked 4, and now at 4 and a half he looks like he's at least 5 or 6. At three he had only a few simple sounds or words. He went through the "babbling" stage after three too. His SLPs say that is typical, and a good thing, since it's an important stage in language development that our apraxic children either miss, or don't fully go through when younger. Apraxic children typically go through most of the "normal" stages of language development if they are getting appropriate therapy, but just LOTS slower and later than a typical "late talker" that is not apraxic. Today Tanner talks "like a baby" using 3 to 5 word sentences, and not only are we all proud of him, but he's proud of himself! We don't want to lose that healthy self confidence, so if he doesn't notice any strange looks cast his way, I ignore them. But if these people say anything, or Tanner notices them staring at him, I use my now classic, "He's learning to talk, and he's doing great!" Works like a charm! Also read What's wrong with him? It's pretty funny.
Lisa Geng, President of Cherab Foundation

If you have questions you believe need to be answered on the site, please send them on. Please state if you want a parent's or a professional's perspective.

 

 


The Cherab Foundation is a world-wide nonprofit organization working to improve the communication skills and education of all children with speech and language delays and disorders. Our area of emphasis is verbal and oral apraxia, severe neurologically-based speech and language disorders that hinder children's ability to speak.

The Cherab Foundation is committed to assisting with the development of new therapeutic approaches, preventions and cures to neurologically-based speech disorders. We bring together parents and medical, research, and educational professionals. Please join us and help to give our children a smile and a voice.

Cherab Foundation
Communication Help, Education, Research, Apraxia Base
P.O. Box 8524 PSL, Florida 34952-8524
Phone: 772-335-5135

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Last Update: June 18, 2006