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Apraxia

Apraxia is a neurological disorder Diagnostic criteria of developmental

characterized by loss of the ability to
execute or carry out learned (familiar) apraxia of speech used by clinical
movements, despite having the desire
and the physical ability to perform the speech-language pathologists
movements. more... From American Journal of Speech-Language Pathology, 8/1/03 by
Forrest, Karen
Home
Diseases The diagnostic criteria used to identify developmental apraxia of speech (DAS)
A have been at the center of controversy for decades. Despite the difficulty in
Aagenaes syndrome determining the characteristics that differentiate DAS from other speech
Aarskog Ose Pande acquisition disorders, many children are identified with this disorder. The
syndrome current report presents the criteria used by 75 speech-language pathologists to
Aarskog syndrome establish a diagnosis of DAS. Although 50 different characteristics were
Aase Smith syndrome identified, 6 of these characteristics accounted for 51.5% of the responses.
Aase syndrome These characteristics included inconsistent productions, general oral-motor
ABCD syndrome difficulties, groping, inability to imitate sounds, increasing difficulty with
Abdallat Davis Farrage... increased utterance length, and poor sequencing of sounds. These results are
Abdominal aortic aneurysm consistent with the general ambiguity of the diagnostic criteria of DAS and
Abdominal cystic... suggest that no single deficit is used among clinicians.
Abdominal defects
Ablutophobia Key Words: developmental apraxia, children, speech, diagnosis
Absence of Gluteal muscle
Acalvaria Developmental apraxia of speech (DAS) has been labeled as a disorder "in
Acanthocheilonemiasis search of a population" (Guyette & Diedrich, 1981, p. 39) largely because of
Acanthocytosis the ambiguity surrounding the nosological criteria used to establish a
Acarophobia diagnosis. The existence of DAS as a distinct disorder continues to be debated,
Acatalasemia with some reports suggesting that the disorder is subsumed under the general
Accessory pancreas category of phonological disorder (Gierut, 1998), whereas other classification
Achalasia schemes regard DAS as a separate disorder with a motor-based etiology
Achard syndrome (Robin, 1992). Despite this controversy, the label of DAS continues to be
Achard-Thiers syndrome assigned to some children with speech sound acquisition problems.
Acheiropodia
Achondrogenesis Of late, research has been reassessed in an effort to differentially define DAS
Achondrogenesis type 1A (Davis, Jakielski, & Marquardt, 1998; Shriberg, Aram, & Kwiatkowski, 1997a,
Achondrogenesis type 1B 1997b, 1997c; Stackhouse, 1992); unfortunately, these analyses do not result
Achondroplasia in a singular perspective on the disorder. For example, Shriberg et al. (1997e)
Achondroplastic dwarfism concluded that inappropriate stress production serves to differentiate children
Achromatopsia with DAS from those with speech delays of unknown etiology. Prospective
Acid maltase deficiency investigations to evaluate this proposal have yielded varied results (Munson et
Ackerman syndrome al., 2003; Skinder, Strand, & Mignerey, 1999; Velleman & Shriberg, 1999).
Acne Skinder et al. found that when listeners were asked to evaluate stress
Acne rosacea production by children with DAS and their normally articulating peers, children
Acoustic neuroma with DAS were perceived to be less accurate than children with normal
Acquired ichthyosis articulation. However, acoustic analyses did not identify the basis for this
Acquired syphilis percept. Similar results were found when comparisons were made between
Acrofacial dysostosis,... children diagnosed with DAS and those identified as having a phonological
Acromegaly disorder; that is, although listeners judged differences in stress production, no
Acrophobia significant acoustic differences were found in the control of prosody (Munson et
Acrospiroma al., 2003). Results presented by Velleman and Shriberg yielded an intermediate
Actinomycosis proposal. In this study, metrical phonology was applied to the data presented
Activated protein C... by Shriberg et al. (1997b, 199Tc) to determine if lexical stress patterns
