Apraxia vs. Dysarthria

A speech-language pathologist is a care provider who assesses, diagnoses, treats, and aids in preventing disorders related to speech, language, cognitive-communication, voice, swallowing, and fluency.

Motor speech disorders are the inability to speak properly when formulating sentences or saying single words. Coordination, timing, and strength needed to verbalize words are affected. When speaking of motor speech disorders, two main disorders are dysarthria and apraxia. When comparing dysarthria and apraxia, patients who present with dysarthria show consistent errors in speech while patients who present with apraxia demonstrate inconsistent and unpredictable errors.

Childhood apraxia of speech, also commonly seen in literature as CAS, is a motor speech disorder that is characterized by the child demonstrating difficulty of producing sounds, syllables, and words. This is not because of muscle weakness or paralysis but rather the child’s brain has problems planning to move the articulators needed for speech, such as lips, the mandible, and tongue. An individual with apraixa is aware or what they want to say but the brain is unable to plan muscle movements necessary to verbally communicate the individual’s ideas in a fluid manner.

Depending on age, there are different symptoms of a child with apraxia however, not all children diagnosed with CAS show the same signs. In a very young child, a child may not coo or babble as an infant, have late production of first words, demonstrate the inability to combine sounds, and have difficulty in eating. In an older child, there is a pattern of inconsistent sound errors, difficulty imitating speech, difficulty saying longer words, difficulty speaking while anxious, and may be seen groping while attempting to produce sounds to coordinate articulators such as lips, tongue, and the mandible. The child may be hard to understand or have choppy, monotonous speech (Caruso & Strand, 1999). Other issues noticed are delayed language development, difficulties with fine motor movement, coordination, hypersensitivity or hyposensitivity in the child’s mouth. An example of hypersensitivity or hyposensitivity in the mouth is the dislike of brushing teeth or eating crunchy foods. As with most speech problems, the child diagnosed may have trouble learning to read, spell, or write.

There are numerous methods and techniques used to diagnose CAS. The different assessments serve the purpose of assessing the child’s oral-motor abilities, melody of speech, and sound development (Forrest, 2003). Prior to motor assessments, an audiologist should perform a hearing evaluation to rule out hearing loss as a possible cause of the speech difficulties. During an oral motor assessment, the speech-language pathologist will assess for signs of weakness or low muscle tone in the lips, jaw, and tongue; in order to differentially diagnose dysarthria. Typical children with CAS do not exhibit signs of weakness, however, assessing for this helps limit the possibility of other disorders. During this exam, it’s assessed how well the child can coordinate mouth movement by performing prompted tasks such as smiling, puckering of the lips, or frowning. In addition to movements, the child’s rote ability is also tested by comparing the individual’s function to actually performing a real life situation versus pretending (Forrest, 2003). An example of a rote ability assessment would be asking the child to lick a lollipop versus pretending to lick a lollipop.  Intonation, or melody of speech assessment, determines whether or not the child can use pauses and pitch changes to mark different types of sentences such as interrogatives or declaratives. In a speech sound assessment, the clinician evaluates vowel and consonant sounds, as well.

For children diagnosed with CAS, there are different treatments available. Research has shown that children who receive intense, frequent, one on one treatment have much more success than those children who receive inconsistent treatment or participate in a group session. The treatment focuses on improving the planning, sequencing, and coordination of muscle movements for speech production (Forrest, 2003). As with a large majority of treatment plans, time and commitment is stressed to the patient and in this case, to the child’s care-provider.

