Challenging Case
Apraxia, Autism, Attention-Deficit Hyperactivity Disorder: Do We Have a New Spectrum? Jayna Schumacher, MD,* Kristine E. Strand, EdD, CCC-SLP,† Marilyn Augustyn, MD* CASE: Gio is a bilingual 6-year 10-month-old boy new to your practice who presents for an unscheduled visit with concerns for speech and language delay. He was born in Portugal, and his native language is Portuguese. When he was 21 months old, his family moved to Italy and then moved to the United States 3 years later. He had very little contact with other children while living in Italy, but his parents report that he has made friends quickly in the United States. His family speaks Portuguese at home, although his father is fluent in English. He started school 3 months after moving to the United States and is currently repeating kindergarten. He is in a sheltered English classroom with several other students who speak Portuguese. He is able to understand and follow directions in English. A recent school evaluation revealed solidly average nonverbal reasoning skills and relative weaknesses in verbal reasoning and working memory. His speech is described as unintelligible in conversation, both in English and Portuguese. Results of a special education evaluation qualified him for services with a bilingual therapist. His teachers are very concerned that he may have autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD). They describe him as having limited interest in other children, poor eye contact, and hypersensitivities. He wanders at recess. He is very skilled at art and seems to prefer to draw rather than interact with others. He needs constant support and redirection throughout the school day. He has difficulty putting on his coat, using playground equipment, and following daily classroom routines. On the Vanderbilt Rating Scale, his teacher endorses 17 of 18 ADHD symptoms as present often or very often and significant impairment in his performance. Gio presents to your clinic as a relatable young boy with childhood apraxia of speech. Only his productions of single words and short routine phrases are intelligible. He attempts to engage in conversation but averts his gaze and becomes frustrated when asked to repeat things. Scores on the Parent Conners Rating Scale and Social Responsiveness Scale are not elevated. When you bring up school’s concerns, his father describes feeling somewhat badgered by his teachers about possibility of ASD. School is considering placement in an inclusion classroom for children with ASD. What do you recommend? How would you advise his parents? (J Dev Behav Pediatr 36:124–126, 2015) Index terms: apraxia of speech, ADHD, autism.
Kristine E. Strand, EdD, CCC-SLP Childhood apraxia of speech (CAS) is a developmental disorder of speech motor planning or programming in which children have problems saying sounds, syllables, and words. Specifically, the brain has problems planning to move the body parts (e.g., lips, jaw, and tongue) needed for speech.1 However, children with this diagnosis often present with multiple behaviors that lead to questions of how this diagnosis might be integrated with other domains of functioning, in Gio’s case, ASD and/or ADHD. Because of the complementary nature of these disorders, an interdisciplinary team approach to diFrom the *Boston University School of Medicine, Department of Pediatrics, Division of Developmental and Behavioral Pediatrics, Boston, MA; †Boston University, College of Health and Rehabilitation Sciences, Sargent College, Boston, MA. Disclosure: The authors declare no conflict of interest. Address for reprints: Marilyn Augustyn, MD, Department of Pediatrics, 818 Harrison, Maternity-5, Boston, MA 02118; e-mail: [email protected]. Copyright Ó 2015 Wolters Kluwer Health, Inc. All rights reserved.
