It is not the case that all children with a history of speech and language difficulties have associated literacy problems. However, school-age children whose speech difficulties persist beyond 5 years of age are most at risk for associated difficulties in reading, spelling and sometimes maths. Let us first consider the nature of persisting speech difficulties with reference to a simple psycholinguistic model of speech processing.

This illustrates that we receive spoken information through the ear (input). The information is then processed as it goes up the left hand side of the model and is stored at the top in a word store (lexical representations). When we want to speak we can access stored information and programme it for speaking on the right hand side of the model (output). Some children with speech difficulties have difficulties with speech input (e.g. differentiating between similar sounding words); others have imprecise or ‘fuzzy’ storage of words which makes it difficult to access them (as in word finding difficulties) or to programme a clear production of them because of missing elements in the word store; while others have a difficulty pronouncing speech at an articulatory output level (on the right hand side of the model) even though they know the words involved perfectly well. Children with persisting difficulties, however, may well have pervasive problems which involve all of these aspects of speech processing: input, representations and output. Where this is the case they may also have language difficulties (comprehension and/or _expression).
The speech processing system, as illustrated above, is not only the basis for speech and language development but also the foundation for literacy development; ‘written language’ being an extension of ‘spoken language’. For example, if a child has delayed understanding of spoken language s/he will find it very hard to access meaning from the printed word even though s/he may be able to decode the letters perfectly well. Sometimes, children with comprehension or ‘semantic-pragmatic’ difficulties are described as ‘hyperlexic’; this term indicates that a child can read print mechanically better than they can understand it. Other children, particularly those with persisting speech difficulties, have a problem with the mechanics of reading and are more likely to be described as ‘dyslexic’ or as having ‘specific’ reading and spelling problems. This suggests a problem at one or more levels in the speech processing system depicted above.

Typically developing children use this speech processing system not only to develop speech but also use their speech skills to develop another skill: ‘phonological awareness’. This is ‘an ability to reflect on and manipulate the structure of an utterance as distinct from its meaning’. You use your phonological awareness skills to play sound and rhyme games, e.g. judging if two spoken words begin with the same sound or not (e.g. CAT CAR; CAT BALL); or producing a string of words which rhyme with e.g. CAT. Children who find such games difficult, compared to their peers, often have problems with cracking the alphabetic code of languages such as English. Cracking the code is what children do when they sound out letters of a written word and then blend them together to read/pronounce it, or when spelling they take a word, break it up into it into its bits and put letters to each sound segment. Cracking the code therefore involves not just knowing about letters and sounds but also recognising the sequence of sounds in a word, e.g. what is at the beginning, middle and end. This phonological awareness is helped by being able to repeat words consistently and accurately to allow reflection on the structure of the word. Thus, children with persisting speech difficulties often need specific help not only with learning letter sounds and names but also with how these are combined in words through graded phonological awareness activities.

Clear and consistent speech production is particularly important for spelling or when learning new vocabulary. Typically, when asked how many syllables there are in a word (another phonological awareness skill), children repeat it, segment it out loud or in a whisper and then count the beats on their fingers. If they are not able to produce the right number of syllables in the word or if they cannot say the word in the same way on more than one occasion then they cannot spell it correctly or store it clearly. When trying to spell a long word, Danny, a 12 year old boy with apraxia of speech and dyslexic difficulties said exasperatedly: “If I can’t say it I can’t split it up!”

This is a really important insight and true of many children with speech difficulties. Michael, for example, had dyspraxia of speech with inconsistent production of multisyllabic words and particular difficulties producing clusters/blends (e.g. ‘br’ in BRUSH, ‘fl’ in FLOWER, ‘spr’ in SPRAY). His IQ was within normal limits but he had specific reading and spelling difficulties. When trying to spell a long word at 11 years of age he attempted to segment it into its sounds but then transcribed each of his many attempts. The result was rather dramatic. He spelt UMBRELLA as ‘rberherrelrarlsrllles’, and CIGARETTE as ‘satersatarhaelerar’. In his spelling of UMBRELLA he has dropped the first unstressed syllable (‘um’) from his spelling and is trying to write the first stressed syllable ‘br’ which he cannot pronounce. This takes up at least half of the spelling attempt. He is, however, aware that the word includes more than one letter ‘l’! When spelling CIGARETTE he wrote down the beginning sound (‘sa’) and end sound (‘ter’) of the word twice before losing it completely (haelerar). Combining work on all aspects of his speech processing system with phonological awareness and letter knowledge training helped him to have a more consistent approach to his spelling.

Spelling can also be a persisting problem for children who appear to have resolved their speech difficulties .In a recent study we compared the performance of a group of 7 year old children with speech difficulties with a matched control group of their peers (who did not have speech difficulties )on National (UK) tests of reading, spelling and maths. We then compared performance on the same tests of children with persisting speech difficulties with those children who had resolved their speech difficulties. More children with speech difficulties scored below average performance on the tests than did their IQ matched controls, particularly in spelling and reading comprehension. The children who had resolved their speech difficulties performed significantly better than the children who had persisting speech difficulties on all tests and did as well as the controls on everything except spelling.

