Webwords 36 March 2010
MOTOR
SPEECH
DISORDERS
Caroline Bowen

There is little point in telling Speechwoman not to worry. Webwords has tried, but the over-conscientious doyenne of Elastic Webbing, Lycra and Spandex daywear, Stretchwear for the gym and what's-best-for-us on the Internet worries constantly. High on her list of key concerns are midriff bulge and the standard of web based information relating to communication sciences and disorders. Webwords found her in deep despair after a frustrating week of trawling for plain-English articles on motor speech disorders.

"What's up?"

That was all it took for the usually contained Speechwoman to unleash a rare and uncharacteristic outburst.

"If there was an Internet booby prize for the communication disorder associated with the most misinformation", she said hotly, "it would surely be awarded to a site about Childhood Apraxia of Speech."

"I know."

"Yes, well," she spluttered. "But do you also know that if you look on the Internet for soundly-based information for families and consumers of speech-language pathology services there is virtually nothing about dysarthria in children or adults or about acquired Apraxia of Speech either?"

"Nothing?"

"Virtually nothing."

"Crumbs."

"Crumbs indeed. And when you think you have found a good page you discover that it links to a site containing the most unutterable rubbish."

"May I quote you?"

"Quote me?"

"I have to help her write a column on Motor Speech Disorders."

"Well, yes. Put the word out there by all means. But you'd better not say 'unutterable rubbish'."

"Blithering nonsense then."

"No!" At least she was laughing.

"OK. We'll call it "Other Sites". But is it as bad as all that?"

Ever the optimist, Speechwoman admitted to being pleased with the clarity and accuracy of the Childhood Apraxia of Speech page on the Victorian Better Health Guide (produced in consultation with and approved by Speech Pathology Australia) and the excellent Family Start Guide on the Apraxia-KIDS site. 

THE DYSARTHRIAS AND APRAXIAS
The motor speech disorders commonly diagnosed and treated by speech-language pathologists are the dysarthrias and apraxias. The dysarthrias may be flaccid, spastic, ataxic, hyperkinetic, hypokinetic or mixed in adults and children. The apraxias are Apraxia of Speech (AOS) in adults and a different symptom complex with a confusingly similar name, Childhood Apraxia of Speech (CAS), in children (Maasen, 2002).

• The dysarthrias are due to weakness, incoordination or paralysis of the speech musculature. They are characterised by any combination of effortful or slurred speech, hyponasality, hypernasality, low or variable loudness, voice and prosodic difficulties, dysfluency and breathing problems. These characteristics usually result in poor speech intelligibility, or even an absence of intelligible speech. Older people with dysarthria may have a particular difficulty with making themselves understood if their important communicative partners are contemporaries with age-related hearing loss and slowed cognitive processing.

• Apraxia of Speech (AOS) involves difficulty planning and sequencing voluntary muscle movements related to speech. AOS can affect people at any age, but it is usually precipitated by stroke, head injury, tumour, or other neurological illness. Often accompanied by aphasia its characteristics are difficulty initiating speech movements, disrupted fluency with frequent pauses and restarts, groping for correct articulatory configurations, articulatory errors including distortions, and comparatively intact automatic speech.

• Childhood Apraxia of Speech (CAS) is a symptom complex rather than a unitary disorder. It is hypothesised by some researchers to be due to a genetically transmitted deficit in speech motor control, but this putative cause has not been confirmed and is the subject of ongoing research (Shriberg, 2006). To date there is no phenotype for CAS although there is general agreement that at its core is an impairment in planning and/or programming the spatiotemporal parameters of movement sequences. These space-time difficulties result in speech and prosodic errors and a characteristic receptive-expressive gap where the child with CAS has receptive language abilities that are superior to their expressive performance. Affected children exhibit speech errors including variable production of consonants and vowels in multiple repetitions of syllables or words (that is, token-to-token variability); lengthened and disrupted coarticulatory transitions between sounds and syllables; inappropriate prosody, especially when they come to apply stress to words or phrases (ASHA, 2007), and inconsistent application of nasal resonance (Shriberg Campbell, Karlsson, McSweeney, & Nadler, 2003).
  
  The term CAS is applied to all presentations of apraxia in children, acquired and idiopathic. Although it is taking a little while to catch on in some parts of the world, "CAS" is now preferred  by the research and clinical communities over more traditional labels like developmental verbal dyspraxia and "dyspraxia" which were usually only applied to idiopathic presentations.

