Infinite Potential Program

Cortical Integrative Therapy in Apraxia of Speech:

Dr. Victor M. Pedro
Department of Clinical Sciences, University of Bridgeport, Bridgeport, Connecticut, U.S.A.

ABSTRACT

A case study is described of a 7-year-old right-handed Caucasian male with moderate to severe developmental apraxia of speech. Mother developed gestational diabetes during third trimester, pregnancy otherwise normal. Anoxia noted at birth or shortly thereafter, also breast-feeding difficulty observed during infancy. Intelligence testing at age 3 revealed a moderate receptive language delay and significant delays to expressive language skills and speech articulation. Diagnosed with pronounced farsightedness and bilateral stigmatisms with suspected color blindness at age 6. Prior to age 7, while speech-language skills improved somewhat, difficulties with expressive grammar and speech intelligibility worsened. A fear of loud noises became more pronounced. Motor coordination deficits were noted. Difficulty in understanding and following directions was observed. Intelligence and performance tests registered in the low range for mathematics, reading, written language and expression, and oral expression areas. At age 7 years 1 month, a single area of testing, picture vocabulary, revealed a relative strength in the low average range. After three years of special education interventions with no significant improvement in any measurable area of function, a multimodal approach using techniques aimed at facilitating inter-hemispheric communication was provided. At completion of the Cortical Integrative Therapy program, significant improvements were observed in ability to read and reading comprehension, mathematics, written and oral expression, and motor coordination.

KEY WORDS: apraxia, apraxia of speech, breast-feeding, speech delays, Cortical Integrative Therapy

Apraxia results when sounds do not easily form into words. To produce even the simplest words, a complex coordination of lips, tongue, and throat muscles as mediated by neural processes is required. Acquired apraxia occurs in adults, often as a result of a stroke or other experiential trauma. Acquired apraxia differs significantly from developmental apraxia (Maassen B., 2002). Developmental apraxia, referred to variously as developmental verbal apraxia, developmental dyspraxia, developmental verbal dyspraxia (Thoonen G. et al), childhood apraxia of speech, and most commonly developmental apraxia of speech (DAS), occurs in children and is resultant from a coordination deficit involving those muscles used in producing speech or language. While it often manifests as a severe communication disorder, speech-language pathology literature supports the idea that DAS also can be exhibited in children with only mildly disordered articulation (Hall P.K., 1989). Debate continues as to whether a given motor speech disorder (especially apraxia of speech and stuttering) should be understood at the phonologic level, the motoric level, or both of these (Kent R.D., 2000). Although the etiology and pathology of DAS are unknown, it has often been described in a neurological context despite convincing evidence of vocal or lateralized brain lesions (Bornman et al, 2001). It has long been known that DAS is probably not due to a congenital or an acquired speech defect in Broca's motor speech area or adjacent brain area of the left hemisphere (Kornse et al, 1981), yet family pedigrees may be indicative of developmental apraxias. In one recent study of apraxic children, 13 of 22 children (59%) had, at least, one affected parent (Lewis et al, 2004). Hearing in DAS children is often judged to be relatively normal, but auditory processing deficits can occur (Groenen P. et al, 1996) especially deficits and idiosyncrasies involving auditory and phonetic perception of vowels (Maassen B. et al, 2003). The practice of "bridging," making the transition from one sound to another or from one word to the next, as a reflection of the child's ability to generate hierarchical linguistic structures, may also be affected (Velleman S.L., 1994). In fact, DAS is primarily a spectrum disorder without definite behaviors identifying its presence. Jaffe pointed out that in describing DAS, all symptoms and signs need not be present to diagnose it, nor must one typical sign or symptom be present in order to establish the diagnosis (Jaffe, 1984). Instead, a child is identified as having apraxia if he/she exhibits a number of characteristics that are highly indicative of apraxia. These may include a decreased ability to imitate speech, slowed production of rapid, repetitive consecutive oral movements, difficulties in initiating speech movements, severely limited consonant and vowel repertoire with fricative errors, impaired production of sound sequencing, specific difficulty in sequencing of syllables, syllable omissions (Velleman S.L. et al, 1999), planning of syllables (Nijland L. et al, 2003), the integrity of the syllable (Marquardt T.P. et al, 2002), form and motion coherence processing (O'Brien J. et al, 2002), inconsistent and unusual errors, and depressed expressive language skills relative to receptive abilities. DAS is distinguishable from so-called "functional" defective articulation when this is manifested as a discrete and singular deficit (Williams et al, 1981). Children may have difficulty speaking longer words or sentences. Terms such as isochrony, syllable segregation, scanning speech, and staccato-like rhythmic quality have been used to characterize the temporal regularity that may be a core feature of apraxia of speech (Shriberg L.D. et al, 2003). Diagnostic criteria used to identify DAS have been at the center of controversy for decades (Forrest K., 2003). The disorder may be present into adulthood (Poole J.L. et al, 1994), although the phenotype for DAS changes with age. Language disorders persist in these children despite partial resolution of articulation problems.