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agnosis and treatment is optimal. Given our current health care system, interdisciplinary service provision may often be sequential rather than functioning in the same place at the same point in time. Although Gio had an existing diagnosis of CAS, questions remained about the extent to which this diagnosis related to other domains of his social and cognitive functioning. With the complexity of questions about diagnosis and more importantly educational planning, a speech-language pathologist who has expertise in differentially diagnosing factors contributing to a spectrum of communication and language-based learning disorders becomes a valuable member of the team. Gio’s father described Gio’s speech as unintelligible both in Portuguese and English indicating that there is a pervasive underlying speech production deficit rather than a language-specific phonological difference. Gio’s difficulty planning, sequencing and coordinating speech sounds, and syllable patterns particularly as the length and complexity of the motor movements for precise speech production increased is consistent with a diagnosis of CAS. Although the general intent of Gio’s novel Journal of Developmental & Behavioral Pediatrics
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
conversational interactions could be assumed if the topic was known, the intelligibility of most of the words in his connected speech utterances was severely limited. His productions of single words and short routine phrases although not precise were more intelligible. Further testing of Gio’s language production found that even in sentence imitation tasks, he typically reduced the 4-word sentences to 2 words. He primarily used atypical speech sound and syllable structure errors. This pattern would indicate that Gio’s expressive language skills are substantially constrained by his speech production limitations. It was observed that during Gio’s connected speech attempts, his tongue was often humped particularly in the back of his mouth. This pattern of limited differentiated tongue movement highlights the extent to which motor planning/programming for speech is extremely difficult for Gio. Other oromotor signs of CAS include making inconsistent sound errors that are not the result of immaturity, sounding choppy, monotonous, or stressing the wrong syllable or word. In addition, children may have difficulties with fine motor movement and coordination as well. For many children, such as Gio, with significant speech production disorders, interactions with peers are extremely difficult and often unsuccessful.2 As a result, they compensate with a variety of behaviors that mimic the behavior pattern seen in children with ASD. For example, they often avoid eye contact especially when the amount of motor and linguistic planning in the interaction increases and frequently chose to play by themselves rather than risk of unsuccessful peer interactions in the classroom or on the playground. It would be important for the speech and language pathologist working with Gio to assist him in developing increased intelligibility and automatic verbal responses with a small core vocabulary of single words and phrases that would have maximal communicative effectiveness across a spectrum of academic and social contexts before assuming that his behaviors have a primary social or attentional basis. Gio’s communication disorder appears to stem from significant speech under production and resulting expressive language constraints rather than more pervasive social or attentional disorders. Therefore, placement in a classroom for children with ASD would not address his issues or lead to the greatest improvements in either academic or social functioning. It would be more appropriate to consider a diagnostic placement in a substantially separate class for students with language-based learning disorders in combination with intensive speech and language therapy as part of his educational plan.3
REFERENCES 1. American Speech-Language-Hearing Association. Childhood apraxia of speech [Technical report]. 2007. Available at: http://www.asha. org/policy/TR2007-00278.htm. Accessed February 2, 2014. 2. Lewis B, Freebairn L, Hansen A, et al. School-age follow-up of children with childhood apraxia of speech. Lang Speech Hear Serv Sch. 2004;35:122–140. Vol. 36, No. 2, February/March 2015
3. Murray E, McCabe P, Ballard K. A systematic review of treatment outcomes for children with childhood apraxia of speech. Am J Speech Lang Pathol. 2014;23:486–504.
Jayna Schumacher, MD This case illustrates the importance of evaluating a child’s behavior across multiple settings when making developmental diagnoses. Although Gio’s school speech and language therapist suspected childhood apraxia of speech (CAS), she believed that his social anxiety, hypersensitivities, and distractibility warranted comorbid diagnoses of autism spectrum disorder (ASD) and/or ADHD while his parents did not report these behaviors. When faced with discordant school and parent reports of behavior, the following considerations become critical in addition to clinical observations: (1) differences in demands and supports in varying contexts and (2) possible under- or over-representation of symptoms. CAS may be part of a more global language processing delay,1 which may explain why Gio presents with more functional impairments in settings with increased demands for sustaining attention and processing complex information. Because of how special education services are delivered in Gio’s school district, his school only has substantially separate classrooms for children with ASD. This has implications for school assignment but may also influence how similar behaviors observed in different conditions are interpreted despite evidence, for example, that children with CAS may exhibit sensory profiles similar to children with ASD.2 More important than diagnostic labels is developing a treatment plan that addresses Gio’s constellation of symptoms. Although evidence for specific treatment approaches is lacking,3 CAS is believed to require intensive individual speech and language therapy with 3–5 sessions per week.4 Augmentative and alternative communication systems should be used to expand communication opportunities. We recommend that his parents advocate for a language-based substantially separate classroom for students with language-based learning disabilities, as Gio would benefit from a smaller classroom setting and specialized curriculum in language-based academic areas. Establishing intensive special education services is easier said than done, especially when school is reluctant to accept CAS as the primary diagnosis for Gio. This is when support and guidance from specialists and an interdisciplinary team approach is helpful in securing adequate services.
REFERENCES 1. Lewis BA, Freebairn LA, Hansen AJ, et al. School-age follow-up of children with childhood apraxia of speech. Lang Speech Hear Serv Sch. 2004;35:122–140. 2. Newmeyer AJ, Aylward C, Akers R, et al. Results of the sensory profile in children with suspected childhood apraxia of speech. Phys Occup Ther Pediatr. 2009;29:203–218. 3. Morgan AT, Vogel AP. Intervention for childhood apraxia of speech. Cochrane Database Syst Rev. 2008;CD006278. doi: 10.1002/14651858.CD006278.pub2. Copyrigh © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
4. American Speech-Language-Hearing Association. Childhood apraxia of speech [Technical report]. Available at: http://www.asha. org/policy/TR2007-00278.htm#sec1.6. Accessed January 7, 2015.
