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Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 182-185

Multidisciplinary early intervention in a child with autism and childhood apraxia of speech

1 New Horizons Child Development Centre, Mumbai, Maharashtra, India
2 New Horizons Health and Research Foundation, Mumbai, Maharashtra, India

Date of Submission04-May-2021
Date of Decision31-Jul-2021
Date of Acceptance09-Aug-2021
Date of Web Publication31-Aug-2021

Correspondence Address:
Dr. Samir H Dalwai
New Horizons Child Development Centre, Saira Mansion, Near Pahadi School, Road Number 2, Peru Baug, Jay Prakash Nagar, Goregaon East, Mumbai - 400 066, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipcares.ipcares_136_21

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Background: Childhood apraxia of speech (CAS) is a neurological pediatric speech sound disorder, in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits. It is a common comorbidity in autism spectrum disorder (ASD) and requires detailed analysis to identify the typical errors in speech. Clinical Description: A 25-month-old boy presented with speech delay. The evaluation revealed an impaired absence of meaningful speech, impaired nonverbal communication and social skills, repetitive atypical behavior, and sensory issues with normal hearing. Although autism was suspected, the diagnosis could not be established, and intervention was started based on strengths and weaknesses. There was minimal improvement and discordance between receptive and expressive language was noted. Manifestations evolved over 15 months until a diagnosis of ASD was established by standard protocol. CAS was diagnosed at almost 4 years when a few meaningful words had developed and errors in oral movements, articulation, and phonological development were identified. Management and Outcome: Initially, the child received multidisciplinary management customized according to the strengths, weaknesses, and needs of the child. There was minimal improvement in communication, social interaction, and overall functioning. Identification of autism and slight changes in intervention did not bring about any remarkable changes. Once CAS was identified, and the focus of management changed there was a remarkable improvement in speech, and mild improvement in other aspects. Conclusion: Nonverbal or minimally verbal children with autism should be evaluated for CAS, especially if there is discordance between expressive and receptive language.

Keywords: Childhood apraxia of speech, pediatric speech sound disorder, phonology

How to cite this article:
Dalwai SH, Parakh A, Garg M, Chawla B, Joshi MR, Kumari S. Multidisciplinary early intervention in a child with autism and childhood apraxia of speech. Indian Pediatr Case Rep 2021;1:182-5

How to cite this URL:
Dalwai SH, Parakh A, Garg M, Chawla B, Joshi MR, Kumari S. Multidisciplinary early intervention in a child with autism and childhood apraxia of speech. Indian Pediatr Case Rep [serial online] 2021 [cited 2021 Sep 26];1:182-5. Available from: http://www.ipcares.org/text.asp?2021/1/3/182/325080

Childhood apraxia of speech (CAS) is a neurological pediatric speech sound disorder, in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.[1] Essentially, this means that the sequence of movements involved in speech production is impaired, which disrupts a child's ability to produce sounds, syllables, words, or sentences precisely, consistently, and rhythmically.[2] Not only is the sound production impaired, but also there is inappropriate prosody, i.e., the normal rhythm and intonation of speech.

CAS occurs in 0.1%–0.2% children,[2] with higher prevalence in boys compared to girls, the ratio being 2–3:1.[3],[4] Although the magnitude is uncertain, CAS is frequently seen in nonverbal or minimally verbal children with autism spectrum disorder (ASD). These are children who have no meaningful speech even by the age of 5 years and comprise around 25%–30% of children with ASD.[5] On extrapolating, this percentage to the prevalence of ASD in Indian children between 2 and 6 years (1.0%),[6] and the magnitude of the 0–6-year-old population according to the 2011 census (15.87 crore),[7] it is evident that there will be a huge number of children with both ASD and CAS. If CAS goes unrecognized and is not addressed in the individualized education plan, neurodevelopmental outcomes will get adversely affected. Most pediatricians encounter children with ASD in their practice, nowadays. Not only should they be able to suspect ASD in children with developmental/behavioral issues, make a clinical diagnosis and refer them to experts, but they should also provide continuity of health care including checking adherence to the management.

We present the evolution of manifestations and management of a toddler who presented with speech delay and was eventually diagnosed as ASD with CAS. This condition has traditionally been considered to be the domain of the expertise of speech and language pathologists. We believe that pediatricians who provide health care to children with ASD (especially minimally verbal children) should be aware of this relatively unknown disorder.