WEB RESOURCES
MOTOR SPEECH DISORDERS IN ADULTS
Mindful of Speechwoman's words, it was delightful to find a classic article, Rosenbeck & Wertz (1972) on the treatment of AOS on the University of Pittsburgh site, Julie Wambaugh with contemporary guidelines for AOS intervention, and Duffy (2008) on motor speech disorders and the diagnosis of neurologic disease. It was also interesting to locate Motor Speech Laboratories at Arizona State University, the University of Canterbury and the University of Hong Kong.

WEB RESOURCES
MOTOR SPEECH DISORDERS IN CHILDREN
On the ASHA site Hammer (2009) writes about providing services in schools to children with CAS, Strand & McCauley (2008) offer useful guidelines for differential diagnosis of severe speech impairment, Gildersleeve-Neumann (2007) outlines the application of motor learning principles to intervention, and the jewel in the crown is the ASHA (2007) Technical Report and Position Statement.

Meanwhile, a review of intervention for CAS in the Cochrane Collaboration challenges the profession with news that their review, "demonstrates that there are currently too few well-controlled studies in this field to enable conclusions to be drawn about the efficacy of treatment for the entire CAS population, and calls for SLPs working in this area to design better studies." The collaboration makes a similar call for research into dysarthria in children and adolescents with acquired brain injury, saying there are "currently too few studies performed in this area to draw any conclusions about the efficacy of treatment for dysarthria in children and teenagers."

Do we care?

In 2009 the Ethics Board and Council of Speech Pathology Australia conducted a comprehensive review of the 2000 version of the Code of Ethics. Focus groups were consulted at our national conference and all members had the opportunity to participate in a widely publicised survey. And what did we do? Well, 98.5% of us did nothing. Webwords and I won't be telling Speechwoman about this, of course. She'll only worry.

REFERENCES
ASHA (2007). Childhood Apraxia of Speech [Position Statement] pp. 2-3. Retrieved September 7, 2009 from www.asha.org/policy

Clark, H.M. (2003). Neuromuscular treatments for speech and swallowing. American Journal of Speech-Language Pathology. 12, 400-415.

Duffy, J. R. (2008, Nov. 25). Motor speech disorders and the diagnosis of neurologic disease: Still a well-kept secret? The ASHA Leader, 13(16), 10–13.

Gildersleeve-Neumann, C. (2007, Nov. 6). Treatment for childhood apraxia of speech: A description of integral and stimulation and motor learning. The ASHA Leader, 12(15), 10-13, 30.

Hammer, D. (2009, Sep. 22). Perspective: Apraxia Services in the Schools. The ASHA Leader, 14(12), 24, 34.

Maassen B. (2002).Issues contrasting adult acquired versus developmental apraxia of speech. Seminars in Speech and Language, 23, 4, 257-66.

Rosenbek, J., & Wertz, R. T. (1972, May). Treatment of Apraxia of Speech in Adults. Second Clinical Aphasiology Conference: Albuquerque, NM, 191-198. LINK

Shriberg, L. D. (2006, June). Research in Idiopathic and Symptomatic Childhood Apraxia of Speech. Paper presented at the 5th International Conference on Speech Motor Control Nijmegen, the Netherlands.

Shriberg, L.D., Campbell, T.F., Karlsson, H.B., McSweeney, J.L., Nadler, C.J. (2003). A diagnostic marker for childhood apraxia of speech: The lexical stress ratio. Clinical Linguistics and Phonetics, 17, 7, 549-574.

Strand, E. A., & McCauley, R. J. (2008, Aug. 12). Differential diagnosis of severe speech impairment in young children. The ASHA Leader, 13(10), 10-13.

ACQ
ACQ (ACQuiring Knowledge in Speech, Language and Hearing) is Speech Pathology Australia's clinical and professional journal. It provides a forum for the >4,500 members of the association, and is published three times a year in March, July and November. Each issue of ACQ has a main theme or topic as well as articles that are not tied to a particular subject area. Its Internet column, Webwords, usually addresses the central theme of the issue of ACQ in which it appears. You can find Webwords in print in the magazine itself, and also here on this site, with live links to featured resources.

Page updated Tuesday, 23 March 2010

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