Apraxia and Autism: Where to Start

Because I think I’m generally hilarious, I decided that an unofficial subcategory of “Take That, Autism!” shall be “In Your Face, Apraxia!” because we’ve got more than one challenge on our plate.

I’ve talked to you about what Childhood Apraxia of Speech is and incidence rates of it in children with Autism here. Now, I want to tell you about what we’ve been working on and how to prepare ourselves for “true” intervention for apraxia.

Caleb says so many things that aren’t jargon, but true productions that are just that unintelligible. Because apraxia. Apraxia makes vowels beastly to form, consonants the trickiest of the tricksters, and then when you go to put those Consonants and Vowels into various CV, VC, CVCV, CVC, etc. sound combinations it all can become a very “say what?” situation. And that’s when you’re able to imitate things verbally on a 1:1 compliant ratio. But what about when you have Autism and are 3 and your verbal skills are just starting to develop and your ratio of imitating a single word is more of a 20:1 input/output ratio? And that’s just to maybe label…..NOT to produce specific sounds in specific sound patterns.

But your child wants to try. You can tell. They want to try to say more things. Where do you start? Here’s where we’re at.

Imitation Hierarchy

There are sooooo many things kids imitate before they imitate at the word level. Here’s the breakdown:

– Gross Motor Movements (jumping, kicking, etc. and then expanding to movements with objects such as rolling cars)

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Fine Motor Movements (clapping, motions to songs, playing with small objects and tools, etc.)

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– Oral Motor Movements (blowing, sticking out tongue, kisses, etc.)

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– Imitation of nonsense or environmental sounds (moo, vroom, etc.)

– Imitation of single sounds and simple words

I could not expect Caleb to say “car” if he wasn’t rolling a car across the floor or knew that it went “vroom.” And this hierarchy is not profound. It’s typical language development, really. The difference is that in typically developing kids, the first 4 steps usually don’t need to be “taught”. You probably don’t know when your child started imitating actions, play, animal sounds, etc. because they just kind of did it. Everything with Autism takes more work , more time, and a lot of times formal intervention to learn. Caleb did not imitate rolling a ball. It was taught. He didn’t start imitating motions to songs until last summer right before he turned 3. And it took a lot of watching YouTube song videos and hand-over-hand until he knew his own head, shoulders, knees, and toes. You can’t just look at Caleb and say “stick out your tongue”. It has to be this very elaborate back and forth in front of a mirror where ridiculous faces are made and you will ultimately end up getting lizard licked. Right now we’re teeter tottering between imitating nonsense sounds, single sounds, and 1 syllable words. Caleb can do some solid “ahhhhhhh”, “eeeeeee”, “oooooo” imitations to practice vowels and early developing consonants are coming through, but we are not ready to imitate sounds at the word level. We’ll get there, but it’s a marathon, not a sprint.

I wanted to review a solid imitation hierarchy because when we have 4, 5, 6, year olds who are not yet talking it can be very instinctive to just throw words at them and hope they stick. But imitation of movements, actions, and sounds are a crucial part of development. And if those skills didn’t develop, they need to go back and be addressed and facilitated. That does not mean; however, that you should not work on talking about all of the things all of the time. While you’re working on learning actions, talk about them. When you’re playing trucks, make truck sounds. You’ll get some back sometimes and that’s awesome. You don’t want to walk before you crawl. And I know parents get jazzed and bragged “my child didn’t crawl, they went straight to walking and walk just fine!” but I promise you don’t want that. Yes, maybe they’re walking now but if they never learned that crawling step, there could be implications one day of never having learned the proper skills needed for appropriate visual-spatial recognition, motor coordination leading to good handwriting, and a host of other things (which is a whole other post for a whole other day). Same principle applies here. Imitating actions contributes to increased attention to task, appropriate play development, improved eye contact and social interaction, etc. Do you want to skip straight to talking and skip all those other important developmental milestones? Probably not. No matter what your child’s age, it’s never too late to go back and start working on those skills.

Please stay tuned for future updates on Caleb and our Apraxia-Autism interventions (that will challenge mommy’s creativity and ingenuity) as we find the strategies and approaches that he’s going to respond best to. Thanks for being a part of our journey.

