Is it Apraxia or Autism?

Is it Apraxia or Autism?

Many parents of children with speech and language delays are often confused what is the underlying cause of the delay. Is it Apraxia or Autism?

Let’s look at both conditions one by one. It is important to differentially diagnose the condition because that helps in choosing the correct approach for treatment and support.

Childhood Apraxia of Speech

Apraxia, technically known as Childhood Apraxia of Speech (CAS) is a complex neurodevelopmental disorder. This condition causes decreased accuracy, consistency, and clarity of speech due impairment in the ability to plan and sequence speech movements.

In layman’s terms, children with CAS have difficulty making accurate movements of the mouth while speaking. The brain struggles to plan those movements. The speech muscles, including the tongue, jaws, lips, etc. are not weak, but they lack the coordination to produce correct speech. Many children with CAS also have language challenges, like delayed speech, reduced vocabulary, or difficulty with word order.

Some common characteristics that help us to identify Childhood Apraxia of speech are:

• Trouble in smooth progression from one sound /word to another.
• There can be groping movements in lips, tongue, and jaw while trying to produce accurate speech sounds.
• Receptive language or the ability to understand the language will be better than the expressive language skill.
• Impairment in the rhythm of speech.
• Inconsistent errors in vowels and consonants are observed while using words or syllables, especially on new/long/complex words.
• There can be excessive and equal stress on all syllables while producing words or sentences
• The child might take several attempts and also experiences difficulty in imitating words.
• Decreased voluntary oral movements and difficulty with food intake.

Research on Apraxia of Speech

Apraxic speakers have preserved awareness of phonological forms of the words that they want to produce similar to how the words sound. There will not be any motor execution difficulty (ataxia or akinesia) that would stop them from carrying out the required speech movements. Instead, they face problems in transforming the abstract representation of word forms into the motor commands that guide the positioning and sequencing of articulators (Darley, 1968; Code, 1998).

Autism Spectrum Disorder

Autism is a developmental disorder and it manifests differently with age. Its core features, existing in different forms, at all levels of ability and all stages of development, are:

1. Social interaction
2. Communication
3. Imagination/Repetitive Restricted Behaviors and Interests.

One of the core features of autism spectrum disorder is the deficit in communication involving a delay in language development.  The variance in expressive/spoken language features seen across Autism ranges from no productive expressive language to verbal fluency.  Few studies manifested that functional speech developed by the age of 9 years in approximately 80-90% of autistic children.

Research on Autism

Autism is a neuro-developmental disorder with impairments in different domains like linguistic, social, cognitive, etc (Wetherby & Prutting, 1984). They can exhibit symptoms like repetitive /stereotypic behaviors, activities or interests, sensory issues, and difficulty maintaining eye contact while conversing. Imitation ability is thought to be impaired in ASD cases (Rogers, Hepburn, Stackhouse, & Wehner, 2003; Receveur, Lenoir, Desombre, Roux, Barthelemy, & Malvy, 2005). In comparison to the imitation of meaningless gestures, children with autism may respond well to spontaneous imitation enclosed in meaningful contexts (Nadel and Aouka, 2006).

Comparing Childhood Apraxia of Speech with Autism

Childhood Apraxia of Speech	Autism Spectrum Disorder
Difficulty in performing the learned or practiced action that cannot be explained by sensory/motor deficit or a language comprehension disorder.	Sensory issues are not related to apraxic motor movement issue
Exhibit better receptive and expressive language skills exhibit.	Exhibit deterioration in both receptive and expressive language skills.
Central planning and programming disorder more.	More of a sensory integration disorder.
Cognition is always normal	Possible impact on Cognition
There are different types like Ideational/ Ideomotor/ Conduction/ Dissociation/ Conceptual apraxia.	Can be verbal or non-verbal
Impact on language	Limited speech and language output
Under language components: Phonology (the way sound comes together to form speech) is normal   Normal Semantics (meaning or interpretation of words/sentence structure/signs) Impact on Morphology (how words are formed and their relationship with other words), even though the concept is known.   Pragmatics (social use of language) is not affected in CAS but they might be socially withdrawn.	They do not have abstract concepts.     Semantics limited to their abilities   Affected       Majorly affected in case of ASD
Under components of speech: Voice: is generally not affected in CAS Impact on articulation Impact on fluency	Possible impact on voice, articulation and fluency