Language development is often delayed with a late onset of first words resulting in infants and toddlers being labeled as 'silent babies' followed by a late combination of two-word sentences. Language development is also atypical, in that there is sometimes a prolonged use of single words for multiple meanings. Parents have reported that words are 'lost' and that children increase their use of gestures (Love, 1992). Children may speak unevenly or very slowly. Great variability in speech production patterns may exist with any population of DAS children (Marquardt et al, 2004), although it has long been known that adult speakers with acquired apraxia of speech and child speakers with developmental apraxia of speech systematically reduce linguistic complexity and simplify the production of consonants (Klich et al, 1979). DAS can effect a child's perception and production of rhyme (Marion M.J. et al., 1993). Accuracy in producing linguistic stress can also be effected in DAS populations (Munson B. et al, 2003) as well as co-articulation patterns suggesting an underlying language expressive deficit (Nijland L. et al, 2002). The accuracy of articulatory movements of speech in a group of first graders has also been studied, providing additional insights about speech production patterns in children (Qvarnstrom et al, 1993). Children with DAS are also at risk for reading and spelling problems (Lewis B.A. et al, 2004).

DAS may also manifest as oral motor deficits including feeding problems in infants. For instance, sucking and oral groping behaviors may be affected, later manifested as motor programming deficits in school-age children (Nijland L. et al, 2003) which can affect motor sequencing strategies in such populations (David K.S., 1985). In addition, DAS can engender other language or learning problems, hyperactivity, and motor coordination problems involving movement. The latter can be indicated by trophic limb changes such as asymmetric hands and feet observed in clumsy children (Iloeje S.O., 1988). A seminal study of Nigerian children with developmental apraxia revealed by neurological examination a higher incidence of abnormality, principally dysdiadochokinesia, among clumsy children (Iloeje S.O., 1987). Other studies have linked DAS with limited manual dexterity (Kornse D.D. et al, 1981) and with the specific diagnosis of developmental coordination disorder (Miyahara M. et al, 1995). In fact, it is now well established that children with DAS have difficulties with coordination (Chia S.H., 1997) and that language development and motor performance in the clinical diagnosis appear to follow a similar course of maturation (LeNormand M.T. et al, 2000). Motor impairment and evidence of proprioceptive deficits in Asperger syndrome individuals appear to be similar (Weimer A.K. et al, 2001).

The therapeutic process is a mix of technique and insight and effective clinicians are able to blend theory with practice. This is especially true in the area of DAS. Children with the symptom complex of apraxia are a challenge to any therapy program (Helfrich-Miller K.R., 1994).