Love, Autism, and Apraxia, everybody. Here’s to the feeling of satisfaction we’ll have when we end up where we’re going to end up and the patience for us to hold on tight until we do.

Erin

Apraxia of Speech: Defining and Describing the Disorder

It’s Saturday night, it’s getting late (in Mom world at least), I’ve been taking care of two sick kiddos all day, but I just wanted to introduce a topic I’ll be talking about a lot coming up because it’s something we’re starting to work on everyday: Apraxia of Speech.

What is Apraxia?

It’s a motor speech disorder. What’s that? Speaking feels so natural but is actually a very intricate and complex process. A motor speech disorder means there’s difficulty with the motor planning part of moving your tongue, lips, etc. to execute the necessary sounds in the consonant-vowel combinations they need to be in to produce a target word. The words are in the child’s head, but the articulators have a hard time executing the movements to make those words.

What does Apraxia look like?

Here are some of the more common signs and symptoms:

  • delayed acquisition of speech/language milestones
  • very limited inventory of consonants or vowels a child is able to produce
  • difficulty producing multi-syllable words
  • atypical sound error substitutions and inconsistent use of those substitutions. Example: Most kids who can’t produce a /g/, substitute it with a /d/. That would be a typical substitution. If they make that /d/ instead of the /g/ every time, that’s a consistent error. If they can’t produce a /g/, but sometimes produce an /l/ or another sound or sometimes completely omit the target, those are atypical and inconsistent errors which are more concerning.
  • gap between receptive versus expressive language abilities, meaning a child can understand much more than they are able to express verbally
  • Groping: abnormal movements of the lips or tongue that make a child appear to be physically struggling to verbalize something
  • difficulties (sometimes extreme) with intelligibility

Is there a relation between Autism and Apraxia?

I am not a doctor, so I will just tell you some research statistics here. There is research that has come out in recent years that indicates a higher incidence rate of Apraxia of Speech in children with Autism Spectrum Disorder. That does not mean that having Autism means you have Apraxia or that Autism causes Apraxia. It just means that when you isolate a population of children who have Autism and another population of children who are otherwise typically developing, the group of children with Autism may have more children who have a true diagnosis of Apraxia versus the typically developing group. Dr. Cheryl Tierney, M.D. published a paper in the Journal of Developmental and Behavioral Pediatrics in 2015 that found that 64% of children who had a diagnosis of Autism Spectrum Disorder in her clinic also met the diagnostic criterion for Apraxia of Speech.

Do I have a two cents on it? You know it. I always thought….even before I zeroed in conclusively on Autism…..that Caleb may have Apraxia. He was really young and it’s so difficult to label accurately at that age, but I like to think that I am very good at my job and that I know my child very well, so it most definitely was brought up to my colleagues and his pediatrician as a possibility. Now that he is becoming more verbal on a daily basis, the fact that he is having such  a hard time coordinating that little mouth to say what I ask him to say is glaring to say the least, really.

There’s lots more I can go into about how Apraxia of Speech can be addressed therapeutically, the importance of tactile cues, etc…..but I’d be here all night and it would be overwhelming. What I would like to leave you with is the first step of what you should do if anything that you read above alerts you to red flags in your child: talk to your child’s doctor and get a script for a referral to a speech therapist. Therapeutically, for myself as a professional, it’s very important to me to determine if a child does in fact have Apraxia of Speech because whether or not it is present will absolutely dictate how we go about intervention and the order that I pick targets to work on. 

Here are some things that I WILL leave you with though!:

  • Check out some infographics and links to articles on the “Take That, Autism!” Apraxia Pinterest Board.
  • “Take That, Autism!” also has a YouTube channel now! Here are some links to a couple videos of Caleb so you can hear an example of severe apraxia. Listen for the decreased use of consonants, extreme difficulty with anything more than one syllable, limited intelligibility, etc. Some attempts sound like babble or just a vocalization as a place marker but hey…..we’re getting there. And one day, with the most intelligible speech he can muster up, Caleb’s gonna post a video on YouTube hollering “Take That, Apraxia!” Here are the links:
  • Don’t forget to follow us on Instagram @take_that_autism. Caleb has a sweet video that’s a good example of his speech abilities while he “reads” The Very Hungry Caterpillar on there.

Let me know if you have any questions! Catch me at ErinSamsell@takethatautism.org