This advice-column-style blog for SLPs was authored by Pam Marshalla from 2006 to 2015, the archives of which can be explored here. Use the extensive keywords list found in the right-hand column (on mobile: at the bottom of the page) to browse specific topics, or use the search feature to locate specific words or phrases throughout the entire blog.
Misdiagnosing Mild Dysarthria as Apraxia
By Pam Marshalla
SLPs often overlook the diagnosis of mild dysarthria. This therapist’s letter perfectly describes such a client. My answer below summarizes the problems and offers links to treatment.
Q: I was hoping you could provide some guidance for me with a student I am evaluating. She is 11 years old and has been in speech for R, L, S, Th for several years. I met her for the first time this week when I began her re-evaluation. The SLP who has worked with her previously was concerned about possible language impairment and felt there was something “odd” about her speech…
She can produce all sounds in all positions at the word level. She occasionally has errors with R, L, and Th in phrases, sentences, and conversational speech. She is about 98% intelligible to the unfamiliar listener. She hates coming to speech. Her language standard scores were around 90-95, and commensurate with IQ. Her social skills were slightly immature, but not of concern.
My concern is that her speech is “odd.” It almost sounds as if she has an accent of some type. She puts stress on the wrong syllables at times, and her voicing was slightly off occasionally (i.e, “to” sounded close to “do”). She appeared to be over-articulating everything. Her oral mechanism showed some groping behaviors and decreased control. Her tongue deviated to the left slightly when protruded. She occasionally deleted medial consonant (“bottle caps” became “bo-uh caps,” “medicine” became (me-cine”). Her diadokokinetic rate slowed as she went on and her productions were imprecise. She had no vowel errors and her consonant errors were fairly consistent. She had much more trouble with multi-syllabic words like “statistical analysis” and “alternative opinion.” She was able to perform nonspeech tasks such as wave goodbye or pretend to lick a sucker easily and smoothly.
My question is can there be very mild cases of apraxia and if so what do we do for that child? She seems to have responded well to conventional articulation therapy, and I didn’t think that was typical of apraxia. I would appreciate any tips you have!
Answer: You are looking at mild dysarthria, not apraxia. I am certain of this. Most SLPs miss this diagnosis.
Mild dysarthria is characterized by general imprecision, high level consonant errors, occasional CCR, occasional syllable deletion, occasional phoneme deletion, occasional prevocalic voicing, slight disturbance of prosodic features, and mild OM dysfunction. Usually there also is slight distortion of vowels and diphthongs, and substitution of schwa for vowels. I would listen more carefully to those vowels and diphthongs. The vowels probably are passible but not perfect, not fully resonant, not what the elocutionists called “round and orotund.”
See this blog’s past posts for more info on dysarthria. Some of these QAs are about very severe dysarthria, others about mild. But the therapy is essentially the same for both. She may be over-articulating everything to help her be as intelligible as she can be. It may be a strategy to help her sound better. Without the over-articulation she may sound absolutely terrible, as she probably does when she is very tired or when she is not paying good attention to her speech.
Speech at this level switches from phonemes to voice, resonance, and prosody. For treatment strategies see the other QAs about dysarthria in this blog.
0 thoughts on “Misdiagnosing Mild Dysarthria as Apraxia”
Hi Pamela, great points. I do think too that dysarthria is often missed.
Thanks for this article. I find it very helpful!