Acute febrile... differed for children with suspected DAS and those children with speech delays
Acute intermittent porphyria of unknown origin. In general, patterns of lexical stress errors were consistent
Acute lymphoblastic across these groups of children and were comparable to previous investigations
leukemia of lexical stress production in typically developing children. One difference that
Acute lymphocytic leukemia did emerge from this metrical analysis was that children with suspected DAS
Acute mountain sickness who were perceived to produce inappropriate sentential stress maintained
Acute myelocytic leukemia patterns of syllable omission to a later age than was found in the children with
Acute myelogenous leukemia speech delay. In summary, perceptual analyses of stress generally point to a
Acute necrotizing... deficit in children with DAS; the basis of this deficit is unclear in that both
Acute promyelocytic
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leukemia acoustic and metrical phonological analyses do not explain these perceptual
Acute renal failure effects.
Acute respiratory...
Acute tubular necrosis Stackhouse (1992) proposed four independent factors to characterize DAS. In
Adams Nance syndrome addition to phonetic deficits, Stackhouse suggested that a child must
Adams-Oliver syndrome demonstrate motor, cognitive, and linguistic disturbances to be diagnosed with
Addison's disease DAS. Although experimental evaluation of this proposal has been limited to two
Adducted thumb syndrome... case studies (Stackhouse & Snowling, 1992), Ozanne's (1995) retrospective
Adenoid cystic carcinoma analysis of children's speech errors provides a similar perspective. By contrast,
Adenoma Davis et al. (1998) identified only speech production errors, including some
Adenomyosis problems that are typical in most children with speech delays (e.g., limited
Adenosine deaminase... phonetic inventory) as well as some atypical features (e.g., high variability,
Adenosine monophosphate... vowel errors, and suprasegmental deficits) in children with DAS.
Adie syndrome
Adrenal incidentaloma Other investigations have centered on identifying the diagnostic criteria for
Adrenal insufficiency DAS relative to age-appropriate speech acquisition (Thoonen, Maassen,
Adrenocortical carcinoma Gabreels, Schreuder, & de Swart, 1997) and have identified singleton
Adrenogenital syndrome consonant errors and cluster reduction as distinguishing factors. These criteria
Adrenoleukodystrophy may not serve to distinguish children with DAS from children with
Aerophobia phonologically based disorders (Forrest & Morrisette, 1999).
Agoraphobia Given the ambiguity of the defining characteristics of the disorder, it is not
Agrizoophobia surprising that the prevalence of DAS is unknown (American Speech-
Agyrophobia Language-Hearing Association, 2002). However, the numerous Web sites,
Aicardi syndrome therapy materials, and discussions on the topic would suggest that the disorder
Aichmophobia is not uncommon. As many reviews indicate (Davis et al., 1998; McCabe,
AIDS
Rosenthal, & McLeod, 1998; Ozanne, 1995) there are many different factors
AIDS Dementia Complex
that have been identified to distinguish DAS and often there are contradictory
Ainhum
perspectives regarding the signs and symptoms of the DAS. For example,
Albinism
difficulties with nonspeech movements have been cited to characterize DAS in
Albright's hereditary...
some reports (e.g., Hall, 2000), whereas others have not specified any causal
Albuminurophobia
relationship between DAS and other oral-motor behaviors (e.g., Davis et al.,
Alcaptonuria
1998; Shriberg et al., 1997a, 1997b, 1997e).
Alcohol fetopathy
Alcoholic hepatitis It is clear that considerable effort is being made to develop the nosological
Alcoholic liver cirrhosis criteria for DAS; however, controversy surrounding the criteria for diagnosis
Alektorophobia still remains. Despite the lack of such a definition, children are being diagnosed
Alexander disease with this disorder. If children receive a clinical diagnosis of DAS, what are the
Alien hand syndrome deficits that lead to this assessment? In the present article, this issue was
Alkaptonuria addressed by asking a sample of speech-language pathologists (SLPs) to