In summary, children’s speech difficulties arise from problems at one or more points in their underlying speech processing system. This system is the foundation for their written language as well as their spoken language skills. If this foundation is unstable, additional support will be needed to enable a child to use the strengths s/he has to develop phonological awareness skill and letter knowledge. This is tough but not unsurmountable. Once at school, children with delayed spoken and written language can benefit from intensive and explicit letter-sound linkage work coupled where necessary with targeted speech and language work. Add supportive home and school environments and the active involvement of the child in his or her own intervention programme to this and progress will follow. When Danny was asked at 14 years of age what advice he would give to others, he stated:

“If you have any problems to see a therapist, to always try and write letters. Enjoy it. Do not take it as thing you never get out of it ‘cause if you try you will.”

[Professor Joy Stackhouse is a registered speech and language therapist, chartered psychologist and teacher of children with specific literacy difficulties. She currently has the Chair in Human Communication Sciences in the Department of Human Communication Sciences at the University of Sheffield, UK. Prior to this she was Professor of Speech and Literacy at University College London. Joy’s research and practice focuses on children with persisting speech difficulties and their associated literacy and psychosocial development. She has co-authored books and papers in this area particularly with Professor Maggie Snowling, Professor Bill Wells and is currently writing a book on persisting speech difficulties with Dr Michelle Pascoe.]

Many parents wonder if their young child with apraxia of speech (verbal dyspraxia) will go on to experience difficulties in their education . While there is no certainty that literacy problems will or will not develop, there is research that has shown that children with spoken language problems are at higher risk for literacy related problems. The purpose of this paper is to summarize some pertinent research and articles on the relationship of spoken language problems to literacy development.

Children with spoken language problems may have difficulty developing what are called phonological awareness skills. Joy Stackhouse has described phonological awareness in this way:

“Phonological awareness refers to the ability to reflect on and manipulate the structure of an utterance (e.g., into words, syllables, or sounds) as distinct from its meaning. Children need to develop this awareness to make sense of an alphabetic script, such as English, when learning to read and spell. For example, children have to learn that the sounds (phonemes) in a word can be represented by letters (graphemes). When spelling a new word, children have to be able to segment the word into its sounds before they can attach the appropriate letters, and when reading an unfamiliar word, they have to be able to decode the printed letters back to sounds.” (Stackhouse, 1997, p.157)

Phonological awareness is made up of many related skills including: recognition and production of rhyme; identification of number of syllables; sound to word matching, word to word matching; sound deletion; and sound segmentation.

Research has found that a strong predictor of literacy development is phonological awareness. Perhaps the stronger predictors of literacy development are later developing phonological awareness skills like sound segmentation and manipulation. When children demonstrate difficulty with phonological awareness, as do many children with spoken language problems, they are at higher risk of difficulty in literacy related skills like reading and spelling. Stackhouse writes that, “Although recent work has clarified how visual deficits may also affect reading performance, there is an overwhelming consensus that verbal skills are the most influential in literacy development (Catts, Hu, Larrivee, & Swank, 1994).” (Stackhouse, 1997, p. 163)

However, not all children with spoken language problems differ in developing reading and spelling skills. Stackhouse compared the reading and spelling skills of a group of children ages 7 – 11 years. She compared children who had speech problems deriving from cleft palate/cleft lip to those described by their therapists as having developmental verbal dyspraxia. The study showed that children with cleft palate did not differ significantly from age-matched typically developing children in tests of reading and spelling. However, the children with developmental verbal dyspraxia did show significant differences and did poorer on these same tests than did their age matched typically developing peers. Many of these children demonstrated errors that suggested they used guess work versus sounding out strategies. Their spelling errors were somewhat bizarre and illogical compared to those children with cleft palate. Therefore, Stackhouse concluded that, ” It is the children with persisting speech difficulties with no obvious medical etiology (who are often described as having phonological impairments or Developmental Verbal Dyspraxia), however, who are most at risk for related specific literacy problems.” (Stackhouse, 1997, p. 169) Other studies appear to report similar findings. One by Bridgeman and Snowling which compared children with developmental verbal dyspraxia to reading age-matched, typically developing children concluded that, “children with persisting phonological impairments have sound segmentation difficulties when processing sound sequences within novel words.” (Stackhouse, 1997, p.175)

A study of four dyspraxic children by Snowling and Stackhouse found that, “children diagnosed as having DVD experience more difficulty in using a phonetic spelling strategy than children who have normal articulation.” (Snowling & Stackhouse, 1983, p. 435) The results support earlier work suggesting that dyspraxic children are less able to carry out grapheme-phoneme conversions than would be predicted from their reading age (Stackhouse, 1982). Finally, Stackhouse writes that, “Persisting phonological impairments beyond the age of 5.6 years may be a sign that a child is at risk for literacy problems.” (Stackhouse, 1997, p.169)

Reading and Spelling Issues:

While many people want to think about reading and spelling as two sides of the same coin, research does not bear this out. Various researchers point to the growing evidence that reading and spelling are independent of one another. For instance, Bradley and Bryant demonstrated that young children may be able to read words that they cannot spell and, conversely, spell words that they cannot read. Snowling and Stackhouse write:

“Spelling is more difficult than reading for most people because reading is a recognition process which can proceed using only ‘partial cues,’ where as spelling is a retrieval process which requires ‘full cues’. In order to spell well one must be able to reproduce the correct letter-by-letter sequence of words (Frith & Frith 1980).” (Snowling & Stackhouse, 1983, p.431)

Reading

There are various models that describe the acquisition of reading skills. To simplify this, one can say that in normal reading development children first develop a sight vocabulary – words that they can identify purely by looking at the whole word. This can be described as the direct route. Later, children learn phoneme – grapheme correspondences (sound-letter correspondences) and learn strategies for sounding out words they are trying to read. This can be described as the indirect route. It is important for children to develop this indirect route because if they do not, their reading only progresses to the limits of their visual memory. If they don’t learn phonological strategies via the indirect route then when they are attempting to read an unfamiliar word they will have difficulty decoding the printed letters back to sounds. It is suspected that some children with apraxia of speech or verbal dyspraxia may have difficulty making the leap from the direct to indirect route in reading acquisition.