Marilyn Augustyn, MD As illustrated in the case above, intra- and interprofessional collaboration is critical but never straightforward. A recent study examining the diagnosis of Developmental Coordination Disorder (DCD), a similar chronic neurodevelopmental condition, illustrated the importance of cross professional work.1 This study was designed to determine the feasibility and impact of an educational outreach and collaborative care model to improve chronic disease management of children with DCD. Physicians receiving educational outreach visits significantly improved their knowledge about DCD and their ability to identify and diagnose children with this condition. Physicians who collaborated with occupational therapists in providing care reported more confidence in diagnosing children with DCD and were more likely to continue to use screening measures and to provide educational materials to families.
Childhood apraxia of speech like DCD is often thought to be a “neurologic” diagnosis but it lies well within the realm of Developmental and Behavioral Pediatrics. But neither a neurologist nor a DBP could appropriately tease out these details without the knowledge and insight of a speech-language pathologist. When we jump to diagnoses based on a constellation of behaviors as was the case in the school system leaping to autism spectrum disorder or attention-deficit hyperactivity disorder, we are often wrong. As medical professionals, we can often consider inaccurate diagnoses when we do not appropriately consult colleagues for their expertise. Informed and collaborative practices across disciplines will increase the efficiency and effectiveness of delivery systems to promote team-based child and family-centered health care.
REFERENCE 1. Gaines R, Missiuna C, Egan M, et al. Educational outreach and collaborative care enhances physician’s perceived knowledge about developmental coordination disorder. BMC Health Serv Res. 2008; 24:21.
CORRECTION Childhood Feeding Difficulties: A Randomized Controlled Trial of a Group-Based Parenting Intervention: Correction In the article that appeared on page 293 of Volume 34, Issue 5 of Journal of Developmental & Behavioral Pediatrics, there is an error in the disclosure provided. The statement “Disclosure: The authors declare no conflicts of interest.” should not have been included. REFERENCE: 1. Adamson M, Morawska A, Sanders MR. Childhood feeding difficulties: a randomized controlled trial of a group-based parenting intervention. J Dev Behav Pediatr. 2013;34:293–302.
126 Challenging Case
Journal of Developmental & Behavioral Pediatrics
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Apraxia, Autism, Attention-Deficit Hyperactivity Disorder: Do We Have a New Spectrum? Jayna Schumacher, MD,* Kristine E. Strand, EdD, CCC-SLP,† Marilyn Augustyn, MD* CASE: Gio is a bilingual 6-year 10-month-old boy new to your practice who presents for an unscheduled visit with concerns for speech and language delay. He was born in Portugal, and his native language is Portuguese. When he was 21 months old, his family moved to Italy and then moved to the United States 3 years later. He had very little contact with other children while living in Italy, but his parents report that he has made friends quickly in the United States. His family speaks Portuguese at home, although his father is fluent in English. He started school 3 months after moving to the United States and is currently repeating kindergarten. He is in a sheltered English classroom with several other students who speak Portuguese. He is able to understand and follow directions in English. A recent school evaluation revealed solidly average nonverbal reasoning skills and relative weaknesses in verbal reasoning and working memory. His speech is described as unintelligible in conversation, both in English and Portuguese. Results of a special education evaluation qualified him for services with a bilingual therapist. His teachers are very concerned that he may have autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD). They describe him as having limited interest in other children, poor eye contact, and hypersensitivities. He wanders at recess. He is very skilled at art and seems to prefer to draw rather than interact with others. He needs constant support and redirection throughout the school day. He has difficulty putting on his coat, using playground equipment, and following daily classroom routines. On the Vanderbilt Rating Scale, his teacher endorses 17 of 18 ADHD symptoms as present often or very often and significant impairment in his performance. Gio presents to your clinic as a relatable young boy with childhood apraxia of speech. Only his productions of single words and short routine phrases are intelligible. He attempts to engage in conversation but averts his gaze and becomes frustrated when asked to repeat things. Scores on the Parent Conners Rating Scale and Social Responsiveness Scale are not elevated. When you bring up school’s concerns, his father describes feeling somewhat badgered by his teachers about possibility of ASD. School is considering placement in an inclusion classroom for children with ASD. What do you recommend? How would you advise his parents? (J Dev Behav Pediatr 36:124–126, 2015) Index terms: apraxia of speech, ADHD, autism.
