Parent friendly signs of verbal apraxia... from
a parent
Written
By Lisa
Geng in 2000
My
son Tanner
was diagnosed with both severe oral as well as verbal apraxia, but each
child is different, and some may not go through all the signs that Tanner
had, with his severity, and/or some children may have other aspects.
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."
1. It took forever
for Tanner to learn how to say ANYTHING other than the word "ma" or the
sound "mmm," which were his only "words" up until almost 3 years old.
Even though the therapy he received was not appropriate for apraxia (we
didn't know this at the time), it was some type of therapy, and it took
months of this speech therapy, 1/2 hour sessions, two or three times a
week (from 2 years, 4 months, to 2 years, 8 months) for him to learn simple
sounds like "t" or "ch" or "sh," sounds most babies and toddlers say when
they babble.
During
this time, even though Tanner was in speech therapy, we followed our pediatrician's
advice that Tanner was a "late talker" and never knew Tanner was qualified
for early intervention by the state (a federal program) so we paid out
of pocket for all the therapy (insurance didn't cover it and even though
we appealed, at that time, we didn't know how to fight the denials). Tanner
did babble with some of these sounds, though rarely. Many apraxic children
babble very little. The problem was that when Tanner wanted to use one
of these sounds, on command, he didn't know how. Many parents of apraxic
children have examples, like us, of their child starting to develop speech
and then, for some reason, they lose the speech they had developed. Since
there is still no large scale research on apraxia in children, nobody
knows why this happens. In a small research project by Tom Campbell out
of the Pittsburgh Hospital, the findings were that it required 81% more
therapy for apraxic children to show results than children with severe
phonological delays.
2.
Tanner did not go through normal speech development as he aged. He would
say a sound (before 3) or word (3 and up) and not say it again for months.
Most children with delays of speech will learn sounds and words and build
upon that, in a developmentally typical pattern.
3. Another frustrating aspect of verbal apraxia is that even when Tanner
learned how to say a sound like "p" before a vowel, he could not say the
same sound after a vowel, so he would either drop it, or change it to
another sound. For example, if the therapist modeled (said) the sounds
"pa," Tanner could say "pa." If the next word the therapist modeled for
him was "up," Tanner would say "uf." This has to do with the difficulty
of movement of the tongue and mouth positions. Professionals refer to
this as "motor planning" (which is why apraxia is also called a motor
planning disorder.)
4. Tanner understood
us and knew what he wanted and developed his own "sign language" to try
to communicate. They say this is very common with apraxic children. When
Tanner has more to tell us than he is able to say yet with words, he now
also uses sound effects with his unique sign/body language. He's actually
pretty good at making himself understood. (Remember Harpo Marx?) Many
children with apraxia have high receptive (understanding) ability, and
low expressive (talking) ability. There was never a doubt to anyone that
Tanner was intelligent and apraxia does not affect a child's cognitive
(intelligence) ability. (To discern your child's cognitive ability, view
what his/her evaluations state about expressive and receptive ability.)
Due
to the differences in appropriate therapies and treatments, it is horrible
that apraxic children are sometimes misdiagnosed as autistic, or even
mentally retarded. Apraxia can co-exist with conditions like autism, cerebral
palsy, downs, etc., but apraxia is often times there "alone." (I'll explain
later on.) Too often, children are diagnosed as having "receptive" delays,
when they do not have receptive delays. Receptive delays are a "red flag" that there could be cognitive issues going on. It's one thing if there
really are cognitive issues, but seek second opinions privately from a
speech and language pathologist, developmental pediatrician and/or neurologist
knowledgeable about apraxia and other disorders.
5. Even
when Tanner learned to say the sound "t," if he tried to say the word
"pot" it would come out "pop," because he will switch the "t" to a "p." The professionals say this is due to motor planning difficulties and children
with apraxia will carry the sound from the beginning of the word to the
end.
6. Tanner's intelligibility will "break down" the longer the word or sentence
is. Even with a model, he can't repeat back a longer sentence using all
the words yet, he will repeat back only a few of the words.
7. Tanner
never "picked up" speech like other children. He also seemed to regress
and didn't talk at all when he was around large groups of children that
were talking and playing, even when they tried to play with him. He tended
to do better with one other child, or his brother and maybe one more.
Then he would try to talk too. Tanner's older brother was also a late
talker, but that was because of birth injuries that he was in therapy
for from birth. (He's doing great now! He's 6 and unless I tell someone,
they never would have known.) Where Tanner wilted in
groups of children, Dakota thrived, and Dakota did "pick up" speech when
I put him in a wonderful preschool a few times a week.
8. When Tanner started
to use words, he would repeat the same sound over, using sentence inflections,
rather than saying the different words. A good example is, he would point
to the door, or out the window, while saying, "die, die, die, die, die."
Of course that meant, "I want to go outside." I heard some apraxic children
are monotone, but that wasn't Tanner.
We would
have to say to Tanner, "I...want...to...go...outside," really emphasizing
and waiting after each word, so he could repeat it. Tanner can now say
many words clearly, but he still does better when he hears someone say
them first. Now at 4, Tanner will, "I doe side now peas. Tay?"
9. Tanner's apraxia still affects his ability to use the back of his tongue
to say sounds like "k" or "g." He substitutes the "k" for the "t," so
cookie is "tootie." And the "g" for the "d," so girl is "dirl." He has
yet to make either the "k" or the "g" sound, but we are working on it.
When Tanner said, "hud n' tiss," the other night, I had to stop and switch
the "d" and "t" to know he was asking for a hug and a kiss.