Spelling Issues

When spelling new words a child needs to be able to segment the word into sounds before they attach an appropriate letter to the sound. In the case of children with apraxia of speech or phonological impairments the types of spelling errors they make aren’t always directly related to their mispronunciation of the words. It is believed that more frequently, their spelling errors are a result of limited phonological awareness, specifically sound segmentation abilities. The literature reports that these children appear to use guesswork vs. logical strategies and that their spelling errors can seem quite bizarre. However, the nature or underlying reason for their spelling difficulties needs to be explored and evaluated because not all children are affected similarly. For any particular child the root of the problem can stem from input, output, representation or a combination of factors.

Some clues that a child with apraxia of speech (verbal dyspraxia) may be having difficulty in reading and/or spelling are:

• The child is not progressing from reading words as visual wholes to breaking the words down into their sounds.
• The child fails to segment the word into syllables and syllables into sounds. Spelling attempts may seem bizarre.
• The child has difficulty in rhyme detection and particularly, rhyme production.
• The child has difficulty with sound blending.

What Can Be Done To Help?

Various studies conducted with children with limited phonological awareness or poor reading skills point to some suggestions. For instance, a study by Hatcher, Hulme, & Ellis who divided seven year olds who were poor readers into three groups and provided different arrangements of phonological awareness training, reading instruction, or no other training outside of the routine classroom work, found that the only group that made significantly more progress than the control group, was the group that focused on both phonological awareness plus explicit reading strategies. In her article reporting the results of this study, Stackhouse writes, “phonological awareness training alone does not necessarily facilitate literacy development. Literacy development is dependent on children’s ability to link their phonological awareness skills to letter knowledge and reading experience.” (Stackhouse, 1997, p.162) An earlier study by Bradley and Bryant of 65 children with below average ability on phonological awareness tasks as nonreaders before entering school demonstrated that phonological awareness training needs to be combined with explicit letter knowledge teaching for these children to make actual gains in literacy development.

Further, a complete language assessment needs to be done. Such an assessment must not only look at and define the symptoms of the speech, reading, and spelling problems but also the underlying nature of those problems. A full assessment would include: speech, language and oral-motor abilities; auditory skills (such as auditory discrimination, memory and organization); rhyme detection and production; syllable and phoneme segmentation; reading comprehension and expression; spelling and awareness of reading and spelling strategies. It is also important to include more difficult items in reading and spelling tests (for instance, multisyllabic words) in order to determine a particular child’s difficulty. At the end of a thorough assessment, Stackhouse suggests that:

“…having identified through the assessment

• (a) a profile on speech, language, and reading tests
• (b) the level and modality of breakdown
• (c) the severity of the difficulties and their manifestation in ‘real life’
• (d) the coping strategies adopted

then remediation can be planned” (Stackhouse, 1985, p.109)

The Role of the Speech and Language Pathologist:

The literature and studies reviewed for this paper indicate that there needs to be awareness and vigilance to the literacy development of children with spoken language problems, especially those who have apraxia of speech. “There is a danger that as intelligibility reaches an acceptable level, the child is discharged from the speech therapist’s care only to be left struggling with residual speech difficulties and related spelling problems,” concludes Joy Stackhouse. (Stackhouse, 1985, p.115) While the role of the speech and language pathologist is not to teach reading and spelling per se, Snowling & Stackhouse indicate that, “the role is one of identification and promoting the underlying skills that contribute to literacy development.” (Stackhouse, 1997, p.190) It is hoped that by receiving early, intensive communication therapy for apraxia of speech or phonological deficits, these children may, in fact, heighten their phonological awareness and, in part, strengthen a potentially intrinsic weakness.

Stackhouse suggests that some possibly relevant tools, techniques and activities include:

• phoneme-grapheme matched cards (cards with pictures that represent sounds)
• color coded systems as visual reminders of language structures or of sound groups
• sound categorization activities using multi-sensory approaches
• syllable and sound segmentation activities
• rhyming work
• explicit teaching of reading and spelling rules

Reading instruction

Research accumulated over time indicates that many children need explicit teaching using a phonics approach with phonological awareness; sound-letter correspondence and decodable text with kindergartners and first graders. Research appears to indicate that whole language can enhance comprehension and that a balance of comprehension and decoding skills should be focused on but that whole language should not be the only strategy used with nonreaders. This data may be especially important to children with apraxia of speech and residual problems.

What can parents do?

