Early Communication Skills for Children with Down Syndrome

From Chapter 8: Speech and Intelligibility Problems

Childhood Verbal Apraxia
In contrast to dysarthria, childhood verbal apraxia is a motor programming problem, not a muscular problem. Children with apraxia, often called developmental verbal apraxia, developmental apraxia of speech (DAS), or pediatric verbal apraxia, have the physical ability to make the movements needed for speech, but have difficulty putting them into proper order. The muscles themselves are not affected, and there may be no difficulty in using the muscles for eating or swallowing.

Children who have childhood verbal apraxia are very inconsistent. One time, a child may be able to produce his cousin's name clearly; another time, he may great difficulty. Typically, children with apraxia also make many sound reversals in their words. They might say "aminal" or "hopsital" or "efelant." They be physically capable of producing all the speech sounds, but have trouble putting them in the proper sequence. When the speech-language pathologist tests for this problem, she usually asks the child to say multisyllabic words such as "hamburger," "elephant," or "hospital," or complex words such as "aluminum," "linoleum," or "statistics." As words get longer, children with motor programming problems such as apraxia start to have difficulty. So, a child might be able to say "light," but "lightning bug" may be difficult. Or "eel" might be fine, but "electricity"will be difficult.

Many children with Down syndrome appear to have difficulties with motor planning for speech. In a survey of over 1000 families that I conducted in 1994, 48 to 72 percent of parents reported that their children had signs of motor planning problems, including difficulty in sounds and making sound reversals and sound errors. The parents of younger children reported fewer problems; the parents of older children reported more problems, which is why there was such a range. This is probably because younger children are using shorter, less complex words, while older children are using longer phrases, sentences, and conversation.

Strangely enough, children with Down syndrome have historically not been identified as having childhood verbal apraxia. This is because early studies that identified and described the disorder included only individuals who demonstrated "ormal intelligence,"hearing within normal limits, and absence of muscle weakness or paralysis. The diagnosis of childhood verbal apraxia was not generalized beyond the original subject groups. Another problem is that children with Down syndrome often have oral motor difficulties such as feeding problems and low muscle tone, in addition to motor planning difficulties. Sometimes problems that are really due to apraxia are attributed to the oral motor difficulties alone. The bottom line is that assessment and treatment for childhood verbal apraxia has usually not been provided for children with Down syndrome.

In a recent survey of over 1500 families (Kumin, 2003), to determine whether apraxia is a widespread problem for individuals with Down syndrome, results confirm that children with Down syndrome are not being diagnosed with childhood verbal apraxia. Whereas 61 percent of the families had been told that their child had oral motor problems (such as low muscle tone in the facial muscles), only 16 percent of the parents had been that their child had apraxia. (And those who were told that their child had apraxia were always given that diagnosis in conjunction with a diagnosis of oral motor problems. That is, no child with Down syndrome was diagnosed solely with childhood verbal apraxia.) And yet, even when parents had not been given a diagnosis of apraxia, survey responses often documented that the children were exhibiting many symptoms characteristic of childhood verbal apraxia. The survey also documented that children with Down syndrome who have apraxia tend to begin speaking at a later age (average five years) and have more difficulties with speech intelligibility than other children with Down syndrome.

Some current definitions of motor planning difficulties are beginning to include children with Down syndrome (Hall et al, 1993). Whether the motor planning difficulty in children with Down syndrome should or should not be labeled as childhood verbal apraxia, developmental apraxia of speech,etc. can be debated by others. My concern is that we learn more about the difficulties so that children with Down syndrome get the help they need.

Characteristics of Apraxia
Childhood verbal apraxia is defined by a cluster of characteristics of speech. No one symptom must be present for a diagnosis, but having certain symptoms in combination leads to the diagnosis. The most frequently reported symptoms that differentiate this disorder from other speech disorders include:

Struggling or groping when speaking or trying to speak. Your child seems to be working hard to talk, but the correct sounds are not coming out. Sometimes, you even see him move his lips or tongue, but he is not saying the correct sounds.

Inconsistency in sound and speech production. One time, he can say a sound or a word clearly, but at other times, he has great difficulty with the same sound or word.

Less sound play (babbling and cooing) as infants. A tendency to use a small number of sounds. More vowels are used, without consonants attached, which makes the speech hard to understand.

A difference in intelligibility between automatic, frequently used phrases and more spontaneous speech. He may say " don' care"or " don' know"very clearly but have great difficulty in spontaneous conversation or when asked for a specific answer to a question.

Difficulty combining and sequencing phonemes. Your child may be able to imitate or produce individual sounds, but when he tries to combine them into words, he has difficulty, especially as the word gets longer or more complex. So, he can say "ham," but when he says "hamburger," it may come out as "hangurber." "Banana" may be "nabana." Sounds and syllables are frequently reversed. This reversal is known as metathesis.

Decrease in intelligibility as utterance length increases. He has more difficulty with longer words and phrases. So, he may say "key" easily, but have difficulty with "monkey" or "monkey bars."

Prosodic or rhythm difficulties. Your child may talk slowly or rapidly or have an uneven pace.

Children with apraxia appear to understand (receptive language) more than they can produce (expressive language), but this is characteristic of most children with Down syndrome.

Although all children with apraxia show some difficulty in planning and sequencing motor speech behaviors, they have a wide variety of error patterns and a wide range of severity. Some children have a great deal of difficulty developing speech and are very delayed. Other children may not display any signs of difficulty until after they have developed speech, and only have difficulty when the task becomes more complex. Perhaps this is a reason why some children with apraxia are not diagnosed right away. The signs may be subtle.

HOME ACTIVITIES
Regular practice is critical for children with apraxia, and the SLP should provide a home practice program for you and your child to work on together. Here are examples of activities and strategies the SLP might suggest for you to use at home:

Use singing and melody, especially songs with hand movements or songs with repeated choruses. The repetition will make it easier for your child.
When you read with your child, use repetitive books or books with predictable phrases. Chicken Soup with Rice; Four Furry Feet; and Are You Mother? are examples of this type of book. Children know what the repeated phrase is and can practice it in advance and say it in a singsong manner. If they cannot say the phrase, they can say some of the words. This will give them successful experiences saying words.
During daily routines, use scripts and phrases that are repeated. For example: "Hi, how're you doing?" "See you later." This will also provide successful experiences, and opportunities to practice familiar phrases.
If your child is having difficulty speaking, never insist that he say a word in order to receive a reward or receive a desired item. Don't say, "I won't give you this ice cream until you ask for it."
To promote communication when your child cannot speak, Total Communication using signs or picture communication systems can be used. You use speech and the sign or pictures, but your child can respond using only the sign or picture, if necessary, to request things that he wants or to communicate with you in other ways. For children who are having difficulty speaking, this can cut down on frustration.
Many of the therapy methods suggest helping children practice with slowed-down speech. You can slow down songs and sing them together with your child like a choir in slow motion. Or play Time to Sing! a new CD that contains slowed-down versions of twenty-six popular children's songs that has been helpful for children with apraxia who want to sing along but can't sing the words at fast speeds. (See the Resource Guide.)