Shahnoor Dharamsi MS, OTR/L and Amy Berss Sherman, M.A., CCC-SLP
Apraxia is a weakness in motor planning, i.e., a disconnect in the brain that interferes with a child’s ability to “just do it.” A child with apraxia has trouble imitating and repeating the movements that come naturally to other children. We take for granted the movements and timing involved in catching or kicking a ball, speaking words and sentences, or tying shoes. Children with apraxia have to be taught each smaller step that makes up the major task.
A person with apraxia has a neurological disorder where he is unable to execute movement. Typically, most people do not spend time thinking about what is required to catch a ball or to combine sounds to say a word; however, someone with apraxia or dyspraxia has to work at each part of the movement to coordinate a task. Then, the task is further complicated by the need for repetition until it becomes a learned behavior that flows easily. Apraxia is a movement disorder in which a child experiences a disconnect between what he wants to achieve or accomplish and the ability to plan and coordinate the movements required to reach the end result.
What does apraxia looks like?
A 6-month-old is learning how to crawl. She tries to transition from sitting to crawling, but keeps falling over. When she is placed in the crawling position, she tries to rock back and forth, but is not able to coordinate the movement of moving an arm and the opposite leg to begin the crawling pattern.
A 2-year-old girl can organize her thoughts inside her head and knows what she wants to say, but she cannot appropriately express herself with the words out loud. She hums aloud with meaning, in tune, and inflection to familiar songs, yet cannot coordinate the lips, teeth, jaw, and tongue to verbalize her thoughts. It is difficult for these children to learn these tasks, and their brain processes work differently from other children.
A 3-year-old communicates physically by acting out his feelings. He seems to be playing a game of charades or pantomiming because he cannot verbalize his thoughts. Imagine how difficult it is and how much work and focus it takes to get his point across!
A 5-year-old boy has more complex issues and has trouble catching a ball, as well as eating. Several different strategies are implemented to increase his ability for catching (different size balls, weighted balls, etc.), however, it remains difficult for him to grasp this concept. He may also have an issue with eating (tasting, maneuvering the food, and swallowing it) but when presented with different textures he finally accepts one that is smooth. Any amount of texture and he will gag and refuse further bites.
These are examples of bright, resourceful children who are trying ways to get their feelings, thoughts, and movements across to us, yet are unable to with their speech and motor movement. It is not because they are being stubborn, difficult, or defiant. It is because they truly cannot verbalize and coordinate the muscles to make sounds, words, or movements.
What causes apraxia?
The causes of apraxia are unknown. Some scientists believe that it is part of a neurobehavioral disorder (metabolic or genetic) or a disorder related to a child’s overall language or motor development. Others believe it is a neurological disorder (i.e. stroke or loss of oxygen during birth) that affects the brain’s ability to send the proper signals to move the muscles. However, brain imaging and other studies have not found evidence of specific brain lesions or differences in brain structure in children with apraxia. It involves the loss or impairment of existing speech or motor abilities. Acquired apraxia of speech may occur with muscle weakness (also called dysarthria) or language difficulties caused by damage to the nervous system (known as aphasia). Children with apraxia often have family members who have a history of communication disorders or learning disabilities. This observation and recent research findings suggest that genetic factors may play a role in the disorder?
Apraxia or dyspraxia?
Although in the day-to-day world, the terms apraxia and dyspraxia are frequently used interchangeably, in actuality, they have differences in their definitions. With dyspraxia, a person may have limited ability to execute movements, and this condition is usually mild. If a child has dyspraxia, his brain may not signal that he is ready to complete tasks, and therefore, the child may react in a confused or negative way rather than learn because he feels overwhelmed. When teaching a child how to complete a new task, a parent, teacher, or therapist may encounter signs of frustration or anxiety. The child may tune-out, ignore, reduce attention, or the child may complete the task how he wants to complete it, instead of listening to the directions that are provided. When the activity does not make sense, the child’s reactions and responses tend to come from a place of stress, anxiety, confusion, or frustration. Typically, the reason for the frustration may be because the child is unaware of how to complete the task that is being requested, and in turn, negative responses are observed.
Often times the words apraxia of speech (AOS), dyspraxia of speech, acquired dyspraxia, or verbal dyspraxia are used to describe apraxia; however, these are a less severe version of the disorder. AOS is a speech disorder characterized by the inability to speak, or the struggle one goes through to speak clearly. Two main types of apraxia that exist are acquired apraxia of speech and developmental apraxia of speech. Although acquired apraxia of speech typically occurs in adults, it can affect a person at any age.
The second type of AOS is developmental apraxia of speech (DAS). This occurs in children and seems to affect more boys than girls. DAS is different from what is known as a developmental delay of speech, in which a child follows the “typical” path of speech development, but it takes longer. With apraxia, a child may say the targeted word, yet cannot repeat the word or the combination of sounds that created the word, correctly over and over. Therefore, carryover to be able to put that word into a sentence becomes tedious.