Alliumphobia indicate the criteria that they use to establish a diagnosis of DAS.
Alopecia
Alopecia areata Method
Alopecia totalis
Alopecia universalis Participants
Alpers disease
Participants included 75 SLPs who attended a continuing education workshop
Alpha 1-antitrypsin...
sponsored by the Indiana Speech-Language-Hearing Association in February
Alpha-mannosidosis
2000. The topic of the 1-day workshop, presented by the author, was
Alport syndrome
assessment and treatment of DAS. Although no precise demographics were
Alternating hemiplegia
obtained from the participants, information about the workshop indicated that
Alzheimer's disease
it was geared toward SLPs working with preschool and schoolage children.
Amaurosis
According to the Continuing Education Coordinator for the state organization,
Amblyopia
more than 90% of the people who attended this workshop were employed as
Ambras syndrome
SLPs and held the required state licensure for their work environment (A.
Amelogenesis imperfecta
Densmore, personal communication, May 2002). An informal survey of the
Amenorrhea
participants revealed that about 40% of the participants worked in home-
American trypanosomiasis
based early intervention settings, 50% of the workshop attendees worked in
Amoebiasis
the public schools, and the remainder of the SLPs in the audience worked in
Amyloidosis
Amyotrophic lateral... hospitals or university clinics. Most of the participants indicated that they
Anaphylaxis worked with children who were diagnosed with DAS. This information was
Androgen insensitivity... obtained by a "show of hands" when participants were asked if they had
Anemia children with DAS in their caseloads. No information was obtained about the
Anemia, Diamond-Blackfan amount of experience that these clinicians had with children with speech sound
Anemia, Pernicious disorders of any etiology. Visual examination of the audience indicated that the
Anemia, Sideroblastic majority of participants were women, with approximately 5 men in attendance.
Anemophobia
Procedures
Anencephaly
Aneurysm At the start of the workshop, following the introductions, the workshop
Aneurysm participants were asked to write down three characteristics that they felt were
Aneurysm of sinus of... necessary to result in a diagnosis of DAS. The purpose of this request was to
Angelman syndrome obtain information for discussion within the workshop and to give participants
Anguillulosis a sense of the potential diversity associated with the term. Participants were
Aniridia given 10 min to complete their responses and responses were collected.
Anisakiasis Questions that arose, mostly relating to the necessity to list three criteria,
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Ankylosing spondylitis were answered but no additional instructions were provided. In response to the
Ankylostomiasis question about the requirement to include three criteria, the instructions were
Annular pancreas altered to require up to three features of DAS. Therefore, all responses can be
Anorchidism considered to emerge from an open-ended set; however, because of the
Anorexia nervosa limitations placed by the instructions (i.e., list up to three features) the
Anosmia responses may not represent all the characteristics that a given clinician uses
Anotia to diagnose DAS.
Anthophobia
Anthrax disease The author tabulated the responses during the lunch break and the results
Antiphospholipid syndrome were relayed to the participants at the start of the afternoon session. More
Antisocial personality... careful examination of the data was undertaken at a later date to determine
Antithrombin deficiency,... frequency counts for all characteristics that were mentioned by the
Anton's syndrome participants. When possible, features were grouped to reflect similarities
Aortic aneurysm between responses. Many of the categories were identical to participants'
Aortic coarctation responses (e.g., motor programming problem). Decisions about group
Aortic dissection affiliation for the remaining responses were based on thematic similarities and
Aortic valve stenosis inductive analysis. For example, responses that referred to increased number
Apert syndrome of errors with increased syllables or words were grouped in the category
Aphthous stomatitis increased errors with increased utterance length; the category inconsistent