Childhood dysarthria is a motor speech disorder that affects speech by weakened muscles. It’s caused by neurological damage prenatally, perinatally, or postnatally. It’s characterized by the strength, steadiness, tone, accuracy, and speed or range of movement. An individual with dysarthia can have all speech systems affected such as, respiration, phonation, articulation, resonance, and prosody.  There are numerous types of dysarthria such as flaccid, spastic, ataxic, hypokinetic, hyperkinetic, and mixed (Walshe & Miller, 2011). Dysarthria can either be congenital or developmental. In the case of congenital dysarthria, a child experiences development of dysarthria at birth and developmental dysarthria takes place prior to the development of speech and language. There are also instances where dysarthria is acquired from an injury.  Dysarthria has various combinations of weakness and hypertonicity in the muscles that control phonation, respiration, resonation, and articulation. Characteristics of childhood dysarthria manifests in each of the speech systems. Respiration is at a low intensity and speech is typically limited to short phrases because of the low intensity respiration. Breathy phonation is common because of unilateral or bilateral vocal fold paralysis. Hypernasality during resonation is because of weak movement of the soft palate which causes velopharyngeal incompetence. Articulation is distorted therefore imprecise consonants are produced. Imprecision in articulation is due to weakness and the in-coordination of the mandible, lips, and tongue. “Hot potato speech” is a way to describe dysarthric speech because it sounds like someone is trying to talk with something hot in his or her mouth (Fogle, 2008). Children diagnosed with dysarthria also display non-speech characteristics such as having difficulty with sucking, chewing, or swallowing. As a result of these difficulties, drooling, gagging, or choking may be seen. Childhood dysarthria, there are often other associated syndromes or disorders such as Down’s Syndrome or Spina Bifida (Walshe & Miller, 2011).

Dysarthria tends to affect all speech systems, therefore, each system needs to be individually evaluated. Since having any in-coordination of the soft palate or articulators can cause distorted speech sounds, clinicians evaluate the symmetry and structure of each articulator. The articulators evaluated include the mandible, tongue, and lips. Their functioning is also evaluated such as the range of motion, strength, coordination, and rate of movement (Fogle, 2008).

Due to brain plasticity, children generally have a better outcome from treatment. The main goal for children diagnosed with dysarthria is to help them maximize their speech intelligibility. Other goals of treatment include slowing the rate of speech, improving respiratory support, strengthening muscles, increasing mouth, tongue, and lip movements, improving articulation, and family teaching (Caruso & Strand, 1999). Sometimes, in severe cases, the use of an augmented communication device may be used. Treatment for dysarthria is based on severity; the level of severity and type of dysarthria forms the type of intervention used. As seen in mild to moderate cases, compensatory strategies are used to assist in the child’s function. In severe dysarthria, alternate forms of communication tends to be necessary. It’s important for treatment to also incorporate the development of literacy and self-esteem (Walshe & Miller, 2011).

According to Pennington (2007), speech and language therapy for young children who have motor disorders targets both the children and parents. Therapy for parents often involves training about communication and how to foster children’s development. From an early age, interaction patterns between the children and their parents may differ from those involving non-disabled children, therefore, children are then at risk of failing to develop a full range of communication skills. Speech and language therapy for children with motor speech disorders aim to maximize their communication skills and help them to take a full and active role in conversation. Therapy can focus directly on the children, teaching them individual conversation skills, introducing augmentation communication systems, or working on maximizing their intelligibility of their speech production.

Learning the steps involved in a clinical practice ensure successful implementation of diagnostic and intervention procedures. There’s a need for speech-language pathologists to problem solve in an organized way in addition to logically analyzing the components of the speech processes. In doing so, impairments will be isolated and specific goals can be targeted. Understanding the basic anatomical and physiological foundations of human communication is an essential skill for every clinician. Once clinicians understand the basic anatomical and physiological components of human speech and language, with experiences, diagnosing, and treating specific speech language impairment becomes easier (Pena & Kiran, 2008).

In order to be a successful speech-language pathologist, one must be capable of expressing clear views about training programs and their outcomes for both the child being treated in addition to the parent or family unit. In order to concisely express this, the speech pathologist must be thoroughly familiar with the pathology of specific disorders, diagnostic tests, and rehabilitation procedures (Janet, 2010). Speech-language pathologists develop a specific plan which is individually created to target the patient’s needs. Clinicians should communicate diagnostic test results, diagnose, and propose treatment in a way that is understood by patients and families. Compassion is a necessary characteristic to hold; according to Janet (2010), speech pathologists often grow to profoundly know their client through their struggles. Often the case with children, progress may be slow so patience, compassion, understanding, and good listening skills are necessary throughout treatment.

Lisamarie Ricigliano M.S. CF-SLP, TSSLD

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