Who can help?
A developmental pediatrician, neurologist, or developmental psychologist can assist in figuring out the appropriate diagnosis. At times, doctors may request several studies to be completed, such as an MRI, to determine if it is apraxia of speech; however, apraxia is usually diagnosed through an evaluation. An evaluation may take several hours and may look at the coordination of muscle movements, neurological abilities, cognition, oral-motor movements, and speech-language abilities. Discussing concerns with an occupational, physical, or speech-language pathologist may be beneficial in understanding apraxia. For more information, discuss questions and observations with the pediatrician, or talk with other parents who have a child already diagnosed with apraxia. Resources are available for further information regarding the topic discussed in this article.
Now What?
Physical, occupational, or speech therapy services may help a child perform the tasks required of them. Therapists use different techniques that break down tasks into simple steps in order to teach a child how to complete certain activities. Unfortunately, no exact treatment technique works for all children who have been diagnosed with apraxia; rather several different techniques are utilized. Through one-on-one therapy services, children can learn how to coordinate and complete various tasks that initially cause struggle and frustration. Sometimes communication devices and adapted equipment are used to help a child complete day-to-day tasks. Techniques using a variety of modalities can be successful. Using the PROMPT (see resources for links) technique for speech and oral-motor improvements, movements involving coordination, crossing the midline, oral-motor exercises, listening, seeing, and feeling how the movement is made may be helpful. It depends on each child’s areas of strength and weakness in order to determine which strategy or what combination of options would be best implemented.
For children who have difficulty in the school setting, parents may also need to discuss an IEP (Individualized Education Plan) to obtain additional assistance at school. Increased assistance can be provided in the form of a paraprofessional, use of electronic devices (i.e., laptop to take notes), augmentative communication devices, or increased verbal/gestural cues to complete requested tasks. Each IEP is personalized for each child and the amount of assistance that is required can be changed.
At home, parents can use different techniques to teach their child a specific activity. For example, if a child has difficulty writing letters, using play dough, shaving cream or wooden sticks to show him how to form letters may be beneficial. Using popsicle sticks, blowing toys, cotton balls, certain food items, and different textures applied to the face, lips, cheeks, tongue, and more may provide excellent input when teaching difficult activities. Visual, auditory (sound) and tactile models for the child may assist in creating a positive change, which impacts and often reduces apraxia. Therapists can also provide different home programs to assist with activities. Schedules, timers, books, and verbal/gesture cues are typically utilized to increase the child’s participation in daily living tasks.
The good news is that there is help for your child. Once a diagnosis has been determined, then intervention can begin. You are not out there alone and there is great hope for your child.
Shahnoor S. Dharamsi has been an occupational therapist since 2002, working with children ranging from birth up to 21 years with a variety of diagnoses. She holds BS and MS degrees in Occupational Therapy from Brenau University. Her specialties include feeding therapy and sensory processing disorders. Shahnoor works with Children’s Healthcare of Atlanta providing evaluation and treatment to children of all ages. She works with Clay White providing children with sensory activities to enhance daily-living skills. Shahnoor works with the Orion school teaching and training handwriting programs, providing techniques to increase sensory processing in the classroom, and initiating innovative ways to increase social interaction skills for the children. Shahnoor is an adjunct faculty member with Brenau University. She is a member of the Professional Advisory Board for Kids Enabled (a nonprofit for parents of children with learning differences), a member of Georgia Occupational Therapy Association (GOTA), and American Occupational Therapy Association (AOTA). Shahnoor can be reached via email at funktionalkids@gmail.com.
Amy Berss Sherman is a Georgia licensed speech-language pathologist. She specializes in evaluating and treating all ages from young children to adults in the areas of speech development, oral-motor training, apraxia, language comprehension and expression, language processing, accent reduction, and voice, and has training in PROMPT. Amy’s private practice, Atlanta Speech Therapy and Training, LLC., has been serving the Alpharetta, Roswell, Milton, Cumming, and Dunwoody areas since January, 1994. Amy earned her BA in Speech-Language Pathology and Audiology in 1986 from the University of Florida. She attended the University of Memphis on a full scholarship and received her MA in Speech-Language Pathology in 1988. In 1989, she earned her Certificate of Clinical Competency. She is on the Professional Advisory Board of Kids Enabled, a non-profit for the learning differences community. Amy is a member of GSHA, as well as ASHA. She can be reached via email at atlspeech@comcast.net.
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Thank you for publishing such a clear and concise article about apraxia. Many parents know that “something” is not quite right, but are not sure who or where to turn to for help. This article is very educational, but also encouraging; it offers practical strategies that parents can implement immediately. Thank you!!
Comment by carol ann brannon — May 2, 2011 #