Kristine E. Strand, EdD, CCC-SLP Childhood apraxia of speech (CAS) is a developmental disorder of speech motor planning or programming in which children have problems saying sounds, syllables, and words. Specifically, the brain has problems planning to move the body parts (e.g., lips, jaw, and tongue) needed for speech.1 However, children with this diagnosis often present with multiple behaviors that lead to questions of how this diagnosis might be integrated with other domains of functioning, in Gio’s case, ASD and/or ADHD. Because of the complementary nature of these disorders, an interdisciplinary team approach to diFrom the *Boston University School of Medicine, Department of Pediatrics, Division of Developmental and Behavioral Pediatrics, Boston, MA; †Boston University, College of Health and Rehabilitation Sciences, Sargent College, Boston, MA. Disclosure: The authors declare no conflict of interest. Address for reprints: Marilyn Augustyn, MD, Department of Pediatrics, 818 Harrison, Maternity-5, Boston, MA 02118; e-mail: [email protected]. Copyright Ó 2015 Wolters Kluwer Health, Inc. All rights reserved.
124 | www.jdbp.org
agnosis and treatment is optimal. Given our current health care system, interdisciplinary service provision may often be sequential rather than functioning in the same place at the same point in time. Although Gio had an existing diagnosis of CAS, questions remained about the extent to which this diagnosis related to other domains of his social and cognitive functioning. With the complexity of questions about diagnosis and more importantly educational planning, a speech-language pathologist who has expertise in differentially diagnosing factors contributing to a spectrum of communication and language-based learning disorders becomes a valuable member of the team. Gio’s father described Gio’s speech as unintelligible both in Portuguese and English indicating that there is a pervasive underlying speech production deficit rather than a language-specific phonological difference. Gio’s difficulty planning, sequencing and coordinating speech sounds, and syllable patterns particularly as the length and complexity of the motor movements for precise speech production increased is consistent with a diagnosis of CAS. Although the general intent of Gio’s novel Journal of Developmental & Behavioral Pediatrics
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
conversational interactions could be assumed if the topic was known, the intelligibility of most of the words in his connected speech utterances was severely limited. His productions of single words and short routine phrases although not precise were more intelligible. Further testing of Gio’s language production found that even in sentence imitation tasks, he typically reduced the 4-word sentences to 2 words. He primarily used atypical speech sound and syllable structure errors. This pattern would indicate that Gio’s expressive language skills are substantially constrained by his speech production limitations. It was observed that during Gio’s connected speech attempts, his tongue was often humped particularly in the back of his mouth. This pattern of limited differentiated tongue movement highlights the extent to which motor planning/programming for speech is extremely difficult for Gio. Other oromotor signs of CAS include making inconsistent sound errors that are not the result of immaturity, sounding choppy, monotonous, or stressing the wrong syllable or word. In addition, children may have difficulties with fine motor movement and coordination as well. For many children, such as Gio, with significant speech production disorders, interactions with peers are extremely difficult and often unsuccessful.2 As a result, they compensate with a variety of behaviors that mimic the behavior pattern seen in children with ASD. For example, they often avoid eye contact especially when the amount of motor and linguistic planning in the interaction increases and frequently chose to play by themselves rather than risk of unsuccessful peer interactions in the classroom or on the playground. It would be important for the speech and language pathologist working with Gio to assist him in developing increased intelligibility and automatic verbal responses with a small core vocabulary of single words and phrases that would have maximal communicative effectiveness across a spectrum of academic and social contexts before assuming that his behaviors have a primary social or attentional basis. Gio’s communication disorder appears to stem from significant speech under production and resulting expressive language constraints rather than more pervasive social or attentional disorders. Therefore, placement in a classroom for children with ASD would not address his issues or lead to the greatest improvements in either academic or social functioning. It would be more appropriate to consider a diagnostic placement in a substantially separate class for students with language-based learning disorders in combination with intensive speech and language therapy as part of his educational plan.3
REFERENCES 1. American Speech-Language-Hearing Association. Childhood apraxia of speech [Technical report]. 2007. Available at: http://www.asha. org/policy/TR2007-00278.htm. Accessed February 2, 2014. 2. Lewis B, Freebairn L, Hansen A, et al. School-age follow-up of children with childhood apraxia of speech. Lang Speech Hear Serv Sch. 2004;35:122–140. Vol. 36, No. 2, February/March 2015
3. Murray E, McCabe P, Ballard K. A systematic review of treatment outcomes for children with childhood apraxia of speech. Am J Speech Lang Pathol. 2014;23:486–504.