  Clinical Description Top

A 25-month-old boy presented to our center with delayed speech. The child did not speak any meaningful words and only uttered syllables. He did not point when he needed something but would drag his mother toward the object of desire and use her hand for indicating it. He displayed difficulties in understanding gestures. Although the parents had not appreciated any delay in other domains, we identified impairment in social skills. Apart from occasional smiling, he avoided social interactions. The parents thought he was shy and would outgrow it.

On probing, further, we also elicited the presence of atypical behavior. He was fascinated by patterns on surfaces (i.e., on the furniture or walls) and would stare at them for hours. He frequently ground his teeth and plucked his hair. He would get agitated and cover his ears at loud sounds such as horns or the whistle of a pressure cooker. There was no history of seizures or impairment in vision, hearing, chewing, swallowing, or locomotor abilities.

The child was born of a nonconsanguineous union, at term, by a cesarean section (the indication being fetal distress). Details of the Apgar Score were unavailable, but there was no history that suggested hypoxic-ischemic encephalopathy. The birth weight was 2.4 kg. He developed neonatal jaundice at 48 h, received phototherapy, and was discharged by the 5th day of life. Neither the past history nor family history was contributory. The parents belonged to the upper socioeconomic strata and were working professionals. We deemed the stimulation being given at home to be quantitatively and qualitatively adequate. The child had undergone brainstem-evoked response audiometry, an ophthalmologic evaluation, and a thyroid profile previously, all of which were normal. The weight, height, and head circumference were within normal limits. Examination of the oral cavity and throat was unremarkable. The child did not display dysmorphism or neurocutaneous markers. Extended neurological and systemic examinations were normal. Since the clinical phenotype comprised delayed communication (verbal and nonverbal) and social interaction, atypical behavior, sensory issues, and normal hearing, autism was suspected.

A multidisciplinary evaluation was performed. The Vineland Social Maturity Scale revealed a Social Quotient (SQ) of 84.96 (average social functioning), but the profile was uneven, with significantly more delay in self-help, eating, and communication skills. Diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM) were not satisfied, and the Childhood Autism Rating Scale (CARS) score was 27.5 (nonautistic). [Table 1] lists the speech and language assessment. According to the receptive expressive emergent language test, the receptive language (RL) age was 12–14 months, whereas the expressive language (EL) age was 7-8 months. Vestibular, auditory, and tactile sensory issues were identified. Despite synthesizing all information, a specific diagnosis could not be established, which is quite common in young children with special needs, sans locomotor impairment. We decided to formulate a multidisciplinary IP based on our functional assessment, monitor his progress, and reassess. The parents were explained about the child's strengths, weaknesses, and needs and the importance of incorporating intervention strategies into their daily routine.
Table 1: Speech and language characteristics pre- and post- intervention plan

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Management and outcome

The intervention plan (IP) was multidimensional. Occupational therapy focused on improving eye–hand coordination, fine motor skills, and perception of depth and space. Sensory integration was employed for sensory issues. At the onset, speech and language therapy aimed at improving cognitive prerequisites for learning language (e.g., developing eye contact, attention and concentration, imitation of body movements and vocal behaviors, improving comprehension and expression, improving social skills, and oral skills). A linguistic approach included facilitating oral sensory and oral-motor development. The scope of language ability was expanded by teaching the child how to make a different sound, the rules of using these sounds, and their sequences. Behavior modification strategies were shared to help parents create a more conducive learning environment and avoid triggering inappropriate behaviors. Regular parental feedback was obtained regarding the child's changing needs and overall learning. Compliance with instruction was good.

[Table 1] lists the various changes that occurred during follow-up. Minimal improvement was observed in communication, social interaction, and independence in activities of daily living. Goals of the IP were modified periodically, according to the mastery attained in skills. Reevaluation at 3.25 years revealed a decrease in SQ (62.5) to mild subnormal levels. The DSM-5 diagnostic criteria of ASD were satisfied, and the CARS score was 30 (mildly to moderately autistic). The intervention continued, after factoring in the additional ASD. However, improvement still did not occur as expected given the severity of autism and good parental adherence to the IP. Problems in verbal expression and articulation were identified on the emergence of a few single words with meaning in the 4th year. A detailed analysis demonstrated the typical error patterns of speech involving oral movements, articulation, and phonology (production of meaningful speech), which confirmed CAS [Table 2]. Subsequently, the intervention was modified with emphasis on speech-based, oral-motor skills, and verbal communication. The history was revisited, but no apparent cause for the CAS could be determined.
Table 2: Features of childhood apraxia of speech noted in child at ~4 years

