All material Copyright © March 2009 The Down Syndrome Centre
Reprinted with the express permission of the Down Syndrome Centre as originally published on their website.
By: Marinet vanVuren
Marinet vanVuren is a South African born Speech and Language Therapist. For the past seven years she has worked with a range of Irish disability organisations including Enable Ireland, St Michael’s House and the Children’s Sunshine Home. She recently set up her own private speech and language therapy practice where she sees children of all disabilities with various speech, language and feeding difficulties.
What is Childhood Verbal Apraxia?
Verbal apraxia is considered to be a motor (movement) speech disorder. For unknown reasons, children with verbal apraxia have great difficulty planning and producing the precise, highly refined and specific series of movements of the tongue, lips, jaw and palate that are necessary for clear speech. Verbal apraxia is a specific speech disorder and not simply a developmental delay of speech. A developmental delay of speech is when a child follows a typical pattern of speech development but at a slower rate. Children with verbal apraxia are not following a typical pattern of speech development. What is generally seen is a wide gap between their understanding of language (receptive language) and their ability to use language (expressive language). This means the child’s ability to understand what is said to them is developing yet their expressive speech may be absent or severely unclear. Verbal apraxia can be seen across the population in children with or without a learning disability.
Can Childhood Verbal Apraxia occur in children with Down Syndrome?
Historically Childhood Verbal Apraxia was not identified or treated in children with Down Syndrome (Kumin, 2006). The original researchers who defined ‘Apraxia of Speech’ in children included only children with IQ scores within the normal range in their research sample (thus excluding children with Down Syndrome). This meant that children with Down Syndrome were not assessed or treated for Childhood Verbal Apraxia. However, recent research (Kumin & Adams, 2000 and Kumin, 2006) has documented that symptoms of Childhood Verbal Apraxia can be found in children with Down Syndrome. In a recent American Speech-Language research study, the researcher has found that 15% of a sample of 1620 children with Down Syndrome had Childhood Verbal Dyspraxia. She also found that a diagnosis of Oral-Motor Difficulty was more frequently given (about 60.2% of the 1620 children surveyed) than a diagnosis of Childhood Verbal Apraxia.
Not all children with Down Syndrome have Childhood Apraxia of Speech. Most children with Down Syndrome have difficulty with speech intelligibility (i.e. how clearly a person speaks). This could be due to a few reasons:

• Anatomical difficulties (size of the oral cavity in relation to the tongue, low muscle tone and strength in the tongue, underdeveloped upper jaw or bridge of the nose).
• Hearing loss, e.g. fluid in the ear or glue ear
• Listening difficulties e.g. auditory discrimination skills (i.e. listening for subtle differences between sounds).
• Weak oral motor skills
• Significant learning disability

Expressive language skills are an area of particular difficulty for most children with Down Syndrome. Children with Down Syndrome have delayed expressive language skills which means they understand more than what they are able to express verbally. But when the gap between a child’s understanding of language (receptive) and use of language (expressive) becomes wider after each review session or their expressive language fails to develop in comparison to their understanding of language, a Speech and language Therapist has to start looking at the underlying reason for this lack of progress.
It can be very difficult for Speech-Language Therapists to make the diagnosis of Childhood Verbal Apraxia in the absence of any speech. Apraxia diagnostic assessments require a speech sample of at least 50-100 utterances in order to identify and diagnose Apraxia, which a lot of children with Down Syndrome might not develop until they are of a school-age.
Libby Cumin and other researchers have compiled a list of characteristics that can be used to serve as early warning signs to alert Speech-Language Therapists and parents of a possible diagnosis of Childhood Verbal Apraxia:

• Feeding difficulties in infancy
• Oral-motor difficulties
• Limited vocalisations, babbling and sound play during infancy (“quiet baby”).
• Your child understands at a much higher level than he/she is able to express (receptive language exceeds expressive language).
• Speech development is not in line with cognitive development.
• Limited number of speech sounds (especially consonants, e.g. p,b,m,t,d,k,g,) in the child’s speech.
• Struggle or groping when speaking .Sometimes children look like they are trying to get a word out but just can’t get the mouth to work.
• May ‘lose’ words. Child may say a word once or twice then lost it.
• Speech becomes increasingly unclear as words and sentences get longer.
• Difficulty combining sounds to make words.
• Inconsistent production of the same word, e.g. ‘book’ may be “boo”, “doo” or sometimes “buh”.
• Vowel errors (e.g. /oy/ in boy, /ee/ in cheese, /oh/ in boat)
• Failure to improve even with extensive therapy
• Difficulty imitating words
• Difficulty saying unfamiliar words.

Childhood Verbal Apraxia is a description of a cluster of clinical symptoms. Other terms that have been used to describe this difficulty include:

• Childhood verbal dyspraxia
• Developmental apraxia / dyspraxia of speech
• Oral motor planning difficulties

What can be done to treat children with Childhood Verbal Apraxia?
98% of children diagnosed with Childhood Verbal Apraxia also have significant oral-motor difficulties. A comprehensive oral-motor programme is essential as part of your child’s treatment plan. An individualised intensive speech and language therapy programme is recommended for children with Childhood Verbal Dyspraxia. This type of service is unfortunately not possible for all children with Childhood Verbal Apraxia due to health service cut backs and limited speech-language therapy resources. In the absence of direct intervention services, parents can link with their local Speech and Language Therapist to devise an intensive home practice programme.
There are two well-known evidence-based programmes used by most Speech-Language Therapists in Irish Disability Organisations. They include
(i) The Nuffield Centre Dyspraxia Programme (3rd edition) and
(ii) The Kaufman Method for Childhood Apraxia of Speech.
The Kaufman Method is a way of teaching children the easiest ways of saying words until they have increased motor-speech coordination. They are taught word approximations without including too many complex sounds , for example ‘bottle’ may begin with ‘ba’ progress to ‘baba’ later becomes ‘bado’ and eventually ‘bottle’.
Sounds a bit complicated? I personally do not follow this approach as according to the Hanen Guidelines (part of the It Takes Two to Talk parent training programme) I prefer to keep my words and labels consistent as not to confuse children. There is no point in using the word ‘teddy’ one day, ‘bear’ the next and ‘toy’ the day after. Children with learning difficulties need clear and consistent word models. Hence my reason for not using the Kaufman Method with children with Down Syndrome.
I follow the Nuffield Centre Dyspraxia Programme. This programme uses visual cues for each sound (for example /d/ is represented by a picture of a toy drum). The programme works in stages, starting at single vowel and consonant sounds, and progressing onto consonant-vowel combinations (e.g. m + e = ‘me’) before targeting words.
Another resource that I found very helpful was: Preschool Motor Speech Evaluation and Intervention (Earnest, 2000). It has a section on teaching children the various speech sounds through tactile cues, e.g. The child produces /m/ while rubbing lip balm on the lips.
It is important to have the following components in your child’s Apraxia Treatment programme:

• Early oral-motor treatment (including feeding therapy)
• Oral motor skills development
• Straw- and/or whistle blowing hierarchy programme
• Teaching speech sounds using visual, verbal and tactile cues
• Sequencing of speech sounds (e.g. consonants and vowels)
• Opportunity for daily repetitive practice

What causes verbal dyspraxia?
There is no known cause of verbal dyspraxia.
Will my child’s speech improve?
This is dependent upon the following factors:

1. Individual characteristics of the child, e.g. receptive language ability, desire to communicate, age of the child and attention span (many children with Down Syndrome will only be able to participate in an intensive programme by 3-4 years of age).
2. The extent to which other cognitive, medical, speech/language issues are present.
3. The extent of therapy follow-up and home practice.

Progress is slow and it is not possible to predict which children will make the best gains. Some children may need to use other forms of communication, e.g. sign language or a communication device, as their main means of being understood.
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