If you have concerns about your child’s development in addition to their speech, other professionals may be called on to get involved in helping your child.  For example, a developmental-behavioral pediatrician can evaluate all aspects of your child’s development.

Developmental Pediatrician

A Developmental Pediatrician is a pediatrician with advanced training in neuro-developmental disorders and “atypical”, out of the ordinary child development.  This type of professional can help recommend specialists and coordinate and advocate for services that the child may need.  You may also find this professional listed as a Developmental-behavioral Pediatrician.

Pediatric Neurologist

A Pediatric Neurologist may be helpful if there are overall neurological concerns in addition to speech.  If you are concerned about whether or not there is a problem of brain structure, wonder about possible seizures, and other brain related activities, the neurologist can help.  Some medical tests that can be done include MRIs to examine brain structure and extended EEGs to investigate the electrical system of the brain.

Clinical geneticist

A Clinical Geneticist may become involved if there is suspicion of an underlying genetic condition.  We know that one way in which CAS may occur is as a characteristic of neurological, genetic, metabolic and/or mitochondrial disorders.  Increasingly, research is demonstrating that there are a number of genetic conditions in which childhood apraxia of speech, and/or severe speech disorder, is a characteristic.  In the last few years, since the Human Genome Project was implemented, a new concept in genetics has appeared.  It is called copy number variant (CNV).  CNV refers to the finding that individuals can have small parts of chromosomes that are missing, duplicated, rearranged, or in some way different from what is expected.  Research has discovered that many people have these small differences.  Some people with CNVs have no noticeable difference in their functioning and others do have problems.  There are some CNVs identified in research publications that have childhood apraxia of speech as one characteristic.  For these reason, a wholistic and comprehensive evaluation of many factors may be warranted.  If there are extended family members who also have histories of speech and/or language problems or if there are medical concerns about your child, parents should speak to their pediatrician about referral to a geneticist.  Currently, a type of genetic testing called Microarray-based comparative genomic hybridization is most useful.

Occupational Therapist

An Occupational Therapist can evaluate your child’s overall ability to function in many aspects of life, including fine motor control.  Often, children with apraxia of speech have difficulty in managing the fine motor movements and coordination with their hands that are necessary for skills such as printing and writing, dressing, manipulating toys or objects and other self-help skills.  Additionally, some occupational therapists are great resources for evaluating children with difficulty eating.  Sensory processing difficulties are often reported by parents of children with CAS, such as difficulty with noises or in touching various textures and more.  A highly trained occupational therapist can help evaluate and treat sensory difficulties.

Physical Therapist

A Physical Therapist can evaluate overall physical functioning, body coordination and motor control of larger muscles of the body (gross motor control) and how the child is able to function in their environment.  A percentage of children with CAS have gross motor planning challenges, but not all.

A Developmental Specialist or Psychologist

A Psychologist or Developmental Specialist can help to examine a child’s cognitive abilities and whether they are developing as expected.  In young children, their ability to participate in play experiences that are typical for their age can be affected.  An astute psychologist will understand that children with a limited ability to speak are not able to participate in some forms of psychological testing that requires verbal responses.

Overall

Many children with apraxia of speech do have other developmental issues to some degree or another.  It is very important for parents and physicians to carefully monitor and respond to any concerns. Some of the most frequent developmental concerns that have been highlighted in the research include difficulties in fine motor control (such as in using the hands for skilled movement) and sensory processing.

By Heidi Feldman, MD, Ph.D.

Developmental-behavioral pediatrics is a subspecialty of pediatrics. As such, it functions with the orientation, beliefs, and practices of Western allopathic medicine. In this tradition, the practitioner gathers information about signs and symptoms and tries to explain them through a single over-riding diagnosis. In the process, the practitioner considers many diagnoses that might account for signs or symptoms and obtains additional history, expands the physical examination or conducts tests to determine which diagnosis is the best fit. Allopathic medicine became inextricably linked to the scientific process in the early 20^th century. Since then, the causes and best treatments for conditions, whenever possible, are determined through rigorous scientific study.

The subspecialty of developmental-behavioral pediatrics aims to understand and foster the development and maintenance of optimal cognitive, social, and emotional functioning in children and their families. The developmental-behavioral pediatrician is typically consulted when children are not making expected developmental gains or when behavior does not conform to social expectations. The physician reviews historical, behavioral, physical, neurological, and environmental issues to find the best diagnosis. If testing is necessary to confirm or disconfirm a possibility, then the pediatrician orders (including genetic testing) and interprets the results. Unlike some disciplines of medicine (but similar to rehabilitation medicine) the goals of treatment in developmental-behavioral pediatrics are often improvements in functioning rather than total cure or prevention. The unique features in the child and family’s circumstances are considered in making treatment recommendations. Developmental-behavioral pediatrics prides itself on being a family-centered discipline.

A child should be referred to a speech and language pathologist for a comprehensive assessment of communication skills and for treatment of the communication disorders. The speech and language pathologist may make a diagnosis within the domain of communication (such as, dysarthria versus apraxia) but typically does not venture to integrate this diagnosis with findings in other domains of function and does not explore underlying genetic, neurological, or environmental causes. The speech and language pathologist monitors progress of treatment, again primarily within the domain of communication. Because of the complementary roles, in many cases of children with developmental delays and disorders, a team that includes a medical professional, such as a developmental-behavioral pediatrician, and a speech pathologist (as well as a psychologist, occupational therapist, or other rehabilitation experts) provides the best service. Given the current health care climate, sometimes this team functions sequentially rather than in the same place at the same time.

Let’s think specifically about children with suspected apraxia of speech. The clinician who makes this diagnosis must have a trained ear to analyze the sound patterns a child uses and compare them across multiple repetitions of the same word or phrase. Most pediatricians and neurologists do not have the training and experience to differentiate among speech disorders. At best, they may be able to differentiate language disorders from speech disorders and differentiate problems of voice or resonance from problems of planning and execution. Thus, a speech and language clinician should definitely evaluate the child. However, children with apraxia of speech frequently have other findings, such as delays in motor functioning, or other diagnoses, such as neurological disorders or autism. Speech and language pathologists typically do not have the training or experience to integrate findings across functional domains and to make the additional diagnoses. Therefore, a developmental-behavioral pediatrician should consider full spectrum of problems that a child faces to determine whether a more inclusive diagnosis than apraxia of speech is appropriate. The developmental-behavioral pediatrician can consider whether management or treatment strategies over and above speech and language therapy should be included for the primary or secondary concerns. Given that the developmental-behavioral pediatrician generally is not actually providing therapy for the child, she might be able to provide objective assessments of progress over time. Finally, children often evolve in their symptoms as they develop. Some children with dramatic communication deficits in early childhood become competent communicators by school age but develop attention or behavior problems. The developmental-behavioral pediatrician has a broad perspective to monitor the evolution of a child’s disorders.

(Dr. Heidi Feldman, a developmental pediatrician, is the Ballinger-Swindells Endowed Professor in Developmental and Behavioral Pediatrics, in the School of Medicine, Stanford University. Additionally, she is the Medical Director of the Development and Behavior Unit at Lucille Packard Children’s Hospital. Dr. Feldman has published numerous articles in peer-reviewed journals in her collaborative research related to child language and is the recipient of numerous professional awards. Dr. Feldman is a member of Apraxia Kids’s Professional Advisory Board.)

Updated 11-1-19