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The recognition of CAS and change in intervention resulted in a slow but steady improvement that had been missing before. Substantial improvement was seen in comprehension, receptive, and expressive vocabulary and naming [Table 1], with two-word phrases appearing at 4.5 years. [Figure 1] depicts the changes in EL and RL during follow-up. Progress was not as remarkable for the cognitive prerequisites for language learning, sensory concerns, independence in ADLs, and social interaction.
Figure 1: Changes in receptive and expressive language age with intervention

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  Discussion Top

CAS can be congenital or acquired (intrauterine or early childhood stroke and traumatic brain injury), occur within complex neurobehavioral disorders such as ASD, fragile X syndrome, Rett syndrome, or idiopathic. The etiology is not ascertainable in many cases,[8] as was seen in this boy. This narrative highlights the fact that CAS should be proactively looked for in nonverbal or minimally verbal children with ASD. It should be suspected in children in whom EL lags behind RL, despite acquiring the ability to speak a few words. The clinician can assess the quality of the oral movements involving the muscles of the mouth, jaw, tongue, lips, and cheeks which are used in actions such as blowing, whistling, or tongue movements. This can be done on demand, during imitation or observed spontaneously. The strength and coordination of all these oral structures help to create sound patterns which when combined, form meaningful words. Diagnosing CAS requires longitudinal observation and monitoring of oral motor skills (speech and nonspeech related), in addition to articulation and phonological development.[9]

The treatment of CAS needs to be intensive and individualized, requiring dynamic planning, programming, and production.[10] Some intervention goals in a child with ASD and CAS will differ from isolated ASD such as the focus on oral-motor movements and imitation of ADL on command in the former. Some goals (developing social interaction, social behaviors, nonverbal communication, prerequisites of language learning, comprehension, expression, receptive/expressive vocabulary, and socialization skills) are the same. It is imperative to focus on earlier goals before working on speech production, as premature insistence on speech production may reinforce echolalia.[11] Persistent deficits in word sound production after successful achievement of early language milestones should alert the clinician to explore the possibility of comorbid CAS.

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Conflicts of interest

There are no conflicts of interest.

  References Top

American Speech-Language-Hearing Association (n.d.). Childhood Apraxia of Speech (Practice Portal). Available from: www.asha.org/Practice-Portal/Clinical-Topics/Childhood-Apraxia-of-Speech/. [Last accessed on 2021 Jul 24].  Back to cited text no. 1
Shriberg LD, Aram DM, Kwiatkowski J. Developmental apraxia of speech: I. Descriptive and theoretical perspectives. J Speech Lang Hear Res 1997;40:273-85.  Back to cited text no. 2
Hall PK, Jordan L, Robin, D. Developmental Apraxia of Speech: Theory and Clinical Practice. 2nd ed. Austin, TX: PRO-ED; 2006.  Back to cited text no. 3
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;35:122-40.  Back to cited text no. 4
Tager-Flusberg H, Kasari C. Minimally verbal school-aged children with autism spectrum disorder: The neglected end of the spectrum. Autism Res 2013;6:468-78.  Back to cited text no. 5
Arora NK, Nair MK, Gulati S, et al. Neurodevelopmental disorders in children aged 2-9 years: Population-based burden estimates across five regions in India. PLoS Med 2018;15:e1002615.  Back to cited text no. 6
Census 2011. Office of the Registrar General and Census Commissioner, India, Ministry of Home Affairs, Government of India. Available from: https://censusindia.gov.in/. [Last accessed on 2021 Jul 24].  Back to cited text no. 7
Childhood Apraxia of Speech. Mayo Clinic. Available from: http://www.mayoclinic.org/diseases-conditions/childhood-apraxia-of-speech/symptoms-causes/dxc-20202057. [Last accessed on 2021 Jul 24].  Back to cited text no. 8
Maas E, Gildersleeve-Neumann C, Jakielski KJ, et al. Motor-based intervention protocols in treatment of childhood apraxia of speech (CAS). Curr Dev Disord Rep 2014;1:197-206.  Back to cited text no. 9
Murray E, McCabe P, Ballard KJ. A systematic review of treatment outcomes for children with childhood apraxia of speech. Am J Speech Lang Pathol 2014;23:486-504.  Back to cited text no. 10
Dalwai SH. Autism spectrum disorders. Differential Diagnosis in Pediatrics. Vol. 32. New Delhi: Jaypee Publishers; 2020. p. 36.  Back to cited text no. 11


  [Figure 1]

  [Table 1], [Table 2]


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