Parents can support the work of speech pathologists and teachers by following through on home activities that are suggested. For young children, these include nursery rhymes and rhyme games; making games with syllable beats in words; drawing attention to the printed word while reading to children; using books with rhymes and word patterns. Most importantly, parents need to be proactive by knowing what is happening in their child’s school program. Developing effective communication with teachers and therapists will help promote skill development and also help to identify potential roadblocks at the earliest possible time, before a significant problem has developed.

Summary

Children with spoken language problems that follow them into school need the proactive involvement of speech pathologists, teachers, and parents. Literacy related skills need to be carefully monitored. Children experiencing difficulty require a full language assessment to not only identify the problems but also to uncover the underlying reason for those problems in order for proper treatment to be outlined and delivered. The potential or risk for literacy related difficulties makes the jobs of both parents and therapists all the more challenged. While much of the focus for children with apraxia is necessarily on their speech production and oral motor sequencing skills, these children also need support and assistance throughout the course of therapy to assure that the proper groundwork is laid for developing literacy skills.

References for this paper:

Stackhouse, Joy (1997). Phonological awareness: Connecting speech and literacy problems. In B. Hodson and M.L. Edwards (Eds.), Perspectives in Applied Phonology (pp. 157 – 196). Gaithersburg, MD: Aspen Publications.

Snowling, M, & Stackhouse, J. (1983). Spelling Performance of Children with Developmental Verbal Dyspraxia. Developmental Medicine and Neurology, 25, 430 – 437.

Stackhouse, J. (1985). Segmentation, speech and spelling difficulties. In M. Snowling (Ed.), Children’s Written Language Difficulties (pp. 96 – 115). Philadelphia: NFER-Nelson Publishing.

Bridgeman, E. & Snowling, M. (1988). The perception of phoneme sequence: A comparison of dyspraxic and normal children. British Journal of Disorders of Communication, 23, 245 – 252.

30 years of research: How children learn to read. G. DeAngelis Sedlak (Ed.) SpeechJargon newsletter, Volume 2, Issue 4, November 1997.

30 years of research: What we know about how children learn to read, a synthesis of research on reading from N.I.C.H.D.

Description of Graphomotor Skills

Handwriting is complex perceptual-motor skill that is dependent upon the maturation and integration of a number of cognitive, perceptual and motor skills, and is developed through instruction (Hamstra-Bletz and Blote, 1993; Maeland, 1992). While a plethora of information exists in lay and professional literature about many of the common problems experienced by school age children, difficulty with handwriting is often overlooked and poorly understood. Students with graphomotor problems are frequently called “lazy”, “unmotivated” and/or “oppositional” because they are reluctant to produce written work. Many times, these are the children who dislike school the most. Because they are sometimes able to write legibly if they write slowly enough, they are accused of writing neatly “when they want to”. This statement has moral implications and is untrue; for children with graphomotor problems, neat handwriting at a reasonable pace is often not a choice.

When required to write, children with written production problems frequently engage in numerous avoidance behaviors. They have to go to the bathroom; they need to sharpen their pencils; they need a Kleenex from their backpack. Sometimes they just sit and stare. Even disrupting the class and getting in trouble may be less painful for them than writing. Work that could be completed in one hour takes three hours because they put off the dreadful task of writing.

The following paragraphs will attempt to elucidate the various components of handwriting and the characteristics which students display when there are breakdowns in these components. Components of graphomotor or handwriting skills include visual-perceptual skills, orthographic coding, motor planning and execution, kinesthetic feedback and visual-motor coordination.

Visual-Perceptual Skills.

Visual-perceptual skills enable children to visually discriminate among graphic forms and to judge their correctness. Thus, visual-perceptual skills involve the ability or capacity to accurately interpret or give meaning to what is seen. Generally a number of specific skills fall into this category including visual discrimination, or the ability to distinguish one visual pattern from another, and visual closure, or the ability to perceive a whole pattern when shown only parts of that pattern. Adequate visual-perceptual skills are a necessary but not sufficient condition for legible written output.

Orthographic Coding.

A second factor important to the production of legible handwriting is orthographic coding. Berninger and her colleagues (Berninger, Yates, Cartwright, Rutberg, Remy and Abbott, 1992) define orthographic coding as the “ability to represent a printed word in memory and then to access the whole word pattern, a single letter, or letter cluster in that representation” (pg. 260). Thus, orthographic coding refers to the ability to both store in memory and retrieve from memory letters and word patterns. The relationship between poor handwriting and orthographic coding deficits has been empirically established (Berninger et. al., 1992).

Motor Planning and Execution.

A third component of handwriting is praxis or the ability to plan and execute motor actions or behavior. Fitts and Posner (1967) describe motor skill acquisition as proceeding through three stages. The first phase is called the cognitive or early phase. In this phase, the learner establishes an understanding of the task and a cognitive map of the movements required to accomplish the task. In the second phase, the associated or intermediate phase, the movement patterns become more coordinated in time and space. During this phase, proprioceptive feedback (the feedback that the brain receives from the muscles and nerves) becomes increasingly important and the importance of visual feedback decreases. The final phase, the autonomous phase, is characterized by the development of larger functional units that are translated into a motor program which then occurs with minimal conscious attention.

