Cherab's free support discussion list:
information about communication impairments, see Cherab's partner informational site, Speechville
more about The Late Talker, a new book for families of children
who are late to talk.
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?
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 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
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
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.
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!"
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
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.
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?"
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.
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?"
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
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.
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
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
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.
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?
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.
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?"
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!)
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.
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.
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
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.