CASE REPORT

J.L. is a 7-year-old right-handed male, born at 6 pounds, 9 ounces following a normal (39 weeks) gestation. Mother experienced gestational diabetes during third trimester of pregnancy. Immediately after birth, symptoms of anoxia - abnormal cry, color, and breathing were noted, and infant was given oxygen. Mother reported that J.L. had difficulty with breast-feeding, with probable oral motor deficit noted. Normal hearing bilaterally and normal mobility of the inner ear system was observed. Father's death from cancer occurred when J.L. was aged 10 months. J.L. began sitting at 9 months, crawling at 10 months, standing at 12 months, and became ambulatory at 13 1/2 months. He was finger-fed at 11 months, used a spoon to eat at 22 months, completed toilet training at 3 years, and dressed himself at 3 1/2 years. His early language development is described as follows: J.L. used single words and named simple objects at 22 months, he combined words at approximately 32 months, he asked simple questions and engaged in a simple conversation at approximately 3 years, 6 months. Mother noted that at age two, J.L. wasn't saying as many words as other children of the same age. By age 2 years, 6 months, J.L. had achieved little progress. Mother noticed that by age two, J.L. was extremely sensitive to loud noises. J.L. was first evaluated for speech and language delays at age three. Results indicated a moderate receptive language delay and significant delays to expressive language skills and speech articulation. Based on J.L.'s extremely limited sound repertoire, a diagnosis of moderate to severe apraxia was first suggested. J.L. was also observed to have difficulties with attention and responding to verbal, visual, and tactile stimulation and cues.

At age three, J.L. was primarily using single words, with occasional two-word utterances. He required considerable structure and visual support. For speech and language services conducted at a therapeutic center at ages 4 and 5 (pre-school age), J.L. was using a picture communication board for initiating requests and making choices. Movement therapy focused on increasing the variety of sensory-motor activities he engaged in. J.L. was observed to benefit from activities that provided significant proprioceptive feedback, such as climbing and jumping. He demonstrated a pronounced reluctance to engage in a variety of movement activities and exhibited slow (i.e. clumsy) fine motor development in a carefully structured occupational therapy program. Between ages three and seven, J.L. achieved some progress in speech-language skills. But while his frequency of speech improved, he experienced difficulty with expressive grammar and speech intelligibility. Academic issues began in kindergarten. He began experiencing difficulty with classroom activities that required language processing and verbal expression. He often used pronouns incorrectly (e.g. "me" for "I" and "he" for "she"). When producing sentences, J.L. would sometimes leave a word out. Unfamiliar adults had difficulty understanding J.L.'s speech, especially out of context. J.L. would often use gestures or substitute words that he could say better in efforts to improve his communication skills. Sometimes he would become frustrated and say "never mind" in cases in which he was unable to get the listener to understand his message.

While attending first grade at his elementary school, J.L. received speech therapy, occupational therapy, remedial reading, and special education curriculum. He was experiencing difficulty across all subjects. Specifically, difficulties were noted in retaining information and following multistep directions. He had expressive language difficulties and fine motor difficulties (e.g. writing letters and numbers, using scissors, tracing, and buttoning his clothes). He could be inattentive and easily distracted at times. He often showed improvement when he received one-on-one help reinforced with constant repetition. He demonstrated consistent speech errors, such as substituting "f" for "s" or leaving out a consonant in the middle of a multisyllable word. His vowels often didn't sound appropriate. While described by his mother as "an easy-going child who makes friends easily," he most enjoyed solitary (self-driven) pleasures such as books with repetition (e.g. Brown Bear, Brown Bear), 25-piece jigsaw puzzles, building with blocks, and playing with Matchbox cars, trucks, and action figures.