Luria (1966) notes that a motor action begins with an idea about the purpose of an action and the possible ways in which this action may be performed. The ideas are stored as motor engrams. Thus, in order to carry out a motor behavior, we must have both the idea or image for what must be accomplished (i.e., the plan) and the ability to match our motor output to that plan. Therefore, both adequate motor planning and execution are necessary for handwriting.
Levine (1987) includes in the definition of dyspraxia difficulty with assigning the various muscles or muscle groups to their roles in the writing task. This definition focuses on the execution or output aspect of dyspraxia. According to Levine, in order to hold a pencil effectively and produce legible handwriting at an acceptable rate, the fingers must hold the writing utensil in such a way that some fingers are responsible for stabilizing the pencil or pen and others are responsible for mobilizing it. In a normal tripod grasp, the index finger is responsible for stabilizing the writing instrument and the thumb and middle finger are responsible for the mobility of the instrument during writing.

Kinesthetic Feedback.

Yet another component of motor control for legible handwriting produced at an acceptable rate is feedback of the sensorimotor system, especially kinesthetic feedback, during the performance of motor actions. Luria (1966) points out that for effective motor action, there must be afferent impulses from the body to the brain that inform the brain about the location and movement of the body. The body then makes adjustments based on these impulses to alter its movement pattern until the desired pattern is achieved. Thus, it is kinesthetic feedback that facilitates a good match between the motor plan and motor execution. In writing, the writer has a kinesthetic plan in mind and compares this plan to the kinesthetic feedback and then either corrects, persists or terminates the graphomotor pattern (Levine, 1987).

Visual-Motor Coordination.

Visual-motor coordination is the ability to match motor output with visual input. Although it is the nonvisual or kinesthetic feedback that is crucial for handwriting, visual feedback is also important. Visual feedback provides gross monitoring of writing rather than the fine-tuned monitoring provided by nonvisual feedback. It is this gross monitoring that prevents us from writing on the desk, crossing over lines (Levine, 1987) and staying within the margins.

Problems with Graphomotor Skills

Deficits in Visual-Perceptual Skills.

Children with visual-perceptual problems may have a history of reading problems because of difficulty with letter and word recognition. In addition, if a child cannot accurately visually discriminate the letter b from the letter d, he/she will be unable to reliably reproduce these letters upon demand. If students have problems with visual closure, they may have difficulty with accurate letter formation and handwriting legibility may be poor. For example, they may print the letter o with a space in the top, but perceive the letter as closed. When deficits in visual-perceptual skills are suspected, they can be readily identified by informal or standardized tests.

Deficits in Orthographic Coding.

Students who have trouble with orthographic coding will often forget how to form certain letters in the middle of a writing task. They frequently retrace letters or exhibit false starts or hesitancies as they write. Observations of their written output may show that they have formed the same letter several different ways. When asked, these students can usually report if they have difficulty remembering what letters look like. Children who cannot reliably make use of visual recall to form letters and words often prefer to print rather than write in cursive because print involves only twenty-six different visual letter patterns, whereas letters written in cursive have a seemingly endless number of visual patterns. Their spelling errors may be phonetic in nature (Levine, 1987, 1994).

Deficits in Motor Planning and Execution.

Poor motor planning and execution is referred to as dyspraxia. Deuel and Doar (1992) define dyspraxia as the “inability to learn or perform serial voluntary movements with the proficiency expected for age and/or verbal intelligence” (pg. 100). Helmer and Myklebust (1965) discuss the role that memory for motor sequences play in correctly forming letters when writing. Luria (1966) described two forms of dyspraxia. The first form involves difficulty in creating an image of a required motor movement. The second involves a breakdown in the central nervous system mechanism that is responsible for putting the plan into action. Thus, the child has the blueprint for the action/behavior, but has difficulty implementing it motorically (Levine, 1987).

Ayres (1972, 1975, 1985) suggested that the problem in developmental dyspraxia is in the neural activity that takes place prior to motor execution. According to Ayres, dyspraxia is generally viewed as an output problem because the motor component is more observable than the sensory component. However, in her view, dyspraxia is an inability to integrate sensory and motor information, rather than merely motor production.

Children who suffer from fine motor dyspraxia show poor motor coordination. At times, they assign too many muscles to stabilizing the pencil or pen and too few muscles to mobilizing it. At other times, they assign too many muscles to mobilizing the writing utensil and too few muscles to stabilizing it. Thus, their pencil grips are often inefficient. They may develop a hooked grip in which they stretch out the tendons in the back of the arm so that the fingers move very little if at all during writing. With this grip, they are using the larger muscles of the wrist and forearm which may be easier to control than the smaller muscles in the fingers. They often perform poorly with other fine motor tasks that involve coordinated motor movements such as tying shoes or holding a fork correctly (Levine, 1987).

Another pencil grip which suggests fine motor dyspraxia is one in which the child holds the pencil very tightly and near the point when writing. Further, students with dyspraxia often change pencil grips and prefer writing in cursive rather than print. They do not like to write and complain that their hand hurts when they write. Writing for them is a labor-intensive task. Fine motor dyspraxia is frequently associated with speech production problems because these children often have difficulty assigning the muscles in the mouth to specific speech sounds (Levine, 1987, 1994).

Impaired Kinesthetic Feedback.