Apiphobia production comprised responses that indicated problems in repeated
Aplastic anemia productions of the same word or sound as well as responses that noted
Appendicitis inconsistency within a sound across contexts. In many cases, the
Apraxia correspondence between different participants' responses was not clear, so
Arachnoiditis these features were listed separately (e.g., swallowing problems, regression of
Argininosuccinate... word production).
Argininosuccinic aciduria
Because the participants were not asked to rank order the criteria, all
Argyria
characteristics were given equal weight.
Arnold-Chiari malformation
Arrhythmogenic right... Results
Arteriovenous malformation
Arteritis Of the 75 participants in this workshop, 67 provided three criteria that would
Arthritis lead to a diagnosis of DAS; the remaining 8 participants listed only two criteria
Arthritis, Juvenile for this disorder. Responses from participants indicated 50 different
Arthrogryposis characteristics that were used to diagnose DAS. Table 1 lists the criteria that
Arthrogryposis multiplex... were suggested as well as the frequency with which that characteristic was
Asbestosis noted. The criteria that were noted most frequently include inconsistent
Ascariasis productions, groping/effortful productions, general oral-motor difficulties,
Aseptic meningitis inability to imitate sounds, increasing difficulty with sound production as the
Asherman's syndrome utterance length increased, and poor sequencing of sounds. These six criteria
Aspartylglycosaminuria accounted for 117 of the 227 responses (51.5%) that were obtained. Each of
Aspergillosis the remaining criteria was noted in less than 10 of the responses received.
Asphyxia neonatorum
Asthenia Discussion
Asthenia
Asthenophobia The purpose of the current research was to determine the diagnostic criteria
Asthma that practicing SLPs use in identifying DAS. The results revealed that the
Astrocytoma nosological criteria for DAS remain ambiguous, as noted by the numerous
Ataxia telangiectasia characteristics that practicing SLPs used to diagnose the disorder. Clinicians'
Atelectasis views of characteristics of DAS appear consistent with the research literature in
Atelosteogenesis, type II this regard; that is, there is no standard for the definition of the term. Further,
Atherosclerosis the present study is consistent with the findings of Davis et al. (1998) in that
Athetosis there appears to be large variation in the use of the term DAS. Whether this
Atopic Dermatitis variability can be related to varied educational backgrounds (i.e., definitions
Atrial septal defect that were learned in different educational programs), from reading of current
Atrioventricular septal... literature, or from clinical experience, there is little congruence across SLPs in
Atrophy the characteristics that they use to diagnose DAS.
Attention Deficit...
Autoimmune hepatitis It is clear that many of the respondents in the current investigation use
inconsistent production as a feature of DAS, yet the meaning of the term may
Autoimmune...
vary. For example, some respondents indicated that DAS was characterized by
Automysophobia
inconsistent productions across repetitions of the same sound sequence or
Autonomic dysfunction
word. Other clinicians noted inconsistency in the production of a single sound
Familial Alzheimer disease
across varying contexts, whereas other SLPs considered a child's production to
Senescence
B be inconsistent if a sound was produced differently in isolation versus in
C conversational speech. Despite these variants of definition, inconsistency
D appears to be a characteristic that commonly is associated with DAS. However,
E even this feature was not listed by a majority of the respondents.
F
The utility of inconsistency as a marker for DAS is somewhat congruent with
G
research on this disorder (Davis et al., 1998; McCabe et al., 1998; Ozanne,
H
1995) as well as studies that note different profiles of children with functional
I
articulation disorders. Specifically, Forrest and her colleagues (Forrest & Elbert,
J
2001; Forrest, Dinnsen, & Elbert, 1997; Forrest, Elbert, & Dinnsen, 2000)
K
found that children with variable substitutes for sounds that were excluded
L