Autism and Suspected Childhood Apraxia of Speech

A study conducted in 2015 shows that 63.6% of children initially diagnosed with autism also had apraxia, 36.8% of children initially diagnosed with apraxia also had autism, 23.3% had neither, and 23.3% had both. According to Tager‐Flusberg, H., & Kasari, C. (2013) there is a higher prevalence of CAS in ASD children who are non-verbal or minimally verbal which represents 25-30% of the ASD population.

According to Williams, Whiten, and Singh (2004), individuals with autism had significant difficulty while imitating novel motor tasks, which can be a sign of apraxia. They did not notice any impairment while imitating familiar motor tasks. Due to different motor impairments children with autism may show impairments in motor imitation and for task that doesn’t require any motor learning – children may perform differently in a task of cognitive imitation (Subiaul et al., 2007). Prosodic production deficits are often exhibited by children with autism (Schoen, Paul, & Chawarska, 2009; Shriberg et al., 2001)

Diagnosis of CAS and ASD

The oral movement sequencing difficulty experienced by children with apraxia can be indicative of speech motor planning disorder, especially childhood apraxia of speech

Children diagnosed with ASD can also have speech sound errors. However, they are not always diagnosed with CAS.  A study conducted by Tierney et al., (2015) shows that apraxia and autism are highly comorbid. Children with autism may be non-verbal due to which the diagnosis of apraxia can be delayed in comparison to that of children without autism. On the other hand, the diagnosis of autism can also be delayed to the presence of apraxia. With the high comorbidity nature of these conditions, it is highly essential to observe signs of autism in all children diagnosed with apraxia and signs of apraxia in all children diagnosed with autism.

Delayed expressive language skills are one of the factors that affect the differential diagnosis of ASD and CAS and there are specific management options available for both conditions.

Impaired Oro-motor skills, prosody, and gross motor movements in ASD cases indicate the necessity of focused assessment of apraxia of speech.

Hence is it important to check signs of apraxia in ASD cases and vice versa which highlights the importance of differential diagnosis in the case of both disorders.

Early identification allows access to appropriate management options for their needs, which improves the quality of their life. There are groups of professionals who can help children with CAS.

• Speech-Language Pathologists
• Occupational Therapists
• Developmental Pediatrician
• Special Educators

Tips for Parents

• We can help them to express themselves with the use of AAC/ Communication books/ Portable devices/ Sign language etc.
• Appreciate/ acknowledge the child’s efforts
• Never pressurize the child to speak
• Be patient and encourage all attempts to speak
• Take the appropriate professional help when required
• Hold the objects closer/ next to the mouth and repeat the name so that the child can visualize the movements of the articulators
• Use different sounds (including voice modulation by involving different pitches and intensity) and emphasize the sound which in turn helps in gaining their attention and improving their imitation
• Use different sensory cueing methods like auditory/tactile/ visual to facilitate a sequence of movement during speech production.

Extra research insights

Shriberg et al. (2017a, 2017b) reported groping, voicing errors, greater struggle with multisyllabic words, distorted vowels, syllable segregation, and slow speech were some of the signs of CAS. Shriberg, Aram, & Kwiatkowski, 1997 estimated 1-2 children per thousand to have Apraxia without any comorbid conditions or any other diagnosis. Recent research identified its occurrence with other neurodevelopmental disorders like galactosemia (Shriberg, Potter, & Strand, 2011), FOXP2 mutations (Morgan, Fisher, Scheffer, & Hildebrand, 2016), 16p11.2 deletion (Fedorenko et al., 2016) and children with autism spectrum disorder who are minimally verbal (ASD; Chenausky, Brignell, Morgan, & Tager-Flusberg, 2019).

Read more on autism spectrum disorders and childhood apraxia of speech.