Children with impaired kinesthetic feedback often develop a fist-like grip of the writing instrument. With this grip, they extend their thumb over the index and middle finger, limiting the mobility of the fingers. They may also press very hard on the paper with the writing utensil in an attempt to compensate for the lack of kinesthetic feedback. Further, they may look closely at the pencil or pen when writing thus attempting to guide the hand using visual feedback which is a much slower process. This is why children with impaired kinesthetic feedback may produce legible handwriting at a greatly reduced pace. As they progress in school, however, the demands placed on written output are too great and legibility deteriorates. These are the children who are often accused of writing neatly “when they want to”. They also often prefer to use mechanical pencils and “scratchy” pens because these provide more friction on the paper when writing. They complain that their hand hurts when writing and they do not like to write. Performance in other fine motor skills may be adequate or good because many fine motor skills do not place such reliance on kinesthetic feedback.

Research has shown that tasks which were designed to improve kinesthetic sensitivity improved handwriting performance more than a task that involved only practice in handwriting (Harris and Livesay, 1991).

Deficits in Visual-Motor Coordination.

Children with visual-motor incoordination function much differently than those with impaired kinesthetic feedback because of the different demands of certain motor tasks. Poor visual-motor integration may lead to problems with fine motor tasks that rely heavily on visual feedback. These include threading a needle, drawing, painting, craftwork, building things with blocks, repairing things, playing games such as Nintendo and using a mouse on a computer.

Strategies for Graphomotor Problems

• For children who have difficulty with orthographic coding, it may be helpful to tape an alphabet line to the corner of their desk for easy reference.
• Students with graphomotor problems should be given extended time to complete written assignments and/or a reduction in the volume of written output. For example, if the exercise given is to correctly capitalize and punctuate sentences or a passage, these should be provided to the student in typed form so that he/she has to only correct the work, rather than write it and then correct it. Also, if the assignment is to answer the questions at the end of the chapter in social studies, the student should be required only to write the answers, not both questions and answers. Additionally, he/she should be allowed to state answers in short phrases. In other words, if the subject matter being assessed is knowledge of information presented in the social studies chapter, it is this that should be assessed, not how competent the student is with the physical act of writing, or how much writing interferes with his/her ability to demonstrate his/her knowledge of social studies.
• Children with handwriting difficulties may need to be given the opportunity to provide oral answers to exercises, quizzes, and tests.
• Learning to type is helpful for these students. Writing assignments should be done in stages. Initially, the child would focus only on generating ideas. Next, he/she would organize his/her ideas. Finally, the student would attend to spelling and mechanical and grammatical rules. There are computer software programs available with spell and grammar checks.
• Students with graphomotor problems may need to be provided with information presented on the board or on overheads in written form, such as teacher-prepared handouts or Xerox copies of other students’ notes.
• Children with handwriting problems should be provided with written outlines so that they do not have to organize lectures or class materials themselves. This becomes particularly important in junior high grades.
• Parents should be given the opportunity to purchase an extra set of textbooks for the purpose of highlighting, particularly for content area subjects. Also, notes may be made on Post-Its and then the Post-Its could be attached to a larger sheet.
• It is often necessary to use alternative grading systems for children with graphomotor problems. One grade would be given for overall appearance and mechanics of writing, and the second for content.
• When writing reports, it may be helpful for the student to identify his/her own errors and to correct these after learning specific strategies to do so. He/she would then list his/her most frequent errors in a workbook and refer to this list when self-correcting.
• It should be stressed to school personnel that slow work habits are often a result of graphomotor difficulties and do not reflect deficits in motivation.
• Electronic devices, such as the Franklin Speaking Spelling Ace may be helpful for students with handwriting problems.

References

Ayres, A. J. (1972). Sensory Integration and Learning Disorders. Los Angeles: Western Psychological Services.
Ayres, A. J. (1975). Sensorimotor foundations of academic ability. In W. Cruickshank & D. P. Hallahan (Eds.), Perceptual and learning disabilities in children: Volume 2, Research and Theory (pp. 300-360). New York: Syracuse University Press.
Ayres, A. J. (1985). Developmental dyspraxia and adult onset apraxia. Torrance, CA: Sensory Integration International.
Berninger, V., Yates, C., Cartwright, A., Rutberg, J., Remy, E., & Abbott, R. (1992). Lower-level developmental skills in beginning writing. Reading and Writing: An Interdisciplinary Journal, 4, 257-280.
Deuel, R.K., & Doar, B.P. (1992). Developmental manual dyspraxia: A lesson in mind and brain. Journal of Child Neurology, 7, 99-103.
Fitts, P. M., & Posner, M. I. (1967). Human Performance. Belmont, CA: Brooks/Cole.
Hamstra-Bletz, L., & Blote, A.W. (1993). A longitudinal study on dysgraphic handwriting in primary school. Journal of Learning Disabilities, 26, 689-699.
Harris, S.J., & Livesey, D.J. (1992). Improving handwriting through kinesthetic sensitivity practice. Australian Occupational Therapy Journal, 39, 23-27.
Levine, M.D. (1987). Developmental Variation and Learning Disorders. Educators Publishing Service, Inc.: Cambridge, Massachusetts.
Levine, M.D. (1994). Educational Care: A System for Understanding and Helping Children with Learning Problems at Home and in School. Educators Publishing Service, Inc.: Cambridge, Massachusetts.
Luria, A.R. (1966). Higher Cortical Functions in Man. Basic Books, Inc.: New York.
Maeland, A.F. (1992). Handwriting and perceptual-motor skills in clumsy, dysgraphic, and ënormalí children. Perceptual and Motor Skills, 75, 1207-1217.
Myklebust, H.R. (1965). Developmental disorders of written language: Vol. 1.
Picture story language test. Grune & Stratton: New York.

