Q: My client is a five-year-old with polymicrogyria. He drools severely, eats only purees, basically is non-verbal, and has a non-verbal IQ of about 85. He is labeled as apraxic. Can you give me advice on how to proceed?

I had not heard of this disorder, so I Googled it and found quite a bit under “polymicrogyria ” and “children with polymicrogyria.” Apparently it is a developmental malformation of the human brain characterized by an excessive number of small convolutions on the surface of the brain.

Diagnosis

A client like this should be diagnosed with cognitive impairment and dysarthria, not apraxia. See my other posts about the differential diagnosis of apraxia and dysarthria.

Prognosis

I would assume this client would progress just like all other children with significant cognitive impairment and neuromuscular disorder that results in limited speech that is dysarthric. Progress probably will be slow, painstaking, and limited. I could be completely wrong on this, of course, and he could fly through treatment and become a verbal child who is completely intelligible. But I would not expect it. I would expect this to be a lifelong SL disability. My prognosis would be that he will not be “cured” of the speech-language problems, but that he can be helped to communicate the best way he can given his cognitive and neuromuscular status. I would teach the parents this basic idea in words and concepts they can handle over time. Sometime, however, the parents have to face the truth of the disability, and you may be the one to do it.

Treatment Approach

The key to speech improvement at this level is to focus on basic functional communication and intelligibility of spoken utterances. Help him say whole words with an accurate number of syllables, the best vowels he can do, and with prosody that matches intent, and make all of this within the context of functional communication. I would accept ANY productions he made as intentional communication.  I also would include all types of communication systems–– verbal, vocal, gestural, signs, pictures, objects, computerized, and voice output.

In terms of oral control, I would assume that he has tone problems. He either will have overall low tone, or low tone with fixing which means that he is floppy and stiff at the same time. The OT/PT team can help you specify tone issues. I also would assume that he is either hypersensitive or hypersensitive to touch, or both, in the oral area. This means that he needs treatment to stimulate improved oral function in terms of both awareness (tactile) and control (movement). Techniques should be designed to relax stiff muscles in the speech subsystems, and to facilitate improved gross control of oral movement. Specific phonemes may not be stimulable at this time, but they may be as time unfolds. He also needs a feeding program that does not only focus on holding a spoon correctly, but which is designed to facilitate improved oral movement.

Logistics

I am not a proponent of seeing these kids many times per week to try to drive fast progress. The cognitive impairment means that his progress will be very slow, and I have not found that “more-therapy-now” is the solution. I am an advocate of “good-therapy-over-the-long-haul” instead. In practical terms, do not ask yourself how he can be made to say a particular phoneme correctly this week, except occasionally. Instead, ask instead what you want this child to be able to do by the time he graduates from high school, and guide his therapy in that direction instead. For example, do not make your goal to say P correctly today. Instead make your goal be one of having him learn to say “papa,” “please,” “popcorn” and other P-words in ways that people can understand him as he names, describes, requests, refuses, and so forth in conversational and classroom dialogues.