10. Tanner
talks better when he is singing, or playing, when he isn't thinking about
it.
11.
I could go on, but
another one Tanner has developed now that he is really pushing himself
is stuttering (dysfluency.) This does not always happen with apraxic children,
it's partly developmental, but it's not uncommon with apraxia. Many children
with apraxia can get "stuck" here for a bit. I say how cruel, he has trouble
talking, and to add stuttering to that is like adding insult to injury.
Many experts say his brain is working faster than his mouth. You can visibly
see him struggle to talk when he does. Lots of thought goes into each
word; you don't see that with late talkers. I never did.
Some "soft" neurological signs that are not uncommon to apraxic children:
I
thought Tanner only had apraxia, with no other issues, but I was wrong.
These other "issues" however are typically overlooked by us as parents,
and by many pediatricians, however these are the conditions that neurodevelopmental
MDs (developmental pediatricians and pediatric neurologists) are trained
to spot. "Soft signs" which typically present as mild
in most of our children -which is why they are overlooked -such as hypotonia
or fine or gross motor planning issues of the body, or sensory integration
dysfunction.
Even
though all of us and Tanner's regular pediatrician thought Tanner was
fine outside of being "just a late talker" had other "neurologically
based" signs, hypotonia and sensory integration disorder that none of
us knew how to spot. I know that "neurological soft signs" may
sound severe, and perhaps they could be, but fortunately because Tanner
had early intervention, he is overcoming them, and they are now only noticeable
to experts. Both were treated by Occupational Therapists, Physical Therapists
and even his Speech Professionals as well.
Hypotonia,
or low tone, gave Tanner the appearance of a Cherub, and that was his
nickname when he was 2, "Cherub Boy." Everyone said that Tanner looked
like a Cherub because he was so cute. Hypotonia, however, needs to be
addressed, because it affected Tanner's truncal strength and breath control,
which is important for many reasons, including speech.
Tanner
also had mild sensory integration (SI) issues. There is lots of information
online about SI, but mostly it makes the child seem like the tantrum child,
for "no" reason. Children with hSI do not sense things like we do, the
same way all the time. One example from when Tanner was a baby (and this
is before I knew what SI was, or that Tanner had it) is that he would
sometimes "freak out" when I tried to bring him into a store. He would
scream like he was in intense pain, like there was a pin in him, tighten
his whole body and act hysterical. Other shoppers would look at me like,
"What are you doing to that child!" My sister, who is a certified nanny,
was often with me when this happened, and we would check his diaper, offer
a bottle, take all his clothes off, looking for what was causing the screaming,
but we never found anything. This same child would go for shots and wouldn't
cry. I used to call him the "tough one." More
recently, I was tickling his arm and he said, "Ow! Hurt me." I asked him,
"Does this hurt?" and tickled him again. He pulled his arm away and said,
"Yes." Sometimes if I pat his head he says "Ow," too. SI is another unknown
one, and it can affect different senses. For Tanner, it's touch.
Read
more about Parent Friendly Signs of "soft signs" to look for
in any late talker
Dear
Parents;
All these terms thrown
at you and nowhere to go to get answers to your questions about your child's
diagnoses? Here are some critical differences that may help you to determine
what, and if, your child is Verbally Apraxic. Your reports from therapists
may contain the phrases in italics below.
Your child may
say the same word four different ways. Sound
errors are significantly inconsistent.
Your child adds
vowel sounds to the end of words that finish with a consonant (Up-pa).
Intrusion of a vowel.
Apraxic children
may be able to produce sounds in imitation, which they do not use in
connected speech.
Your child becomes
less and less understandable as his speech unit gets longer. Severity
of apraxia increases as the length of the word or utterance increases.
Your child tends
to mix-up consonants within a word. Sound swapping errors are common
(efelant vs elephant). Metathetic errors are frequent.
Your child may
drop final consonants in single syllable words (omission errors)
simplifying his/her speech unit to contain consonant-vowel pairs in
short strings. "Cat come home" = "Ca co hoe".
Your child may
not be able to change his pitch during speech production. Prosodic
disturbances of speech, pitch, stress and rate are frequently in error.
Your child may
use only /b/, /m/, /d/, /g/, /z/ with simple vowels like /uh/, /ah/,
/oh/, but not /p/, /t/, /k/, or long vowels /ay/, /ee/, /i/ or /ow/.
Voicing errors, nasal resonance errors, and lengthening vowels before
omitted consonants are present.
Your child has
difficulty repeating two different consonant + vowel pairs over and
over again. Marked difficulty repeating series of speech sounds in
diadokokenetic series /patika/.
Other
elements of difference include:
a big discrepancy between your child's ability to move his/her lips,
tongue and jaw for eating or non-speech activities and the use of these
parts during speech on command.
general
normal EEG/MRI results
the
ability to understand everything said to him/her. Normal receptive
language.
traditional
speech therapy techniques are ineffectual. General speech progress is
slow and requires intensive, appropriate, speech therapy.
Apraxia
of speech is not a developmental disorder but a neurological disorder.
A pediatric neurologist evaluation along with a speech assessment from
an experienced speech therapist will be crucial for an accurate diagnosis.
After
that, the therapy approach should focus on the motor planning issue, as
well as the language issue. Reading and writing expression will need consideration
as well. Just presenting a word as a model will not meet an apraxic child's
needs for therapy. Visual cues and kinethestic or tactile information
must also be provided. The goal of therapy should always be to increase
the automatic movement of speech and increase functional communication
as quickly as possible.
Lori
Roth MS CCC/SLP