Dr. Thorne is Vice President of Clinical Services for the Center for Development and Learning (CDL) in Louisiana. CDL specializes in the development and dissemination of leading edge reasearch, knowledge, training and best practices from diverse yet related fields that impact educational success. Visit CDL’s website at: https://www.cdl.org/

Language processing refers to the mental operations by which we perceive, recognize, understand and remember sounds, words, and sentences. Because it happens “inside the head,” language processing can’t be seen directly, instead, we have to test for processing problems.

It’s natural to focus on the speech production difficulties of children with CAS, but there are good reasons for parents and clinicians to take a careful look at their comprehension and processing. For one thing, speaking and understanding are tightly linked; in fact, one influential theory suggests that our knowledge of speech movements helps us perceive speech sounds. For another, children who have processing and comprehension problems often “get by” in everyday situations by using their knowledge and previous experiences to help them understand at least when they are young. But as they get older, they face more and more situations in which there are no extra clues to comprehension, and even mild processing difficulties can slow down their understanding and interfere with their performance.

Some “symptoms” of comprehension and processing problems:

• The child may understand single words, and have an excellent vocabulary, but have difficulties in understanding phrases or sentences. Because comprehension can be so variable, others may think that the child is “just not trying” or “not paying attention.”
• The child’s understanding will likely be better in everyday situations than in situations where there are few or no extra clues to meaning. In such situations, the child may fail to respond, may repeatedly say “Huh?”, may simply guess what has been asked, or may even repeat some or all of what was said.
• Lengthy, complex, and abstract sentences are especially difficult for children with processing problems, especially if presented at normal or faster speaking rates.

If your child has normal hearing but you suspect a processing problem, a speech-language pathologist can assess his or her skills in single-word and sentence comprehension, as well as in phonological processing and phonological memory.

Some suggestions for parents whose children have processing problems:

• Draw your child’s attention to speech sounds in words, using rhyming and silly sound games. Point out how new sounds and words are similar to and different from sounds and words your child knows well.
• Don’t pretend you understand when you don’t. Show your child that communication breakdowns happen to everybody, and that people have to work together to fix them. Children who are at least 5 years old can be taught to monitor their comprehension, and to know what to do when they fail to understand.
• When possible, be face-to-face when talking to your child. Speaking at an unhurried rate, repeating key words and important information.
• Try not to give too much information at once. Rather than saying, “Get your coat on because we’re going to stop by Grandma’s house to pick up her dry cleaning after we pick up some things from the grocery story and pick up your brother from soccer,” you can say, “Let’s get your coat on. We have 3 things to do today. First, we are going to pick up your brother from soccer. Then I need to go to the grocery store to pick up food for our dinner. After that, we can stop by Grandma’s to pick up her dry cleaning.”
• Children who have difficulty with language processing and comprehension may become frustrated or worry about disappointing people when they are given instructions to follow that are too long or complex. You can simplify your instructions by giving one or two instructions at a time rather than a big list of things to do. When you give instructions, you can do a quick comprehension check by asking your child to retell the instructions. You also can ask your child to check in with you after they have completed an instruction. For instance, if you’re taking your child to the park, but they need to do a few things before you leave, you can tell your child, “We’re going to the park. Please put your puzzles back on the shelf. Where do your puzzles go?” “On the shelf.” That’s right. Let me know when you’re done… Great! Thanks for cleaning up your puzzles. Go upstairs and put on the shorts and t-shirt I set on your bed. Let me know when you’re dressed… Oh good. Wash your hands, and then we can go to the park.”
• When reading books, stop periodically and ask questions or have short discussions about what you’re reading. If possible, make connections between what you’re reading and your child’s life. Some books for children may contain complex sentence structures and sophisticated vocabulary. Consider rewording complicated sentences while reading aloud to your child. Don’t hesitate to stop and explain the meaning of words that may be unfamiliar to your child.

(Chris Dollaghan, Ph.D., CCC-SLP, is a professor in the Department of Communication Science and Disorders at the University of Pittsburgh, where she teaches and conducts research in pediatric speech and language disorders. She also previously served as chairperson of ASHA’s Research and Scientific Affairs Committee.)

Parents have many questions about what will happen when their child becomes school age.  Can my child attend preschool? What kind of preschool?  Should my child go to kindergarten this year?  Educational placements for children with apraxia can cause parents a lot of stress.  In a nutshell, educational settings for children with apraxia of speech are just as varied as the children themselves!  There is no one “right” type of classroom or school setting that is perfect for all children with CAS.

What is Special Education?

Special education refers to laws, policies, rules, and very importantly – services for children who are determined to have a disability and who, because of their disability, are in need of specially designed instruction and related services in order to benefit from their educational program.

Special Education Rights, Rules, and Procedures.

