When children first begin talking, it is common for parents to have to ‘translate’ for unfamiliar listeners. My two-year-old daughter calls bandaids ‘ban-bans’ and refers to ‘milk’ as ‘poke’’. This makes her fairly unintelligible to unfamiliar listeners. As children continue to develop language and speech skills, their speech becomes more intelligible to a larger audience. Parents find themselves translating less and less. When a child has apraxia, however, their speech continues to be highly unintelligible. So what is apraxia? 

Definition 

Apraxia of speech is a motor speech disorder that makes it challenging to speak and clearly produce speech sounds. Apraxia of speech may also be referred to as verbal apraxia, dyspraxia, childhood apraxia of speech (or CAS), or acquired apraxia of speech. It will be referred to as ‘apraxia’ throughout this post. Motor speech disorders are neurological. With apraxia, the brain has difficulty coordinating the appropriate body parts to produce intelligible speech. This includes the lips, tongue, and lower jaw.

Cause

In many cases, the cause of apraxia is not known. Apraxia by definition is not due to muscle weakness, limited range of motion, or paralysis. It can be caused by infection, illness, injury or trauma but this is not always the case. Additionally, apraxia is not something that children can just outgrow. It can co-occur with other neurobehavioral syndromes or disorders such as Autism Spectrum Disorder, epilepsy, or Fragile X syndrome (among others).

Characteristics

Apraxia of speech may be difficult to diagnose as characteristics vary from person to person.

Some key characteristics observed in most people with apraxia include:

  • Inconsistent errors
  • Vowel errors
  • Errors producing longer syllables/sequences of sound
  • Difficulty with prosody/intonation of speech
  • Groping/extraneous movement of lips, lower jaw or tongue when producing speech

Other characteristics may include:

  • Errors in the order of sound production
  • Unusual/atypical sound errors or substitutions
  • A decreased sound inventory 

Assessment

A comprehensive assessment is required to diagnose apraxia. Screening is often the first step to assessment. Screening helps an SLP determine if there is a need for further evaluation. According to the American Speech-Language-Hearing Association (ASHA), there are currently no standardized screening tools for apraxia. Additionally, screening may reveal speech sound errors and the need for speech therapy, without identifying apraxia as a concern. Apraxia is often identified over the course of therapy, due to continued errors or any of the above-mentioned characteristics. 

Part of the diagnosis also includes ruling out other concerns. For example, muscle weakness, comprehension, or hearing problems. A comprehensive assessment for speech sound disorders includes a case history, an oral mechanism examination, and a speech sound assessment. It can also include language assessments if language concerns are present. A motor speech assessment that evaluates movement accuracy should also be included.

Activities in this exam may include: 

  • Nonspeech postures (ex. smiling) and sequencing (ex. smile, kiss)
  • Speaking tasks including single postures/sounds (ex. ‘ah’) and sequenced sounds (ex. mama)
  • Speech productions with increasing length, moving from producing a single syllable to bisyllables, multisyllables, phrases, and sentences
  • Volitional versus automatic/well-rehearsed speech
  • Sequential and alternating movements (ex. pa-ta-ka) 

Treatment 

There is no ‘one size fits all’ approach to treatment for apraxia. The following is a brief description of treatment options. Your child’s SLP can talk with you in more depth about the recommended treatment for your child.

In general, treatment for apraxia focuses on increasing overall intelligibility. It can also include supplementing/augmenting language output with aided devices as appropriate (ex. picture symbols, speech-generating devices, AAC). Treatment goals will include increasing intelligibility and improving sound and syllable shaping. It may focus on speech sounds as well as linguistic/language-based factors, to improve overall outcomes. Treatment may be frequent and intensive, however, frequency and duration can be impacted by many factors. This includes where the service is delivered, and approval from funding sources such as insurance.

Treatment for apraxia may focus more on movement patterns versus speech sound patterns and can include:

  • Shaping the best/most accurate production possible 
  • Visual cueing, which include visual cues for accurate production of sounds
  • Verbal cueing, which includes verbal instructions on how to move articulators into the correct positions for speech production
  • Tactile cueing/facilitation, which includes direct tactile cues (touch) for correct placement and production

Possible Outcomes

Treatment is important to support children with apraxia to improve intelligibility and decrease the presence of errors. Many children have success in improving their intelligibility through speech and language therapy. Some, however, will have persisting speech difficulties through school and into adulthood. Even with improved intelligibility, persistent errors may include difficulty with prosody, difficulty with unfamiliar multisyllabic words, and persistent speech sound distortions. Discuss transition planning with your child’s SLP. This will support their communication skills into young adulthood. 

How can I help my child? 

If your child has a diagnosis of apraxia or suspected apraxia, family support is key. Parents and caregivers play an important role in creating a supportive environment for their child to communicate. You can help them by showing patience when they speak. Create low-pressure speaking situations and be positive about your child’s efforts. Model for others how to be patient while your child speaks. Children with apraxia benefit from a supportive environment, in addition to speech and language therapy, to help them feel more confident in their communication. 
If you have concerns about your child’s ability to produce speech sounds accurately, we recommend that you schedule a consultation or evaluation with a licensed speech and language pathologist to discuss your concerns. If you’re in the San Diego area, our directory is a great place to start your search to find an SLP who is the right fit for your child.

Cocoa Berry
Author: Cocoa Berry