Jayna Schumacher, MD This case illustrates the importance of evaluating a child’s behavior across multiple settings when making developmental diagnoses. Although Gio’s school speech and language therapist suspected childhood apraxia of speech (CAS), she believed that his social anxiety, hypersensitivities, and distractibility warranted comorbid diagnoses of autism spectrum disorder (ASD) and/or ADHD while his parents did not report these behaviors. When faced with discordant school and parent reports of behavior, the following considerations become critical in addition to clinical observations: (1) differences in demands and supports in varying contexts and (2) possible under- or over-representation of symptoms. CAS may be part of a more global language processing delay,1 which may explain why Gio presents with more functional impairments in settings with increased demands for sustaining attention and processing complex information. Because of how special education services are delivered in Gio’s school district, his school only has substantially separate classrooms for children with ASD. This has implications for school assignment but may also influence how similar behaviors observed in different conditions are interpreted despite evidence, for example, that children with CAS may exhibit sensory profiles similar to children with ASD.2 More important than diagnostic labels is developing a treatment plan that addresses Gio’s constellation of symptoms. Although evidence for specific treatment approaches is lacking,3 CAS is believed to require intensive individual speech and language therapy with 3–5 sessions per week.4 Augmentative and alternative communication systems should be used to expand communication opportunities. We recommend that his parents advocate for a language-based substantially separate classroom for students with language-based learning disabilities, as Gio would benefit from a smaller classroom setting and specialized curriculum in language-based academic areas. Establishing intensive special education services is easier said than done, especially when school is reluctant to accept CAS as the primary diagnosis for Gio. This is when support and guidance from specialists and an interdisciplinary team approach is helpful in securing adequate services.
REFERENCES 1. Lewis BA, Freebairn LA, Hansen AJ, et al. School-age follow-up of children with childhood apraxia of speech. Lang Speech Hear Serv Sch. 2004;35:122–140. 2. Newmeyer AJ, Aylward C, Akers R, et al. Results of the sensory profile in children with suspected childhood apraxia of speech. Phys Occup Ther Pediatr. 2009;29:203–218. 3. Morgan AT, Vogel AP. Intervention for childhood apraxia of speech. Cochrane Database Syst Rev. 2008;CD006278. doi: 10.1002/14651858.CD006278.pub2. Copyrigh © 2015 Wolters Kluwer Health, Inc. All rights reserved.
125
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
4. American Speech-Language-Hearing Association. Childhood apraxia of speech [Technical report]. Available at: http://www.asha. org/policy/TR2007-00278.htm#sec1.6. Accessed January 7, 2015.
Marilyn Augustyn, MD As illustrated in the case above, intra- and interprofessional collaboration is critical but never straightforward. A recent study examining the diagnosis of Developmental Coordination Disorder (DCD), a similar chronic neurodevelopmental condition, illustrated the importance of cross professional work.1 This study was designed to determine the feasibility and impact of an educational outreach and collaborative care model to improve chronic disease management of children with DCD. Physicians receiving educational outreach visits significantly improved their knowledge about DCD and their ability to identify and diagnose children with this condition. Physicians who collaborated with occupational therapists in providing care reported more confidence in diagnosing children with DCD and were more likely to continue to use screening measures and to provide educational materials to families.
Childhood apraxia of speech like DCD is often thought to be a “neurologic” diagnosis but it lies well within the realm of Developmental and Behavioral Pediatrics. But neither a neurologist nor a DBP could appropriately tease out these details without the knowledge and insight of a speech-language pathologist. When we jump to diagnoses based on a constellation of behaviors as was the case in the school system leaping to autism spectrum disorder or attention-deficit hyperactivity disorder, we are often wrong. As medical professionals, we can often consider inaccurate diagnoses when we do not appropriately consult colleagues for their expertise. Informed and collaborative practices across disciplines will increase the efficiency and effectiveness of delivery systems to promote team-based child and family-centered health care.
REFERENCE 1. Gaines R, Missiuna C, Egan M, et al. Educational outreach and collaborative care enhances physician’s perceived knowledge about developmental coordination disorder. BMC Health Serv Res. 2008; 24:21.
CORRECTION Childhood Feeding Difficulties: A Randomized Controlled Trial of a Group-Based Parenting Intervention: Correction In the article that appeared on page 293 of Volume 34, Issue 5 of Journal of Developmental & Behavioral Pediatrics, there is an error in the disclosure provided. The statement “Disclosure: The authors declare no conflicts of interest.” should not have been included. REFERENCE: 1. Adamson M, Morawska A, Sanders MR. Childhood feeding difficulties: a randomized controlled trial of a group-based parenting intervention. J Dev Behav Pediatr. 2013;34:293–302.
126 Challenging Case
Journal of Developmental & Behavioral Pediatrics
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