Learning about special education rights is crucial for your participation in your child’s educational planning and to prepare you to be your child’s best advocate.  This is no easy feat given the busy lives we lead insuring that our children are receiving speech therapy and possibly other therapies, raising other children, working, etc.  However, it is well worth the effort because it is the only way you as the parent will be able to fully insure that your child is receiving what they are entitled to receive – a free, appropriate education.  Also, learning what the law says about special education rights may also apply to parents who are planning to send their children to private schools and/or home-school.  If you in any way plan to use public services to assist in your child’s educational development, it is critically important for you to pursue knowledge and understanding of your child’s special education rights.

There are many internet resources that provide quite detailed information on special education rights under federal law and as interpreted through specific state regulations in your state.  Apraxia-KIDS can help you locate appropriate sources of information to begin that learning process.  However, following is a review of some generally important concepts.

Evaluation for Special Education Eligibility and Services.

Most children with significant apraxia of speech, after evaluation by the school district, will be eligible for special education services, or, depending on which state you live in, a special education unit.  Speech therapy is one of many related services that can be provided through special education.  Support to children for their special education needs is based on a child’s unique needs and abilities.  There is no “one size fits all” when it comes to children that are eligible for special education.

In order to receive preschool or school-age special education services, the school district or designated appropriate agency has to evaluate your child in all areas of suspected disabilities.  If a child has been enrolled in a birth to three early intervention program, the planning for transition to preschool should occur prior to the child’s third birthday.  The school system will gather past and current information and will then, with your signed consent, create an evaluation plan to fully evaluate your child.  Parents may contact their school district Special Education Administrator or school principal to request that their child be evaluated for special education.  Putting the request for evaluation in writing is the best strategy to assure that a response is provided in a timely manner.

As the parent, you have a right to know what tests will be administered to your child.  Please be aware that some tests would be invalid and inappropriate for a child with low or limited verbal skills, including many tests of cognitive or intellectual abilities.  Also, testing by the school for eligibility for special education is free to you.  At the end of the evaluation process, you will receive an Evaluation Report that will share the results and interpretation of scores, strengths and needs, recommendations regarding whether or not your child is eligible for special education, and if eligible, what types of goals and services may be required to meet your child’s individual education needs.

Individual Education Planning (IEP)

After an evaluation is complete, a meeting should occur to review the findings of the evaluation and begin to identify a number of things about your child, including:

• His/her present level of functioning (what CAN your child currently do, and what CAN’T your child do).  This includes your child’s strengths, needs, learning style.
• Based on present level of functioning, the creation of clear and objectively measurable goals for the child to achieve in one years time (annual goals)
• Steps to achieving the goals (short-term objectives or benchmarks)
• Types of supports and services the child needs to achieve the goals and objectives
• Amount of services to be provided and method of delivering the services.

When the above steps are in place, the IEP team should discuss classroom placement.  Parents should be aware that the point of special education is to meet your child’s individual educational needs by providing appropriate supports and services.   A plan is to be designed around your child’s educational needs, not around a predetermined classroom and what services are reported to be available.  Your child’s needs must be the focus. Thus be wary if you are told that your school district doesn’t provide a service (for example, “we only provide group speech therapy”).  A policy that would limit the available service delivery for speech therapy would be frankly illegal.  Again, the kinds of services and ways that they are to be delivered must be based on the child’s individual needs and not on convenience, budget, or preference of school systems.

Some things to know or remember:

• All children with apraxia of speech are unique individuals and have unique needs.  The children do share a speech diagnosis, and thus, are likely to require frequent and intensive speech therapy for a period of time, however; other speech, language or learning needs are often present in many children.  In the special education process, try to focus on your particular child’s strengths and needs vs. comparing them to another child who may or may not have the exact same issues.
• Remember, that speech, language and communication impact many areas of the education process.  If you are struggling to understand how your child’s education may be affected or what areas may be important, secure information about your state’s educational standards for your child’s grade level.  Or, if for some reason, the school disagrees that your child’s speech disability impacts education, knowing what speaking and listening standards are expected of ALL students can help make your case for services.  Get information by going to Google.com and searching with terms, “<your state> and education standards and <grade level>” (for example, “Pennsylvania and education standards and kindergarten.”  Examples for children in early grades may include items such as:
  • Ask questions for clarification
  • Retell stories using appropriate grammar and sequence of events
  • Use correct vocabulary and word usage when speaking
  • Ask and answer appropriate questions and share personal experiences within a group
  • Respond to and initiate conversations

Each of the areas above would be important at any grade level and would be made very challenging for a child with a significant speech disorder!  Understanding what standards your state expects for children of your child’s age and grade level can help you advocate for an appropriate education plan and services.

• Children with apraxia often have areas of concern that are in addition to speech production or speaking ability.  For example, children with apraxia of speech often have expressive and/or receptive language difficulties; reading, writing or spelling challenges, etc.  It is the school’s responsibility to assure that your child is evaluated in all areas of suspected disability.

• It is helpful to start with the idea that your child’s school staff and you, the parent, can work effectively in partnership with one another.  That should be a main goal because your child will benefit when that sort of partnership occurs!  While it may not always be possible, we observe that time and time again children with apraxia benefit immensely when educators, professionals, and families are able to unite behind what a child needs and work together.

• The special education process can be very overwhelming, confusing, and scary!  There are organizations in each state that are funded by the federal government to assure that parents receive help and training in understanding their child’s rights and the special education process.  These entities are called “Parent Training and Information Centers.”  To find one in your state, go to Google.com and put “parent training and information centers and special education” in the search.