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M from the inventory had different patterns of phonological learning as a result of
N treatment compared to children who used a consistent substitute for an
O omitted sound. Children who used variable substitutes did not learn treatment
P targets nor show any generalization of knowledge to untreated sounds even
Q though the techniques used had been proven effective with children with more
R consistent phonological error patterns (Elbert, Dinnsen, & Powell, 1984; Gierut,
S 1985). Although it is not clear that these children have DAS, their substitution
T and learning patterns suggest that they are distinct from children with more
U consistent sound usage. Further, Davis et al. (1998) identified these patterns
V as markers of DAS.
W
X Inconsistency in speech production also has been cited as a hallmark feature of
Y DAS by Dodd and her associates (Dodd & McCormack, 1995; Dodd & Iacono,
Z 1989). Children with this diagnosis were found to have inconsistent
Medicines phonological errors and demonstrated the use of deviant phonological
processes (i.e., processes that are not seen in the typical acquisition of
The root word of Apraxia is praxis which phonology). Further, these children showed deficits in language performance as
is Greek for an act, work, or deed. well as motor planning of speech and nonspeech activities.
Types The presence of groping behavior and general oral-motor difficulties also were
frequently associated with DAS. Again, this characteristic has been cited
There are several types of apraxia
including: frequently in the literature (e.g., Crary, 1984, 1993; Hall, Jordan, & Robin,
1993; Ozanne, 1995; Stackhouse & Snowling, 1992). Ozanne (1995) noted
limb-kinetic (inability to make groping and oral-motor problems in children with developmental verbal
fine, precise movements with a dyspraxia and concluded that clusters of symptoms are needed for accurate
limb), diagnosis of the disorder. She suggests that these clusters represent deficits in
ideomotor (inability to carry out a
phonological planning, phonetic programming, and general oromotor control.
motor command),
ideational (inability to create a The current investigation cannot confirm or refute this hypothesis, in part
plan for or idea of a specific because of the methodology employed. That is, participants in this
movement), investigation were asked to supply "up to three" criteria that they use to
buccofacial or facial-oral (inability diagnose DAS. It is possible that in an attempt to comply with the instructions,
to carry out facial movements on some participants included additional characteristics that they don't normally
command, i.e., lick lips, whistle,
associate with this disorder. Other participants may have limited their
cough, or wink) - which is
perhaps the most common form, responses to include only three features even though additional characteristics
verbal (difficulty coordinating typically are used in their diagnosis of DAS.
mouth and speech movements),
constructional (inability to draw Despite restrictions placed on the number of DAS features that participants
or construct simple should list, the results from the current investigation provide some insight into
configurations), the concept of DAS. Review of Table 1 indicates that across clinicians there is
and oculomotor (difficulty moving great divergence in the characteristics of DAS, as noted by the 50 different
the eyes).
features that the SLPs cited. Not only were there a large number of different
Apraxia may be accompanied by a features suggested as diagnostic of the disorder, but some of the criteria were
language disorder called aphasia. contradictory. For example, some respondents viewed difficulty in speech
without concomitant problems in movement of the articulators for nonspeech
Developmental Apraxia of Speech (DAS)
activities as a marker of DAS (e.g., motor problems for speech with normal
presents in children who have no
evidence of difficulty with strength or movement for feeding, difficulty in voluntary speech movement), whereas
range of motion of the articulators, but other SLPs noted that general oral-motor deficits served as an important
are unable to execute speech characteristic of DAS. Similarly, respondents stated that normal auditory
movements because of motor planning perception should be evident in children with DAS and other clinicians indicated
and coordination problems. This is not to that auditory perception and processing impairments were markers of the
be confused with phonological disorder. This variation across individuals in the understanding of DAS may
impairments in children wtih normal
lead to errors in the diagnosis of the disorder, as noted by Davis et al. (1998).
coordination of the articulators during
speech. Experience in our university clinic is consistent with this claim. In our ongoing
research, we have found that many children referred for evaluation and
Symptoms of Acquired Apraxia of Speech treatment of DAS show signs of dysarthria. For example, in a recent group of
(AOS) and Developmental Apraxia of 10 children who had received diagnoses of DAS from area SLPs, 2 children had
Speech (DAS) include inconsistent
abnormally high velar air flow and 2 other children demonstrated excessive
articulatory errors, groping oral
movements to locate the correct laryngeal resistance. These physical deviations may account for much of the
articulatory position, and increasing treatment failure that was noted by the referring clinician.
errors with increasing word and phrase
length. AOS often co-occurs with Oral Clearly, additional research on DAS criteria is needed. The present study is
Apraxia (during both speech and non- limited in that the instructions to the participants (i.e., provide three criteria for
speech movements) and Limb Apraxia. diagnosing DAS) may have forced the clinicians to provide extraneous features.
Therefore, a replication of this study with less restrictive directions is
Treatment warranted. Further, the participants' level of experience in working with
Generally, treatment for individuals with
children with articulation disorders is unknown. Although most people who
apraxia includes physical therapy, attended this workshop were working as SLPs, and presumably these
occupational therapy or speech therapy. individuals were interested in the topic of DAS, precise information about the
If apraxia is a symptom of another participants was not obtained. Finally, the participants in this study were
disorder, the underlying disorder should obtained from a sample of convenience rather than by more controlled
be treated. procedures. Therefore, the results of this study remain purely descriptive.
Despite these limitations, the present investigation provides insight into the
Prognosis
features that SLPs use to diagnose DAS. Although a large number of features
The prognosis for individuals with emerged from this analysis, the category of "inconsistent errors" was most
apraxia varies, With therapy, some frequently cited as a diagnostic marker for DAS. However, it does not appear
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patients improve significantly, while that there is good consensus among working clinicians regarding the
others may show very little characteristics that define DAS.
improvement.
Acknowledgments
Read more at Wikipedia.org
This research was supported by National Institute on Communication Disorders
Grant DC04575.
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Received December 10, 2001

Accepted February 19, 2003

DOI: 10.1044/1058-0360(2003/083)

Karen Forrest

Indiana University, Bloomington

Contact author: Karen Forrest, PhD, Department of Speech and Hearing

Sciences, Indiana University, 200 South Jordan Avenue, Bloomington, IN
47401.

E-mail: kforrest@indiana.edu

Copyright American Speech-Language-Hearing Association Aug 2003

Provided by ProQuest Information and Learning Company. All rights Reserved

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