At the age of six years, ten months, J.L. underwent an extensive speech and language evaluation. Testing included examinations for speech production (Goldman-Fristoe Test of Articulation -Second Edition or GFTA-2) and consistency of productions (Khan-Lewis Phonological Analysis -Second Edition or KLPA-2). He also was tested in speech intelligibility, oral mechanism, language, narrative skills, and phonological awareness. While his results in the GFTA-2 were in the low normal range, his KLPA-2 results were prone to serious errors such as deleting final consonants of words (e.g. scissors became "scisso") and producing fewer syllables in target words (e.g. balloons became "bwon"). When J.L. performed a story re-telling, an unfamiliar listener without knowledge of the story understood only 34% of the words in J.L.'s speech sample. In an oral mechanism test, J.L. experienced difficulty with repetitions of the word "puppy," which were slow, imprecise, and dysrhythmic and increased difficulty with expressing complex words and phrases. His language scores fell in the Delayed to Very Delayed range. Because his speech was difficult for adult listeners to understand, he received very low narrative skills scores. He had memorized a few rhymes (e.g. "house-mouse"), but demonstrated very poor rhyming skills. In summary, J.L. presented with a serious speech disorder (developmental apraxia of speech) that was adversely impacting his academic progress in most areas.

At the age of 7 years, 1 month, J.L. received further intelligence testing, specifically a Woodcock Johnson III Test of Achievement. He performed in the low range (70-79) on Broad Math and Math Calculation Skills when compared to others at his age level. His Broad Reading score fell in the very low range (60-69) for his age level as did his Written Language, Written Expression, Oral Expression, and Oral Language, and Listening Comprehension skill sets. His only relative strength area proved to be Picture Vocabulary (80-89) where he achieved in the low average range.

METHOD

12-week program of Cortical Integrative Therapy

RESULTS

At the conclusion of the 12-week treatment program, J.L. showed considerable gains in his ability to understand directions as noted by an independent examiner, a school psychologist. His overall academic performance, as noted by his classroom teachers and parents, was also significantly improved especially in the areas of reading and reading comprehension, listening skills, oral expression, and rhyming ability. Of perhaps greater significance, his speech is easier to understand, if slightly slower and more melodic. In addition, his perceptual motor skills and fine motor coordination seem to have substantially improved. He is much less clumsy.

There were also other documented gains. Subsequent to receiving Cortical Integrative training, at age 7 years, 7 months, J.L. underwent further neuropsychological testing. While his conversational speech remained "somewhat unclear" and he spoke with a slight lisp and often mispronounced words, he received a Verbal IQ score of 76, a Performance IQ score of 74, and a Full Scale IQ of 73, all in the mildly impaired range for others of his age group, but considerably improved from earlier testing. Fluency to a phonemic characteristic was in the low average range, while fluency to a semantic category was average suggesting the J.L. benefits greatly from external structure and support. Recognition memory was average for retention of simple information. His ability to sustain attention to search for a shape was fast and accurate. Immediate recall of stories was in the low average range and improved slightly to the average range over delay. The subsequent testing also revealed a low average ability to use feedback to discover categorical rules and solve novel problems. While J.L.'s deficits are more extensive than being exclusively apraxia-related, his adaptive skills are too high to consider him as mentally retarded. In addition, in separate trials, receptive single-word vocabulary (as demonstrated by his recognition of words by sight) was significantly improved. Showing a newfound predilection for visual scanning, J.L. has gone from recognizing only 3 words on sight to a recognizing at least 146 words, with the ability to reproduce results independently and upon command.

DISCUSSION

Developmental apraxia of speech is often associated with serious impediment to academic success. J.L. had been stymied throughout his academic career by this disability, and his quality of life was severely restricted. But when a multimodal approach using techniques aimed at facilitating inter-hemispheric communication was provided, evidence was produced to indicate that when such techniques are applied, the prospect of indirect neuronal or network modulation occurring as cortical pathways are stimulated becomes a real possibility worthy of further investigation. In addition, there are valuable intangibles effecting quality of life. Prior to participation in Cortical Integrative therapy, J.L. often grew frustrated with simple homework tasks and academic work. His speech sounded like "babble" and he was reduced to gestures to be understood much of the time. It seems that his speech is now significantly improved, and he is less frustrated while communicating.

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