Childhood Apraxia of Speech (CAS) and Autism
Patti Hamaguchi, M.A., CCC-SLP
Four year old Ben climbs up the stool and announces, “Jah gih ME… day-duh”. His mother looks down and sees the bagel in his hand, then to the couch where Ben’s brother James is sitting. “Yeah I gave it to him.” Oh, ok, ‘James give me bagel.’ Got it. For so long, the struggle was to get Ben to point. To sign. To talk. To talk to someone in particular. To move beyond nouns and rote phrases. So saying “James give me bagel” brings joy to his mom in that it is a spontaneous and beautifully appropriate comment about something Ben is experiencing. Yet…there is a nagging feeling that with the emergence of Ben’s language development, his articulation seems to often be incredibly hard to understand.
For many children, it is difficult to command their mouth to move the way they want it to, in order to speak correctly. When a child is very young and delayed in talking, we often suspect this problem, but really can’t definitively diagnose it until there are some verbalizations (or attempts at talking) that we can properly analyze. Apraxia (known in children as “Childhood Apraxia of Speech” or CAS) isn’t a problem with weak muscles. Their muscles are often just fine. The problem is with the “wiring”- getting the message from their brain to their mouth. When a child has apraxia, it can create significant difficulties in learning to talk and be understood. When a child has CAS, we find that the child’s receptive comprehension of language is quite a bit higher than their expressive language. We are also finding that more and more children with autism exhibit childhood apraxia of speech as well, often in cases where speech is slower to develop. ( Exact, reliable statistics are still not known.)
Therapy for children with apraxia usually needs to be fairly intensive in order to achieve the desired results, typically 3-5 times per week. The frequency is more important than the length of time. In other words, it is better to have 3 or 4 sessions of 30 minutes, than one long session for an hour and a half. The parents and child will also need to work hard at home with the recommended exercises. Progress can sometimes be slow, but there should always be progress. For children with severe CAS with little functional speech, augmentative communication systems are often recommended to help the child have some means to communicate. That said, for children with autism, the primary emphasis of speech-language therapy should always be developing functional language, social engagement, reciprocal interaction/joint attention, initiation, and learning how to put words together. The biggest challenge to both the speech pathologist and the parent will be to find a healthy balance between helping to support the child’s articulation improvement while not putting too much emphasis on the pronunciation itself in a way that will literally turn off the child to the communication process altogether.
What are the symptoms of apraxia?
• Delayed onset of first words, little babbling, and lots of grunting or whining instead of recognizable words
• Inconsistent and atypical speech errors- the words are not produced the same from production to production
• A noticeable reduction in speech intelligibility as the length of the phrase or sentence increases. That is, the child can sometimes say the word correctly when imitated in isolation, but makes more errors when the word is used in a sentence.
• Has distortions of vowel sounds, which is less common with other articulation disorders.
• Typically has a severe articulation disorder, making it very difficult to understand the child
• Rate of speech is often slow and labored, often accompanied by poor jaw control.
How does verbal apraxia affect a child?
Children with verbal apraxia can struggle with their articulation, but also with putting sentences together and using grammatical rules correctly. There is often a high degree of frustration as they perform their speech exercises because it is very difficult to do.
Children with apraxia often have difficulties in the areas of expressive language, word retrieval, auditory processing, attention span, learning disabilities, and sensory integration. There is typically accompanying difficulties in motor planning in other fine motor areas (e.g. handwriting) and gross motor (coordination and balance).
What will the SLP do in therapy for this problem?
Unfortunately, there are no easy solutions for remediating apraxia. There are a number of interventions which can be helpful. Sometimes the speech-language pathologist needs to experiment a bit to see which one is most helpful or use a combination of several approaches, depending on the child’s response and progress. Here are a few that should be considered:
• Tactile Prompts: This refers to the speech-language pathologist using touch cues on different points in the oral-facial area. One well-regarded method is called the “PROMPT” system, developed by Deborah Hayden. This multisensory approach helps the child “feel” how to move the articulators to form a sound or sequence of sounds.
• Word shells: This method is particularly helpful in the early stages of therapy for children who have great difficulty producing the target word. The speech pathologist provides an approximation of a target word instead of the actual word-a simplified version of the actual word. For example, if the child cannot say his brother’s name (Alexander) the speech pathologist may help the child produce a consistent “version” of the name (such as “Anna-sanna”) so there is at least a label the child can use for everyday, functional communication tasks. Over time, the word is formed with greater accuracy. This approach is advocated by Nancy Kauffman.
• Exercises to improve the flow of speech and reduce the choppy, labored manner of speech can be helpful, especially for predictable conversational questions, responses and “power phrases” such as “I don’t know.”
• Jaw/tongue/lip control: If the child has accompanying difficulties with jaw, tongue or lip control, a variety of exercises may be employed in order to facilitate smaller and more precise jaw /tongue /lip movements so the positions of the speech sounds can be made with greater accuracy.
• Articulation drills: The key for children with apraxia is to have many, many repetitions of newly-learned words, and to try and minimize over-exaggerated productions as much as possible so the speech pattern sounds natural. For children with autism, the focus of these exercises should be the production of words that are essential to the child’s everyday life, such as the names of his peers, teacher, address, etc. so it is integrated into a meaningful context.
What can parents do to help?
Parents can help their child in the following ways:
1. Be patient and don’t draw too much attention to how your child pronounces words. It’s important not to make every communication interaction about “fixing” the child’s speech. Focus on the message and content. Avoid turning your interactions into mini-speech therapy sessions. (VERY important!)
2. Become informed. There is a terrific organization The Childhood Apraxia of Speech Association of North America (CASANA) and their website, apraxia-kids.org, that you should check out. It has lots of great information about this disorder and supportive chat groups and message boards for parents.
Patti Hamaguchi, M.A., CCC-SLP is a licensed speech-language pathologist and the Director at Hamaguchi & Associates Pediatric Speech-Language Pathologists Inc., (Cupertino) and the CEO of Hamaguchi Apps for Speech, Language & Auditory Development. She is the author of Childhood Speech, Language & Listening Problems: What Every Parent Should Know, A Meta- cognitive Program for Treating Auditory Processing Problems, and It’s Time to Listen.
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