How Speech Language Pathologists Treat Patients with Apraxia of Speech

What would it feel like to suddenly lose your ability to communicate? To have been a perfectly well-functioning professional who suddenly finds yourself met with blank stares or uncomfortable side-glances when you speak?

Apraxia, a motor-speech disorder that disrupts the brain’s ability to communicate with speech-related muscles, can appear suddenly as the result of a traumatic event such as a stroke or injury, or it can develop slowly over time.

When offering therapy to individuals with apraxia you not only help them communicate their needs more effectively, but you also help them re-enter society and better connect with their families and loved ones.

A Brain-Mouth Disruption

With apraxia the brain loses its ability to plan and program speech.

Normally, our brains send impulses to our muscles, telling them what to do. Each time you speak, your brain relays messages to organize your tongue, lips, jaw, breathing, palate and voice box to work in harmony so the right sounds will come out.

For someone with apraxia, damage to the motor cortex region of the brain confuses the messages the brain sends out. So the speaker knows exactly what they want to say, and initially the right message is launched in the brain.

Imagine a conductor wanting his orchestra to play Beethoven’s Ninth Symphony. He knows what he wants them to play and he hands out the sheet music, not realizing it has severe water damage and that the sheets are out of order. He raises his arms to signal the orchestra to play, but the music is unclear and disorganized, so what comes out sounds nothing like Beethoven’s Ninth.

The person with apraxia is like the conductor…they know exactly what they want to say, and they pass that message on to the motor-cortex region of the brain. The message is like the sheet music, which the motor cortex is supposed to organize and pass on to the muscles, or the orchestra, in order for sounds to come out. Unfortunately the message gets distorted in the damaged motor-cortex region. When the distorted message reaches the muscles each part plays out of order or doesn’t play at all.

Perhaps the most maddening thing about apraxia is that at times the speakers themselves can’t tell that they are mispronouncing a word.

“What frustrated me the most,” says YouTuber Jason Knotts, “[Is that] I thought I was talking perfect. I thought everyone could understand me. But…no one could….[It] a took a while for me to realize [that] what sounds right in my head wasn’t necessarily coming out right.”

Apraxia affects people across the age and gender spectrum, with some cases more severe than others.

Acquired Apraxia

Gina was a normal, healthy mother whose world was rocked by an unexpected stroke.

“Sometimes people think I’m not smart, but I am…[I] just can’t get my words out,” she says.

If you’re working with someone like Gina, you’ll be working with people who face the frustration of learning a skill that was once natural.

Depending on the type of trauma, these individuals may be struggling with other brain injuries impacting their physical or cognitive abilities, but many still have the same mental skills they had before the inciting incident.

Events that can induce apraxia include:

• Traumatic Brain Injury
• Stroke
• Brain Tumor
• Surgical Trauma
• Dementia
• Neurodegenerative Illness

For those with dementia or a neurodegenerative illness, apraxia isn’t sudden but appears through a process, where an individual starts to notice they aren’t speaking as clearly, or starting to mix up words.

Dr. Joseph Duffy explains that when this form of apraxia first starts, patients will come to him and say that their words aren’t coming out right, that they are starting to mispronounce words or even just that they can’t speak rapidly anymore, but have to speak slowly.

Symptoms of acquired apraxia include:

• Inconsistent errors
• Groping for sounds
• Inaccurate stress on syllables or words
• Distorted vowel sounds
• Repeatedly attempting to pronounce the same word
• Omitting beginning and ending consonants

Apraxia can be incredibly isolating, so in hopes of connecting with others going through the same thing Gina started chronicling her experience, including her surprise pregnancy and journey of learning to communicate with her new baby.

Progress through acquired apraxia can be slow, but each step a patient like Gina takes towards improvement is a step into more normal relations with their families and friends.

What About Apraxia in Children?

Childhood Apraxia of Speech (CAS) is a bit more mystifying. While in some cases it results from a genetic disorder, metabolic condition, or specific syndrome, in many cases the underlying factor is unknown.

One baffling aspect of the “unknowns” is that doctors usually can’t see damage to the brain, as they can with acquired apraxia.

Most parents begin to notice symptoms during the first year or two of life. Maybe the child doesn’t start speaking as early as expected. Maybe the number of sounds they do produce seems limited to only a few vowel and consonant sounds.

“My mom knew something wasn’t right when I was, like, one,” shares Knotts in videos.

He would launch into long stories that to her sounded like gibberish. Sometimes he appeared to be telling jokes, breaking into peals of laughter even though others had no idea what he was saying.

CAS often (but not always) occurs alongside other speech or developmental disorders, so as a provider you will need to watch for these signs. It is also not something that will simply “go away with time”, and because one of the most important factors in success is early intervention you will want to stress this reality when speaking with parents.

The Difficulty With Diagnosing Childhood Apraxia of Speech

Unfortunately, there is no definitive test or checklist that will tell you a child has apraxia. In young children it can be mistaken for autism or dysarthria (poor muscle tone of the mouth); on the other hand there are disorders that can look like CAS, leading practitioners to make the diagnosis in error.

