"Apraxia,
What's That?"
Here are some answers...
Medical
Director, NYC Early Intervention Program
Medical
Director, CHERAB Foundation
Presented at:
The First Conference for
Verbal Apraxia, July 23-24, 2001, Headquarters Plaza Hotel, Morristown, New
Jersey, U.S.A.
What’s in a Name and
Definitions
What
is apraxia, verbal apraxia V.A. (or apraxia of speech or verbal dyspraxia), orofacial
apraxia and motor apraxia. How is V.A. 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 & 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" maybe generic)
Sounds/syllablee
omissions, vowel distortion, cluster simplificatio
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 (not always relevant)
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) Presschool Children with Inadequate Communication
(2)
Wetherby, et al (2000) Autism SpectrumDisorders
Verbal Apraxia
Controversies (1)
Nomenclature:
Nameborrowed
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) (3) Ferry , Hall $ Hicks (1975)
(2)
Yoss & Darley (1974) (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 tx)
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 dx 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