Apraxia experts warn against giving an official diagnosis of CAS until a child is roughly 3 years old, when other speech delays have been ruled out. Red flags therapists look for include:

• Limited/no babbling
• Loss of words previously used
• Says a word differently with each try
• Lack of phonetic diversity
• Inconsistent errors
• Feeding difficulties
• Limited intonation

Even though CAS isn’t diagnosed immediately you should still treat the child for speech difficulties. Practitioners often work off of a “soft diagnoses” of apraxia, adjusting their methods as they work with children under three until they find those that work best for the individual child. Through this process the child’s speech can improve and the provider is more likely find the root cause. Again, early intervention is the key to success.

Treatment Options for Patients with Apraxia of Speech

When you’re treating apraxia (or any other disorder) it can be tempting to look for a “silver bullet” treatment. The Internet will churn up blogs and articles touting one treatment over another, but in reality what produces outstanding results in one person may bring only minimal progress for another.

ASHA divides treatment options into four categories:

1. Motor-Programming
2. Linguistic
3. Sensory Cueing
4. Rhythmic
5. Combination (usually a motor-programming approach combined with one of the above)

One issue parents and those with apraxia express frustration about is the difficulty in finding a therapist well versed in the various approaches.

Speech therapist and mom Nicole shares that even with her own training she had difficulties helping her son:

“No matter what I did, no matter what anybody did, it just didn’t seem to help. He needed a very specific type of therapy and therapist to motivate him to keep going.” Nicole’s son finally started making significant progress when they found a therapist trained by the Childhood Apraxia of Speech Association of North America (CASANA).

While apraxia will be covered in your graduate training, you may want to consider getting additional training in this area. Many parents and caregivers affirm Nicole’s experience: there may not be a silver bullet, but apraxia-specific training makes a huge difference in speech progress.

Augmentative and Alternative Communication (AAC): Is it a Crutch?

It can be really tough living in a home where a child or spouse can’t easily communicate their basic needs. One way you can help families is to offer assistive technologies that enable more fluid communication. These might include:

• Sign language
• Tablet with communication apps
• Speech generating device
• Communication book

Sometimes parents or caregivers are worried that these technologies will stunt language learning, but this isn’t the case. AAC is usually used in the early stages of intervention, and as the individual’s speech grows they usually self-select speech over AAC.

At times some individuals with severe apraxia may need to continue using AAC methods, but this should be seen as the exception instead of the rule.

First, Do No Harm…to the Second Language

Often, well-meaning SLP’s will encourage parents or caregivers to choose one language and stick with it. Unfortunately, when working with children, these SLP’s may be putting children and families at an unnecessary disadvantage.

Current research demonstrates that bilingual children don’t experience any additional difficulties or delays when holding onto both languages. So, for example, if the family speaks Spanish in the home and the child speaks English at school and with friends, you as an SLP can encourage this practice to continue.

With adults the waters are a little muddier. While experts note parallel issues between the first and second language damage and recovery, other factors such as pre-apraxia proficiency in both languages influence progress. To date, there are few evidence-based studies examining this issue, although the trend seems to be leaning towards encouraging families to maintain both languages.

Specializing in Treatment of Apraxia

While your graduate program will cover the topic of apraxia, you may find additional training helpful. Some families, like Nicole (mentioned above) find that the base level of training their SLP received isn’t adequate for treating their child or loved one. Following are some options you may want to explore:

• Childhood Apraxia of Speech Association of North America (CASANA): CASANA offers a host of on-demand webinars that can improve your ability to serve those with apraxia. Many SLP’s find this training invaluable to their growth as a practitioner.
• The Kauffman Speech to Language Protocol: This 4-hour training program on evaluation and treatment of apraxia focuses on the Kauffman approach and is available for ASHA continuing education credits.
• The PROMPT Method: This therapy method can be used with patients facing motor speech disorders, like apraxia. ASHA offers CEU’s for this training.
• Nuffield Dyspraxia Program: These one- to two- day training courses and educational packages prepare you to use a “bottom-up” approach that begins with single speech sounds and simple syllables to build speech.
• Rapid Syllable Transition Treatment: This is a newer treatment method aimed at children ages 4-12. The method is based out of the University of Sydney, but their website offers a training package for those working with childhood apraxia.

You may also want to consider pursuing board certification from the Academy of Neurologic Communication Disorders and Sciences (ANCDS).

In order to be eligible for this certification, you’ll need to fulfill the following requirements:

• Be a fully certified CCC-SLP
• Have five years of clinical experience with neurologic communication disorders
• Submit your CV or resume with three letters of recommendation from health care professionals familiar with your skills
• Complete the Board Certification Candidacy Application and pay applicable fees

The certification process involves submitting two case studies, giving an oral presentation, and taking part in a discussion following your presentation. The reviewers will then give you a “Pass” or notify you that your work “Does not meet standards”.

Learning from others who specialize in apraxia and neurologic disorders will empower you to help patients improve with greater speed and possibly to more fully recover their language abilities, making the time investment well worth your while.